Every finding on record at Lake Mills Health Services

Based on interview and record review, the facility did not ensure 5 (R33, R27, R29, R7, and R28) of 5 residents received adequate supervision and assistance devices to prevent accidents. * On 5/5/26, R33 was found on the floor and transferred to the hospital. R33 returned to the facility on 5/12/26 with hospital discharge diagnoses of right acetabular fracture and right nondisplaced proximal fibula fracture. Previous falls were not thoroughly investigated to determine whether prior interventions were in place or identify root causes to help prevent further falls. The care plan was also not consistently revised following previous falls to address identified interventions. R33 is being cited at a scope/severity of G, actual harm/isolated. *R27's falls on 2/24/26, 5/30/26, 6/7/26, and 7/19/26 were not thoroughly investigated, prior interventions were not in place and/or investigated to determine if they were in place, and the root cause was not consistently determined to help prevent additional falls. *R29's falls on 1/19/26, 4/3/26, and 7/21/26 were not thoroughly investigated, there is no indication if prior interventions were in place, and a root cause was not consistently determined to help prevent additional falls. *R7's coughing episode which was documented as choking on 3/11/26 was not investigated by the facility when R7 coughed up an entire Brussels sprout. *R28 had seven falls in a four-month period that were not investigated thoroughly. Findings include: The facility's policy titled, Fall Prevention and Management Guidelines and last reviewed/revised 7/18/24 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. Under the Policy explanation and Compliance Guidelines section it documents: #7 When any resident experiences a fall, the facility will: f. Obtain witness statements from other staff with possible knowledge or relevant information. 8. Review each fall/fall investigation during the next morning meeting/clinical meeting with the interdisciplinary Team (IDT). Actions of the IDT may include: a. Review of investigation and determination of potential root cause of fall. b. Review of fall risk care plan and any updates to plan of care completed post-fall. c. Additional revisions to the plan of care including any physical adaptation to room, furniture, wheelchair, and/or assistive devices. d. Education of staff as to any care plan revisions. e. Scheduling resident/family conferences. f. Verification of timely notification of physician and responsibly party of the fall. Note: If after IDT review, it is determined that existing interventions in the care plan are most appropriate, document rationale and describe any additional actions taken. On 7/30/26 at 12:04 p.m., Surveyors met with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyors asked NHA-A and DON-B to explain the facility's fall process. NHA-A explained staff does an initial assessment, the nurse calls the DON, they walk through the fall to ensure immediate intervention, they obtain a statement from the nurse, risk management is completed and reviewed by the IDT (interdisciplinary team). NHA-A informed Surveyors they look at what was in place, any other interventions, notifications are completed and if this could impact other residents they would do a house wide sweep. DON-B informed Surveyors neurological checks are completed; they check for injury before moving the resident as they are a no lift facility unless the resident can get up on their own. Surveyors inquired about staff statements. Surveyors were informed they put the statements into PCC (pointclickcare) and they are working with staff especially the floor nurses to get statements. 1.) R33's diagnoses include wedge compression fracture of first and second lumbar vertebra, injury of right hip and right shoulder injury. R33's at risk for falls care plan initiated 2/12/26 and revised 2/20/26 documents the following interventions:*Bed in low position. Initiated 2/12/26.*Encourage to transfer and change positions slowly. Initiated 2/12/26.*Fall Risk (FYI) (for your information). Initiated 2/12/26.*Have commonly used articles within easy reach. Initiated 2/12/26.*Reinforce w/c (wheelchair) safety a needed such as locking brakes. Initiated 2/12/26.*Report development of pain, bruises, change in mental status, ADL (Activities of Daily Living) function, appetite, or neurological status post fall. Initiated 2/12/26. R33's admission assessment has a fall risk score of 17 which indicates at risk for falls. R33's admission MDS (Minimum Data Set) with an assessment reference date of 2/18/26 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R33 is cognitively intact. R33 was assessed as requiring partial/moderate assistance for toileting hygiene, roll left and right, chair/bed to chair transfer, and toilet transfer. R33 was assessed to be continent of bowel and bladder and R33 fell prior to admission, had a fracture in last 6 months before admission, and has had no falls since admission. R33's Falls CAA (Care Area Assessment) dated 2/25/26 documents under the care plan considerations section: CAA triggered r/t (related to) impaired mobility, fx (fracture) L1-2. pain, BPH (benign prostatic hyperplasia), ad meds, opioid regimen, anticonvulsant meds. risk factors include decline in ADL (activities daily living) functional mobility, incontinence, pain, falls, PI/MASD (pressure injury/moisture associated skin damage), adverse reaction, infection/dehydration. RD (registered dietitian) to assess intake, WT (weight), labs, licensed nurse to assess skin PPOC (physician plan of care), pharmacy to review meds per facility/PPOC. Md (medical doctor) updated w/ coc. (with change of condition) see cp (care plan). R33's physician note dated 2/23/26 documents: Was admitted to the hospital on [DATE] after a mechanical fall at home where he tripped and missed his walker, falling to the right side. He/she presented with significant pain in his/her right hip, back and trigeminal neuralgia area on the right side of his/her face, rating the pain as 10/10 in both areas. Fall #1 R33's nurses note dated 3/6/26, at 1715 (5:15 p.m.), documents: Resident reported ambulating in room ad lib with walker. He/she fell on his/her left side. He/she denied hitting his head. Skin check revealed that he/she has a small abrasion to left lateral lower leg. 1.2cm (centimeters) x (times) 0.8cm x 0.1. Resident assisted from floor with mechanical lift. Stepped on his/her L (left) foot with his/her right foot and tripped. ROM (range of motion) and Neuro checks all negative. DON (Director of Nursing), VA (Veterans Administration), MD (Medical Doctor) made aware left message for daughter. R33's nurses note dated 3/11/26 documents IDT (Interdisciplinary Team) met to review fall, Dx (diagnoses) include but not limited to: Muscle weakness, difficulty in walking, Trigeminal neuralgia. Resident was made independent with ambulation by therapy, resident states he/she stepped on his foot and lost his/her balance in his room. Resident educated on foot placement with ambulating, working with therapy. Resident does at times walk with foot turned in, when observing ambulation. Therapy is working with him/her. On 8/3/26, Surveyor reviewed the facility's investigation for R33's fall on 3/6/26. The post fall assessment dated [DATE] sections for 2. Fall History, 3. Current Fall Info (information), 4. Physical Status, & 5. Mental/Behavior Status have not been completed. Current fall information includes questions ask the following questions of the resident immediately after fall Why do you think you fell? What time was the resident last seen?; Who was the staff member that last saw the resident? What position was the resident when last seen? Surveyor was only provided with the statement section of the facility's incident report dated 3/6/26 at 17:15 (5:15 p.m.). The rest of these questions were not answered and left blank. CNA-S's statement dated 3/6/26 documents: Heard resident yelling for help from dining room and went to see what it was. Went to room [Number] and saw resident lying on his left side in between his dresser and wardrobe yelling for help to get him off the floor. Pulled green light. [CNA-CC's first name] came and then [first name RN-BB]. I moved resident's walker out from in front of him/her in fear of him hurting him/herself because he/she was moving round way too much trying to get up and not listening to anyone at the time. [NAME] was in front of the resident but backwards. CNA-CC's statement dated 3/6/26 documents: Last saw resident when passing trays for supper, he was lying in bed. On 8/3/26 at approximately 2:30 p.m., Nursing Home Administrator (NHA)-A provided Surveyor with additional information. Surveyor was provided with the post fall assessment, nurses notes dated 3/6/36 and 3/11/26, and the complete incident report dated 3/6/26. The incident report section titled Nursing Description documents: Resident reported ambulating in room ad lib with walker. He fell on his left side. He denied hitting his head. Skin check revealed that he has a small abrasion to left lower leg. 1.2 cm x 0.8 cm x 0.1. Resident assisted from floor with mechanical lift. Resident Description documents: Resident reported that he stepped on his left foot and lost his balance. Under immediate action taken for description documents Updated DON (Director of Nursing). Resident educated to ensure he knows his foot placement before stepping. Skin check completed. Surveyor noted that R33's risk for falls care plan was not revised until 3/11/26, when R33 sustained a second fall. Intervention of Assistive device: 4 wheeled walker and Resident specific intervention: working with therapy for turned feet when ambulating were initiated on 3/11/26. Surveyor noted that the facility did not thoroughly investigate R33's fall as CNA-CC's statement does not include what time CNA-CC saw R33 and how R33 was positioned in bed. There are no statements from other staff, including RN-D, RN-BB, and CNA-S, for when they last observed R33 and what was R33 doing. There is no evidence of whether prior interventions were in place or the root cause of R33's fall to help prevent further falls. Fall #2 R33's nursing note dated 3/11/26 at 13:12 (1:12 p.m.), by Licensed Practical Nurse (LPN)-C documents: Unwitnessed fall. Background: Res (resident) AAOx3 (alert orientated times three) forgetful @ (at) x (time). Hx (history) of falls. Assessment (RN)/Appearance (LPN): Heard res call out help, 0 (zero) use of call-light. Res sitting upright on floor leaning back onto bed. Chair next to bed and walker brakes on next to res. Wearing socks only. Neuro-check unremarkable. 0 bruising/injuries noted. Recommendations: Use of gripper socks while in bed. Provider Notification (Include Provider Name): [medical group name] NP (nurse practitioner) [first name]. Additional Notifications (Include Names): DON (Director of Nursing) [name]. R33's post fall assessment dated [DATE] documents a risk score of 3 which indicates low risk for falls. R33's nurses note dated 3/16/26 documents: IDT met to review fall Dx include but not limited to: muscle weakness, wedge compression fracture of 1st lumbar, cognitive communication deficit, trigeminal neuralgia. Resident was in room and attempted to sit in chair to put on shoes and missed the chair when sitting, was found calling for help sitting with back against chair on his butt, no injury noted. Got off floor on his own without hands on assistance after shoes put on, ambulates independently without difficulty. Immediate intervention for gripper socks when in bed so resident doesn't walk barefoot till getting shoes on. working with therapy for ambulation and strengthening. On 8/3/26, Surveyor reviewed the facility's fall investigation for R33's fall on 3/11/26. The post fall assessment dated [DATE] at 12:45 p.m. documents: Assigned caregiver documents name of CNA-DD. For the question who was the staff member that last saw the resident documents name of CNA-EE and time last seen at 1230. For what position was the resident when last seen documents in bed. Surveyor was only provided with the statement section of the facility's incident report dated 3/11/26 at 12:45 p.m. Under the statement section it documents: No statements found. Surveyor noted that the facility did not conduct a thorough investigation of R33's 3/11/26 fall as there are no staff statements. Although CNA-EE observed R33 at 12:30 p.m., there is no statement as to how R33 was positioned in bed. There is no evidence of whether prior interventions were in place or the root cause of R33's fall to help prevent additional falls. R33's at risk for falls care plan, following R33's fall on 3/11/26, was not revised until 5 days later on 3/16/26 with an intervention of: Resident to wear gripper socks when in bed. On 8/3/26 at approximately 2:30 p.m., Nursing Home Administrator (NHA)-A provided Surveyor with additional information for R33's fall on 3/11/26. Surveyor was provided with the first page of R33's incident report dated 3/11/26. The incident description of the incident report for Nursing Description documents: Heard res calling out Help, res sitting upright leaning back onto bed, wearing socks. Regular chair next to bed, walker net to res. Res denied pain, Neuro-check unremarkable. 0 bruising/injuries noted. Res denied bumping head. Res refused to wait for assist with transfer, assisted res with shoes and res stood self-up by pulling self-up and standing. Res walked use of walker s sic (0) difficulty proceeded to sit down in room to each lunch. Under the Resident Description section it documents: I needed to put my shoes on, unable to do that sitting on edge of bed so I went to sit in that chair and missed it, landed on my butt. Immediate action taken - Res assisted with applying shoes. Res to wear gripper socks while in bed. MD's office updated 0 new orders. Surveyor noted that the additional information provided by NHA-A did not include any staff statements. R33's nurses note dated 3/18/26 at 2028 (8:28 p.m.), documents: Was alerted by CNA that resident wants his nurse. Upon entering residents room, he was laying in bed and stated his leg hurt. When asked what happened he stated, I got up to go to the bathroom and stepped on my toe and hit the bed. Upon further examination there was a large bruise noted on residents' left hip which is where he stated he hit the footboard. Resident was able to move his leg up and down without problem but reports it hurts when touched. R33's nurses note dated 3/26/26 at 10:07 a.m., documents: IDT met to review bruise. Dx include but not limited to: trigeminal neuralgia, muscle weakness, peripheral vascular disease, wedge compression fracture of first lumbar vertebra. Resident was transferring and stepped on toe causing him to fall into foot board. Large bruise formed on hip. Immediate intervention was to assist resident with transfer and therapy to evaluate resident with foot placement. Physician, IDON notified, resident own and did not want anyone called at this time. Interventions in place are appropriate at this time. Resident is independent with ambulation in facility. Fall #3 R33's nurses note dated 4/22/26 at 11:03 a.m., documents: Situation: Unwitnessed fall. Background: Hx of falls. Assessment (RN)/Appearance (LPN): Res sitting upright in hallway onto L (left) side next to walker fully dressed wearing shoes. Denied bumping head/pain. ROM (range of motion) WNL (within normal limits). Neuro-check unremarkable. 0 bruising/injuries noted. Provider Notification (Include Provider Name): [Name] NP. Additional Notifications (Include Names): VA (Veterans Administration), [Name] POA (Power of Attorney), DON (Director of Nursing) Interim [Name]. R33's post fall assessment dated [DATE] has a risk score of 4 which indicates low risk for falls. R33's nurses note dated 4/29/26 at 12:00 p.m., documents: IDT met to review fall. Dx include but not limited to: Compression fracture of 1st lumbar, cognitive deficit, chronic pain, Trigeminal Neuralgia. Resident was ambulating in hallway and when turning stepped on his foot. No injury noted and resident got off the floor with minimal assistance. Physician, IDON, and POA notified. Interventions to remind resident to concentrate on foot placement when walking. Working with therapy. Interventions: sign to be placed for reminders of feet placement on walker. Surveyor noted that R33's care plan was not revised with the intervention of sign to be placed for reminders of feet placement on walker. On 8/3/26, Surveyor reviewed the facility's fall investigation for R33's fall on 4/22/26. The post fall assessment dated [DATE] at 10:30 a.m. documents: Assigned caregiver documents name of CNA-DD. For ask the following question of the resident immediately after the fall why do you think you fell documents I stepped on my foot. For what time was the resident last seen documents 1015. For who was the staff member that last saw resident documents name of Licensed Practical Nurse (LPN)-C. For what position was the resident when last seen ambulating documents ambulating. Surveyor noted there is not a statement from CNA-DD. On 8/3/26 at approximately 2:30 p.m., Nursing Home Administrator (NHA)-A provided Surveyor with additional information for R33's fall on 4/22/26, which included a witness statement from CNA-DD. The witness statement under unwitnessed for when did you last see the resident documents 2 min (minutes) before fall (was coming back from shower). What was your last interaction with the resident documents gave resident shower. What was the resident's activity at that time documents on his way back to room. Fall #4 R33's nurses note dated 5/5/26, at 0413 (4:13 a.m.), documents: Writer was in the nurses' station when a voice for help was heard down the hallway. Came and check with another RN in the facility and found resident on the floor with body parallel to the wall and door. Resident had an unwitnessed fall at 0230 (2:30 a.m.). Picked up resident with Hoyer and placed on to his bed. Resident did not press call light. Not wearing shoes, socks or pants except for his t-shirt. I was trying to go to the bathroom and next thing I knew I was on the floor Head to toe assessment done. Neuro checks done. Lifted resident and placed on bed.No bumps and denies hitting head. No cervical pain and no back pain. Resident is A&O x4 (alert and oriented times four). Vitals stable. Neuros WNL. Can follow finger with eyes. With changes in ROM (range of motion) on RLE (right lower extremity). Extremities equal in length. Severe pain on R (right) hip when being touch or move. No headache or dizziness, nausea, vomiting. DON and MD updated. POA updated. R33's nurses note dated 5/5/26, at 0948 (9:48 a.m.), documents: The current status is Res currently @ (at) hospital. R33's post fall assessment dated [DATE] has a risk score of 9 which indicates low risk for falls. R33's late entry nurses note dated 5/8/26 documents: IDT review of unwitnessed fall 5/5 NOC (night) shift. Resident was attempting to get out of bed to go the bathroom. Complaint of hip pain. Transferred to hospital. CP reviewed. Resident remains hospitalized at this time. On 8/3/26, Surveyor reviewed the facility's fall investigation for R33's fall on 5/5/26. Surveyor was provided with post fall assessment dated [DATE] for fall at 2:30 a.m. which documents: For assigned care givers documents the names of RN-O and CNA-Y. For ask the following question of resident immediately after the fall why do you think you fell documents I was trying to go to the bathroom and next thing I knew I was on the floor. For the question, what time was the resident last seen was not completed. For the question who was the staff member that last saw the resident was not completed. For the question what position was the resident when last seen was not completed. For the question what footwear was the resident wearing barefoot/no footwear is answered. CNA-Y's witness statement dated 5/5/26 under the unwitnessed section was not completed for the following questions: when did you last see the resident, what was your last interaction with the resident, and what was the resident's activity at that time. For other pertinent information related to the incident documents said he was getting up to change his shorts. Nurse was already on scene. With other resident taking them to the bathroom. Surveyor noted that the facility did not conduct a thorough investigation as there are no staff statements as to when they last saw R33 and what was R33 doing. The facility's investigation didn't include why prior interventions weren't in place such as gripper socks, whether prior interventions were in place or the root cause of R33's fall to help prevent further falls. R33's hospital Discharge summary dated [DATE] under the final diagnoses section documents: right acetabular fracture, right nondisplaced proximal fibula fracture, hyponatremia, and L1 & L2 fractures. R33's nurses note dated 5/12/26 documents: Resident is on follow up for: Readmission. The current status is Resident returned to facility from [Name] hospital, S/P Right pelvic fx (fracture). Resident alert and oriented x 4. Resident had reported pain at 0410 (4:10 a.m.) in hip, rating 10+. 5mg (milligrams) oxycodone and 650mg of Tylenol administered and was effective. Encourage resident to call for pain medication sooner verses letting pain get out of control. On 8/3/26 at 7:25 a.m., Surveyor met with Director of Nursing (DON)-B to discuss R33 and R33's falls. Surveyor asked DON-B what she could tell Surveyor about R33. DON-B informed Surveyor R33 had some confusion, had difficulty with the walker and would put one foot in front of other foot and trip over it once in a while. DON-B informed Surveyor R33 had fallen several times and the last fall fractured R33's pelvis. DON-B informed Surveyor that's pretty much R33's stay with them. Surveyor informed DON-B R33 was admitted following a fall with L1 & L2 fractures and inquired how R33 was low risk if R33 fell prior to admission and had multiple falls while at the facility. DON-B replied, I'm not sure explaining at one point R33 was up ambulating so R33 would be at greater risk. Surveyor asked DON-B if she was involved with R33's fall investigations. DON-B replied yes. Surveyor informed DON-B that R33's fall investigation on 3/6/26 did not included staff statements from staff who were working. DON-B informed Surveyor there should have been more statements. Surveyor informed DON-B that the investigation did not document whether prior interventions were in place and R33's care plan was not revised until 3/11/26. Surveyor informed DON-B R33's fall investigation on 3/11/26 did not include any staff statements and Surveyor who would obtain staff statements. DON-B informed Surveyor staff go directly in the computer or staff bring statements to DON-B or NHA-A. DON-B informed Surveyor that DON-B was not sure if NHA-A was out on leave at the time. Surveyor informed DON-B that the fall investigation did not document if prior interventions were in place or what the root cause of the fall was to help prevent additional falls. Surveyor informed DON-B that R33's fall investigation on 4/22/26 did not document any revisions to R33's care plan with the intervention of sign to be placed for reminders of feet placement on walker. Surveyor informed DON-B for that R33's fall investigation on 5/5/26 did not include staff statements as to when staff last observed R33 and what R33 was doing prior to the fall. The investigation didn't include why prior interventions were in place and the root cause of R33's fall to help prevent additional falls. Surveyor asked if there was any discussion regarding someone ambulating with R33. DON-B informed Surveyor that therapy thought R33 was alright to be independent with foot placement and they had been working with R33. On 8/3/26 at 9:09 a.m., Surveyor met with Director of Rehab (DOR)-J to discuss R33. DOR-J informed Surveyor when R33 first came in, R33 was already moving around with a four wheeled walker and needed supervision and then R33 was modified independence. DOR-J informed Surveyor R33's most recent fall occurred in the middle of the night when R33 got up to go to the bathroom and didn't use the call light. DOR-J informed Surveyor when R33 walked in therapy there were no issues with gait and there were no falls with therapy. DOR-J informed Surveyor when R33's daughter would come or late at night they recognized R33 was not steady and wouldn't use the call light. Surveyor asked when R33's ambulation status changed. DOR-J informed Surveyor that on 2/18/26, R33 was a one assist and on 3/6/26 changed to ad lib in facility with four wheeled walker. Surveyor asked if there was any discussion about R33 not being independent. DOR-J informed Surveyor nursing can downgrade a resident but with therapy, R33 was very safe and could lock the four wheeled walker. DOR-J also informed Surveyor there were three trials with R33 where R33 had to show therapy three different times R33 was safe. On 8/3/26 at 9:49 a.m., Surveyor informed NHA-A that R33 had three falls prior to 5/5/26 which were not thoroughly investigated, there was no root cause of the fall to prevent additional falls and one fall care plan was not revised. NHA-A informed Surveyor NHA-A was on maternity leave during this time and informed Surveyor NHA-A would look into this and get back to Surveyor. Additional information provided by NHA-A is referenced above. 2.) R27's diagnoses include atrial fibrillation and pulmonary hypertension. R27's at risk for falls due to limited mobility, hx (history) of falls initiated 8/13/25 and revised 8/14/25 documents the following interventions: *Encourage to transfer and change positions slowly with assistance. Initiated 8/13/25 and revised 2/26/26. *Fall Risk (FYI). Initiated 8/13/25. *Have commonly used articles within easy reach. Initiated 8/13/25. *Report development of pain, bruises, change in mental status, ADL (activity daily living) function, appetite, or neurological status post fall. Initiated 8/13/25. *Reinforce need to call for assistance, place call light on left side of bed. Initiated 8/13/25 and revised 11/4/25. *Place call light on L (left) side of bed when in bed. Initiated 11/6/25 *Encourage resident to allow use of Medi lift to assist off the floor if resident falls. Initiated 11/6/25. *Place w/c (wheelchair) next to recliner to prevent potential for self-ambulation from recliner. Initiated 12/11/25 and revised 1/26/26. *Reinforce w/c safety as needed such as locking brakes. Initiated and revised 1/26/26 *Encourage resident to pause for a few moments upon standing to steady self. Initiated 1/28/26. *Tennis balls to dining room chair. Initiated 1/28/26 *Remove slippery blankets of clothes from chair before sitting. Initiated 1/29/26. R27's self-care deficit care plan initiated 8/13/25 and revised 8/14/25 includes interventions that included: *Ambulation/locomotion: 2A (two assist) with gait belt and 4WW (four wheeled walker) for transfers and ambulation as resident tolerates, wheelchair for long distance. Initiated 8/13/25 and revised 1/30/26. The ambulation/locomotion was revised on 3/5/26 to 1 assist with gait belt and four wheeled walker for transfers and ambulation as resident tolerates, wheelchair for long distance. *Transfer: Assist of 2 with gait belt and 4WW initiated 8/13/25 and revised 1/30/26. The transfer intervention was revised on 3/5/26 to 1 assist with gait belt and 4WW. R27's fall CAA (care area assessment) dated 8/21/25 under analysis of findings for nature of problem/condition documents CAA triggered secondary to fall risk d/t (due to) impaired balance. Under care plan considerations documents Resident is at fall risk d/t balance problem during transition. Therapy is working with resident to improve balance and muscle strength. Goal is to ensure resident will be safe and free of serious injury if fall occurs. Will proceed POC (plan of care). R27's quarterly MDS (minimum data set) with an assessment reference date of 2/19/26 has a BIMS (Brief Interview for Mental Status) score of 14 which indicates cognitively intact. R27 is assessed as requiring substantial/maximal assistance for toileting hygiene, roll left and right is independent, chair/bed to chair transfers and toilet transfers are dependent. R27 is assessed as always continent of urine and bowel. R27 has fallen since prior assessment with two or more falls, no injury. Fall #1 R27's nurses note dated 2/24/26 at 20:03 (8:03 p.m.), documents: This nurse was notified by [Name] CNA (Certified Nursing Assistant) that resident was on the floor. Entered room and found resident laying on his Rt (right) side next to his recliner. VS (vital signs) were taken and resident had no complaints of pain, no injuries noted. Resident was assisted off the floor by use of a Hoyer and placed into bed. Neuro checks performed and were unremarkable. States was trying to get my cart [walker] that was not within his reach. Notified the following: [Name] interim DON, [Name] NP (Nurse Practitioner), VA (Veterans Administration) [Name] RN (Registered Nurse), [Name] spouse. Per medical, follow fall protocol. R27's post fall assessment dated [DATE] has a score of 14 which indicates moderate risk for falls. R27's nurses note dated 2/28/26 at 12:02 p.m., documents IDT met to review unwitnessed fall. Resident was attempting to get his walker. Dx (diagnoses) include but not limited to: Hx (history) falls, Hypertensive heart disease, CHF (congestive heart failure). Resident was attempting to get his walker from across room and fell

Based on observation, interview and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R20 and R3) of 4 residents reviewed for pressure injuries. *R20 has a history of pressure injuries and is at risk for developing pressure injuries. Facility staff did not put resident-specific care plan interventions in place to prevent the development of pressure injuries. R20 developed a stage 3 pressure injury to R20's left outer ankle. *R3 did not receive care to prevent the development of an unstageable pressure injury (PI) to R3's left foreskin. R3 also developed pressure injuries on 3/26/2026 to the left peri area skin fold (not staged by facility), on 5/2/2026 to the right foreskin (stage 2), on 5/12/2026 to the right peri skin fold (deep tissue injury (DTI)) and on 5/13/2026 the left side foreskin is open again (not staged by facility). Surveyor was unable to locate documentation showing weekly assessment and tracking of the pressure injuries from onset to closure. Many assessments lack PI staging, a description of the PI's characteristics, progress toward healing and identification of potential complications, and/or a description of dressings and treatments used. Findings include: The facility policy with a last reviewed date of 7/20/22, and titled, Pressure Injuries and Non-pressure Injuries, documents, in part: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. Upon admission: . Initiate the baseline plan of care related to current skin status and skin risk level. (The comprehensive care plan will be developed within seven days of the completion of the comprehensive assessment. ) Consider the following: Braden Scale Score. Co-morbid conditions. The presence of previously healed [Pressure Ulcer.]. The history of any healed assessment information, since areas of healed Stage 3 or 4 [Pressure Ulcer/Pressure injury] are more likely to have recurrent breakdown. Assess current wounds at least every seven days, or more frequently as needed. A comprehensive skin integrity care plan is based on resident history, review of skin assessment. Braden scale scoring, nutritional assessments, resident and family interviews, and staff observations. Develop interventions based on individual Risk Factors including, but not limited to, weight, presence of edema, overall health status/comorbidities, use of medical devices, presence of acute infection, . resident choice/preferences. R20 was admitted to the facility on [DATE] with diagnosis that include: Type 2 Diabetes, Congestive Heart Failure, Pulmonary Hypertension and Atherosclerotic heart disease. R20's admission Minimum Data Set assessment dated [DATE] documents that R20 is cognitively intact. R20 requires partial to moderate assistance from staff for bathing, bed mobility and transfers. R20 is frequently incontinent of urine. R20 has one stage 2 pressure injury and two Stage 3 pressure injuries present on admission. R20 is at risk for developing pressure injuries. R20's admission Pressure Injury Care Area Assessment (CAA) dated 4/26/26 documents, in part: CAA triggered [due to] Urinary incontinence, presence of unhealed [pressure ulcers], and [Activity of Daily Living (ADL)] assessments. R20's Braden Scale assessment dated [DATE], documents R20 is at risk of developing pressure injuries. R20's skin integrity care plan with a start date of 4/20/26 documents, in part: Administer treatment per MD orders. Air mattress on bed and pressure reduction cushion on chair. Float heels as able. Encourage and assist to turn and reposition; use assistive devices as needed. Use pillows and/or positioning devices as needed. Surveyor noted that R20's care plan did not include a schedule for turning and repositioning even though R20 requires partial/moderate assistance for bed mobility. Surveyor noted that R20's intervention for floating heels as able does not include pressure relieving boots, or instructions on when or how to float heels. Surveyor noted that R20's care plan intervention for the air mattress did not include settings for the air mattress to be set on. On 7/29/26 at 2:08 PM, Surveyor interviewed Registered Nurse (RN)-G. Surveyor asked when R20's air mattress was put in place. RN-G stated that they were not sure. Surveyor asked what other documentation is needed when a resident has an air mattress. RN-G stated that the air mattress with the desired setting is listed on the care plan and an MD order is in place to check function each shift. Surveyor reviewed R20's MD orders and noted that R20 did not have a MD order to check the air mattress function every shift since admission. On 7/29/26 at 2:16 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-N. Surveyor asked where CNA-N would be able to find interventions for R20's skin. CNA-N stated that interventions are found in the care plan. Surveyor asked if the care plan would include a turn and repositioning schedule. CNA-N stated yes. That is where they would look if residents were on a schedule. CNA-N stated that the nurses will also communicate to the CNA what needs to be done with the residents. R20's diabetic care plan with a start date of 4/22/26 documents, in part: Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. R20's MD orders, dated 4/20/26 documents, in part: Weekly skin review in the evening every [Tuesday] for monitoring. and . Licensed Nurse to complete diabetic foot check at bedtime. R20's admission skin assessment dated [DATE] documents, in part: Left elbow stage 2 pressure injury. Right buttock stage 3 pressure injury. Sacrum Stage 3 pressure injury. From 4/21/26 through 5/19/26 Wound MD-K visited R20 weekly to treat R20's pressure injuries. With each weekly visit, Wound MD-K documented R20's pressure injury assessment and documented R20's support surface under R20's feet was a pillow. Surveyor noted R20's Left elbow pressure injury resolved on 4/28/26. R20's Right buttock pressure injury resolved on 5/5/26. R20's Sacrum pressure injury resolved on 5/19/26. R20's MD order with a start date of 5/20/26 documents: Air mattress Check function and settings every shift. Settings are 150. R20 care plan interventions added 5/20/26 documents: Float heels with pillows. Specialty bed air mattress setting 150. Surveyor noted that facility staff changed the intervention that previously read Float heels as able to Float heels with pillows. Surveyor noted that facility added further instructions to R20's air mattress intervention. On 8/3/26 at 7:41 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor asked about R20's air mattress. NHA-A indicated that R20's air mattress was in place since admission. NHA-A stated that NHA-A was completing an audit in May and found that R20's care plan was not up to standard. NHA-A found that the specific details of the mattress was not on the care plan. NHA-A stated that the care plan was updated and an order to check function of the air mattress was added. Surveyor reviewed R20's Treatment Administration Record (TAR) and noted that on 5/20/26, facility staff began documenting every shift that R20's air mattress was functioning and at the correct settings. R20's progress note dated 5/21/26 at 4 PM, documents, in part: Resident has unstageable wound to left outer ankle dark necrotic tissue in center with red blanchable peri wound, Hemosiderin staining on bilateral lower extremities. Resident has air mattress. Interventions float boots when in bed, skin prep to ankle. R20's pressure injury weekly tracker assessment dated [DATE], documents, in part: Left outer ankle. Unstageable Pressure Injury. 3 x 2. 75% skin. 25% necrotic. Measurements are of whole area including periwound. Necrotic tissue measures 1 x 1. R20's care plan intervention added 5/21/26 documents: Encourage and assist to turn and reposition every 2 hours; Use assistive devices as needed. R20's care plan intervention added 5/22/26 documents: Boots in bed. Surveyor noted that after facility staff documented an unstageable pressure injury, facility updated R20's care plan with an intervention to assist R20 with turning and repositioning scheduled every 2 hours and added boots to be on R20's feet while in bed. On 7/29/26 at 2:08 PM, Surveyor interviewed RN- G. Surveyor asked if floating heels and pressure relieving boots were interventions before R20 developed R20's pressure injury. RN-G stated that would have to look but stated that they believe it was after the development. On 7/30/26 at 9:21 AM, Surveyor interviewed RN-O. Surveyor asked why they think R20 developed a pressure injury. RN-O stated that R20 always would lay on R20's left side. Surveyor asked when heel boots were implemented. RN-O stated that they were implemented after R20 developed the left ankle pressure injury. On 7/30/26 at 10:17 AM and at 1:04 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked why they believed R20 developed the left ankle wound. DON-B stated that the wound is located on the bony prominence on the outside of the left ankle. R20 always likes to lay on R20's left side. Even if staff reposition R20 on the right side, R20 will get back on their left side. DON-B stated the wound was caused by pressure from laying on that left side. Surveyor asked if pressure relieving boots were in place to prevent the development of a pressure injury prior to the ankle wound. DON-B stated that they could not remember exactly but stated that they believed the boots were started within the first month of resident being at the facility. Surveyor noted that multiple staff observed that R20 liked to lay on R20's left side. Surveyor noted that resident specific interventions to offload the left side of R20's body was not put in place to prevent the development of pressure injuries. Surveyor noted that pressure relieving boots were not documented as being in place until after the development of R20's ankle wound. R20's Wound MD-K note dated 5/26/26 documents, in part: Stage 2 pressure wound of the left ankle partial thickness. Etiology: pressure. Wound size: 1 x 1 x 0.1. Surveyor noted the difference between the facility documentation of an unstageable pressure wound on 5/21/26 and Wound MD-K's assessment of a Stage 2 pressure wound on 5/26/26. On 7/30/26 at 9:44 AM, Surveyor interviewed Wound MD-K. Surveyor asked about the staging of the ankle wound. Wound MD-K stated that when Wound MD-K first saw R20's wound it appeared to be a stage 2 pressure injury. Wound MD-K stated that it had a clean wound bed and Wound MD-K did not see slough or eschar. Wound MD-K stated that if there was slough or eschar, they would have staged it a stage 3 pressure injury. Wound MD-K stated that they could not speak to what facility staff saw when they first classified the wound. Surveyor reviewed R20's progress notes and noted the following documentation: On 5/21/26 facility staff documented resident refusing to wear boots. On 5/22/26 facility staff documented, boots not on, [resident] refusing to have them. On 5/23/26 facility staff documented, Refusing boots at this time. On 5/24/26 facility staff documented, Refusing boots at this time. On 5/28/26 facility staff documented, Continues to refuse boots on while in bed. On 5/30/26 facility staff documented, Continues to refuse boots on while in bed. On 5/31/26 facility staff documented, Continues to refuse boots on while in bed. Surveyor noted multiple refusals to wear the pressure relieving boots. R20's Risk vs Benefit document dated 5/29/26 documents, in part: Spoke with [R20 and R20's spouse] regarding risks and benefits of boots. [R20's spouse] wants [R20] to wear boots when in bed. [R20] has agreed to wear. If [R20] refuses to wear remind resident that [R20's spouse] has request [R20] to wear. [R20] request that staff be firm with [R20] as [R20] was a boot sergeant in the service. R20's added care plan intervention on 5/29/26 documents: [R20] requests that staff be firm and straight forward with [R20] as [R20] was a boot sergeant in the service. EXAMPLE: You need to put boots on now. Surveyor reviewed R20's progress notes and noted that after facility staff added this care plan intervention, Facility staff did not document refusals of the heel boots in June 2026 going forward. R20's Wound MD-K visit note dated 6/2/26, documents, in part: Stage 3 pressure wound of the left ankle full thickness. Etiology: Pressure. Wound size: 0.5 x 1 x 0.1. 100% slough. Wound progress: Not at goal due to patient non-compliant with wound care. Surveyor noted that R20's wound is now documented as stage 3 pressure injury. Surveyor noted that Wound MD-K documented that R20 is non-compliant and that is why the wound is not at goal. R20's care plan intervention added 6/3/26 documents: Turn and reposition every 2 hours. Notify nurse if patient refuses and reapproach in 30 minutes. Complete risk verses benefit for refusal. Place pillow between knees whenever lying on [R20's] side for pressure relief. Surveyor reviewed R20's medical record and did not locate a completed risk vs benefit for refusal of repositioning. Surveyor noted that this indicated that facility staff did not document refusal of repositioning. R20's MD order dated 6/3/26 documents: Doppler [ultrasound] to [Bilateral lower extremities] for wounds. On 7/30/26 at 9:44 AM, Surveyor interviewed Wound MD-K. Wound MD-K indicated that the doppler study of the lower extremities was ordered because a wound on R20 toe was not healing despite interventions and treatments. R20's Doppler results with a report date of 6/5/26 documents, in part: Conclusion: Moderate stenosis in the arterial system of the lower extremities. R20's Wound MD-K visit note dated 6/9/26 documents, in part: Stage 3 pressure wound of the left ankle full thickness. Etiology: Pressure. Wound size 0.5 x 0.7 x 0.1. 100% slough. Wound progress. Improved evidenced by decreased surface area. Surveyor noted that R20's left ankle wound continued to be documented as a pressure injury. Surveyor noted R20's left ankle wound decreased in size and was documented as improved. R20's Wound MD-K note dated 6/11/26 documents: Toe wound stage as unstageable [necrosis] with pressure and arterial mixed etiology. Surveyor noted that the toe wound that Wound MD-K mentioned in interview had a mixed etiology including arterial disease. Surveyor noted that Wound MD-K did not include R20's left ankle pressure injury in this designation. R20 was hospitalized from [DATE] through 6/19 for bacteremia and amputation of 2 of R20's toes. R20 returned the facility on 6/19/26. R20's Wound MD-K visit note dated 6/23/26 documents, in part: Stage 3 pressure wound of the left ankle full thickness. Etiology: pressure. Wound size: 0.5 x 0.5 x 0.1. 100% slough. Wound progress: Improved evidenced by decreased surface area. Surveyor noted that R20's left ankle wound continued to be documented as a pressure injury. Surveyor noted R20's left ankle wound decreased in size and was documented as improved. R20's Wound MD-K visit note dated 6/30/26 documents, in part: Stage 3 pressure wound of the left ankle full thickness. Etiology: pressure. Wound size: 0.8 x 0.5 x 0.1. 30% slough. 70% granulation. Wound progress: Improved evidenced by decreased necrotic tissue. Surveyor noted that R20's left ankle wound continued to be documented as a pressure injury. Surveyor noted that R20's left ankle wound was documented as improved due to the decrease in the amount of slough in the wound. R20's Wound MD-K visit note dated 7/7/26 documents, in part: Stage 3 pressure wound of the left ankle full thickness. Etiology: pressure. Wound size: 0.6 x 0.5 x 0.1. 30% slough. 70% granulation. Wound progress: Improved evidenced by decreased surface area. Surveyor noted that R20's left ankle wound continued to be documented as a pressure injury. Surveyor noted R20's left ankle wound decreased in size and was documented as improved. R20's Wound MD-K visit note date 7/14/26 documents, in part: Stage 3 pressure wound of the left ankle full thickness. Etiology: pressure. Wound size: 0.5 x 0.5 x 0.1. 30% slough. 70% granulation. Wound progress: not at goal due to need more time. Surveyor noted that R20's left ankle wound continued to be documented as a pressure injury. Surveyor noted R20's left ankle wound decreased in size. R20's Wound MD-K visit note dated 7/21/26 documents, in part: Stage 3 pressure wound of the left ankle full thickness. Etiology: pressure. Wound size: 0.5 x 0.3 x 0.1. 30% slough. 70% granulation. Wound progress: Improved evidenced by decreased surface area. Surveyor noted that R20's left ankle wound continued to be documented as a pressure injury. Surveyor noted R20's left ankle wound decreased in size and was documented as improved. R20's Wound MD-K visit note dated 7/28/26 documents, in part: Stage 3 pressure wound of the left ankle full thickness. Etiology: pressure. Wound size: 0.4 x 0.3 x 0.1. 20% slough. 80% granulation. Wound progress: Improved evidenced by decreased necrotic tissue, decreased surface area. Surveyor noted that R20's left ankle wound continued to be documented as a pressure injury. Surveyor noted R20's left ankle wound decreased in size and the amount of slough decreased. Wound MD-K documented this wound as improved. On 7/28/29 at 9:53 AM, Surveyor observed R20 sitting in R20's wheelchair in R20's room. R20 had a pressure-relieving cushion in the chair and an air mattress on R20's bed that was on and functioning. R20 was wearing green pressure off-loading boots on both feet. On 7/29/29 at 9:16 AM, Surveyor observed R20 sitting in R20's wheelchair in R20's room. R20 had a pressure-relieving cushion in the chair and an air mattress on R20's bed that was on and functioning. R20 was wearing green pressure off-loading boots on both feet. On 7/29/26, R20 had an MD appointment outside of the facility. R20 was admitted to the hospital from that outside appointment. Surveyor was not able to observe R20's wound. On 7/30/26 at 9:44 AM, Surveyor interviewed Wound MD-K. Surveyor asked about R20's ankle wound. Wound MD-K mentioned that R20 has progressive arterial disease that was diagnosed after the development of the left ankle wound. Wound MD-K stated that R20 also had a toe wound that was determined to be arterial in nature. Wound MD-K stated that R20's left ankle has progressively been getting better but below the ankle, the vascular is worse and that is why the toe wound was not healing and eventually had to be amputated. Wound MD-K indicated that during the amputation surgery, revascularization of the foot was not completed leading to the surgical site not healing as expected. Wound MD-K stated that despite off-loading and completing wound care, the surgical wound continued to deteriorate leading to the determination of an arterial wound. Wound MD-K stated that with Peripheral Artery disease, the wound gets worse despite proper care and treatment. With pressure wounds, they typically get better with care and treatment. Surveyor noted Wound MD-K indicated that arterial wounds typically get progressively worse from the start despite interventions. Wound MD-K indicated that pressure wounds typically get better with care and treatment. Surveyor noted that Wound MD-K acknowledged that R20's ankle wound has progressively been getting better. On 7/30/26 at 3:01 PM, Surveyor informed NHA-A, DON-B and Consultant-L of the concern regarding R20's wound. Facility staff did not place resident-specific interventions to prevent the development of pressure injuries and R20 developed a stage 3 pressure injury to R20's left ankle. R20's air mattress was not monitored for function every shift and did not have the air mattress setting on the care plan. Facility staff did not implement pressure relieving boots until after the development of R20's ankle wound. Facility staff observed that R20 laid on R20's left side and did not implement a resident specific care plan intervention to address those observations until after the development of the ankle wound. On 7/30/26 at 3:19 AM, NHA-A returned to Surveyor. NHA-A informed Surveyor that in June, NHA-A identified that R20's care plan was not fully up to the facility standard on admission. NHA-A stated that education was completed on the importance of skin and appropriate interventions on admission. NHA-A stated that they made a critical event at that time. NHA-A provided Surveyor with the Critical event action plan. The Critical Event Analysis and Action Plan Worksheet, dated 6/18/26, documents, in part: Date of discovery: 6/18/26. Summary of critical event: During review of hospitalization for [R20], the [NHA-A] identified interventions were not in place at the time of admission to prevent skin injuries. Action: Current residents at risk for skin injuries: An audit was conducted by the [NHA-A] of current residents to identify those at moderate and high risk for skin injury. DON/designee conducted skin sweep. Review of care plans for residents identified in audit were reviewed for accuracy. [NHA-A]/designee re-educated licensed nurses on weekly skin assessments, steps when new skin impairment is identified, orders required for skin impairments. [NHA-A]/designee re-educated CNAs on appropriate notification process when skin impairments are identified. [NHA-A]/designee re-educated DON and [Unit Manager] on immediate interventions in place at time of admission for those with skin impairments and at risk for skin impairments. Performance effectiveness. [NHA-A]/designee will audit new admission skin care plans and interventions 5 days a week for 6 weeks. Results will be brought to the Quality Assurance and Assessment Committee for review and recommendation. An Ad HOC QAPI was held on 6/18/26. Surveyor noted NHA-A identified that R20 did not have all the necessary interventions in place at the time of R20's admission to prevent skin injuries. Surveyor noted that facility staff were educated and audits were actively conducted to address this concern. On 8/3/26 at 9:19 AM, NHA-A along with Consultant-L provided a timeline of R20's wounds. Consultant-L indicated that a lot was done by the facility to address R20's skin and manage changes. On admission, R20 had a cushion, air mattress, float heels, turn and position and diabetic foot checks. Consultant- L stated that prior to the development of the ankle wound, Wound MD-K was documenting that R20's feet were on pillows. Consultant-L stated that the air mattress was on the bed on admission. After an audit was completed, the order and settings for the air mattress was added. Surveyor asked why more specific off-loading of feet like pressure reducing boots was not added. Consultant-L indicated that R20 had an air mattress and would not have to have boots. Pillows would be sufficient. Surveyor asked what care plan interventions were not in place when NHA-A identified the concern on 6/18/26. Consultant-L stated that they noticed interventions in multiple care plans instead of one. They wanted to make it more concise. Consultant-L stated that there was also something about resident choice and verbiage to use. Consultant-L stated that the care plan did not capture everything that the facility was doing. On 8/3/26 at 12:07 PM, Surveyor informed NHA-A and Consultant-L of the continued concern that resident specific care plan interventions were not initiated on admission to prevent pressure injuries from forming. Interventions were added after the development of the wound to prevent it from worsening. Surveyor informed NHA-A and Consultant-L that they reviewed the critical event documentation and informed NHA-A that Past non-compliance would not apply to this citation because of an additional example of concerns with R3. NHA-A understood. Consultant-L and NHA-A stated that R20's left ankle wound is also an arterial wound and they would get back to Surveyor. On 8/3/26 at 1:18 PM, NHA-A and Consultant-L had Wound MD-K on the telephone. Wound MD-K informed Surveyor that R20's ankle wound is more arterial and not just pressure. Wound MD-K stated that R20's ankle wound was getting worse despite off loading and treatments. That would indicate it is more arterial. Surveyor asked what part pressure played in the development of the ankle wound. Wound MD-K stated that R20 did get an insult to the skin from pressure, but the baseline issue is arterial disease. Wound MD-K stated that any insult to a patient with arterial disease can cause wounds. Wound MD-K stated that if the wound was purely pressure, it would have gotten better from the get-go. Wound MD-K stated that it was not the case with R20. R20's ankle got worse despite adequate off loading and treatments. Surveyor asked why all the documentation documents pressure. Wound MD-K stated that the computer system does not allow more than one etiology. Surveyor asked when Wound MD-K determined the etiology to be more arterial. Wound MD-K stated that they should have changed the etiology to arterial after the second visit (6/2/26) when the ankle worsened. Wound MD-K stated that they should have included the ankle in the documentation (on 6/11/26) that stated that the toe was mixed etiology. Surveyor noted Wound MD-K did acknowledge that R20 did get an insult to the skin due to pressure. Surveyor noted that Wound MD-K stated that R20's ankle worsened despite interventions and treatments. Surveyor noted that Wound MD-K stated that R20's wound is more arterial. Surveyor noted that in the interview with Wound MD-K on 7/30/26, Wound MD-K informed Surveyor that R20's ankle wound was progressively getting better. In contrast, on 8/3/26, Wound MD-K informed Surveyor that R20's ankle wound was getting worse despite treatment and interventions. Surveyor noted multiple discrepancies between Wound MD-K's documentation and Wound MD-K's interview. Surveyor noted that Wound MD-K's documentation from the beginning of the ankle wound to present time documents that R20's wound etiology is pressure. Surveyor noted that Wound MD-K's documentation on 6/2/26 documented that the wound worsened due to the patient's non-compliance. In interview Wound MD-K stated that they would have changed the etiology to arterial (on 6/2/26) because it worsened despite adequate offloading and treatment. Surveyor noted that Wound MD-K documented on 6/23, 6/30, 7/7, 7/21 and 7/28 that the ankle pressure injury was improved. In interview, Wound MD-K stated that R20's ankle wound continued to get worse leading Wound MD-K to conclude that the wound is more arterial in nature. On 8/3/26 at 2:46 PM, Surveyor informed NHA-A, DON-B and Consultant-L of the continued concern that R20 did not have adequate resident specific interventions in place on admission to prevent pressure injuries from developing. R3 did not receive care to prevent the development of an unstageable pressure injury to the left foreskin. R3 subsequently developed additional pressure injuries to the left peri-area skin fold (not staged), right foreskin (Stage 2), right peri-area skin fold (deep tissue injury), and the left foreskin, which later reopened (not staged). Surveyor could not locate documentation demonstrating consistent assessment and tracking of the pressure injuries in each affected area from onset through their current status. Assessments lacked pressure injury staging, descriptions of wound characteristics, identification of potential complications, and/or documentation of dressings and treatments used to promote healing. 1.) R3 was admitted to the facility on [DATE] with diagnoses that included paraplegia, age-related physical debility, pressure ulcer of sacral region (stage 4), type 2 diabetes mellitus, spinal stenosis, Asperger's syndrome, and neuromuscular dysfunction of bladder. R3's Quarterly Minimum Data Sets (MDS) with assessment reference dates of 4/12/2026 and 7/13/2026 document a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact for decision making. R3 was assessed to have no behaviors exhibited and for the question Did the resident reject evaluation or care the MDS documents that this behavior occurred for 1-3 days. The MDS documents that R3 is able to make themselves self-understood and understands others and that R3 has an indwelling catheter. The MDS assesses R3 to be at risk of developing pressure ulcers/injuries and documents that R3 has one stage 4 pressure injury that was present at admission. Surveyor noted R3's EHR (Electronic Health Record) documented that R3 had five new pressure injuries developing between 3/26/2026 and 5/13/2026 that were not captured on R3's MDS. R3's care plan initiated 1/21/2025, documents: ACTUAL alteration in skin integrity related to: Diabetes, history of pressure ulcer, impaired mobility, incontinence, use of foley catheter indicates the following interventions: Administer treatment per MD orders, date initiated 1/21/2025; Bariatric Alternating Air Mattress: Check function and settings every shift. Settings are 350lbs, mobility cushion in specialty tilt and space electric wheelchair to offset pressure, date initiated 1/21/2025; Encourage and assist every 2hrs (hours) and prn (as needed) to turn and reposition; use assistive devices as needed. document and report to nurse if resident chooses not to reposition, date initiated 1/21/2025; Monitor skin that touches foley catheter tubing for signs of redness/irritation, date initiated 3/10/2026; Monitor skin under catheter securement band daily, date initiated 7/27/2026. Surveyor reviewed R3's care plan and noted that facility staff did not document any revised interventions to R3's care plan to prevent a pressure injury that was caused by R3's catheter. R3's progress note dated 3/11/2026, written at 11:40pm, documents: Resident (res) is on follow up for: readmission. The current status is res seen in bed, had recent change of foley cath (catheter) 3x (times) within 24hrs. (hours) res still c/o (complains of) leaking in the system. MD (medical doctor) aware. to monitor. denies pain or discomfort. skin prep to R (right) buttock, heels and R toe as ordered. Surveyor noted issues with R3's catheter that required changing three times in 24 hours. R3's Pressure Injury Weekly Tracker dated 3/26/26, with the date acquired of 3/26/26, documents an unstageable pressure injury to the le

Based on interview and record review, the facility did not ensure professional standards of practice were followed for 1(R7) of 1 Residents that receive an altered textured diet and coughed up a Brussel sprout. This deficient practice also has the potential to affect the 7 residents who currently receive altered texture diets.The facility does not follow current standards of practice for altered texture diets by not following IDDSI (International Dysphagia Diet Standardization Initiative).Findings include:The IDDSI Framework (the Standard) website (The IDDSI Standard - Standards - IDDSI; https://www.iddsi.org/standards/framework) documented, in part: The IDDSI framework consists of a continuum of 8 levels (0 - 7), where drinks are measured from Levels 0 - 4, while foods are measured from Levels 3 - 7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness. IDDSI Testing Methods are intended to confirm the flow or textural characteristics of a particular product at the time of testing. Testing should be done on foods and drinks under the intended serving conditions (especially temperature). The clinician has the responsibility to make recommendations for foods or drinks for a particular patient based on their comprehensive clinical assessment.Per the National foundation of Swallowing Disorders, IDDSI is a global initiative that provides a standardized framework for diet modification for individuals with swallowing difficulties. IDDSI was launched in 2015 as a response to the confusion and inconsistencies surrounding food and drink modifications used for dysphagia management. Different countries and healthcare facilities had their own systems, which made it difficult for patients to understand and for caregivers and healthcare providers to communicate effectively. By creating a universal set of definitions and descriptors, IDDSI aims to ensure that individuals with dysphagia receive safe and appropriate diets regardless of where they are located. (https://swallowingdisorderfoundation.com/iddsi-nfosd)R7's physician orders include an order dated 8/7/24 which documents Regular diet L2/Mech Alt (altered) texture, Regular/Thin consistency, inner lip plate, handle cup w/(with) lid, built up utensils.R7's nurses note dated 3/11/26, at 1745 (5:45 p.m.), written by Registered Nurse (RN)-D documents Resident had choking episode in dining room, choked on Brussel sprout. VS (Vital Signs) stable and patient states feels fine. DON (Director of Nursing) notified.On 7/30/26, at 12:35 p.m., surveyor spoke with RN-D regarding R7's choking incident on 3/11/26. RN-D informed surveyor she remembers the incident, but choking is not the word she should have used. RN-D explained R7 started coughing, it was a hard cough, she went over to R7 and R7 coughed the Brussel sprout up. RN-D stated she could see R7 still had the Brussel sprout in his mouth, so she removed the Brussel sprout, it was a hard cough. Surveyor asked RN-D if it was a whole Brussel sprout. RN-D informed surveyor it was. Surveyor asked RN-D if R7 should have had a whole Brussel sprout. RN-D informed surveyor on R7's diet R7 should not have had a whole Brussel sprout.On 7/30/26, at 8:07 a.m., surveyor spoke with Speech Language Pathologist (SLP)-I to inquire if R7 is on speech therapy. SLP-I informed surveyor R7 was on their case load quite a while ago, over a year ago, and they worked with R7 on diet modification. SLP-I explained that R7's progress slowed down and R7 was discharged with carryover for staff. Surveyor inquired about R7's diet. SLP-I explained that R7 is on a regular diet L2/Mechanical altered texture which is comparable to IDDSI level 5 which is meant for food to be ground with a sauce, easier to chew. SLP-I informed Surveyor they are not currently doing IDDSI. Surveyor asked SLP-I if Brussel sprouts are on the menu should the Brussel sprout been cut up. SLP-I replied it should. SLP-I explained she believes in R7's care plan if something was presented whole needs to be cut up by staff.On 7/30/26, at 12:43 p.m., surveyor spoke to Registered Dietitian (RD)-H on the telephone. Surveyor asked RD-H what type of diet R7 receives. RD-H informed surveyor R7 is on a regular L2 mechanical diet with thin liquids. Surveyor asked RD-H if the meat and vegetables are ground up. RD-H informed surveyor it follows the NDD (national dysphagia diet) level 2. Surveyor asked RD-H if a resident on this diet should receive whole Brussel sprouts. RD-H replied I don't believe so.On 8/3/26, at 12:03 p.m., surveyor spoke with RD-H on the telephone. Surveyor asked RD-H what standard of practice their altered diets are based on. RD-H replied to NDD, national dysphagia diet. Surveyor inquired about IDDSI. RD-H informed surveyor their corporation is working on implementing IDDSI in waves explaining she has one building that has implemented IDDSI. Surveyor asked if there has been any discussion about implementing IDDSI at the facility. RD-H informed surveyor she doesn't know until she is told.On 8/3/26, at 12:31 p.m., surveyor asked Nursing Home Administrator (NHA)-A when the facility is going to implement IDDSI. NHA-A informed surveyor she believes it will be rolled out in the next few months explaining they (the corporation) are doing one building at a time.

Based on observation, record review and interview, the facility did not assess the risk of entrapment and review the risk and benefits for 2 residents (R1 and R27) of 2 residents observed having bed rails. *) R1 was observed to have bilateral grab bars to bed without an assessment. *) On 7/29/26, R27 was observed in bed with a left quarter side rail up. R27's ADL (activity daily living) care plan initiated 8/13/25 & revised 8/14/25 includes an intervention initiated 8/13/25 & revised 11/3/25 of bed mobility: assist of 1 with use of bilateral enabler bars. R27's side rail assessment dated [DATE] includes documentation of left sided mobility bar. The facility did not revise R27's ADL care plan when R27's side rail was changed from bilateral to left side. Findings include: The facility's polity titled Proper Use of Side Rails, dated 9/23/22, documents the following: It is the policy of this facility to utilize a person-centered approach when determining the use of side rails, also known as bed rails. Alternative approaches are attempted prior to installing a side or bed rail. If used, the facility ensures correct installation, use, and maintenance of the rails. In conjunction with review of resident's comprehensive assessment, the Side Rail Assessment will be completed in the electronic medical record. *) R1 was admitted to the facility on [DATE], with diagnoses that include neuromuscular dysfunction, Parkinson's Disease and difficulty walking. R1's quarterly Minimum Data Set (MDS) dated [DATE], documents (R1) is independent with rolling left to right and requires partial/moderate assistance when lying to sitting position. On 7/28/26, at 9:19 AM, during the initial tour, Surveyor observed R1 laying in bed with bilateral grab bars on both sides of the bed. The grab bars were in a fixed position and did not move up and down. A review of R1's Activities of Daily Living (ADL) self-care deficit care plan initiated on 12/31/25, documents the intervention (R1) requires assistance of one with bed mobility. Surveyor notes, R1's care plan does not document R1 having bed rails. Surveyor reviewed R1's Electronic Medical Record (EMR) which documents a Bed Rail Risk Assessment Tool dated 1/27/26. (R1) requires moderate assistance for bed mobility and is approved for bed rail use. Surveyor reviewed R1's EMR and notes there is no order placed for bilateral grab bars. On 7/29/26, at 1:19 PM Surveyor interviewed Licensed Practical Nurse (LPN)-C who stated bed rail assessments are completed quarterly by Director of Nursing (DON)-B. On 7/29/26, at 1:28 PM Surveyor interviewed DON-B who stated bed rail assessments are completed quarterly by nursing staff or herself. DON-B stated all bed rail assessments are completed in the EMR and a tracker in the EMR populates quarterly, notifying staff to complete the quarterly bed rail assessment. Surveyor notified DON-B of concerns with observations of R1 having bed rails with no physician order, bed rails not being on R1's care plan and no quarterly assessment was completed. DON-B acknowledged these concerns and stated she would look into it. On 7/30/26, at 11:39 AM, Surveyor notified Nursing Home Administrator (NHA)-A of concerns listed above with R1's bed rails. NHA-A acknowledged these concerns. 2.) R27's diagnoses include congestive heart failure and atrial fibrillation. R27's ADL (activities daily living) self-care deficit related to decreased mobility and weakness care plan initiated 8/13/25 & revised 8/14/25 includes an intervention of Bed Mobility: Assist of 1 with use of bilateral enabler bars. Initiated 8/13/25 & revised 11/3/25. R27's side rail assessment dated [DATE] under the section device indication documents Resident has decreased functional mobility, continues to benefit from use of bilateral mobility bars to increase independence and reliance on staff for bed mobility. R27's side rail assessment dated [DATE] under the section device indication documents Resident has decreased functional mobility, continues to benefit from use of left sided mobility bar to increase independence and reliance on staff for bed mobility. On 7/29/26, at 7:28 a.m., surveyor observed R27 in bed on the back with one leg over the edge of the bed with Certified Nursing Assistant (CNA)-E in R27's room. Surveyor observed that the right side of R27's bed is against the wall and there is a quarter side rail up on the left side of R27's bed. On 8/3/26, at 1:09 p.m., surveyor asked Director of Nursing (Don)-B who is responsible for revising resident's care plans. DON-B replied it's kind of a group effort, I kind of go in and do majority of it all. Surveyor asked DON-B when R27's side rail was changed from bilateral to only the left side. DON-B replied not 100% sure when it changed over. DON-B explained R27's bed has always been against the wall. Surveyor informed DON-B R27's ADL care plan was not revised for bed mobility as the care plan has bilateral mobility bars. DON-B looked in the computer and informed surveyor R27's care plan has been updated to use of left enabler bar. Surveyor asked when this was done as when surveyor reviewed R27's care plans and received a copy of the care plans the ADL care plan for mobility had bilateral enabler bars. DON-B replied on 7/29. DON-B informed surveyor after speaking with surveyors about rails they did an assessment of all their rails and updated care plans. The facility's policy titled, Comprehensive Care Plan and last reviewed/revised 9/23/22 under policy explanation and compliance guidelines for #5 documents The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly MDS (minimum data set) assessment, and as needed with changes in condition.

Based on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 5 medication errors in 30 opportunities which resulted in a medication error rate of 16.67%. Medication errors were identified for R24 & R15.*R24's Omeprazole 20 mg (milligrams), Acetaminophen ER (extended release) 650 mg, and Gabapentin 300 mg were administered late.*R15's Metoprolol Tartrate 25 mg and Gabapentin 600 mg were administered late.Findings include:The facility's policy titled, Medication Administration General Guidelines and dated 2007 under procedures for medication administration documents 14. Medications are administered within 60 minutes of scheduled time, expect before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at mealtimes or in the dining room unless specifically ordered with meal.1.) On 7/29/26, at 10:38 a.m., surveyor observed Registered Nurse (RN)-G prepare R24's medication which consisted of Omeprazole 20 mg (milligrams) one tablet, Acetaminophen ER (extended release) 650 mg one tablet, Clear lax 17 grams, Gerikot 8.6 mg two tablets, Amitriptyline HCI 25 mg two tablets, Dapagliflozin 5 mg one tablet, Furosemide 10 mg one & one half tablets, Gabapentin 300 mg one capsule, and Losartan Potassium 25 mg one tablet.On 7/29/26, at 10:42 a.m., surveyor observed R24's medications on the computer screen are red and asked RN-G what the red means. RN-G replied it's overdue or are going to be overdue.On 7/29/26, at 10:53 a.m. surveyor verified with RN-G there are 11 pills in R24's medication cup. After verifying the number of pills, RN-G added water to R24's Clear lax.On 7/29/26, at 10:55 a.m., RN-G administered R24's medication whole with pudding. RN-G then handed R24 the Clear lax.On 7/29/26, surveyor reviewed R24's July 2026 MAR (medication administration record) and noted the administration time for Omeprazole 20 mg is AM (morning) 06, Acetaminophen ER 650 mg is AM7, and Gabapentin 300 MG is AM 7.On 7/29/26, surveyor reviewed R24's physician orders and noted an order date of 8/27/25 Omeprazole Tablet Delayed Release 20 mg. Give 1 tablet by mouth two times a day for acid indigestion. An order dated 8/25/25 Gabapentin Oral Capsule 300 mg. Give 1 capsule by mouth three times a day for neuropathy. An order dated 7/29/25 Acetaminophen ER Oral Tablet Extended Release 650 mg. Give 1 tablet by mouth three times a day for pain. RN-G administered these medications late to R24 at 10:55 a.m. On 7/29/26, at 1:40 p.m., Surveyor asked RN-G if the administration time on a MAR is AM 7 when the medication should be administered. RN-G informed surveyor AM 7 is 7:00 to 9:00, have an hour before and hour after. Surveyor asked if a resident's medication is administered after the time what do you do. RN-G replied I would say we have to call the doctor that they got their meds late. Surveyor informed RN-G R24's medication was administered late and asked if she called the doctor. RN-G replied not yet.On 7/30/26, at 7:19 a.m., surveyor asked Director of Nursing (DON)-B when a MAR has a medication to be administered at AM 06 when should the medication be administered. DON-B informed surveyor should be administered from 5:00 to 7:00 a.m. Surveyor asked if the MAR is AM 7. DON-B replied then it's 6:00 a.m. to 8:00 a.m. DON-B informed surveyor she's trying to fix up the MARs, so the medication is administered anywhere from 6:00 a.m. to 9:00 a.m. Surveyor informed DON-B R24 receives Omeprazole 20 mg, Gabapentin 300 mg and Acetaminophen ER 650 mg more than once daily. Surveyor informed DON-B Omeprazole 20 mg should have been administered by 8:00 a.m., Gabapentin 300 mg & Acetaminophen ER 650 mg should have been administered by 9:00 a.m. R24's medications were administered at 10:55 a.m. which resulted in 3 medication errors for R24.2.) On 7/29/26, at 10:58 a.m., surveyor observed Registered Nurse (RN)-G prepare R15's medication which consisted of Acetaminophen ES (extra strength) 500 mg (milligrams) two tablets, Aspirin 325 mg one tablet, Fluticasone Propionate 50 mcg (micrograms) nasal spray, Ferrous Sulfate 325 mg one tablet, Fish oil 1000 mg one capsule, Gabapentin 600 mg one tablet, Metoprolol 25 mg one tablet, and Clopidogrel 75 mg one tablet.On 7/29/26, at 11:04 a.m., surveyor verified with RN-G there are 8 pills in R15's medication cup.On 7/29/26, at 11:05 a.m., RN-G administered R15's medication whole with water.On 7/29/26, at 11:06 a.m., RN-G placed gloves on, shook R15's nasal spray and administered two sprays in each nostril of Fluticasone Propionate 50 mcg. On 7/29/26, surveyor reviewed R15's July MAR (medication administration record) and noted the time of administration for Gabapentin 600 mg & Metoprolol Tartrate 25 mg is AM (morning) 06.On 7/29/26, surveyor reviewed R15's physician orders and noted an order dated 7/12/24 Metoprolol Tartrate Oral Tablet 25 mg. Give 1 tablet by mouth two times a day for HTN (hypertension) and an order dated 7/12/24 Gabapentin Oral Tablet 600 mg. Give 1 tablet by mouth two times a day for pain.On 7/30/26, at 7:19 a.m., surveyor asked Director of Nursing (DON)-B when a MAR has a medication to be administered at AM 06 when should the medication be administered. DON-B informed surveyor should be administered from 5:00 to 7:00 a.m. Surveyor asked if the MAR is AM 7. DON-B replied then it's 6:00 a.m. to 8:00 a.m. DON-B informed surveyor she's trying to fix up the MARs, so the medication is administered anywhere from 6:00 a.m. to 9:00 a.m. Surveyor informed DON-B R15 receives Gabapentin 600 mg & Metoprolol Tartrate 25 mg more than once a day. Surveyor informed DON-B Gabapentin 600 mg & Metoprolol Tartrate 25 mg should have been administered by 8:00 a.m. R15 received Gabapentin 600 mg & Metoprolol Tartrate 25 mg at 11:05 a.m. which resulted in two medication errors for R15.

Based on interview and record review the facility did not ensure communication between the facility and hospice for 2 (R27 & 29) of 3 residents reviewed for hospice.R27 & R29 receives hospice services from the same hospice agency. The facility did not have communication sheets from hospice staff providing services, such as Certified Nursing Assistants, Social Worker, etc. for R27 & R29. Hospice RN progress reports are not consistently sent to the facility for R27 & R29. The hospice agency did not provide the facility with hospice MD (medical doctor) recertification of terminal illness for R27 & R29. Facility staff were unaware of who is the facility's designated staff member who is responsible for coordinating with hospice.Findings include:The facility's policy titled, Hospice Services Facility Agreement and dated 7/15/22 under policy documents It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. Undre policy explanation and compliance guidelines documents 4. The written agreement(s) will set out at least the following: d. A communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. 6. The designated member of the facility working with hospice representative is responsible for: d. Obtaining the following information from the hospice: iii. Physician certification and recertification of the terminal illness specific to each resident.1.) R27's diagnoses include hypertensive heart disease with heart failure, congestive heart failure and atrial fibrillation.R27's election of hospice benefits is signed by R27 and a hospice representative on 5/29/25.R27's admission MDS (minimum data set) with an assessment reference date of 8/19/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Hospice care is checked yes for while a resident.R27's quarterly MDS with an assessment reference date of 5/22/26 has a BIMS score of 12 which indicates moderate cognitive impairment. Hospice care is checked yes for while a resident.R27's resident has a terminal prognosis r/t (related to) heart disease with heart failure, CHF (congestive heart failure), disease of pancreas and chronic atrial fibrillation. Resident is on hospice thru [Name] hospice care plan initiated & revised 7/2/26 includes an intervention of Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual physical and social needs are met. Initiated 7/3/26.On 7/29/26, at 10:05 a.m., surveyor asked Licensed Practical Nurse (LPN)-C if there are hospice binders. LPN-C replied yes and showed surveyor where the binders are located behind the nurse's station. Surveyor asked LPN-C if the hospice binders are for individual residents. LPN-C replied no and explained they are by the hospice agency. Surveyor asked LPN-C for [Name of] hospice.On 7/29/26, at 10:07 a.m., surveyor reviewed [Name of] hospice binder. Surveyor noted inside this binder includes an entrance conference worksheet, [Name of] hospice care/new facility check list, & facility sign in sheets. Following this there is a tab for [Name of] hospice overview and admission tools, a symptom management tab, tab for death, grief, & bereavement and policies. Surveyor noted there are no hospice communication sheets for R27 in the hospice binder and the sign in sheet is blank.On 7/29/26, at 10:11 a.m., surveyor reviewed R27's medical record and noted under the miscellaneous tab for hospice there are the following progress reports by hospice Registered Nurse (RN) dated 3/11/26, 5/1/26, 5/27/26, 6/7/26, 6/9/26, 6/9/26, 6/16/26, & 7/19/26.Surveyor was unable to locate any hospice communication sheets for CNA, social worker and any other hospice staff for R27. Surveyor was also unable to locate hospice MD (medical doctor) certification of terminal illness for R27. On 7/29/26, at 10:20 a.m., surveyor asked Certified Nursing Assistant (CNA)-E if she knew how often hospice comes to the facility for R27. CNA-E informed surveyor she knows they come in once a week to shower R27 but feels like they are here more often because she always sees them.On 7/29/26, at 10:26 a.m., surveyor asked LPN-C how often hospice comes in for R27. LPN-C informed surveyor the aide comes in twice a week and a nurse once a week.On 7/29/26, at 11:07 a.m., surveyor asked RN-G how often hospice comes in for R27. RN-G informed surveyor two times a week. Surveyor asked if hospice leaves communication sheets. RN-G showed surveyor [Name of] hospice binder. Surveyor asked if the communication sheets are in the binder. RN-G replied they should be.On 7/29/26, at 12:53 p.m., surveyor asked LPN-C who is the facility's designated staff member who coordinates with hospice. LPN-C informed surveyor she didn't know.On 7/29/26, at 12:54 p.m., surveyor asked RN-G if she knew who the facility's designated staff member who coordinates with hospice. RN-G informed surveyor she really doesn't know and thinks they all work together.On 7/29/26, at 1:11 p.m., surveyor asked Medical Records Coordinator (MRD)-F where surveyor would be able to locate the hospice MD certification of terminal illness for R27. MRD-F informed surveyor she would have to get back to surveyor. Surveyor then asked MRD-F where surveyor would be able to locate hospice communication sheets for when the hospice CNA, social worker, nurse, and anyone from hospice who comes into the facility for R27. MRD-F informed surveyor she's not really sure. MRD-F explained hospice will fax the nurses progress notes after a visit and she will scan them in. Surveyor asked MRD-F if she knew who the designated staff member is who coordinates with hospice. MRD-F replied I really don't know.On 7/29/26, at 1:43 p.m., RN-G informed surveyor the hospice nurse sends a progress report within 24 hours after the visit then they review this for any new orders. Surveyor asked about other hospice staff such as CNA, social worker, etc. RN-G informed surveyor, surveyor should ask DON-B or Nursing Home Administrator (NHA)-A as she thought they were in there, referring to the hospice binder.On 7/29/26, at 1:48 p.m., surveyor asked Director of Nursing (DON)-B where surveyor would be able to locate hospice communication sheets. DON-B informed surveyor they are at the nurse's desk in a binder. Surveyor asked DON-B if she could accompany surveyor to the nurse's station and show surveyor where the communication sheets are for R27. DON-B removed [Name] hospice binder and looked inside. DON-B informed surveyor she will have to speak with [Name] hospice as there are no communication sheets in the binder and hospice doesn't keep anything in their room. Surveyor informed DON-B surveyor has not been able to locate any communication sheets and according to interview the hospice nurse sees R27 once a week but there aren't weekly progress reports in R27's medical record. Surveyor asked DON-B who is the designated staff member who coordinates with hospice. DON-B informed surveyor she is but with all the changes she hasn't spoken with the coordinator at hospice.On 7/29/26, at 3:00 p.m., Nursing Home Administrator (NHA)-A provided surveyor with R27's hospice MD recertification of terminal illness dated 7/21/26. Surveyor asked [NAME]-A where this form was as surveyor was unable to locate the form. NHA-A informed surveyor DON-B called hospice. NHA-A informed surveyor they are starting individual hospice binders tomorrow.2.) R29's diagnoses includes hypertensive heart disease with heart failure, congestive heart failure, pulmonary arterial hypertension and blindness related to glaucoma.R29's election of hospice benefits was signed by R29's power of attorney and hospice representative on 6/17/25.R29's [Name] Hospice care need due to congestive heart failure care plan initiated 7/25/25 includes an intervention of Hospice staff to visit to provide care, assistance, and/or evaluation initiated 7/25/25.R29's admission MDS (minimum data set) with an assessment reference date of 7/25/25 has a BIMS (brief interview mental status) score of 9 which indicates moderate cognitive impairment. Yes is checked for hospice while a resident.R29's quarterly MDS with an assessment reference date of 4/30/26 has a BIMS score of 9 which indicates moderate cognitive impairment. Yes is checked for hospice while a resident.On 7/29/26, at 10:05 a.m., surveyor asked Licensed Practical Nurse (LPN)-C if there are hospice binders. LPN-C replied yes and showed surveyor where the binders are located behind the nurse's station. Surveyor asked LPN-C if the hospice binders are for individual residents. LPN-C replied no and explained they are by the hospice agency. Surveyor asked LPN-C for [Name of] hospice.On 7/29/26, at 10:07 a.m., surveyor reviewed [Name of] hospice binder. Surveyor noted inside this binder includes an entrance conference worksheet, [Name of] hospice care/new facility check list, & facility sign in sheets. Following this there is a tab for [Name of] hospice overview and admission tools, a symptom management tab, tab for death, grief, & bereavement and policies. Surveyor noted there are no hospice communication sheets for R29 in the hospice binder and the sign in sheet is blank.On 7/29/26, at 11:07 a.m., surveyor asked RN-G if hospice leaves communication sheets. RN-G showed surveyor [Name of] hospice binder. Surveyor asked if the communication sheets are in the binder. RN-G replied they should be.On 7/29/26, surveyor reviewed R29's medical record and noted under the miscellaneous tab for hospice progress report from hospice RN dated 1/5/26, 1/19/26, 3/3/26, 4/4/26, 5/4/26, 5/7/26 (2 reports), 5/27/26, 6/9/26, 6/21/26, 6/24/26, 7/1/26, 7/13/26, & 7/22/26, & 7/27/26. On 7/29/26, at 12:55 p.m., surveyor asked RN-G how often hospice comes in the facility for R29. RN-G informed surveyor the same as R27, two times a week for the Certified Nursing Assistant (CNA) and one time a week for the nurse.On 7/29/26, at 1:11 p.m., surveyor asked Medical Records Coordinator (MRD)-F where surveyor would be able to locate the hospice MD certification of terminal illness for R29. MRD-F informed surveyor she would have to get back to surveyor. Surveyor then asked MRD-F where surveyor would be able to locate hospice communication sheets for the hospice CNA, social worker, nurse, and anyone from hospice who comes into the facility for R29. MRD-F informed surveyor she's not really sure. MRD-F explained hospice will fax the nurses progress notes after a visit and she will scan them in. On 7/29/26, at 1:43 p.m., RN-G informed surveyor the hospice nurse sends a progress report within 24 hours after the visit then they review this for any new orders. Surveyor asked about other hospice staff such as CNA, social worker, etc. RN-G informed surveyor, surveyor should ask DON-B or Nursing Home Administrator (NHA)-A as she thought they were in there, referring to the hospice binder.On 7/29/26, at 1:48 p.m., surveyor asked Director of Nursing (DON)-B where surveyor would be able to locate hospice communication sheets. DON-B informed surveyor they are at the nurse's desk in a binder. Surveyor asked DON-B if she could accompany surveyor to the nurse's station and show surveyor where the communication sheets are for R29. DON-B removed [Name] hospice binder and looked inside. DON-B informed surveyor she will have to speak with [Name] hospice as there are no communication sheets in the binder and hospice doesn't keep anything in their room. Surveyor informed DON-B surveyor has not been able to locate any communication sheets and according to interview the hospice nurse sees R29 once a week but there aren't weekly progress reports in R29's medical recordOn 7/29/26, at 3:00 p.m., Nursing Home Administrator (NHA)-A provided surveyor with R29's hospice MD recertification of terminal illness dated 6/9/26. Surveyor asked [NAME]-A where this form was as surveyor was unable to locate the form. NHA-A informed surveyor DON-B called hospice. NHA-A informed surveyor they are starting individual hospice binders tomorrow.

Based on interview and record review, the facility did not ensure 1 (R1) of 5 residents reviewed were offered/administered the pneumococcal vaccination. R1's Electronic Medical Record (EMR) does not contain any documentation as to whether R1 was offered, received or declined the influenza immunization. Findings include: The facility's policy titled Pneumococcal Vaccine (Series), dated 9/18/24, last reviewed 3/25/25, documents the following:Each resident will be assessed for pneumococcal immunization upon admission.Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized.The resident/representative retains the right to refuse the immunization. The facility will document in the clinical record the reason for refusal or the medical contraindication of the immunization. R1 was admitted to the facility on [DATE]. Surveyor reviewed R1's EMR and was unable to locate whether R1 was offered, received or declined the pneumococcal immunization. On 7/30/26, at 8:23 AM, Surveyor interviewed Director of Nursing (DON)-B who stated she monitors immunization records for the facility. DON-B stated if residents refuse an immunization, the facility will document the refusal in the EMR and discuss it in care conferences. DON-B stated the facility will offer the immunization to the resident again a couple more times after they refuse to make sure the resident understands the risks associated with refusing an immunization. Surveyor notified DON-B that R1's EMR does not document a pneumococcal immunization was given or refused. DON-B stated she would look into it. On 7/30/26, at 11:39 AM, Surveyor notified Nursing Home Administrator (NHA)-A of concerns that R1's EMR does not contain documentation as to whether R1 was offered, received or declined the pneumococcal immunization. NHA-A acknowledge this concern. On 7/30/26, at 1:03 PM, NHA-A asked to speak with Surveyor and presented a Critical Event Analysis and Action Plan Worksheet which documents the facility discovered on 7/21/26, the facility did not have documentation of acceptance and declinations of immunizations for residents within the facility. NHA-A stated R1 did not receive their pneumococcal vaccination per the facility's policy. NHA-A stated we identified R1 did not receive their pneumococcal vaccination, and an action plan was initiated on 7/21/26. R1 was identified and included in the audit on the action plan. Surveyor asked NHA-A if R1 was offered or received their pneumococcal vaccination and NHA-A stated we have not offered it as of yet and need to speak with R1's Power of Attorney. Surveyor notified NHA-A of concerns with R1 not being offered, received or declined the pneumococcal immunization.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R1 andR4) of 3 residents reviewed for pressure injuries. * R1 admitted to the facility on [DATE] with a hospital discharge summary that included treatment for R1’s right ischium. This treatment was not picked up by the facility. On 5/14/25, the facility documented a stage 2 pressure injury (PI) to R1’s right buttock. Wound Physician-G’s treatment recommendation for the right buttock was not completed by the facility. On 5/27/25, the right buttock PI was noted to have declined, and Wound Physician-G changed the treatment orders. These orders were not picked up by the facility, and the facility did not develop a PI care plan for R1. The facility also failed to implement physician’s treatment orders from 6/3/25 and 6/10/25. Facility also documented R1 as having a right trochanter (hip) PI and a right lower leg vascular wound. When R1 was discharged to an Assisted Living (AL) facility on 6/11/25, the AL noted R1 had a stage 2 open area on her right buttock and 2 open areas on the left gluteal fold. The areas were warm to touch and painful with no dressings or ointments, and resident had blood in her brief where the wounds had made contact. Resident was sent to the hospital for evaluation and determined to have a coccygeal abscess which was concerning for osteomyelitis and a left buttock abscess. The facility's failure to provide care and promote the healing of R1's pressure injury, the failure to develop R1's pressure injuries care plan, and the failure to implement physician ordered treatments created a finding of Immediate Jeopardy (IJ) that began on 5/27/25. Surveyor notified NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, and [NAME] President (VP) of Success-C of the immediate jeopardy on 6/30/25 at 1:20 p.m. The immediate jeopardy was removed on 6/30/25. The deficient practice continues at a scope and severity of G related to the example involving R4 and as the facility continues to implement its action plan. * R4 developed 3 stage 2 pressure injuries in 15 days. The residents care plan was not changed until 6/26. The resident was at risk was not provided with an air mattress for pressure relief for 14 days. R4 then developed an unstageable pressure injury. Findings include: The facility's policy titled, Pressure Injuries and Non Pressure Injuries, and reviewed/revised 7/20/22 documents under policy: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. The following protocols should guide prevention and treatment efforts, unless specified by a physician otherwise. Policy Explanation and Compliance Guidelines documents: 1. Upon admission: a. A head-to-toe body evaluation will be completed on every resident upon admission/readmission and will be documented on the Admission/readmission Evaluation UDA (user defined assessment). If skin is compromised: i. If pressure Injury: Initiate the Pressure Injury Weekly Tracker UDA - one per wound . iii. Ensure primary care physician (PCP) is aware of wounds/location of wounds and current treatment orders. iv. Ensure appropriate treatment orders for each wound area, as needed. v. Ensure resident/responsible party is awaref wounds and current treatment plan. vi. Evaluate for pain related to wounds and develop management plan if pain related to wounds is present. c. Initiate the baseline plan of care related to current skin status and skin risk level. (The comprehensive care plan will be developed within seven days of the completion of the comprehensive assessment - see below for additional information related to the comprehensive care plan). The Care Plan section documents: A Comprehensive Skin Integrity Care Plan is based on resident history, review of Skin Assessment, Braden Scale Scoring, Nutritional Assessments, resident and family interviews, and staff observations. Consider the areas of risk, as well as overall risk assessment score of the Braden Scale. Communicate identified risk factors and interventions to direct care staff. 1.) R1 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (condition where thyroid gland doesn't produce enough thyroid hormones to meet the body's needs), lymphedema (tissue swelling often in an arm or leg), venous insufficiency, dementia (loss of cognitive function that interferes with a person's daily life and activities), PVD (peripheral vascular disease) (circulatory condition which narrows blood vessels reducing blood flow to limbs), chronic kidney disease (characterized by progressive damage and loss of kidney function) stage 2 (mild), adult failure to thrive, and anxiety disorder. R1's hospital Discharge summary dated [DATE] under Discharge Procedure Orders for wound care instructions documents: Location: R (right) ischium. If necessary, give pain medicine 1 hour prior to starting wound care. Remove all old dressings. Actively wash wound with antibacterial soap (i.e. Dial soap) and water using a washcloth. Rinse completely and pat dry with clean wash cloth or towel. Apply foam border to open area. Dressing changes to be done every other day by floor nurses. We will plan to have [R1's name] follow up in the Burn and Wound Clinic (phone number [number] on 5/22 at 3pm at [Name] Clinic. Surveyor was unable to locate these hospital discharge treatment orders in R1’s record nor is there a progress note indicating R1's physician was notified of these orders. R1's admission evaluation dated 5/14/25 completed by Registered Nurse/Unit Manager (RN/UM)-D has a Braden assessment score of 13 which indicates moderate risk for pressure injuries. The skin integrity section documents: 31) Right buttock. Type documents: pressure, measurements are 0.5 x (times) 0.5 x 0.1. Stage is II (2). Surveyor noted this is not a comprehensive assessment as there is not a description of the wound bed, peri wound, drainage, etc. There are no treatment orders for R1's right buttocks pressure injury identified on the 5/14/25 admission evaluation. R1's progress note dated 5/15/25, at 11:00 a.m., by APNP (Advanced Practice Nurse Practitioner)-H under history of present illness documents: [R1's name], female with past medical history of chronic lymphedema, hypothyroidism, CKD (chronic kidney disease) stage 2, anemia, cognitive impairment and hypertension. She was admitted for observation for adult failure to thrive. APNP-H's progress note does not address R1's right buttock pressure injury. Surveyor reviewed R1's care plans and noted the following care plans: Activities initiated 5/20/25, ADL (activities of daily living) self-care deficit initiated 5/14/25, Advanced Directives initiated 5/19/25, Potential for elopement initiated 5/14/25, Cognitive Loss initiated 5/19/25, Difficulty communicating initiated 5/14/25, Urinary incontinence initiated 5/14/25, Bowel incontinence initiated 5/14/25, Dental or oral cavity health initiated 5/14/25, Potential for discharge initiated 5/14/25, At risk for falls initiated 5/14/25, Cardiac disease initiated 5/14/25, Edema/excess fluid volume initiated 5/14/25, At risk for nutritional status initiated 5/14/25, Pain leg initiated 5/14/25, Actual (ulcers at bilateral shins) initiated 5/14/25, Actual (ulcers at bilateral shins initiated 5/20/25, and At risk for retraumatization initiated 5/19/25. Surveyor noted the facility did not develop and implement a comprehensive pressure injury care plan. R1's admission MDS (minimum data set) with an assessment reference date of 5/20/25 has a BIMS (brief interview for mental status) score of 4 which indicates severe cognitive impairment. R1 is assessed as refusing care one to three days. R1 is assessed for eating as independent, roll left and right is partial/moderate assistance, toileting hygiene, showering, chair/bed to chair transfer, and toileting transfer is assessed as substantial/maximal assistance. R1 is frequently incontinent of urine and continent of bowel. R1 is at risk for pressure injury development and is assessed as having one stage 2 pressure injury which was present upon admission. R1's Braden assessment dated [DATE] has a score of 18 which indicates at risk for PIs. R1's pressure CAA (care area assessment) dated 5/23/25 under analysis of findings for nature of the problem/condition documents: Pressure ulcers CAA triggered secondary to actual pressure ulcers. Contributing factors include ADL (activity daily living)/functional/mobility impairment, history of pressure ulcers, actual pressure ulcers, cognitive loss, and use of medications that can contribute to skin breakdown, incontinence, and pain. Risk factors include pain, development of PU (pressure ulcer)/skin condition, and fluid deficit risk. A licensed nurse assess the skin each week. It is also assessed by caregivers with each bath and each time the resident is dressed. The physician is to be notified of any abnormal findings and treatment orders are obtained. Caregivers assist with repositioning at least every two hours and as needed for comfort. Care plan will be initiated or reviewed to improve or maintain current ADL status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer/fluid deficit risk. Location of documentation see NN (nurses notes), Braden, TAR (treatment administration record), wound nurse documentation and measurements for the look back period. Under care plan considerations for describe impact of this problem/need on the resident and your rational for care plan decision has the exact same documentation as documented under the analysis of findings for nature of the problem/condition. R1's pressure injury weekly tracker with an effective date of 5/20/25 completed by Director of Nursing (DON)-B documents for site 31) Right buttock, type is pressure, length 0.5, width 0.5, depth 0.1, and Stage is II (2). Tissue type is granulation tissue, granulation % (percentage) is 100. Drainage is none. Surveyor noted this comprehensive pressure injury assessment was 6 days after R1 was admitted to the facility. Surveyor noted a stage 2 pressure injury does not have granulation and this area should have been staged at a Stage 3. The assessment does not include a description of the wound bed. Wound Physician-G's initial wound evaluation and management summary dated 5/20/25 documents: Stage 2 pressure wound of the right buttocks with wound size (L x W x D) (length times width times depth) of 0.5 x 0.5 x 0.1 cm (centimeters). There is no description of the wound bed. Under dressing treatment plan for primary dressing documents: Zinc ointment apply Q (every) shift (3x (times) day) and as needed: if saturated, soiled, or dislodged. There is no order for the Zinc ointment and the Zinc ointment is not on R1's May 2025 MAR (medication administration record) or TAR (treatment administration record). R1 was receiving physical and occupational therapy. On 5/27/25, therapy changed R1's status to ad lib for ambulation and getting self dressed. R1's pressure injury weekly tracker with an effective date of 5/27/25 completed by Registered Nurse/Unit Manager (RN/UM)-D documents for site: 31) Right buttock, type is pressure, length is 3, width 0.5, depth 0.1, and stage is blank. Tissue type is granulation tissue. Skin % is 50. Drainage is Serosanguinous and amount of drainage is light. Wound Physician-G's wound evaluation and management summary dated 5/27/25 documents: Stage 2 pressure wound of the right buttock, partial thickness with wound size (L x W x D) of 3 x 0.5 x 0.1 cm. Cluster wound documents open ulceration area of 0.75 cm. Exudate is light sero-sanguineous. There is not a description of the wound bed. Under dressing treatment plan for Primary Dressing(s) documents: Alginate honey-impregnated apply once daily and as needed: if saturated, soiled, or dislodged. Secondary Dressing(s) Gauze island w/bdr (with border) apply once daily and as needed: if saturated, soiled, or dislodged. There is no order for R1's right buttock pressure injury treatment and the treatment recommended by Wound Physician-G is not listed on the May 2025 MAR or TAR. Surveyor noted the facility has still not developed a comprehensive pressure injury care plan and the PI has declined. R1's pressure injury weekly tracker with an effective date of 6/3/25 completed by DON-B documents for site: 31) Right buttock, type is pressure, length is 2, width 0.6, depth 0.1 and stage is II (2). Tissue type is Granulation tissue and Granulation % is 100. Drainage is none. Summary of findings is Worsening. Wound Physician-G's wound evaluation and management summary dated 6/3/25 documents: Stage 2 pressure wound of the right buttock, partial thickness with wound size (L x W x D) of 2 x 0.6 x 0.1 cm. Cluster wound documents open ulceration area of 0.60 cm. squared. Exudate is Moderate sero-sanguineous. There is not a description of the wound bed. Under dressing treatment plan for Primary Dressing(s) documents: Alginate honey-impregnated apply once daily and as needed: if saturated, soiled, or dislodged. Secondary Dressing(s) Gauze island w/bdr (with border) apply once daily and as needed: if saturated, soiled, or dislodged. There is no order for R1's right buttock pressure injury treatment and the treatment recommended by Wound Physician-G is not listed on the June 2025 TAR. Surveyor noted the facility has still not developed a comprehensive pressure injury care plan. Surveyor was unable to locate a pressure injury weekly tracker for the week of 6/8/25 to 6/14/25. Wound Physician-G's wound evaluation and management summary dated 6/10/25 documents Stage 2 pressure wound of the right buttock, partial thickness with wound size (L x W x D) of 1.5 x 0.6 x 0.1 cm. Cluster wound documents open ulceration area of 0.45 cm. squared. Exudate is light sero-sanguineous. There is not a description of the wound bed. Under dressing treatment plan for Primary Dressing(s) documents: Alginate honey-impregnated apply once daily and as needed: if saturated, soiled, or dislodged. Secondary Dressing(s) Gauze island w/bdr (with border) apply once daily and as needed: if saturated, soiled, or dislodged. There is no order for R1's right buttock pressure injury treatment and the treatment recommended by Wound Physician-G is not listed on the June 2025 TAR. Surveyor noted the facility has still not developed a comprehensive pressure injury care plan. R1's shower/bath body check dated 6/10/25 documents: refused said she's taking it at home tomorrow. R1's weekly skin review with an effective date of 6/11/25 under skin condition is checked for pressure injury and other. For specify other documents: vascular. For site documents 25) Right trochanter (hip) and description documents pressure. For site documents 41) right lower leg (front) and description documents vascular. R1's discharge note dated 6/11/25, at 13:00 (1:00 p.m.), written by Licensed Practical Nurse (LPN)-E documents Discharge Location: ALF (assisted living facility). discharged With: Res (Resident) discharged with all personal belongings and personal W/C (wheelchair). Family here assisted res with belongings. Belongings: Medications: All medication returned to pharmacy. Skin check: (blank) Vitals: (blank) Additional Information: Res in good spirits, 0 c/o (complaint of) pain/discomfort. On 6/26/25, at 9:32 a.m., Surveyor telephoned and spoke with Assisted Living Staff-K. Surveyor asked Assisted Living Staff-K if they could explain to Surveyor how R1 was when she arrived at their facility. Assisted Living Staff-K read Surveyor their note and informed Surveyor would send this note to Surveyor. Surveyor noted Assisted Living Staff-K's note dated 6/11/25 at 5:24 p.m. documents: [R1's name] arrived at [Assisted Living Facility Name] at approximately 2:15 transported by her family from Lake Mills Care Center. She was accompanied by her children, [Name], [Name], and another daughter. I went to assess [R1's first name] at approximately 2:45 and found her sitting in her lift chair in her apartment, talking with her children. She was pleasant, disoriented to time and place, with severe short term memory loss. We discussed her needs and what would be done by staff to help her, and she and her family stated understanding. Head to toe assessment revealed the following: [R1's first name] wears a wig, and has her own natural hair. She wears prescription glasses, and does not need hearing aids. She has upper and lower dentures that she states she rarely takes out. Her oral mucosa were moist. Her lungs were clear to auscultation in all fields both posteriorly and anteriorly. Heart auscultation revealed a systolic murmur and a slightly irregular rhythm, apical heart rate was 108. She had positive bowel sounds and was drinking an ensure prior to the exam. [R1's first name] bilateral lower legs were extremely edematous from toes to above the knee. Compression garments were in place. When they were removed, skin inspection revealed chronic skin changes, with increased redness on the dorsal aspect of both lower legs. On her right posterior lower leg, there was a bandage in place. [R1's first name] and her family did not know what it was covering. On her left lower leg, there were scattered clear blisters and a pinpoint area that was opened. [R1's first name] stated that her butt hurt, so her pants and undergarments were removed for skin inspection. She had a 1.5 x 1.5 cm stage 2 open area on her right buttock that was surrounded by unblanchable tissue with suspected deep tissue injury. She had two open areas on the left gluteal fold that was covered with whitish slough and were unstageable. They, too, were surrounded by suspected deep tissue injury. To the left of her coccyx there was an opening that appeared to tunnel into the subcutaneous tissue. The area around the opening was covered with white slough, and the tissue surrounding the area was hard, red, and warm to touch. The coccygeal area was also painful to touch. There were no dressings, ointments or creams apparent upon inspection, and there was blood in her brief where the wounds had made contact with it. [R1's first name] stated that the pain prevented her from sitting or lying comfortably. [R1's first name] daughters stated that the prior SNF (skilled nursing facility) had mentioned nothing about wounds on her buttocks or coccyx. They did state that she had a previous pressure injury while at Lake Mills, but that their understanding was that it was healed. These wounds were not present at my initial evaluation approximately 10 days ago when [R1's first name] was still at the skilled facility. Vitals at this time were T (temperature) 101.4 F (Fahrenheit) (forehead); BP (blood pressure) 115/59; Pulse 108, Respirations 24. Because of the elevated temperature and the condition of the wounds, I recommended that the family take [R1's first name] to Urgent Care for evaluation. They agreed and transported her at approximately 1530 (3:30 p.m.). Family was instructed to request wound and skin evaluation, urinalysis, and wound care orders. They know to get any antibiotics prescribed filled at [Pharmacy Name] so that they can be started as soon as possible. Staff is instructed to call me when/if [R1's first name] returns to the facility. Assisted Living Staff-K’s note dated 6/12/25 at 9:08 a.m. documents: [R1's first name] was admitted to [Name] Hospital in [Name] last evening via the urgent care center. [Name], Registered Nurse Case Management (RNCM) called with an update this morning. [R1's first name] coccygeal abscess that is concerning for osteomyelitis and a left buttock abscess. She is having imaging and blood cultures done, and her plan of care is being developed . On 6/26/25, at 11:05 a.m., Surveyor interviewed Certified Nursing Assistant (CNA)-T, who worked the day shift on 6/10/25 and 6/11/25 and was assigned to R1 on 6/11/25,. CNA-T informed Surveyor R1 kind of wanted to do her own thing. Surveyor asked CNA-T on the day R1 was discharged (6/11/25) did she provide any cares for R1. CNA-T replied no, she kind of does her own things. Surveyor asked CNA-T if she ever saw R1's buttocks. CNA-T replied, I would put cream. Surveyor asked the last time she saw R1's buttocks. CNA-T wasn't able to tell Surveyor and informed Surveyor she did help R1 in and out of the bathroom. CNA-T informed Surveyor she would offer to change R1's shirt and wash her up but R1 would say no I'm fine I'll get it. Surveyor asked CNA-T on the day of discharge did she help with R1's discharge. CNA-T replied no and explained R1's family packed everything up. On 6/26/25, at 11:12 a.m., Surveyor interviewed CNA-S, who worked the day shift on 6/10/25, regarding R1. CNA-S informed Surveyor R1 liked to transfer herself a lot, but CNA-S would help her to bathroom and change R1 if she didn't already do it. CNA-S indicated she had to stop R1 from doing things herself and she was impulsive. Surveyor asked CNA-S if she saw R1's buttocks. CNA-S replied, I wiped her guess I didn't put my face up to see, had to be quick as didn't allow you to do much with her. Surveyor stated to CNA-S so you didn't look at her bottom. CNA-S replied no. CNA-S explained R1 would stand up and pull up her pants. Surveyor asked CNA-S if she washed R1 up in bed. CNA-S replied she wouldn't let me, sometimes let me help change her shirt. On 6/26/25, at 11:58 a.m., Surveyor asked DON-B what is the process for when a resident is admitted regarding a skin assessment. DON-B explained RN/UM-D or another RN does a head to toe assessment. Surveyor inquired about R1. DON-B informed Surveyor R1 refused to have the dressings on her legs removed. DON-B explained R1 was admitted on a Wednesday and they changed the dressing on Friday. Surveyor asked about R1 buttocks. DON-B replied, buttocks, I don't remember her butt. Surveyor informed DON-B the admission assessment on 5/14/25 does not have a description of the wound bed. RN/UM-D looked at R1's admission assessment and then stated to Surveyor didn't write a whole lot. Surveyor informed DON-B there wasn't a comprehensive assessment until 6 days later on 5/20/25. Surveyor asked if R1's pressure injury had 100% granulation tissue why was the pressure injury staged as a 2 not a stage 3. DON-B replied that's a good question and explained the pressure injury wasn't that deep. Surveyor asked DON-B why the wound doctor doesn't document the wound bed for R1's pressure injury. DON-B replied that's a good question, I usually write the wound bed. Surveyor informed DON-B on 5/27/25, the wound doctor documents cluster of wound. DON-B explained if there is more than one open area he will measure one greater area. Surveyor informed DON-B the pressure injury weekly tracker dated 5/27/25 has granulation tissue and 50% skin. DON-B informed Surveyor she was on vacation this week and stated that's weird. Surveyor informed DON-B the weekly skin review dated 6/11/25 by RN-F documents a trochanter (hip) pressure injury. DON-B informed Surveyor R1 didn't have anything on her hip and doesn't know where that came from. DON-B informed Surveyor she will have to speak with RN-F. Surveyor informed DON-B Surveyor could speak with RN-F. Surveyor informed DON-B Surveyor was unable to locate an order and didn't see any treatment for R1's right buttock pressure injury. DON-B informed Surveyor she thinks they were doing calazime cream. DON-B looked in R1's physician order and then stated you're right. DON-B explained Wound Physician-G sends his notes electronically, which goes in the resident's record and Wound Physician-G doesn't put orders in. Surveyor informed DON-B Wound Physician-G on 5/27/25 documents a treatment with alginate honey and gauze island border dressing which was never completed. DON-B informed Surveyor that the treatment was never transcribed and it's an area of opportunity. On 6/26/25, at 12:31 p.m., Surveyor telephoned RN-F. Surveyor asked RN-F how she completed R1's skin check. RN-F informed Surveyor she honestly can't remember and would have to look at the computer. RN-F informed Surveyor R1 had wraps on her legs. Surveyor asked about R1's buttocks. RN-F informed Surveyor she didn't think she had anything. Surveyor asked RN-F on 6/11/25 did she look at R1's buttocks. RN-F replied I honestly don't remember. RN-F informed Surveyor first name of DON-B was kind of telling her what Surveyor was looking at and maybe she got her mixed up. RN-F informed Surveyor she was coming to the facility for a 1:30 p.m. meeting. Surveyor asked RN-F to see Surveyor while at the facility. On 6/26/25, at 2:44 p.m., Surveyor met with RN-F regarding R1. RN-F informed Surveyor some nurses document buttocks and some ischium. RN-F informed Surveyor she slipped up and put hip. Surveyor inquired about the right lower leg. RN-F informed Surveyor that was her mistake and it was healed. Surveyor asked RN-F how she did R1's skin check. RN-F replied in the bathroom and had asked the CNAs when they were toileting her to let her know. Surveyor asked RN-F if she looked at R1's buttocks. RN-F replied yes, had her stand up, cleaned her and took a look. Surveyor asked RN-F if the time she charted was the time she did the skin check. RN-F informed Surveyor it may have been earlier and she couldn't say as she didn't know if they had two nurses or she was by herself. Surveyor asked RN-F if staff had to take R1 to the bathroom or could R1 go by herself. RN-F informed Surveyor R1 wasn't supposed to and thinks at the end R1 was a one assist. Surveyor asked RN-F when she was doing R1's skin check did she spread the cheeks of R1's buttocks. RN-F replied I did the best I could. On 6/26/25, at 2:52 p.m. Surveyor interviewed CNA-R, who worked the evening shift on 6/10/25, about R1. CNA-R informed Surveyor R1 could be demanding, she went from being friendly to mean and did a lot of the cares herself. CNA-R informed Surveyor R1 didn't want them to do anything, would put the call light on and would already be in the bathroom. Surveyor asked CNA-R if she saw R1's buttocks. CNA-R replied yes, during the mid-point when she was here, can't say at the end because she was more independent. CNA-R informed Surveyor her buttocks were red and they did offer cream. Surveyor asked CNA-R if she observed R1's buttocks on 6/10/25, the day before R1 was discharged . CNA-R replied no I don't think I did. On 6/26/25, at 3:21 p.m. Surveyor interviewed RN-J, who worked the evening shift on 6/10/25, about R1. Surveyor asked RN-J if she had to do any treatments for R1. RN-J replied no. Surveyor asked RN-J if she ever saw R1's buttocks. RN-J replied no. RN-J informed Surveyor when the CNAs are doing cares, if there are any concerns they will get the nurse and their shower sheets. On 6/30/25, at 7:50 a.m., Surveyor interviewed CNA-U regarding R1. CNA-U informed Surveyor R1 mostly hung out in her room and refused cares. Surveyor informed CNA-U she was on the schedule for the evening shift on 6/10/25, day shift on 6/11/25, and inquired if she did any cares for R1 during this time. CNA-U informed Surveyor not that she could recall. Surveyor asked CNA-U if she observed R1's buttocks. CNA-U replied no she really wouldn't let us help her. On 6/30/25, at 8:03 a.m., Surveyor interviewed CNA-V regarding R1. CNA-V informed Surveyor R1 self-transferred, had a couple falls, refused cares, and would sit on the bed with the walker. CNA-V informed Surveyor R1 really didn't let them do a whole lot. Surveyor asked CNA-V if she ever saw R1's buttocks. CNA-V replied no. On 6/30/25, at 8:09 a.m., Surveyor asked Physician-W if he knows why the wound doctor doesn't describe the wound bed. Physician-W informed Surveyor he has no idea and doesn't follow wounds. Surveyor asked if [Name of Wound company] follows all wounds at the facility. Physician-W replied yes. On 6/30/25, at 8:19 a.m., Surveyor interviewed CNA-Q, who worked the day shift on 6/10/25 and 6/11/25, about R1. CNA-Q informed Surveyor R1 was independent and could be rude. Surveyor asked CNA-Q if she assisted R1 with going to the bathroom. CNA-Q informed Surveyor if she caught R1 and R1 would take herself. CNA-Q informed Surveyor one time R1 called and she helped her but only one time. Surveyor asked CNA-Q if she saw R1's buttocks. CNA-Q replied no, she didn't like them to change her. CNA-Q informed Surveyor she doesn't have R1's assignment often and is usually assigned to other assignments. On 6/30/25, at 8:28 a.m., Surveyor asked RN/UM-D what she does when a resident is admitted . RN/UM-D explained she does a head to toe assessment under the admission evaluation and kick starts the care plan. Surveyor asked RN/UM-D if she remembers R1. RN/UM-D replied yes. Surveyor asked RN/UM-D why there wasn't a pressure injury care plan developed. RN/UM-D replied not sure, I'd have to look at that. RN/UM-D informed Surveyor R1 had lymphedema wounds and an area on her bottom. RN/UM-D informed Surveyor in the beginning R1 didn't want anyone to look at her, she was very shy. On 6/30/25, at 8:38 a.m., Surveyor spoke with Wound Physician-G on the telephone regarding R1. Surveyor inquired why he didn't describe the wound bed for R1's pressure injury. Wound Physician-G explained when he stages the pressure injury as a stage 2 the program locks him out of describing the wound bed to safeguard inappropriate documentation. Surveyor informed Wound Physician-G he was documenting R1's right buttock pressure injury as a stage 2 but the facility was documenting 100% granulation. Wound Physician-G informed Surveyor he didn't think there was granulation and R1 was admitted with the pressure ulcer, not acquired. Surveyor asked Wound Physician-G if he was aware facility staff were not doing any treatment for R1's right buttock pressure injury. Wound Physician-G replied no, he wasn't aware. Wound Physician-G informed Surveyor there are times the nurses take off the bandage before he comes and doesn't get worried if the bandage is off. Wound Physician-G informed Surveyor he can't physically put orders in PCC (pointclickcare). Surveyor asked Wound Physician-G if R1 had any other pressure injuries other than the right buttocks. Wound Physician-G informed Surveyor not that he was made aware of and doesn't do a skin sweep and it was just the butt cheek that they were seeing. Surveyor inquired about when Wound Physician-G clusters areas. Wound Physician-G informed Surveyor if the wounds are on the same anatomical location and required the same treatment he will cluster the wounds. Wound Physician-G informed Surveyor R1 had excoriation and it was his judgement call to cluster together. On 6/30/25, at 9:24 a.m., RN/UM-D stated to Surveyor it was me, don't know how I missed the pressure care plan. Surveyor asked RN/UM-D who reviews the hospital discharge summary. RN/UM-D informed Surveyor it depends, DON-B will put the orders in and someone will double check and if DON-B is not here she will and another nurse will double check. On 6/30/25, at 9:27 a.m., Surveyor asked DON-B if she has any information regarding the assessments documenting 100% granulation and R1's pressure injury being staged at a stage 2. DON-B informed Surveyor it may be her error and informed Surveyor the wound bed was nice beefy red. Surveyor informed DON-B there was not a pressure injury care plan for R1. DON-B informed Surveyor RN/UM-D just told her that. Surveyor asked DON-B when R1 was admitted did she review R1's hospital discharge summary. DON-B informed Surveyor she usually does the discharge summary and RN/UM-D does the physical assessment. Sur

Based on record review and interview, the facility did not ensure 7 out of 8 staff members reviewed received behavioral health training to care for residents diagnosed with a mental, psychosocial, or other behavioral health conditions. Certified Nursing Assistant (CNA)-Q, CNA-R, CNA-T, CNA-V, Registered Nurse (RN)-Y, Licensed Practical Nurse (LPN)-E, and Housekeeping-Z, did not receive behavioral health training.This deficient practice has the potential to affect all 29 residents residing at the facility that have the potential to experience behavioral health issues. Findings include:On 7/3/25, Surveyor randomly selected 8 facility staff members for review. Surveyor reviewed the employee records of CNA-Q, CNA-R, CNA-T, CNA-V, CNA-X, Registered Nurse (RN)-Y, Licensed Practical Nurse (LPN)-E, and Housekeeping-Z. The facility was unable to provide documentation that CNA-Q, CNA-R, CNA-T, CNA-V, Registered Nurse (RN)-Y, Licensed Practical Nurse (LPN)-E, and Housekeeping-Z, received the required behavioral health training within the year based on hire date.CNA-Q Date of Hire: 1/1/23 (did not receive behavioral health training)CNA-R Date of Hire: 10/1/17 (did not receive behavioral health training)CNA-T Date of Hire: 10/1/17 (did not receive behavioral health training)CNA-V Date of Hire: 9/12/22 (did not receive behavioral health training)RN-Y Date of Hire: 8/3/22 (did not receive behavioral health training)LPN-E Date of Hire: 10/1/17 (did not receive behavioral health training)Housekeeping-Z: Date of Hire 8/2/22 (did not receive behavioral health training)Surveyor noted that when asking Nursing Home Administrator (NHA)-A for a policy on required annual in-service training, NHA-A stated, the facility did not have a policy on in-service training. On 7/3/25, at 12:15 AM, Surveyor interviewed NHA-A who stated, the Director of Nursing (DON) is responsible for assuring staff receive the required training and NHA-A completes a second review of the training. NHA-A stated, the facility uses software to provide in-service training. Surveyor notified NHA-A that 7 out of 8 selected staff have not received the behavioral health training. NHA-A stated that she would consult with team and get back to Surveyor if any additional information could be found.On 7/3/25, at 1:45 PM, Surveyor interviewed [NAME] President of Success-C who stated that all 8 of the staff members selected have training on caring for people with substance use disorder and feels this training should account for behavioral health training. Surveyor stated, even though residents with substance use disorders have behaviors that require staff training, this is only one component of behavioral training and staff need to have training on all behaviors that are associated with mental illness, psychosocial, or other behavioral health conditions and could not be counted as the completion of behavioral health training.On 7/3/25, at 3:00 PM, Surveyor notified NHA-A, DON-B and [NAME] President of Success-C of concern that 7 out of 8 staff members did not receive the behavioral health training and even though other trainings such as substance abuse, trauma informed care and dementia all include behaviors of residents, there needs to be a specific training related to behaviors of residents to encompass all resident illnesses or conditions. The facility team expressed understanding. No additional information was provided.

Based on interview and record review the facility did not ensure residents with non pressure wounds received treatment and care in accordance with professional standards of practice for 1 (R1) of 1 residents reviewed with a non-pressure wound.R1 was admitted with a right lower extremity wound on 5/14/25. On 5/21/25, R1's wound treatment was changed. The facility did not recognize the scheduled treatment, only the PRN (as needed) portion of the order was implemented. R1 was not provided with treatment to the right lower extremity wound from 5/21/25 to 5/27/25 when the wound was identified as being healed.Findings include:The facility's policy titled, Pressure Injuries and Non Pressure Injuries and reviewed/revised 7/20/22 under policy documents: For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. The following protocols should guide prevention and treatment efforts, unless specified by a physician otherwise. Examples of impaired skin integrity include, but are not limited to, pressure injuries, venous (stasis) ulcers, arterial (ischemic) ulcers, diabetic (neuropathic) ulcers, surgical wounds, skin tears, and rashes.R1's diagnoses includes lymphedema (tissue swelling often in an arm or leg), venous insufficiency, and non pressure chronic ulcer of other part of right lower leg.R1's admission assessment dated [DATE] documents under the skin integrity section includes documentation of skin issues to the right lower leg front.R1's physician order dated 5/14/25 documents Wound care to bilateral lower extremities: remove old dressing, wash wounds with soap and water rinse areas and pat dry. Apply 3 layer profore wrap from base of toes to base of knee q (every) Tuesday and Friday, every day shift every Tue (Tuesday), Fri (Friday). This treatment was discontinued on 5/21/25.R1's physician order with an order & start date of 5/21/25 documents Wash RLE (right lower extremity) with soap and water pat dry apply calcium alginate to small open area to R (right) lat (lateral) shin cover with a 2 x (by) 2 then wrap leg with ace wrap from mid foot to knee daily and prn as needed.Surveyor reviewed R1's May TAR (treatment administration record). Surveyor noted R1's treatment with an order date & start date of 5/21/25 was not scheduled for daily and was only scheduled for PRN. Surveyor noted from 5/21 to 5/31 there are no checks & initials indicating the treatment was provided PRN.R1's wound evaluation dated 5/27/25 by Wound Physician-G documents Lymphademic wound of the right leg (resolved on 5/27/25).On 6/30/25, at 9:27 a.m., Surveyor informed Director of Nursing (DON)-B R1 was admitted with a right lower leg wound. On 5/21/25 the physician changed R1's treatment to wash the right lower extremity with soap & water, pat dry, apply calcium alginate and cover with a two by two daily and as needed. Surveyor had reviewed R1's May 2025 treatment record, noted this order was in the prn orders but did not see the scheduled order. Surveyor informed DON-B daily treatment was not provided until the wound healed on 5/27/25. DON-B informed Surveyor she will look into this and get back to Surveyor. On 6/30/25, at 1:40 p.m., Surveyor asked DON-B if there is any information as to why R1's treatment ordered on 5/21/25 and scheduled daily was not provided. DON-B did not have any information to provide to Surveyor.No additional information was provided as to why the facility did not ensure R1 received treatment and care in accordance with professional standards of practice for R1's non-pressure related wound.

Based on interview and record review, the facility did not ensure the facility that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider or a discharge summary that includes a recapitulation of the resident's stay to ensure a safe and orderly discharge for 2 (R2, R4) or 2 residents.* R2 has no documented discharge summary included recapitulation of R2's stay in the facility in R2's medical record. There was not documentation that R2 was explained or educated on medications, follow up appointments, self-catheterization or therapies that R2 was to receive after discharge home. * R1 had no discharge documentation, including a recapitulation of R1's stay, sent with R1 when R1 was discharged on 6/11 to an assisted living facility until R1 was already discharged from the facility and residing at the assisted living facility.Findings include:The facility's policy titled, Transfer and discharge: Implemented: June 2017, Reviewed: July 15, 2022, documents:Anticipated Transfers or Discharges-initiated by the resident.A. Obtain physicians' orders for transfer or discharge instructions of precautions for ongoing care.B. A member of the interdisciplinary 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 is not limited to the following:i. A recap of the resident's stay that includes diagnosis, 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 (both prescribed and over the counter). 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. D. Assist with transportation arrangement to the new facility and any other arrangements as needed.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. F. Supporting documentation shall include evidence of the resident's or resident's representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative.1.) R2 was admitted to the facility on [DATE] with diagnosis that include urinary tract infection, hydronephrosis (a condition where the kidney swells due to a buildup of urine, typically caused by a blockage or obstruction in the urinary tract), and acute kidney injury. R2's Discharge Minimum Daily Set (MDS) with an assessment reference date of 4/02/25 documents a Brief Interview for Mental Status score of 14, indicating R2 as being cognitively intact. Under section GG Functional abilities and goals it documents R2 as requiring set up or clean up assist (helper sets up of cleans up resident completes activity. with Chair/bed to chair transfer, toileting hygiene and shower and bathing.R2's non-pressure weekly tracker dated 3/29/25, at 2:05 PM documents R2 had a skin tear acquired on the right dorsal foot. Measured: Length1.5x Width 0.1. Tissue type: 75% epithelial and 100% granulation with light bloody drainage.R2's physician's order dated 03/31/25 documents (PT and OT) physical and occupational therapy 5 times a week for 4 weeks. R2's nursing note dated 4/2/25, at 4:35 PM, documents the current resident status is resident has discharged to home and skin is healed.On 6/26/25, at 11:27 AM Surveyor interviewed Nursing Home Administrator (NHA)-A about R2's discharge process. Surveyor asked if the facility documented all the education and discharge instructions for R2's discharge to home on 4/2/25. NHA-A informed Surveyor that it was documented that R2 was discharged home. Surveyor asked NHA-A if a recapitulation of R2's stay including any home health or PT and OT that R2 was to receive once R2 was home and was this information included in R2's discharge summary. NHA-A informed Surveyor that R2 was involved in R2's discharge. Surveyor asked NHA-A where that information was documented, because Surveyor noted a very basic summary stating that R2 was discharged home. NHA-A informed Surveyor that R2 was provided all information required when R2 was discharged . Surveyor asked NHA-A where that information was documented and could NHA-A provide the Surveyor with the documentation. NHA-A informed Surveyor that R2 declined PT, OT and Home Health services. Surveyor asked NHA-A if the Surveyor could see that documentation in R2's medical record. NHA- A informed Surveyor that R2's declination of service was not in the medical record, but that NHA-A sent out an email to the interdisciplinary team to inform them that R2 has declined Home Health services. Surveyor asked NHA-A if NHA could provide the Surveyor with the Email. NHA-A informed Surveyor that NHA-A would get the Surveyor the Email. Surveyor asked if NHA-A could provide Surveyor a copy of the Discharge Summary. NHA-A informed Surveyor that NHA-A would get the Surveyor a copy. Surveyor asked NHA-A if NHA-A could provide information on the status of R2's right dorsal skin tear acquired on 3/29/25 was healed, because surveyor could not find any information in R2's discharge documentation if the area was healed and if R2 needed to follow up treatment or perform dressing changes at home after discharge. NHA-A informed Surveyor that NHA-A would find out that information and get it to the Surveyor.On 6/26/25, at 12:00 PM, NHA-A informed Surveyor that NHA-A was still looking for the discharge documentation for R2 that Surveyor requested.On 6/26/25, at 12:22 PM Surveyor interviewed Nursing Home Administrator (NHA)-A about R2's discharge process. Surveyor was provided with R2's nursing note dated 4/2/25, at 4:35 PM, documents the current resident status is resident has discharged to home and skin is healed. Surveyor was given occupational therapy notes for 2/15/25 and discharge instructions from R2's hospital stay dated 2/28/25. Surveyor asked NHA-A if the facility had discharge paperwork for R2's discharge from the facility on 4/2/25. NHA-A provided an email dated 3/31/25 at 1:02 PM titled 'Discharges 04/02/25' that documented:R2 will be discharging home on Wednesday, 4/2. His brother will be here after 5PM. No DME needed. Resident decline HH referral. Surveyor asked NHA-A if the was all R2's discharge paperwork. NHA-A informed Surveyor that R2 was discharged with a packet that included R2's medication list and orders. NHA-A informed Surveyor that R2 had signed it and that the facility faxed the list to R2's pharmacy. NHA-A informed Surveyor the packet included a reminder that R2 was on a Regular diet and reminder to follow up with R2's community physician within 7 days of discharge. NHA-A provided the documents to the Surveyor. NHA-A informed Surveyor that there was no additional documentation the facility could provide to the Surveyor, but that it was the facilities customary practice to go over all discharge items with the resident. NHA-A informed Surveyor that R2 and R2's family did not feel that R2 needed any further services at home and that R2 could self-catheter, manage R2's medications and that family could help with the set-up assistance needed at home. Surveyor asked NHA-A if those conversations including any risks and benefits to declining OT, PT and Home Health services had been documented in R2's medical record or discharge summary. NHA-A informed the Surveyor that none of those conversations had been documented in R2's medical record or discharge summary. NHA-A informed Surveyor that NHA-A was working on a discharge form to cover these areas during a discharge of a resident, but it was complete yet. Surveyor informed NHA-A that the Surveyor had a concern there was very little information documented in R2's discharge especially the recapitulation of the resident's stay and any education or risks provided to R2 by declining services. Surveyor asked NHA-A how the facility could verify R2 received and understood R2's discharge instructions without documentation. NHA-A informed Surveyor that R2 was very informed in R2's care and understood all discharge instruction. NHA-A informed Surveyor that NHA-A was working on a form to try and capture that information in the future.On 6/26/25, at 02:59 PM Surveyor informed [NAME] President (VP)-M, Director of Nursing (DON)-B and NHA-A of Surveyor's concern that R2's Discharge Summary and documentation very little information that showed a safe orderly discharge to R2's home. DON-B informed Surveyor that it was documented that R2's foot was healed and that R2 did not need any dressing or wound care instruction for discharge. Surveyor informed DON-B that a recapitulation of R2's stay and the conversations around R2's declination of services and any education should have been in the medical record and discharge summary. No additional information was provided. 2.) R1 was admitted to the facility on [DATE] with diagnoses that includes dementia (loss of cognitive function that interferes with a person's daily life & activities), lymphedema (tissue swelling often in an arm or leg), venous insufficiency, and PVD (peripheral vascular disease) (circulatory condition which narrows blood vessels reducing blood flow to limbs). R1's Advanced Practice Nurse Prescriber (APNP)-H note dated 5/22/25 documents under the Assessment and Plan section: *F03.918 - Unspecified dementia, unspecified severity, with other behavioral disturbance*: Patient demonstrates confusion and poor recall during today's visit. Plans are in place for her to return to a memory care facility. Will continue to monitor cognitive status and ensure safe environment. R1's IDT (interdisciplinary team) clinical review note dated 6/2/25, at 9:23 a.m., written by Previous Nursing Home Administrator (NHA)-I documents Interdisciplinary team reviewed fall at morning meeting. Resident has cognition deficit and is impulsive. OT (occupational therapy) to work on safe toileting techniques. Resident also had a visit from ALF (Assistant Living Facility) this day. Care plan updated.R1's social service note dated 6/2/25, at 15:47 (3:47 p.m.), written by NHA-A, who was the previous social worker, documents Writer spoke with resident's AHCPOA (activated health care power of attorney) stated resident is agreeable at times and other times needs redirection regarding the importance of going to [Assisted Living Facility Name]. Writer placed call to [Assisted Living Facility Name] and left voicemail for DON (Director of Nursing) to discuss documents needed for a smooth transition.R1's physician orders dated 6/3/25 documents May discharge to [Name] Memory Care facility when bed is available on currently prescribed medications.R1's progress note dated 6/3/25, at 19:21 (7:21 p.m.), written by Registered Nurse (RN)-J under summary documents Resident pleasant and cooperative. Alert and Ox3 (orientated times three). No c/o (complaint of) pain. Therapeutic diet. Independent with meals. Possible d/c (discharge) tomorrow. Resident aware but stated, might not be tomorrow. Order is in place however.R1's social service note dated 6/10/25, at 9:23 a.m., written by NHA-A, who was the previous social worker, documents Writer spoke with resident's AHCPOA on 6/9 to issue NOMNC (Notice of Medicare Non-Coverage) with LCD (last covered date) of 6/11 and discharge of 6/12. Writer received an email from AHCPOA stated she was not able to access the document. Writer resent NOMNC for AHCPOA to sign. AHCPOA notified writer that she will have resident discharge to [Assisted Living Facility Name] on 6/11.R1's Recapitulation of Stay - Discharge Summary with an effective date of 6/10/25 Section A. discharge information was e-signed on 6/15/25 by Director of Nursing (DON)-B. Section B Social Services was e-signed on 6/10/25 by Nursing Home Administrator (NHA)-A, who was the former social worker, on 6/10/25. Section C Nursing and rehab Services was e-signed on 6/15/25 by DON-B. Section D Dietary Services & Section E Activity Summary was e-signed on 6/10/25 by NHA-A. Section F Physician Signature was signed on 6/19/25.R1's discharge note dated 6/11/25, at 13:00 (1:00 p.m.), written by Licensed Practical Nurse (LPN)-E documents Discharge Location: ALF. discharged With: Res (Resident) discharged with all personal belongings and personal W/C (wheelchair). Family here assisted res with belongings. Belongings: Medications: All medication returned to pharmacy. Skin check: Vitals: Additional Information: Res in good spirits, 0 c/o (complaint of) pain/discomfort.On 6/26/25, at 9:32 a.m., Surveyor spoke with Assisted Living Staff-K on the telephone. Surveyor asked Assisted Living Staff-K if the facility sent a discharge summary with R1 when she was transferred to their facility on 6/11/25. Assisted Living Staff-K replied no, I had to call and ask them to send it. Assisted Living Staff-K informed Surveyor they did send discharge orders which were their admitting orders.On 6/26/25, at 11:19 a.m., Surveyor informed LPN-E her discharge note does not include what paperwork was sent with R1 when she was discharged to the assisted living facility on 6/11/25 and inquired how would Surveyor know what paperwork was sent. LPN-E informed Surveyor she didn't have to send any paperwork as it was already taken care of. Surveyor asked LPN-E who would of sent the discharge summary. LPN-E replied [first name of Medical Records Coordinator (MRC)-L].On 6/26/25, at 11:28 a.m., Surveyor asked MRC-L if she is involved when a resident is discharged . MRC-L replied yes and explained when the Social Worker or Director of Nursing (DON) as her to do something. MRC-L explained she'll print off the orders and get the orders signed by the medical doctor. Surveyor asked MRC-L if she was involved with R1's discharge. MRC-L replied I was not, she went to another facility. I got the orders signed by the doctor.On 6/26/25, at 11:58 a.m., Surveyor asked DON-B what is the process when a resident is discharged to another facility. DON-B explained they get orders, some assisted living facilities want their medication, others don't want the medication, the Nurse Practitioner comes every Thursday and will sign the discharge. DON-B informed Surveyor they do a summary with medication list. DON-B informed Surveyor they either fax the medication list to the pharmacy or send home the resident home with medication. Surveyor asked who faxes over the information. DON-B informed Surveyor the first names of MRC-L or Nursing Home Administrator (NHA)-A. Surveyor asked if there is a discharge summary. DON-B informed Surveyor they do a recapitulation of stay. Surveyor asked when this is completed. DON-B informed Surveyor they start working prior to discharge. Surveyor asked DON-B who would of sent R1's recapitulation of stay with R1 when she was discharged to the assisted living on 6/11/25. DON-B informed Surveyor they didn't have any communication with the assisted living. Surveyor asked what paperwork is sent with the resident. DON-B informed Surveyor a medication list, history and physical and discharge summary. Surveyor asked DON-B if this was sent with R1. DON-B informed Surveyor it should have. DON-B informed Surveyor she thinks she got a call in the evening asking for the paperwork. Surveyor asked if this call was after R1 was discharged . DON-B replied yes. Surveyor asked why the paperwork wasn't sent with R1. DON-B replied I'm not sure what happened, usually we have it all done. DON-B informed Surveyor she faxed over the paperwork. DON-B explained usually the facility will call and say what they need. Surveyor asked DON-B if the receiving facility doesn't call what do you do. DON-B replied doesn't happen that was strange. Surveyor asked DON-B if the nurse discharging R1 could send the paperwork. DON-B replied she could of. DON-B informed Surveyor they should of sent a signed medication list. DON-B informed Surveyor this was not typical and this is an area they are working on.On 6/26/25, at 12:25 p.m., Surveyor asked NHA-A if she was involved with R1's discharge. NHA-A informed Surveyor R1 went to [Name of Assisted Living Facility] memory care. Surveyor asked NHA-A what was her involvement with the discharge. NHA-A informed Surveyor she was in communication with the oldest daughter who was the APOA (activated power of attorney) and they (the family) did a lot of communicating with the assisted living facility. NHA-A informed Surveyor she attempted to reach out to the assisted living facility but they didn't call back. Surveyor asked NHA-A if she sent any paperwork regarding R1's discharge to the assisted living. NHA-A informed Surveyor in the record she can't tell what was sent with her. Surveyor asked NHA-A if she could look into this and get back to Surveyor. On 6/26/25, at 3:05 p.m., during the end of the day meeting with NHA-A, DON-B and [NAME] President (VP) of Success-M Surveyor informed facility staff it's Surveyor's understanding no discharge paper work was sent with R1 when she was discharged on 6/11 to the assisted living until R1 was already there. NHA-A replied correct. Surveyor asked who is responsible for sending paperwork. DON-B informed between medical records and herself. Surveyor was informed this is something the facility is currently working on as they did not send papers if a resident was going to an assisted living. DON-B indicated when the assisted living called she gathered everything and sent it over. No additional information was provided.

Based on observation, interview, and record review, the Facility did not ensure 1 (R23) of 4 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. R23 had a guided assist to the floor when being transferred with a gait belt and 1 staff member assist. R23 was assessed and the care plan documented R23 required a gait belt and 2 staff members assist with transfers. Findings include: The facility policy titled Fall Prevention and Management Guidelines revised on 7/18/2024 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. Policy Explanation and Compliance Guidelines: . 4. Suggested standard interventions may include: . c. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. R23 was admitted to the facility on [DATE] and has diagnoses that include transient ischemic attack (TIA) and cerebral infarction (CVA) without residual effects, history of alcohol use, depression, myocardial infarction, and congestive heart failure. R23's admission minimum data set (MDS) dated [DATE] indicated R23 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13, and the facility assessed R23 needing moderate assist with 2 staff members for transferring. R23 did not have impairments to the upper or lower extremities. R23's Care Area Assessment (CAA) for falls documents: At risk for falls . Cognition/Orientation: alert and oriented X3 (person, place, time), current BIMS is a 13 and is usually able to make needs known to staff. [R23] is working with physical therapy (PT) and occupational therapy (OT) services to improve functional status. [R23] requires assist with activities of daily living (ADL's). [R23] is at risk for falls and is non-ambulatory at this time. R23 was assessed on 3/6/2025 to be at risk for falls with a fall risk score of 16. R23's ADL self-care deficit related to CVA, and long-term effects of alcohol abuse care plan was initiated on 3/6/2025 with the following interventions: . - TRANSFER: assist of two - TRANSFER: May pivot transfer with gait belt and 2 assist but resident gets stiff and anxious making pivot transfer difficult at times, may use sit to stand lift. R23's at risk for falls due to history of falls care plan was initiated on 3/6/2025 with the following interventions: - Bed in low position. - Have commonly used articles within easy reach. - Reinforce need to call for assistance. - Reinforce wheelchair safety as needed such as locking brakes. - Resident has history of self-transferring, encourage to ask for assistance (initiated 3/20/2025) On 3/19/2025, at 21:07 (9:07 PM), in the progress notes nursing documented R23 assisted back into bed from the floor sitting. post fall assessment started . frequent checks on R23, no pain or discomfort noted . On 3/20/2025, at 14:41 (2:41 PM), in the progress notes an interdisciplinary team (IDT) noted documented review of fall at morning meeting. [R23] was accompanied by staff when lowered to the ground after attempting transfer twice. Previously [R23] stated wanting to self-transfer but decided against is after staff intervention. Post fall intervention to encourage resident to wear shoes as proper footwear was unavailable other than gripper socks. Surveyor reviewed the fall investigation for R23's witnessed fall on 3/19/2025. In the incident description section nursing documents: - Certified nursing assistant (CNA) came to nurse to report R23 was lowered to the floor in R23's room while transferring from the wheelchair to the bed. R23 is weak in the legs and stated that they gave out. R23 had a gait belt on and was lowered to the floor, R23 is a one times assist. In the other information section nursing documents: - R23 is a one times assist with transfers but R23's legs gave out while R23 was standing with the CNA. Surveyor notes per R23's care plan, R23 is to be transferred with assist of two and may use a sit to stand lift if R23 gets stiff and anxious making transfer difficult. Surveyor notes there is no documentation indicating a second staff member assisted with R23's transfer on 3/19/25. On 3/25/2025, at 2:43 PM, Surveyor interviewed Director of Therapy/Physical Therapist (PT)-E who stated R23 required an assist of 2 with a gait belt for transfers and at the time R23 was assisted to the floor. PT-E stated R23 can be impulsive, so frequent reeducation and direction is necessary so R23 does not do things alone such as transferring. On 3/25/2025, at 3:21 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R23 was not transferred according to their assessed need and care plan on 3/19/2025 and subsequently R23 was lowered to the ground. On 3/25/2025, at 3:41 PM, Surveyor interviewed CNA-F. DON-B was also present during the interview. CNA-F stated CNA-F went into R23's room and R23 was sitting in the wheelchair and wanted to go to bed. R23 stated that R23 was cleared to transfer independently. CNA-F did not think that was the case and told R23 CNA-F was going to help. CNA-F put the gait belt on R23 and started to transfer but R23's legs started to buckle so CNA-F lowered R23 to the ground and notified nursing. CNA-F stated CNA-F figured R23 was an assist of one. Surveyor asked where staff would look to verify the transfer status of a resident. CNA-F stated there is a black book at the nurse's station and can also go into point click care (PCC/electronic medical record) to view what transfer status the resident is. CNA-F stated CNA-F did not look to verify what transfer status R23 was prior to transferring R23 by self. DON-B stated R23 can be impulsive and had been trying to self-transfer and when R23 goes to stand up, R23 has a tendency to propel self-up really fast out of the wheelchair. On 3/26/2025, at 8:36 AM, Surveyor was provided a document titled, Verification of Investigation that was dated 3/20/2025 and signed by NHA-A and dated 3/21/2025 and signed by DON-B. In the section titled Summary of factual investigative findings the following is documented: The certified nursing assistant prevented the resident from having an unassisted fall by stepping in and helping in the moment [R23] was attempting to self-transfer from the chair to the bed. In the section titled Interview summary the following is documented: CNA-F provided a verbal statement after reenacting the fall for NHA-A, DON-B, and Director of Social Services. CNA-F reported R23 was observed attempting to self-transfer. R23 was asked not to transfer independently . CNA-F demonstrated how R23 got up quickly and CNA-F was not able to transfer R23 comfortably with the gait belt and sat R23 back down. R23 was insistent that R23's socks be taken off, with much encouragement to leave socks on CNA-F took R23's socks off and attempted to transfer R23 but R23's legs buckled, and CNA-F lowered R23 to the ground. Surveyor reviewed a statement written by CNA-F. Surveyor notes the statement is not dated as to when it was written. The statement documents: I (CNA-F) came into the room and R23 was sitting in the wheelchair and wanted to go into R23's bed. R23 asked if R23 does it by self. CNA-F replied no, and CNA-F will help. R23 stated that R23 was cleared by therapy to transfer independently. CNA-F replied no and thought R23 was assist of 1. CNA-F documented that the gait belt was put on and started to transfer R23 when R23 became unsteady and was lowered to the floor. Surveyor notes the statement written by CNA-F does not indicate R23 was attempting to self-transfer as CNA-F happened to walk in or that CNA-F took off R23's socks as documented in the verification of investigation report. On 3/26/2025 Surveyor shared concern with NHA-A and DON-B that R23 was transferred with assist of 1 staff member which is not according to what R23's assessed needs or care plan document which is an assist of 2 staff members and the statement details do not match regarding R23's fall on 3/19/2025.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 2 (R7 and R23) of 6 residents reviewed. Registered Nurse Unit Manager (RN UM)-H and RN-G did not wear appropriate personal protective equipment (PPE) during a treatment observation for R7. RN UM-H and RN-G were not aware of where PPE is kept for residents requiring enhanced barrier precautions. There was not an enhanced barrier precaution (EBP) sign on R23's door consistent with other residents identified as requiring EBP. Registered Nurse (RN)-I did not wear appropriate personal protective equipment (PPE) during a treatment observation for R23. R23 has a stage 4 pressure injury to the left outer ankle requiring a dressing and did have light serous drainage on 3/25/2025. Findings include: The facility policy titled Enhanced Barrier Precaution reviewed/revised on 8/8/2024 documents: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms (MDROs). Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistance organisms that employs targeted gown and glove use during high contact resident care activities. Policy Explanation and Compliance Guidelines: . 2. Initiation of EBP: . b. An order for EBP (in accordance with physician-approved standing orders) will be initiated for the residents with any of the following: i. Wounds (e.g. chronic wounds such as pressure ulcers, .) . even if the resident is not known to be infected or colonized with a MDRO. 3. Implementation of EBP: a. Make gowns and gloves available immediately near or outside of the resident's room. 4. High-contact resident care activities include: . h. Wound care: any chronic skin opening requiring a dressing. CDC (Centers for Disease Control and Prevention), Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021 documents: . 23. The guidance describes that all residents with wounds would meet the criteria for Enhanced Barrier Precautions. What is the definition of a wound in relation to this guidance? In the guidance, wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. However, the intent of Enhanced Barrier Precautions is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, and chronic venous stasis ulcers. Ostomies, such as colostomies or ileostomies, are not defined as a wound for Enhanced Barrier Precautions. CDC Long-Term Care Facilities, Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes, dated June 28, 2024, documents . 13. If a resident does not have a history of a MDRO but does have an indwelling medical device or wound, should they still be placed on Enhanced Barrier Precautions? Yes. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. 1) R7 was admitted to the facility on [DATE] and has diagnoses that include wedge compression to the first lumbar vertebra, history of alcohol use, dementia, left femur fracture, severe protein-calcium malnutrition, delusional disorder, anxiety disorder, and depression. On 3/24/2025, at 10:05 AM, Surveyor observed R7 sitting in a wheelchair with a green pillow boot on the left foot and an EBP sign outside of R7's bedroom door. Surveyor did not notice personal protective equipment (PPE) available outside of R7's bedroom door or inside R7's bedroom. R7's physician orders included an order for EBP due to wound to left heel every shift. On 3/25/2025, at 8:46 AM, Surveyor interviewed certified nursing assistant (CNA)-J who stated PPE is located in the resident's room in one of their dresser drawers. On 3/25/2025, at 1:35 PM, surveyor observed R7's left heel wound treatment. RN UM-H washed RN UM-H hands and put on gloves and assisted in holding R7's leg up. RN-G washed RN-G's hands, put on gloves and performed the treatment to R7's left heel. Surveyor noted RN UM-H and RN-G did not put on a gown for R7's wound treatment. Surveyor asked where PPE is kept for residents that are on EBP. RN UM-H replied RN UM-H was not sure where the PPE is kept, PPE used to be in carts by the residents' doors, but not sure where it is anymore. RN-G did not respond to Surveyor. Surveyor asked if a resident is on EBP, what kind of PPE is needed during high contact interventions such as wound care treatment. RN UM-H stated that RN UM-H does what they tell us to do. RN-G did not reply to Surveyor. RN UM-H stated RN UM-H will find out where the PPE is kept for Surveyors knowledge. On 3/25/2025, at 1:45 PM, RN UM-H notified Surveyor that PPE is kept in the resident's room in a dresser drawer. On 3/25/2025, at 3:00 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and [NAME] President of Success (VP Success)-C of Surveyors observations of RN UM-H and RN-G not donning a gown during R7's wound treatment and RN UM-H was not aware where PPE is kept in the facility. DON-B stated she was aware of the observation and has already provided reeducation to the staff on the expectations of when to put on PPE and where PPE is located. 2) R23 was admitted to the facility on [DATE] and has diagnoses that include transient ischemic attack (TIA) and cerebral infarction (CVA) without residual effects, history of alcohol use, depression, myocardial infarction, congestive heart failure, and stage 2 and stage 4 pressure injuries. On 3/24/2025, at 12:59 PM, Surveyor observed R23 sitting in a wheelchair eating lunch. R23 was ok to talk with Surveyor at this time. R23 stated R23 fell at home and was on the ground for awhile and had some open areas when they came to the facility. R23 stated most of the open areas are closed and could not remember if staff were doing treatments anymore. Surveyor noted R23 did not have an enhanced barrier precaution (EBP) sign outside of R23's door and no personal protective equipment (PPE) outside of R23's door or in R23's room. R23's weekly pressure injury tracker dated 3/25/2025 documented: - Left outer ankle, pressure injury stage 4, present on admission. - 2 cm (centimeters) X 2 cm X 0.3 cm (length X width X depth), 60% granulation tissue, 40% slough. - Light serous drainage, no odor or infection noted. Surveyor did not find a physician order for EBP. On 3/26/2025, at 11:28 AM, Surveyor observed wound treatment to R23's left outer ankle performed by registered nurse (RN)-I. Surveyor noted there was not an EBP sign outside of R23's door. RN-I washed RN-I's hands and put on gloves. RN-I performed R23's treatment as ordered. Surveyor notes RN-I did not don a gown during R23's left ankle wound treatment. RN-I and Surveyor walked out into the hallway together, RN-I stated to Surveyor, I'm (RN-I) just going to say right now I did not put on a gown. Surveyor asked RN-I if a gown should have been put on. RN-I replied yes. On 3/26/2025, at 11:37 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if R23 should be on EBP. DON-B stated R23 is not on EBP because R23's left ankle wound is not chronic and there is no drainage. Surveyor reviewed the QSO-24-08-NH memo that was issued 3/20/2024. The memorandum Summary Documents: . - EBP recommendations now include use of EBP for residents with chronic wounds . Guidance: . - EBP are used in conjunction with standard precautions and expand the use of PPE to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms (MDROs)to staff hands and clothing. EBP are indicated for residents with any of the following: . -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. - Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (Band-Aid). - Examples of chronic wounds include, but are not limited to, pressure ulcers . On 3/26/2025, at 11:49 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B. Surveyor asked what standards of practice the facility based their criteria for EBP on. DON-B stated the facility based the EBP policy off of CMS recommendations. NHA-A showed Surveyor the QSO-24-08-NH memo from 3/20/2024. Surveyor asked how the facility defines a chronic wound. DON-B stated DON-B would think it was a wound that did not heal within 6 months. Surveyor noted there was no date range indicating what a chronic wound was, but the memo does state that chronic wound example does state pressure injuries and R23 has a stage 4 pressure injury to the left outer ankle requiring a dressing and did have documented light serous drainage on 3/25/2025. DON-B and NHA-A stated they would review the policy so they could educate staff appropriately. Surveyor shared concern R23 does not have EBP initiated for having a wound and RN-I did not wear gown during R23's treatment to R23's left ankle wound.

Based upon interview and record review, the facility did not ensure the mandatory staffing data, submitted for the fourth quarter of 2024 (July 1st-September), was accurate. During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for low weekend staffing. This had the potential to affect all 27 residents. Findings include: Review of the facility PBJ data, as part of the survey offsite process, indicates during the fourth quarter of the federal fiscal year 2024 (July 1st - September 30th) the facility was triggered for excessively low weekend staffing. Surveyor did conduct a review of the daily staff schedules from July 1, 2024, to September 30, 2024. Surveyor noted both licensed nurses and certified nursing assistants present on each shift and for each unit. When call-ins happened, it was indicated on the schedule and it also was documented who placed the call-in, if applicable. On 03/25/25, at 03:05 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A and [NAME] President of Success (VP of Success)- C regarding the PB& J staffing report indicating excessively low staffing on the weekends for quarter #4. NHA- A stated that although she was not the Administrator at the time, she was made aware of the report. NHA- A stated the facility identified that sometimes Scheduler- D will fill in as a Certified Nursing Assistant on the weekends but not clocked-in as such. Her time punches would still identify her as Medical Records/Scheduler. VP of Success- C stated around the time in question (July- September 2024) the corporation started to use a new payroll system. They identified the use agency staff was not always reflected on the staffing report because they were not punching in on the same time clock, so those hours were also not recorded. VP of Success- C stated the facility rarely uses agency staff but when they do, they have fixed the time entries for the payroll/staffing report. On 03/26/25, at 09:33 AM, Surveyor interviewed Scheduler- D regarding staffing on the weekends and the payroll-based reporting. Scheduler- C stated she usually does not have a problem with staffing including on the weekends. She will get an occasional call-in and if she is unable to fill the spot she will help-out as a CNA. Scheduler- C stated she was slightly familiar with the PB& J reporting and was made aware there were concerns about not accurately reporting the hours. Scheduler- C stated she had not been clocking in as a CNA if she helped on the floor but that has changed, and she now enters her time for the work performed as a CNA. Scheduler- D also stated that they have changed the way agency staff clocks -in and this is now reflected in the staffing report.

Based on interview and record review the facility did not have a qualified Infection Preventionist who worked at least part time which had the potential to affect all 24 residents residing in the facility. *The Director of Nursing (DON)-B was serving as the facility's Infection Preventionist and did not have proper credentials. Findings include: On 02/08/24 08:53 AM, Surveyor interviewed DON (Director of Nursing)-B. DON-B informed Surveyor she had overseen infection control since August. Per DON-B, Nursing Home Administrator (NHA)-A assists with Infection Control if the facility has a Covid outbreak. DON-B informed Surveyor she had not completed an infection control certification training program. Per DON-B she had started the CDC (Center for Disease Control) modules but had never completed them. DON-B stated she does plan on completing the training and taking the test. On 02/08/24 at 9:30 AM, Surveyor interviewed NHA-A. NHA-A informed Surveyor he kept track of all the Covid testing and line lists during the facility's Covid outbreak in November. Per NHA-A, he is not Infection Control certified. NHA-A stated DON-B was working on completing the modules. Surveyor relayed the concern of the facility not having an Infection Control certified personnel overseeing the Infection Control program. No additional information was provided.

Based on interview, and record review, the Facility did not ensure 1 (R11) of 5 residents were free from unnecessary medications. *R11 was prescribed Seroquel (Quetiapine) without adequate diagnoses, quantitative behavior monitoring and a lack of a timely Abnormal Involuntary Movement Scale (AIMs) assessment. Findings include: Facility policy entitled, Psychotropic Medications, revised on 10/24/22 documented: Residents should not received psychotropic drugs unless the medication is necessary to treat specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrator by monitoring and documentation of the resident's response to the medication .The indications for use of any psychotropic drug will be documented in the medical record .Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation .Residents who receive an antipsychotic medication will have an AIMs test performed on admission, at least every 6 months, when the antipsychotic medication is changed and PRN (as needed.) . R11 was admitted to the facility on [DATE] and has current diagnoses including Dementia, Depression and Anxiety. R11's most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/2/24, documented R11 was unable to complete the Brief Interview for Mental Status (BIMs) assessment, indicating R11 had severe cognitive impairments; R11 had 1-3 days of physical behaviors; 4-6 days of verbal behaviors; 1-3 days of other behaviors and 1-3 days of rejection of care. This MDS did not address the impact of these behaviors on R11. R11's previous Quarterly MDS assessment dated [DATE] documented R11 had inattentive and disorganized thinking; 1-3 days of physical behaviors; 4-6 days of verbal behaviors; 1-3 days of rejection of care; R11 was not risk for physical injury; R11's behaviors did not interfere with care or participation in social activities; did not put other residents at risk for physical harm and did not disturb living environment. Surveyor reviewed four of R11's most recent Quarterly MDS assessments and noted this assessment, 11/05/23, was the only assessment that addressed the impact of R11's behaviors. R11's Quarterly MDS, dated [DATE] documented R11 had no days of physical behaviors; 1-3 days of verbal behaviors, and no rejection of cares. R11's Quarterly MDS, dated [DATE] documented R11 had 1-3 days of physical behaviors, 4-6 days of verbal behaviors, and no rejection of cares. R11's current Care Plan entitled, Inappropriate calling out r/t (related to) cognitive impairment Dementia, initiated in 6/5/23 had interventions including: -Administer medications as ordered, -Attempt to redirect when calling out to minimize resident agitation; -Avoid type of conversation that could encourage or initiate inappropriate behavior; -Distract if possible and remain calm and avoid angry reactions if exhibits behavior. R11's current Care Plan entitled, At risk for adverse effects r/t use of antipsychotic medication, initiated on 01/28/24 had interventions including: -AIMS testing per facility guidelines . -Evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs . -Non-pharm Interventions for behaviors: 1. Address in calm manner 2. Attempt to orientate to place and time 3. Allow resident to express feelings . Notify physician of decline or mood/behavior related to dose change . Target Behavior: 1. Yelling out Interventions: Attempt to identify needs; Redirect as able; Offer snacks Target Behavior 2. Striking out Interventions: Attempt to redirect and ensure resident is safe and reapproach Surveyor noted the following active physician's order in R11's Electronic Health Record (EHR): Seroquel Oral Tablet 25 MG (milligrams) (Quetiapine Fumarate) Give 1 tablet by mouth two times a day related to UNSPECIFIED DEMENTIA, MODERATE, WITH OTHER BEHAVIORAL DISTURBANCE;ANXIETY DISORDER, UNSPECIFIED (F41.9) AND Give 2 tablet by mouth at bedtime related to UNSPECIFIED DEMENTIA, MODERATE, WITH OTHER BEHAVIORAL DISTURBANCE Active date of 01/16/2024. Surveyor reviewed R11's discontinued Physician's orders and noted the following Seroquel (Quetiapine) orders: Seroquel 25mg 0.5 tab one time a day from 05/16/23-07/28/23. This was the first Seroquel order since discontinuing R11's Seroquel a year prior. On 7/28/23, the physician increased R11's Seroquel to 25 mg two tablets a day. On 12/29/23, the physician changed the Seroquel order to 25 mg one tablet twice a day. On 01/16/24, the physician changed the order to 25 mg one tablet twice a day and two tablets at hour of sleep. Surveyor noted R11 had the following behavior monitoring order, active since May 2021, Monitor resident's moods, behaviors, sleep patterns, oral intake and document. Monitor for lethargy .UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE. Surveyor noted R11 had another behavior monitoring order which started in September 2023, BEHAVIORS - MONITOR FOR THE FOLLOWING: (specify) ITCHING, PICKING AT SKIN, RESTLESSNESS (AGITATION), HITTING, INCREASE IN COMPLAINTS, BITING, KICKING, SPITTING, CUSSING, RACIAL SLURS, ELOPEMENT, STEALING, DELUSIONS, HALLUCINATIONS, PSYCHOSIS, AGGRESSION, REFUSING CARE. If any NEW behaviors observed, document in progress note. Surveyor noted R11 started on Seroquel in May 2023, with an increase in July 2023; however, Surveyor could not locate resident specific, quantitative behavior monitoring related to the Seroquel until September 2023. Surveyor noted multiple nursing progress notes from May 2023 to present documenting R11's behaviors such as yelling out, striking out and inappropriate language with staff. Surveyor did not locate behavior documentation specific to the start of the Seroquel, the effectiveness of the Seroquel or the need to increase the Seroquel. Surveyor reviewed R11's progress notes and noted the following documentation from the Facility's pharmacist: On 5/17/23 the Pharmacy Review progress note read, Recommendations made .quetiapine (Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbances, started 5/16/23 (not appropriate for long term use) .AIMs needed and behavior monitoring. On 6/11/23 the Pharmacy Review progress note read, Recommendations made .quetiapine (Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbances, started 5/16/23 (not appropriate for long term use) .AIMs needed and behavior monitoring .June 2023: continued behaviors, hitting staff, disrupting the unit with screaming/noise .consider increase in Sertraline and/or Melatonin. On 07/31/23 the Pharmacy Review progress note read, Recommendations made .quetiapine(Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbances, started 5/16/23 (not appropriate for long term use) .AIMs needed and behavior monitoring .June 2023: continued behaviors, hitting staff, disrupting the unit with screaming/noise .consider increase in Sertraline and/or Melatonin. July 2023: Quetiapine (Seroquel) 50 mg at bedtime and sertraline 37.5 mg/day. AIMs needed. On 08/31/23 the Pharmacy Review progress note read, Recommendations made .quetiapine (Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbances, started 5/16/23 (not appropriate for long term use) .AIMs needed and behavior monitoring .June 2023: continued behaviors, hitting staff, disrupting the unit with screaming/noise .consider increase in Sertraline and/or Melatonin. July 2023: Quetiapine (Seroquel) 50 mg at bedtime and sertraline 37.5 mg/day. August 2023: same psychotropic medications .AIMs needed. On 09/18/23 the Pharmacy Review progress note read, Recommendations made .quetiapine (Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbances, started 5/16/23 (not appropriate for long term use) .AIMs needed and behavior monitoring .June 2023: continued behaviors, hitting staff, disrupting the unit with screaming/noise .consider increase in Sertraline and/or Melatonin. July 2023: Quetiapine (Seroquel) 50 mg at bedtime and sertraline 37.5 mg/day. August 2023: same psychotropic medications AIMs needed. 10/31/23 the Pharmacy Review progress note read, Recommendations made .quetiapine (Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbances, started 5/16/23 (not appropriate for long term use) .AIMs needed and behavior monitoring .June 2023: continued behaviors, hitting staff, disrupting the unit with screaming/noise .consider increase in Sertraline and/or Melatonin. July 2023: Quetiapine (Seroquel )50 mg at bedtime and sertraline 37.5 mg/day. August 2023: same psychotropic medications AIMs needed, October 2023: consider sertraline increase 50 mg per day x 1 week, then increase to 100 mg/day and for the quetiapine (Seroquel) 50 mg at bedtime every day except 25 mg at bedtime on Wednesdays. Then if there is some improvement-we can decrease quetiapine (Seroquel) again in November 2023. Per state and CMS (Center for Medicare Services) we need to reduce the antipsychotic in residents with dementia . On 11/19/23 the Pharmacy Review progress note read, Recommendations made .quetiapine (Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbances, started 5/16/23 (not appropriate for long term use) .AIMs needed and behavior monitoring .June 2023: continued behaviors, hitting staff, disrupting the unit with screaming/noise .consider increase in Sertraline and/or Melatonin. July 2023: Quetiapine (Seroquel ) 50 mg at bedtime and sertraline 37.5 mg/day. August 2023: same psychotropic medications AIMs needed, October/ November 2023: consider sertraline increase to offset taper down on quetiapine (Seroquel). Per state and CMS (Center for Medicare Services) we need to reduce the antipsychotic in residents with dementia . Surveyor could not locate an AIMs assessment until 01/18/24. The results of the assessment were negative. Surveyor could not locate documentation R11's physician was aware of the above recommendations. On 2/7/23, Director of Nursing (DON)-B provided Surveyor with one pharmacy recommendation for R11 which documented, Current Order: Quetiapine (Seroquel) 50 mg at bedtime. Last dose change was July 2023. R11 is due for a gradual dose reduction(GDR) .The physician documented a GDR is clinically contraindicated at this time .R11's physician signed and dated this recommendation on 11/27/23. On 02/07/24 at 1:45 PM Surveyor interviewed DON-B. DON-B informed Surveyor there was only one pharmacy recommendation for R11 in November 2023, which recommended a GDR for the Seroquel. Surveyor asked DON-B about the pharmacy progress notes. Surveyor showed DON-B pharmacy progress notes documenting recommendations monthly for R11 from May 2023 to November 2023. DON-B stated the pharmacist emails her (DON-B) the pharmacy recommendations and the one she gave Surveyor was the only one she saw. Per DON-B, the pharmacist inputs the progress notes in the resident's EHR but DON-B was uncertain what staff member was responsible for reviewing the pharmacy progress notes. On 02/08/24 at 8:45 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C. CNA-C informed Surveyor she was familiar with R11. Per CNA-C R11 has behaviors related to sundowning on PM and night shift. CNA-C stated R11 is usually fine during the day shift. CNA-C informed Surveyor sometimes she works later and that is the only time she witnesses R11's behaviors. Per CNA-C she can usually redirect R11. CNA-C was uncertain if R11's behaviors had gotten better or worse because according to CNA-C R11 is fine during the day when she works. On 02/08/24 at 9:12 AM, Surveyor interviewed DON-B. DON-B informed Surveyor R11 was pretty status quo and then R11 started sundowning and the Facility started giving R11 sandwiches at night and that seemed to help. DON-B stated R11's Dementia is getting worse, and the Facility just got a referral for R11 to see [name of company] psychiatric nurse practitioner. Per DON-B, previously the physician wanted R11 sent out to see psych or transferred to an inpatient psych, but the family did not want that, and the outpatient places would not see R11. DON-B explained the Facility finally has a contract with [name of company] to provide inpatient psych services and R11 will be seen. DON-B stated prior to started the Seroquel, the Facility had ruled out medical causes. DON-B informed Surveyor she thought R11's behaviors were getting better. DON-B stated R11 still sundowns but the violent outbursts have gotten better. Surveyor asked how a resident's behaviors are monitored. DON-B stated if a resident has an order for a psychotropic medication than the behavior monitoring/side effect monitoring would follow in the resident's Electronic Treatment Administration Record (ETAR). DON-B stated if the staff see something they report it, and the nurse documents it. Surveyor explained the concern of a lack of quantitative behavior monitoring related to the start of Seroquel therapy and the subsequent increases. Surveyor explained it was difficult to assess if the Seroquel was working without quantitative behavior monitoring from the start of therapy. Surveyor stated there were multiple nursing progress notes documenting R11's behaviors such as yelling, hitting, cursing; however, these notes appear to be equally spread out from May 2023 to present. Surveyor explained a lack of specific documentation relating to the Seroquel and its effectiveness. Surveyor asked DON-B when an AIMs should be done. DON-B stated at the start of a medication, every 6 months and when there is a change in medication. Surveyor explained not finding a completed AIMs until January 2024, when R11 was started on the Seroquel in May 2023. Surveyor also relayed the concern of the multiple pharmacy review recommendations documented in R11's progress notes that went unaddressed. Surveyor explained these reviews recommended an AIMs assessment, behavior monitoring and had specific recommendations for decreasing the Seroquel and increasing the sertraline. Surveyor asked if R11's physician had seen those recommendations. DON-B stated she thought R11's physician did address one of those. Surveyor stated the only one Surveyor saw that was addressed by a physician recommended a gradual dose reduction of the Seroquel in November 2023. That specific pharmacy recommendation did not mention increasing the Sertraline, an AIMs assessment or behavior monitoring. DON-B stated that was the one I was thinking of. DON-B informed Surveyor she was going to have a meeting with the Facility's pharmacist to address the recommendations made in the resident's progress notes and request that all recommendations be made via email directly to DON-B. Surveyor relayed the following concerns: start of an antipsychotic medication with a lack of specific, quantitative behavior monitoring, lack of timely AIMs assessment and a lack of follow through on pharmacy recommendations. Surveyor asked for any additional information. DON-B stated she would look and follow up with Surveyor if there was any additional information. On 02/08/24 at 9:43 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor explained the above concerns and asked NHA-A who was responsible for reviewing the pharmacy recommendations made in the resident's EHR (Electronic Health Record). Per NHA-A, DON-B should be responsible for reviewing those recommendations. Surveyor asked for any additional information. No additional information was provided.

Based on interview, and record review the Facility did not ensure 1 (R6) of 1 residents reviewed were free from significant medication errors. *R6 had an order for Apixaban that was transcribed incorrectly. As a result, R6 only received one dose of Apixaban instead of two from 10/31/23 to 11/27/23. Findings include: R6 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Hypertension and Atrial Fibrillation (AFIB) on Chronic Anticoagulation. Surveyor reviewed R6's Electronic Health Record (EHR) and noted the following active physician's order: Apixaban 2.5 mg (milligrams), one tablet twice a day, with a start date of 11/27/23. Surveyor noted the following discontinued physician's order in R6's EHR: Apixaban 2.5mg, one tablet at HS (hour of sleep). This order had a start date of 10/31/23 and a discontinued date of 11/27/23. Surveyor reviewed R6's progress notes and noted the following documentation: On 10/31/2023 a Pharmacy Review stated: Late Entry: (11/01/23) Recommendations/Irregularities:: Recommendations made, review Clinical Pharmacy Report . apixaban 2.5mg dosing clarification AFIB . Surveyor continued to review R6's EHR and noted R6 had returned from a hospital stay on 10/31/23. Surveyor reviewed R6's hospital Discharge Summary, dated 10/31/23, and noted the following physician's order, Apixaban 2.5mg, one tablet two times day. Surveyor noted the order the Facility transcribed on 10/31/23 read: Apixaban 2.5mg one tablet at HS. Surveyor reviewed a Pharmacy Recommendation document in R6's EHR entitled Note to Attending Physician/Prescriber which stated The recommended dose and frequency for Apixaban is twice a day. This resident is currently on daily dosing. Please consider changing the dose and frequency to Apixaban 2.5mg twice a day. The physician documented agreed and signed the recommendation on 11/27/23. Surveyor noted this recommendation was not dated but had a print date of 11/20/23. This documentation was the only physician addressed documentation Surveyor could find relating to R6's Apixaban dose. Surveyor could not find documentation the Pharmacy Review progress note from 10/31/23 was addressed by the Facility staff or a physician. On 02/08/24 at 9:09 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked DON-B how does the pharmacy relay recommendations. Per DON-B, the pharmacy sends her an email addressing any irregularities. Surveyor explained R6's Pharmacy Review progress note from 10/31/23 documenting the need to clarify R6's Apixaban order. Per DON-B, she was not used to the Pharmacy documenting in the progress notes and was not sure who was responsible for following up on those notes. DON-B stated she was going to have a meeting with the Facility's Pharmacist to ensure all recommendations were put in emails and not just documented in the resident's progress notes. Surveyor explained the concern R6 was readmitted to the facility on [DATE] with an order for Apixaban 2.5mg twice a day that the facility transcribed incorrectly. The order the Facility transcribed on 10/31/23 was Apixaban 2.5mg one tablet at HS and not twice a day as R6's discharge orders read. DON-B stated okay. Surveyor explained the Pharmacy noticed it on 10/31/23 and sent the facility a recommendation to clarify the order, however the Facility did not address the recommendation until 11/27/23. Surveyor stated R6 was only given one dose of Apixaban from 10/31/23 to 11/27/23 instead of two doses due to the Facility's transcription error. DON-B did not have any additional information. On 02/08/24 at 9:40 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Per NHA-A DON-B should be reviewing any recommendations by the Pharmacy including the Pharmacy Reviews documented in the progress notes. Surveyor also relayed the above transcription error concerns. No additional information was provided.

Based on observation, staff interview, and record review, the facility did not ensure staff performed proper hand hygiene during the provision of cares for 1 Resident (R) (R4) of 2 residents. On 10/10/23, Certified Nursing Assistant (CNA)-C did not consistently perform hand hygiene during the provision of perineal care for R4. In addition, Director of Nursing (DON)-B did not consistently perform hand hygiene during the provision of wound care for R4. Findings include: The facility's Hand Hygiene policy, with a revision date of 11/2/22, indicated: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .The attached table mentioned in the policy indicated hand hygiene should be performed .After handling contaminated objects .Before applying and after removing personal protective equipment (PPE), including gloves . Before and after handling clean or soiled dressings, linens, etc .After handling items potentially contaminated with blood, body fluids, secretions, or excretions . On 10/9/23, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease and end-stage renal disease (a condition in which the kidneys no longer function normally) which required dialysis (blood purifying treatment given when kidneys are not functioning). R4's Minimum Data Set (MDS) assessment, dated 9/16/23, contained a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R4 had severely impaired cognition. R4's medical record indicated R4's Power of Attorney for Healthcare (POAHC) was responsible for R4's healthcare decisions. On 10/10/23 at 8:56 AM, Surveyor observed CNA-C and CNA-D complete perineal care for R4. Surveyor observed CNA-C remove R4's soiled brief and provide rear perineal care. With the same gloved hands, CNA-C touched the sink faucet handle to wet additional clean wash cloths and then provided additional rear perineal care. CNA-C then removed CNA-C's gloves and, without performing hand hygiene, applied clean gloves. CNA-C and CNA-D repositioned R4 in bed. CNA-C adjusted R4's bedding then waited for DON-B to enter R4's room to provide wound care. Surveyor observed DON-B enter R4's room with wound dressing supplies, perform hand hygiene and apply gloves. CNA-C and CNA-D positioned R4 for wound care to the coccyx. DON-B completed wound care as ordered by R4's physician, removed DON-B's gloves and, without performing hand hygiene, placed R4's unused wound supplies in a drawer. DON-B then put DON-B's gloves in the garbage and performed hand hygiene. Surveyor also observed CNA-C and CNA-D reposition R4, apply a clean brief, and pull up R4's pants. CNA-C and CNA-D used a mechanical lift to transfer R4 from bed to wheelchair. CNA-C then removed CNA-C's gloves and performed hand hygiene. On 10/10/23 at 9:19 AM, Surveyor interviewed CNA-C who verified CNA-C should have performed hand hygiene immediately after glove removal and should not have touched the faucet handle with soiled gloves. On 10/10/23 at 9:26 AM, Surveyor interviewed DON-B who, following a discussion of the above observations, verified hand hygiene should have been performed immediately following glove removal. DON-B also verified soiled gloves should be removed and hand hygiene should be performed prior to touching items in the resident care environment.

Based on staff and family interview, and record review, the facility did not ensure 2 Residents (R) (R5 and R1) of 10 residents on the COVID-19 unit were allowed to receive visitors. R5 indicated the facility did not allow visitors on the COVID-19 unit during an outbreak in February of 2023. R1's family was not allowed to visit on the COVID-19 unit during an outbreak in February of 2023. Findings include: The facility's COVID-19: Visitation & Communal Activities/Dining policy, last revised on 10/4/22, indicated: This facility encourages residents to exercise their right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident .The core principles of COVID-19 infection prevention will be adhered to and as follows: .d. Visitors should be informed about their potential to be exposed to COVID-19 infection in the facility. e. Hand hygiene, using an alcohol-based hand rub, should be performed by the resident and the visitors before and after contact. f. A face covering or mask (covering the mouth and nose) shall be worn in accordance with CDC (Centers for Disease Control and Prevention) guidance and posted signage. g. Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices will be posted . On 10/9/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include wedge compression fracture of first lumbar vertebra (bone in spinal column). R1's Minimum Data Set (MDS) assessment, dated 2/13/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 was not cognitively impaired. R1's Power of Attorney for Healthcare (POAHC) document, activated on 2/16/23, indicated R1's named POAHC agent was responsible for R1's healthcare decisions. R1 received Hospice benefits effective 2/25/23 and was discharged home with Hospice services on 3/6/23. On 10/10/23, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus (a disease in which blood sugar levels are too high) and asthma (a condition in which airways narrow, swell and produce extra mucus). R5's MDS assessment, dated 9/22/23, contained a BIMS score of 15 out of 15 which indicated R5 was not cognitively impaired. On 10/10/23 at 9:50 AM, Surveyor interviewed R5 who indicated R5 had COVID-19 and was moved to the facility's COVID-19 unit in February of 2023. R5 indicated the facility did not allow visitors on the COVID-19 unit when R5 resided there. R5 indicated R5 usually received visitors once or twice per month and did not know if any of R5's visitors tried to visit while R5 was on the the unit. On 10/10/23, Surveyor reviewed a list of residents who were on the facility's COVID-19 unit during the outbreak in February of 2023. There were ten resident names on the list, including R1 and R5. The document indicated R1 and R5 tested positive for COVID-19 on 2/8/23. On 10/10/23 at 10:11 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D. When asked if the facility allowed visitors on the COVID-19 unit during the outbreak in February of 2023, CNA-D stated, No. CNA-D indicated residents who tested positive for COVID-19 were placed on one wing with the fire doors closed. CNA-D indicated staff were careful to keep COVID-19 contained to the COVID-19 unit. On 10/10/23 at 2:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified residents on the COVID-19 unit should have been able to receive visitors. (Of note: NHA-A was not employed at the facility at the time of facility's COVID-19 outbreak in February of 2023.) On 10/12/23 at 11:35 AM, Surveyor interviewed R1's Family Member (FM)-F via phone. FM-F indicated FM-F learned the facility was not allowing visitors on the COVID-19 unit from other family members who attempted to visit R1, but were stopped in the hall by staff and told no visitors were allowed on the COVID-19. FM-F indicated family usually visited R1 every day, however, family were not allowed to visit R1 during R1's time on the COVID-19 unit.

Based on staff interview and record review, the facility did not ensure timely administration of medication for 1 Resident (R) (R1) of 8 sampled residents. R1 did not consistently receive R1's scheduled morphine (used to treat moderate to severe pain) timely. Findings include: The facility's Medication Administration policy, dated 1/2023, indicated: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices .Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the Prescriber, routine medications are administered according to the established medication administration schedule for the nursing center . On 10/9/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include wedge compression fracture of first lumbar vertebra (bone in spinal column). R1's Minimum Data Set (MDS) assessment, dated 2/13/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 was not cognitively impaired. R1's Power of Attorney for Healthcare (POAHC) document, activated on 2/16/23, indicated R1's named POAHC agent was responsible for R1's healthcare decisions. R1 received Hospice benefits effective 2/25/23 and was discharged home with Hospice services on 3/6/23. On 10/9/23 at 2:43 PM, Surveyor interviewed Hospice Director of Quality Compliance (HDQC)-E via phone who indicated Hospice documentation indicated Hospice staff received a call from R1's family with concerns that R1 did not receive morphine timely. On 10/10/23, Surveyor reviewed Hospice documentation and noted the following: ~ A note, dated 3/1/23 at 12:54 PM, indicated: Call received from R1's family member who reported R1 is not eating or drinking anything and stated they have been at the facility since 10:30 AM and R1 only took a few sips, and keeps spitting everything out. R1's family member is aware that Hospice Registered (RN) saw R1 today. R1's family member reported R1 had not received R1's noon medications. R1's family is aware writer will call the facility to speak with the nurse. Writer attempted to call twice with no answer. Writer will try again to try to reach the facility nurse. ~ A note, dated 3/1/23 at 2:58 PM, indicated: Attempted to call facility around 1:15 PM with no answer. Writer called facility back and spoke with facility nurse who reports R1 is comfortable at this time since starting the scheduled morphine and Ativan (used to treat anxiety and restlessness) and has been responding fine. Writer attempted to call R1's family member back with no answer. ~ A note, dated 3/1/23 at 3:47 PM, indicated: Call received from R1's family member to report family member is still waiting for a call back from Hospice Triage RN for an update on R1's administration of pain medication. Caller notified that notes indicate RN attempted to call with no answer. Caller stated R1 is having a rough day with pain and R1 is not getting the medications as ordered at the correct times (morphine). Triage Nurse called the facility and talked to two nurses on the unit who confirmed R1 is scheduled to receive morphine at 8:00 AM, 12:00 PM, and 8:00 PM. Nurse stated R1's 12:00 PM morphine wasn't administered until after 1:00 PM because there was an admission and a fall. On 10/10/23, Surveyor reviewed R1's physician orders which contained an order for Morphine Sulfate Oral Tablet 15 mg (milligrams) Give 0.5 tablet by mouth three times a day related to pain. On 10/10/23, Surveyor reviewed the facility's Medication Admin Audit Report for R1's March 2023 medications that indicated R1's morphine doses were scheduled for 7:00 AM, 12:00 PM and 8:00 PM. The Medication Admin Audit Report indicated R1 received the 12:00 PM dose of Morphine on 3/1/23 at 1:39 PM, the 7:00 AM dose of morphine on 3/2/23 at 10:09 AM, and the 7:00 AM dose of morphine on 3/3/23 at 9:12 AM. On 10/10/23 at 2:00 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the facility's policy indicated scheduled medications should be given within one hour before and one hour after the scheduled time. DON-B verified the above documented examples were administered late.

Based on record review and resident and staff interview, the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 Resident (R) (R1) of 1 resident. When R1's skilled nursing coverage ended on 2/23/22, R1's HMO (health maintenance organization) informed the facility via fax and voicemails that R1 was eligible to remain in the facility under custodial care. The fax was not acknowledged and the voicemails went unreturned. In addition, a copy of the notice of denial of skilled coverage with information on appeal rights was not provided to R1 and the ADRC was not contacted on R1's behalf. R1's plan of care stated R1 had poor safety awareness and was not always aware of oncoming traffic and surroundings. Despite R1's plan or care and medical comorbidities, SW (Social Worker)-E contacted a homeless shelter and arranged transportation for R1 to be dropped off at the shelter outside of business hours. The facility's failure to ensure the provision of medically-related social services created a finding of immediate jeopardy that began on 2/24/22. VPO (Vice President of Operations)-X was notified of the immediate jeopardy on 3/17/22 at 1:36 PM. The immediate jeopardy was removed on 3/18/22; however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: On 3/15/22, the Surveyor reviewed R1's medical record. R1 had diagnoses to include [CONDITION(S)] (paralysis of the legs and lower body), muscle weakness, [CONDITION(S)] and [CONDITION(S)]. R1's Admission MDS (Minimum Data Set), dated 2/09/22, indicated R1 was not cognitively impaired, but was dependent on staff for transfers and required extensive assistance of staff for bed mobility and most ADLs (activities of daily living). R1 had ROM (range of motion) impairments in both lower extremities as well as a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) and a newly acquired ostomy (a surgically created opening in the abdomen that allows waste or urine to leave the body). R1's plan of care stated R1 had self-care deficits, required assistance to restore function related to physical limitations and was at risk for complications due to musculoskeletal problems related to [CONDITION(S)]. R1's plan of care contained interventions to assist with baths/showers, daily hygiene, toileting, grooming, dressing, oral care and eating as needed. The interventions stated R1 required limited assistance, but at times required more assistance due to mental illness, mood and need for attention. R1's plan of care also contained interventions to transfer with supervision for squat pivot transfers to/from edge of bed to wheelchair and to assist with bed mobility. In addition, R1's plan of care stated, Poor safety awareness and judgement when going outside to smoke. Is not always aware of oncoming traffic and surroundings, when upset or distracted on phone with (significant other) and does not maneuver around ice or snow. Does not dress appropriately for weather conditions. A late entry psychosocial note by SW-E, dated 2/28/22 but created on 3/01/22, indicated R1's HMO issued R1 a denial on 2/23/22 and stated, (R1's HMO) informed (BOM (Business Office Manager)-C) that (R1) would transition over to traditional Medicaid. Per phone call from (LTCAM (Long-Term Care Analyst for Medicaid)-T) .(R1) would not be applicable for traditional (Medicaid) until (5/31/22). (R1) at this time does not have a payor source since 2/24/22. Alternate placement found for (R1). (R1) will be discharging on 3/01/22. Will continue to monitor and assist as needed. Transport has been set up for (R1). A late entry psychosocial note by SW-E, dated 2/28/22 but created on 3/02/22 (the day after R1's discharge), stated R1 was aware R1 was scheduled to discharge to (a men's shelter) per multiple conversations with NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B and SW-E. The note stated, It was explained to (R1) what (men's shelter) was and how they operate and what kind of day services are provided. (R1) expressed and (sic) understanding of all of this. (The shelter) had been called regarding (R1) and they stated that they turn away no one .Multiple referrals made to (skilled nursing facilities) in (same town as shelter) but would not accept due to payor source. (R1) stated (R1) was just so happy to be going to (city in which shelter was located) as that is where (R1) wants to be . A discharge summary note, dated 3/01/22 at 11:58 AM, stated R1 was discharged to a men's emergency drop-in shelter. The note listed the address of the shelter and stated pick up and drop off were completed via cab. On 3/16/22 at 2:52 PM, the Surveyor interviewed SED (Shelter Executive Director)-K regarding R1. SED-K said the shelter was unaware of R1's arrival and stated, (R1) just showed up. SED-K also stated there was no communication in the facility's system regarding R1. On 3/16/22 at 3:09 PM, the Surveyor interviewed DPD (Day Program Director)-L who stated R1 was transported to the day programming facility after R1 was dropped off at the homeless shelter during non-business hours. DPD-L stated R1's care needs were beyond what the facility could provide. DPD-L contacted hospital SW-M who assisted R1 with an ER transfer. On 3/15/22 at 11:07 AM, the Surveyor interviewed R1 regarding R1's discharge. R1 stated HMO CM (Case Manager)-G and BA (Benefits Adviser)-H tried to call (SW-E), but (SW-E) wouldn't call back. R1 stated R1 was discharged to a homeless shelter; however, R1 was admitted to a local hospital when the shelter couldn't accommodate R1. R1 stated, (The discharge location) couldn't take me because I'm paralyzed. I was told a (homeless shelter) will never take someone who's paralyzed. I couldn't get into a bed two inches off the floor. When I got to the shelter, they didn't know who I was. (The nursing home) told me everything was set (at the shelter) .(The shelter) never let me in. I (waited) outside and they said they'd get me a cab to (a local day programming facility). R1 stated, I was scared. I didn't know where to go. I'm in a wheelchair. I can't protect myself. On 3/15/22 at 12:36 PM, the Surveyor interviewed SW-E regarding R1. SW-E stated R1 was admitted to the facility for short-term rehab following hospitalization and an ostomy procedure. SW-E stated R1's goal was to return home with SO-R. SW-E stated, I talked and met with (R1) daily. (R1) was in a motorized wheelchair and could get throughout the facility independently. SW-E stated the facility received a letter from R1's HMO that stated R1 no longer needed skilled care (as of 2/23/22) and could discharge home. SW-E stated because R1 was enrolled in an HMO that did not provide custodial care, R1 was not eligible for Medicaid until 5/31/22. SW-E stated, We have a bill for over $2000. We asked what (R1) wanted to do. (R1) stated (R1) wanted to go to (the city where (R1) was discharged ) .Our goal was to find a safe discharge plan .(R1) was independent and could take care of (R1's) self. I explained (to the shelter) (R1) had an ostomy and was in a motorized wheelchair. (The shelter) said, 'We never turn anyone away'. SW-E stated R1 was agreeable to the discharge plan. SW-E could not recall who SW-E spoke with at the homeless shelter and verified the conversation was not documented. SW-E said R1 was able to move R1's lower extremities and could get in and out of bed. Regarding R1's allegation that SW-E did not return calls to staff from R1's HMO, SW-E stated SW-E spoke with CM-G early in R1's care, but not regarding discharge. SW-E stated SW-E retrieved voicemails daily, but did not receive any voicemails from CM-G or BA-H. SW-E was unsure if R1 was aware of R1's right to appeal the termination of skilled nursing coverage. On 3/16/22 at 2:10 PM, the Surveyor again interviewed SW-E regarding R1. SW-E reiterated SW-E was informed by R1's HMO that (R1's) payor source was done. SW-E again stated SW-E did not receive voicemails or messages from HMO staff. SW-E stated SW-E, NHA-A, DON-B and CM-G had a phone conversation in which CM-G stated there was nothing else (R1's HMO) could do. SW-E was unsure if appeal rights were discussed with R1. The Surveyor reviewed a fax sent to the attention of BOM-C on 2/25/22 from R1's HMO. The fax referenced R1 and stated, Please be advised the following dates have been approved for custodial LOC (level of care) 2/3/22 to 5/4/22 . The fax stated questions and concerns should be directed to HMO CM-O and contained CM-O's contact information. On 3/16/22 at 1:15 PM, the Surveyor interviewed BOM-C regarding R1. BOM-C stated BOM-C had a conversation with an unknown individual from R1's HMO on 2/23/22. BOM-C stated BOM-C was told R1's HMO would send a denial letter, would disenroll R1 and R1 would transition to straight Medicaid. BOM-C stated R1 was not eligible for Medicaid until 5/31/22. BOM-C was unsure if R1 was provided with the appeal information when R1's skilled nursing coverage ended. On 3/23/22 at 2:48 PM, the Surveyor interviewed HMO Case Manager (CM) -O regarding communication with the facility. CM-O verified CM-O sent a fax to the facility on [DATE] at 9:32 AM that stated R1 was approved for custodial care from 2/03/22 to 5/04/22. CM-O did not have any further contact with the facility until 3/15/22 at 3:55 PM when CM-O called the facility for an update on R1. CM-O stated, I had a hard time getting a hold of the facility to find out when (R1) discharged and where. CM-O stated CM-O spoke with RN (Registered Nurse)-Q on 3/15/22 who stated R1 discharged but could not tell CM-O where. CM-O stated CM-O left a message for SW-E on 3/16/22 at 10:26 AM to verify R1's discharge date and location; however, the call was not returned. CM-O called the facility again on 3/16/22 and was transferred to SW-E who stated R1 discharged to (a location) on 3/01/22. CM-O was not aware R1 discharged to a homeless shelter because CM-O was unfamiliar with the location and SW-E did not clarify the location was a homeless shelter. On 3/17/22, the Surveyor reviewed documentation provided by HMO DMCO (Director of Medical and Clinical Operations)-F. The documentation indicated R1 was concerned about a discharge plan on 2/14/22. R1 told CM-G that SO-R and R1 broke up and R1 no longer had a home to return to. R1 expressed a desire to remain at the facility due to R1's high-level chronic health care needs. CM-G left a detailed message for SW-E and requested a return call. The call was not returned. CM-G called SW-E again on 2/17/22 at 9:00 AM and left a detailed message. CM-G asked SW-E to return the call and provide an update on R1; however, the call was not returned. CM-G received a call from R1 on 2/18/22 at 8:50 AM. While CM-G was on the line, R1 attempted to hand a cell phone to SW-E so SW-E and CM-G could talk; however, SW-E stated SW-E couldn't take the call. SW-E returned CM-G's call on 2/18/22 at 9:42 AM. SW-E stated SW-E would work with the ADRC to help R1 find housing at a group home or CBRF (community-based residential facility) that had some assistance since R1 did not require skilled nursing care upon discharge. CM-G encouraged SW-E to contact CM-G when R1 discharged . A note written by HMO CC (Care Coordinator)-Z on 2/18/22 stated, Left detailed message for (RN-I/MR-P) requesting they call me back at their earliest convenience in regards to the amount of support (R1's) family is able to provide for (R1) at home .Would like to discuss discharge plans. A note written by CC-Z on 2/22/22 stated, Left another detailed message for (RN-I/MR-P) .requesting they call me at their earliest convenience in the morning of 2/23/22 to discuss whether (SO-R) and son can care for (R1) at home or if (R1) is going to remain at SNF (skilled nursing facility) . A note written by CC-Z on 2/23/22 stated, Discussed case with (BOM-C). (BOM-C) reports (R1) will not be able to return home. (R1) will ultimately need alternate placement, so (R1) will remain at the SNF as LTC (long-term care)/custodial resident for now while social services seeks alternate placement. On 2/28/22, CM-G received a call from R1 who was frantic. R1 stated SW-E told R1 that R1's stay was no longer covered as of 2/24/22 and R1 could go home. The note stated SW-E was notified previously by CM-G that R1 was homeless and needed housing assistance. R1 stated R1 had no money, could not pay privately to stay at the nursing home and could not be placed at another nursing home because R1 did not have custodial care. The note stated R1 was wheelchair bound and the nursing home was told by the ADRC that R1 could not go to a homeless shelter because shelters will not accept (R1) with a wheelchair. CM-G called SW-E on 2/28/22 at 3:48 PM and left a voicemail. The call was not returned. Documentation on 3/02/22 indicated R1's HMO believed R1 was still at the facility. On 3/02/22, CM-G emailed BA-H to determine the status of R1's coverage. BA-H stated R1 had custodial care from 2/03/22 through 5/04/22 and could remain inpatient at the nursing home until Medicaid began. BA-H left a voicemail for SW-E on 3/01/22 to answer questions about custodial care. The call was not returned. On 3/03/22 at 12:05 PM, CM-G spoke with R1 and discovered R1 was discharged from the facility on 3/01/22 and transported to a homeless shelter via cab. R1 stated the shelter could not accommodate R1's wheelchair or meet safety standards for transfers so R1 was taken to a local hospital. On 3/08/22, CM-G received a call from R1 who stated SW-E knew about (R1's) break-up with (SO-R), but proceeded to call (SO-R) and ask (SO-R) to pay over $400 /day for (R1) to stay there. R1 stated when SO-R declined, SW-E sent R1 to a homeless shelter. R1 stated SW-E did not contact the ADRC to start the screening process for housing and support assistance. On 3/22/22 at 11:30 AM, the Surveyor interviewed DMCO-F, CM-G and BA-H regarding communication with the facility. CM-G stated CM-G did not discuss R1's coverage with the facility. CM-G stated, I spoke with (SW-E) on (2/18/22) about (R1's) progress and care. No discharge date was set. That was the only time I was able to get through. DMCO-F stated the facility did not communicate with (the HMO) related to any decisions or appeals. BA-H stated BA-H left a detailed message for SW-E on 3/01/22 at approximately 10:40 AM regarding R1's coverage. BA-H stated, I advised that custodial care was approved through (5/04/22) and asked that (SW-E) call me. On 3/18/22, CCO (Chief Clinical Officer)-BB provided BD (Bureau Director)-CC with a statement written by SW-E. The statement indicated SW-E spoke with an unknown female at (a social services organization that strives to reduce homelessness by collaborating with the community to provide shelter, affordable housing and supportive services). The note stated R1 explained (R1's) condition and was told they do not turn anyone away. The note stated following the call, NHA-A, SW-E and DON-B met with R1 to discuss R1's discharge to the shelter. The note stated, I explained that it is a men's shelter, that check in time is between 5:00 PM and 8:00 PM. I also explained how (the shelter) operated and what kind of services they provided such as day programs and/or being out during the day. (R1) expressed an understanding, was excited to go there .(R1) was aware that (R1) would be being picked up by wheelchair taxi and that (R1's) pick up time would get (R1) to (the homeless shelter) prior to check-in hours. (R1) voiced an understanding and stated (R1) planned on checking out things till check in time. (R1) was very thankful and thanked this writer multiple times for doing all that I could to assist with discharge planning and for mostly getting (R1) to (the city), where (R1) wanted to be. On 3/17/22 at 9:18 AM, the Surveyor again interviewed R1 regarding R1's discharge. R1 stated, (CM-G) told (SW-E) that I was covered .they were not to put me out like that .(SO-R) can no longer take care of me. I'm here temporarily . R1 denied R1 participated in a phone conversation with NHA-A, DON-B, SW-E and CM-G on 2/25/22. R1 stated R1 was told SW-E couldn't take a call from CM-G on 2/28/22 when R1 handed a cell phone to SW-E with CM-G on the line. R1 stated R1 was not given the denial of coverage letter, was not advised of R1's right to appeal, was not given a thirty day involuntary discharge notice and did not sign discharge paperwork. R1 stated R1 discharged from the hospital on 3/04/22 when the hospital called SO-R and stated there was no medical reason R1 required hospitalization . R1 stated the ADRC screened R1 in March (2022) and was scheduled to assess R1 on 4/01/22 for nursing home placement. R1 stated, I wanted to stay (at the nursing home). I let them know that If I let this go, what happens to the next person? The facility's failure to provide medically-related social services to assist R1 in remaining at the facility and to give R1 appeal rights prevented R1 from attaining R1's highest practicable physical, mental and psychosocial well-being. This led to R1 being dropped off in front of a homeless shelter outside the shelter's business hours and created a reasonable likelihood for serious harm (immediate jeopardy). The facility removed the jeopardy on 3/18/22 when it completed the following: 1. Reviewed all discharges planned within the next 72 hours to ensure discharges included a safe location as well as the appropriate referrals and follow-up appointments. 3. Educated SW-E on the facility's discharge policy and procedure. 3. Educated BOM-C on the Medicaid application process and 30 day involuntary discharge notice procedure.

Based on record review and resident and staff interviews, the facility did not ensure a safe discharge for 1 Resident (R) (R1) of 1 resident. reviewed for discharge. R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, R1 required staff assistance with ADLs (activities of daily living) such as bathing, dressing and personal hygiene. R1's care plan indicated R1 had poor safety awareness and judgement. When R1's skilled nursing coverage ended on 2/23/22, R1 was eligible to remain in the facility under custodial care for a total of 90 days until R1 could disenroll from R1's HMO (health maintenance organization) and transition to straight Medicaid. Despite notification from R1's HMO that R1's stay was covered, the facility discharged R1 to a homeless shelter. R1 was dropped off at the shelter outside of business hours. Shelter staff sent R1 to a day programming facility who then sent R1 to the ER (emergency room ). The facility stated they would not allow R1 to return because R1 did not have a payor source. The facility's failure to ensure a safe discharge created a finding of immediate jeopardy that began on 3/1/22. VPO (Vice President of Operations)-X was notified of the immediate jeopardy on 3/17/22 at 1:36 PM. The immediate jeopardy was removed on 3/18/22; however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: The facility's Discharge-Transfer of Resident policy, dated June 2017, states: Purpose: To ensure safe departure from the facility. Procedure: Discharge: 1. Explain discharge procedure and reason to resident and give copy of Transfer & Discharge notice as required. 2. The attending physician is required to write a discharge order. Telephone orders are acceptable . 6. Complete a discharge summary and post discharge plan of care form. a. Include a list of medications with instructions in simple terms. Do no use medical terms or abbreviations. b. Include instructions for post discharge care. Review with the resident and/or representative. c. Have resident and/or representative or person responsible for care sign discharge summary and post discharge care form. This includes release of medications. d. Give copy of form to the resident and/or representative or person(s) responsible for care. e. Place signed original form in the medical record. 7. Check belongings and inventory form. Have resident and/or representative or responsible caregiver sign for belongings. a. Give copy to resident and/or representative. Documentation Guidelines Documentation may include: 7. Whether or not medication was taken by the resident . 10. Disposition of resident's belongings . 12. Signature, date and title on all forms. 13. Keep a copy of all forms and place in resident's medical record. 14. A receipt for medications and equipment sent with the resident is recommended. On 3/15/22, the Surveyor reviewed R1's medical record. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set), dated 2/09/22, indicated R1 was not cognitively impaired, but was dependent on staff for transfers and required extensive assistance of staff for bed mobility and most ADLs. R1 had ROM (range of motion) impairments in both lower extremities as well as a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) and a newly acquired ostomy (a surgically created opening in the abdomen that allows waste or urine to leave the body). R1's plan of care stated R1 had self-care deficits, required assistance to restore function related to physical limitations and was at risk for complications due to musculoskeletal problems related to [CONDITION(S)]. R1's plan of care contained interventions to assist with baths/showers, daily hygiene, toileting, grooming, dressing, oral care and eating as needed. The interventions stated R1 required limited assistance, but at times required more assistance due to mental illness, mood and need for attention. R1's plan of care also contained interventions to transfer with supervision for squat pivot transfers to/from edge of bed to wheelchair and to assist with bed mobility. In addition, R1's plan of care stated, Poor safety awareness and judgement when going outside to smoke. Is not always aware of oncoming traffic and surroundings, when upset or distracted on phone with (significant other) and does not maneuver around ice or snow. Does not dress appropriately for weather conditions. A health status note, dated 2/23/22, stated (R1) needs (one) person assistance with ADLs . An APNP (Advanced Practice Nurse Prescriber) progress note, dated 2/25/22, stated .Staff is looking into getting (R1) into an assisted living facility .Has almost been hit by a car while trying to cross the street to smoke, police have been involved. A late entry psychosocial note by SW (Social Worker)-E, dated 2/28/22 but created on 3/01/22, indicated R1's HMO had issued R1 a denial on 2/23/22 and stated, (R1's HMO) informed (BOM (Business Office Manager)-C) that (R1) would transition over to traditional Medicaid. Per phone call from (LTCAM (Long-Term Care Analyst for Medicaid)-T) .(R1) would not be applicable for traditional (Medicaid) until (5/31/22). (R1) at this time does not have a payor source since 2/24/22. Alternate placement found for (R1). (R1) will be discharging on 3/01/22 . A late entry psychosocial note by SW-E, dated 2/28/22 but created on 3/02/22 (the day after R1's discharge), stated R1 was aware R1 was discharging to a shelter. The note stated, It was explained to (R1) what (men's shelter) was and how they operate and what kind of day services are provided. (R1) expressed and (sic) understanding of all of this. (The shelter) had been called regarding (R1) and they stated that they turn away no one .Multiple referrals made to (skilled nursing facilities) in (same town as shelter) but would not accept due to payor source. (R1) stated (R1) was just so happy to be going to (city in which shelter was located) as that is where (R1) wants to be . A discharge summary note, dated 3/01/22 at 11:58 AM, stated, (R1) to be discharged to (emergency drop-in shelter) (address listed). (Pick up) and drop off was completed by (cab company) (R1) was in good spirits. Communicated with most staff before being discharged . On 3/22/22 at 11:02 AM, the Surveyor interviewed CD (Cab Driver)-N who drove R1 from the nursing home to the homeless shelter. CD-N stated CD-N picked up R1 on 3/01/22 at 12:03 PM and drove R1 to a homeless shelter approximately thirty minutes away. CD-N stated the shelter was closed when they arrived; however, CD-N assumed the nursing home made arrangements with the shelter. CD-N left R1 in a lot near the door to the shelter and stated R1 was dressed appropriately for the weather. On 3/16/22 at 2:52 PM, the Surveyor interviewed SED (Shelter Executive Director)-K regarding R1. SED-K stated the emergency shelter is open daily from 5:00 PM - 8:00 AM. SED-K stated R1 was dropped off at the shelter earlier in the day when it was closed. SED-K said the shelter was unaware of R1's arrival and stated, (R1) just showed up. SED-K stated there was no communication in the facility's system regarding R1. SED-K stated a cleaning person saw R1 outside and arranged for transportation to a local day programming facility. When R1 arrived at the day programming facility, SED-K said R1 and staff spoke with hospital SW-M who sent R1 to the ER. SED-K stated the homeless shelter was bare bones when it comes to assisting people .We're strictly where someone can come to have a night's stay. We shelter them and give them dinner. SED-K stated shelter staff were unable to lift residents per insurance guidelines. SED-K verified those who stayed at the shelter could not leave their belongings there during non-business hours. On 3/16/22 at 3:09 PM, the Surveyor interviewed DPD (Day Program Director)-L who verified R1 was dropped off at the homeless shelter during non-business hours. DPD-L stated R1 was transported to the day programming facility; however, R1's care needs were beyond what the facility could provide. DPD-L contacted SW-M who assisted R1 with an ER transfer. DPD-L stated, We take people in wheelchairs if they can transfer themselves and (provide their own care). We don't have nurses. (R1) needed more care than we could provide. DPD-L stated R1 was lucky when R1 was dropped off at the shelter because there's usually nobody at the shelter during the day. On 3/15/22 at 11:07 AM, the Surveyor interviewed R1 regarding R1's discharge. R1 stated HMO CM (Case Manager)-G and BA (Benefits Adviser)-H tried to call (SW-E), but (SW-E) wouldn't call back. R1 stated R1 was discharged to a homeless shelter; however, R1 was admitted to a local hospital when the shelter couldn't accommodate R1. R1 stated, (The discharge location) couldn't take me because I'm paralyzed. I was told a (homeless shelter) will never take someone who's paralyzed. I couldn't get into a bed two inches off the floor. When I got to the shelter, they didn't know who I was. (The nursing home) told me everything was set (at the shelter) .(The shelter) never let me in. I (waited) outside and they said they'd get me a cab to (a local day programming facility). R1 stated, I was scared. I didn't know where to go. I'm in a wheelchair. I can't protect myself. R1 stated R1 arrived at the day programming facility and was then sent to the ER. R1 spent one night in the ER and was transferred to another branch of the hospital the following day. R1 was discharged from the hospital on 3/04/22 when former SO (Significant Other)-R allowed R1 to move back in until the ADRC (Aging and Disability Resource Center) could find nursing home placement for R1. R1 stated R1 did not receive or sign discharge paperwork. R1 also stated, (The facility) called the police and said I was a risk to myself because I got stuck in the parking lot. I asked (a delivery driver) to help me. (DON (Director of Nursing)-B) said I was unsafe to be out there. On 3/17/22 at 9:18 AM, the Surveyor again interviewed R1 regarding R1's discharge. R1 stated, (CM-G) told (SW-E) that I was covered .they were not to put me out like that .(SO-R) can no longer take care of me. I'm here temporarily. (SO-R) can't take care of (SO-R's) self .(CM-G) was surprised I was discharged and in the street. R1 denied R1 participated in a phone conversation with NHA-A, DON-B, SW-E and CM-G on 2/25/22. R1 stated SW-E told R1 that SW-E couldn't take a call from CM-G on 2/28/22 when R1 handed R1's cell phone to SW-E with CM-G on the line. R1 stated R1 was not given the denial of coverage letter, was not advised of R1's right to appeal and was not sent to the shelter with discharge medications. R1 stated, I had to go to (a local pharmacy) and spend $113.12 on medication. I didn't have any meds with me. There was nothing I had a couple of ostomy supplies in my bag from the hospital. The cab driver left me on the sidewalk (outside the homeless shelter) and said someone would be out in five to ten minutes. I waited twenty five minutes then someone said I had to ring the doorbell. Someone came out and said they weren't expecting me. They called (the day programming facility) and they hadn't heard from anyone. It was a shock to everybody. R1 stated R1 was in the hospital from 3/01/22-3/04/22. R1 discharged on [DATE] when the hospital stated to SO-R there was no medical reason R1 should be in the hospital. R1 stated the ADRC screened R1 and was scheduled to assess R1 on 4/01/22 for nursing home placement. R1 did not enter the the homeless shelter, but was told the shelter beds were two inches off the floor and stated, They said there was no way I could get on a cot. R1 also stated, I wanted to stay (at the nursing home). I let them know that. I had it made there. I didn't do anything wrong. I got along with everyone. (NHA-A) said (NHA-A) would rather have me closer to my family. My family can't drive that far .If I let this go, what happens to the next person? On 3/15/22 at 12:10 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-A regarding R1. NHA-A stated R1 was in therapy for short period of time, made therapy goals and was pretty much able to take care of (R1's) self. NHA-A stated R1 could transfer from bed to wheelchair independently. NHA-A stated R1 had incomplete [CONDITION(S)] and could move R1's lower extremities with the assistance of R1's upper extremities. NHA-A stated SO-R wouldn't allow R1 to return home when R1's skilled nursing coverage ended and R1 didn't have a payor source. NHA-A said the facility called other facilities and made referrals without success and stated, We called a homeless shelter and asked if they could take (R1). (The shelter) said, 'We've never turned anyone down'. NH-A stated NHA-A told shelter personnel R1 used an electric wheelchair. After R1 discharged , NHA-A stated, The shelter called me to see what status (R1) was. I said (R1) was independent with everything. I don't know why (R1) went to the hospital. NHA-A stated R1 was okay with the discharge plan; however, the facility received calls later that day when R1 told hospital staff R1 required a Hoyer lift for transfers. NHA-A stated the hospital wanted to send R1 back to the facility. NHA-A stated, I said (R1) has no payor source and can't stay here. NHA-A said R1 exhausted R1's managed care benefits and didn't qualify for Medicaid until 5/31/22. NHA-A stated R1 could live on R1's own. NHA-A stated NHA-A spoke with CM-G who said R1's HMO couldn't help R1 because R1 didn't have custodial care. On 3/16/22, NHA-A provided the Surveyor with a written statement, signed and dated 2/28/22, that stated NHA-A, SW-E and R1 had a discussion with CM-G on 2/25(22) at 2:13 PM regarding R1's insurance coverage. The statement read, Writer (NHA-A) explained the situation of (R1) receiving letter stating as of (R1) going home on 2/24/22 your stay is not covered as (R1) no longer needs care at this level (sic) Writer asked if there is anything they could do at this time (sic) (CM-G) stated to (R1) there is nothing they could do on their end. On 3/15/22 at 12:36 PM, the Surveyor interviewed SW-E regarding R1. SW-E stated R1 was admitted to the facility following hospitalization and an ostomy procedure. R1 had goals of short-term rehab and to return home with SO-R. SW-E stated, I talked and met with (R1) daily. (R1) was in a motorized wheelchair and could get throughout the facility independently. SW-E stated the facility received a letter from R1's HMO that stated R1 no longer needed skilled care (as of 2/23/22) and could discharge home. SW-E stated because R1 was enrolled in an HMO that did not provide custodial care, R1 was not eligible for Medicaid until 5/31/22. SW-E stated, We have a bill for over $2000. We asked what (R1) wanted to do. (R1) stated (R1) wanted to go to (the city where (R1) was recently hospitalized ) .Our goal was to find a safe discharge plan .(R1) was independent and could take care of (R1's) self. I explained (to the shelter) (R1) had an ostomy and was in a motorized wheelchair. (The shelter) said, 'We never turn anyone away'. SW-E stated, I explained that to (R1) and (R1) said (R1) wanted to go. SW-E said R1 did not require a Hoyer lift for transfers, was able to move R1's lower extremities and could get in and out of bed. SW-E could not recall who SW-E spoke with at the homeless shelter and stated the conversation was not documented. SW-E stated SW-E spoke with CM-G early in R1's care, but not regarding discharge. SW-E stated SW-E retrieved voicemail messages daily, but did not receive any voicemails from CM-G or BA-H. On 3/16/22 at 2:10 PM, the Surveyor again interviewed SW-E regarding R1's discharge. SW-E felt R1's discharge was safe and stated, I was told (R1's) payor source was done. I talked to someone at (the homeless shelter). They said (R1) could keep (R1's) (belongings) there until (R1) checked in . SW-E also stated SW-E was not aware the beds in the shelter were a fixed height. SW-E again stated SW-E did not receive any voicemails or messages from anyone at R1's HMO. SW-E was unsure if an appeal was discussed with R1. On 3/15/22 at 1:35 PM, the Surveyor interviewed CNA (Certified Nursing Assistant)-S and RN (Registered Nurse)-Q regarding R1. CNA-S stated when R1 was admitted to the facility, R1 required a Hoyer lift for transfers. CNA-S stated R1 progressed to a two person assist with a slide board and then a one person assist with a gait belt for bed to chair and chair to bed transfers. CNA-S stated R1 did a jump/twist pivot thing to transfer and bore a little weight. CNA-S stated R1 progressed to a point where R1 could stand and pivot with staff standing by. CNA-S stated CNA-S knew of a few instances in which R1 transferred independently. Regarding R1's safety outside, RN-G stated, We have to make sure (residents) cross the street carefully. (R1) took off (outside) and was almost airborne. It was 6:00 PM .almost rush hour .(R1) didn't stop for cars .no safety awareness or judgement .We asked the police to talk to (R1) numerous times about smoking and being unsafe .(R1) almost ran visitors and old people over in (R1's) wheelchair. When asked if CNA-S thought R1 was safe to discharge to a homeless shelter, CNA-S stated CNA-S was not sure with everything (R1) had going on. RN-Q stated, (R1) said (R1) wanted to stay (at the nursing home). (R1) wanted to live here forever . RN-Q stated when R1 discharged , R1 was on the fourth day of non-payment with no payor source. RN-Q said staff were asked multiple times to teach R1 ostomy cares and stated, We were trying to get (R1) as independent as possible. RN-Q stated, I know (R1) wanted to come back. (R1) was telling the homeless shelter (R1) didn't know why (R1) wasn't here any more, but the night before (2/28/22) (R1) said (the nursing home) is a wonderful place and (R1) knew we did all we could to keep (R1). On 3/16/22 at 10:30 AM, the Surveyor interviewed PTA (Physical Therapy Assistant)-J regarding R1. PTA-J stated R1 was semi-paraplegic and didn't have feeling in (R1's) legs, but had ROM and could push through a little to support (R1's) self. PTA-J stated R1 worked on transfers and safety in R1's wheelchair. PTA-J stated R1 started with a slide board; however, the slide board was a hindrance because R1 could do a squat pivot. PTA-J stated R1 made progress with transfers and was pretty much at baseline. PTA-J stated R1 was listed as a moderate assist on discharge and stated R1 thought therapy was helpful and wanted more; however, therapy could not continue without a payor source. PTA-J stated, I think (R1) probably could've used more therapy. There's always room for improvement. When asked if R1 was safe to transfer from wheelchair to bed independently, PTA-J stated, I'm not sure what the beds were like in the homeless shelter. We always had the bed level with the wheelchair (during transfers). When asked if R1 was able to dress independently, PTA-J stated R1 used a reacher to put on (R1's) pants, but it was difficult. PTA-J also stated PTA-J was not sure if R1 was appropriate for discharge to a homeless shelter. PTA-J stated R1 did not appeal the therapy discontinuation because (R1) was ready to leave at that point. The Surveyor reviewed R1's physical therapy discharge summary, dated 2/23/22. The summary stated, (R1) is safe with wheelchair mobility inside the facility, but is unsafe with wheelchair mobility outside especially in the snow as (R1) gets stuck. (R1) could benefit from continued therapy to work on safety with transfers and wheelchair mobility .Discharge recommendations: (R1) to call for help with transfers and is not to propel the chair outside secondary to safety issues. The discharge summary also stated improvements were noted in R1's short-term goal of performing squat pivot transfers with CGA (contact guard assist) of one staff; however, R1 can require assist for transfers .(R1) not safe with the squat pivot transfers but does them on (R1's) own anyway. The summary stated R1 was discharged from therapy due to a change in payor source. The Surveyor reviewed a fax sent to the attention of BOM-C on 2/25/22 from R1's HMO. The fax referenced R1 and stated, Please be advised the following dates have been approved for custodial LOC (level of care) 2/3/22 to 5/4/22. The current authorization is only valid for the current dates OR unless the member terms or discharges for any reason, a new notification is required Long Term Care/Custodial referrals do not require any continued stay clinical reviews. If you have any questions or if member discharges prior to disenrollment, please contact the following .(CM-O). CM-O's phone number was listed on the fax. On 3/16/22 at 11:26 AM, the Surveyor interviewed HMO DMCO (Director of Medical and Clinical Operations)-F regarding R1. DMCO-F verified R1 transitioned from skilled coverage to convalescent coverage and stated, Medicaid members assigned to an HMO have a skilled nursing coverage benefit .(R1) was assigned for skilled care when (R1) first (arrived at the nursing home), then it was determined (R1) didn't have a need for skilled services so (R1) transitioned and was approved by (HMO) for continued stay under convalescent care. DMCO-F stated R1 could remain at the facility for a full 90 days, disenroll from R1's HMO and transition to straight Title 19 (Medicaid) through the State of Wisconsin. DMCO-F stated, (R1) should definitely be in a long-term care support program. A homeless shelter is an unsafe discharge. DMCO-F stated long-term care coverage is clearly defined in the Long-Term Care Handbook. On 3/23/22 at 2:48 PM, the Surveyor interviewed HMO CM-O regarding CM-O's communication with the facility. CM-O verified CM-O sent a fax to the facility on [DATE] at 9:32 AM that stated R1 was approved for custodial care from 2/03/22 to 5/04/22. CM-O did not have any further contact with the facility until 3/15/22 at 3:55 PM when CM-O called the facility for an update on R1. CM-O stated, I had a hard time getting a hold of the facility to find out when (R1) discharged and where. CM-O spoke with RN-Q on 3/15/22 who stated R1 discharged ; however, RN-Q could not tell CM-O where. CM-O left a message for SW-E on 3/16/22 at 10:26 AM to verify R1's discharge date and location. CM-O stated the call was not returned. CM-O called the facility again on 3/16/22 and was transferred to SW-E who stated R1 discharged to (a location) on 3/01/22. CM-O was not aware R1 discharged to a homeless shelter because CM-O was unfamiliar with the location and SW-E did not clarify the location was a homeless shelter. The Surveyor reviewed HMO documentation provided by DMCO-F. The documentation indicated R1 spoke with CM-G on 2/14/22 and was concerned about a discharge plan. R1 stated SO-R broke up with R1 and R1 no longer had a home to return to. R1 stated R1 would prefer to remain at the facility due to R1's high-level chronic health care needs. CM-G left a detailed message for SW-E and requested a return call. CM-G called SW-E again on 2/17/22 at 9:00 AM and left a detailed message. CM-G asked SW-E to return the call and provide an update on R1. CM-G then received a call from R1 on 2/18/22 at 8:50 AM. R1 told CM-G that SW-E was present and notified SW-E that CM-G was on the phone; however, SW-E stated SW-E couldn't take the call. CM-G told R1 that CM-G left messages for SW-E on 2/14/22 and 2/17/22, but had yet to receive a return call. R1 told CM-G that R1 wanted to stay (in the city where R1 was hospitalized ), but gave SW-E two skilled nursing facilities in the city where R1 resided prior to R1's hospital admission. SW-E returned CM-G's call on 2/18/22 at 9:42 AM. SW-E stated SW-E would work with the ADRC to help R1 find housing at a group home or CBRF (community-based residential facility) that had some assistance. SW-E stated SW-E did not think R1 required skilled nursing care upon discharge. CM-G encouraged SW-E to contact CM-G when R1 discharged . A note written by CC (Care Coordinator)-Z on 2/18/22 stated, Left detailed message for (RN-I/MR-P) requesting they call me back at their earliest convenience in regards to the amount of support (R1's) family is able to provide for (R1) at home .Would like to discuss discharge plans. A note written by CC-Z on 2/22/22 stated, Left another detailed message for (RN-I/MR-P) .requesting they call me at their earliest convenience in the morning of 2/23/22 to discuss whether (SO-R) and son can care for (R1) at home or if (R1) is going to remain at SNF (skilled nursing facility) . A note written by CC-Z on 2/23/22 stated, Discussed case with (BOM-C). (BOM-C) reports (R1) will not be able to return home. (R1) will ultimately need alternate placement, so (R1) will remain at the SNF as LTC (long-term care)/custodial resident for now while social services seeks alternate placement. On 2/28/22, CM-G received a call from R1 who was frantic. SW-E told R1 that R1's stay was no longer covered as of 2/24/22 and R1 could go home. The note stated SW-E was notified previously by CM-G that R1 was homeless and needed housing assistance. CM-G stated R1 told CM-G that R1 had no money, could not pay privately to stay at the nursing home and could not be placed at another nursing home because R1 did not have custodial care. The note stated R1 was wheelchair bound and the nursing home was told by the ADRC that R1 could not go to a homeless shelter because shelters will not accept (R1) with a wheelchair. CM-G called SW-E on 2/28/22 at 3:48 PM and left a voicemail. The call was not returned. Documentation on 3/02/22 indicated R1's HMO believed R1 was still at the facility. On 3/02/22, CM-G emailed BA-H to determine the status of R1's coverage. BA-H stated R1 had custodial care from 2/03/22 through 5/04/22 and could remain inpatient at the facility until Medicaid began. BA-H called SW-E on 3/01/22 to answer questions about custodial care. The call was not returned. On 3/03/22 at 12:05 PM, CM-G called R1 and found out R1 was discharged from the facility on and transported to an emergency shelter on 3/01/22. R1 stated the shelter could not accommodate R1's wheelchair or meet safety standards for transfers so R1 was taken to a local hospital. On 3/22/22 at 11:30 AM, the Surveyor interviewed DMCO-F, CM-G and BA-H regarding communication with the facility. CM-G stated CM-G did not discuss R1's coverage with the facility. CM-G stated, I spoke with (SW-E) on (2/18/22) about (R1's) progress and care. No discharge date was set. That was the only time I was able to get through. DMCO-F stated the facility did not communicate with (the HMO) related to any decisions or appeals. BA-H stated BA-H left a detailed message for SW-E on 3/01/22 at approximately 10:40 AM regarding R1's coverage. BA-H stated, I advised that custodial care was approved through (5/04/22) and asked that (SW-E) call me. On 3/17/22, the Surveyor requested additional discharge information from the facility, including a signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APNP-Y's name was written under the signature line and the date was stamped as 3/03/22. The order summary did not contain a discharge order. NHA-A provided a list of discharge medications contained in a discharge communication to the pharmacy. The discharge communication stated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/18/22, CCO (Chief Clinical Officer)-BB provided BD (Bureau Director)-CC with a copy of an order administration note, written by RN-AA and dated 3/01/22 at 11:06 PM, that stated R1 was given meds to take with (R1). In addition, CCO-BB provided BD-CC with a discharge order, dated 3/01/22 and contained in R1's active orders as of 3/02/22, that stated, (R1) may discharge with all currently prescribed medication and quantities on hand at facility. May have home health and PT/OT (occupational therapy) nursing services. On 3/17/22 at 8:43 AM, the Surveyor interviewed hospital SW-M regarding R1. SW-M stated the day programming facility emailed SW-M and asked for assistance regarding R1. SW-M stated, (The day programming facility) emails us if there's a complex medical case that comes in. I met with (R1) at the facility. (R1) stated there was a funding error. (R1) stated (R1) had supplies, but since (R1's discharge) was abrupt, (R1) didn't know how to care for (R1's) ostomy. (R1) couldn't bathe (R1's) self and needed assistance with transfers. SW-M called the nursing home and said staff stated they tried to keep R1 and work out the financial piece. SW-M stated R1 had a bag of belongings that was too big for (R1) to carry on (R1's) lap. SW-M stated, I've never had that happen where someone didn't have a payor source if (R1's benefits) changed to custodial care, (R1) should be covered. The facility's actions of discharging a resident with poor safety awareness who required assistance with activities of daily living and dropping him off in front of a homeless shelter that would not open for several more hours created a reasonable likelihood for serious harm, thus creating a finding of immediate jeopardy. The facility removed the jeopardy on 3/18/22 when it completed the following: 1. Reviewed all discharges planned within the next 72 hours to ensure discharges included a safe location, the appropriate referrals and follow-up appointments, transportation arrangements and education regarding diagnoses, medications and medical devices. 2. Educated all licensed nurses on the resident discharge policy and procedure including education on medical devices, pertinent medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Educated SW-E on the facility's discharge policy and procedure. 3. Educated BOM-C on the Medicaid application process and 30 day involuntary discharge notice procedure.

Based on observation, interview, and record review the facility did not provide adequate supervision and implement interventions to prevent accidents for 1 (R1) of 3 sampled residents. -R1 has a history of falls and wandering. The facility did not increase R1's supervision when R1 was noted to have wandering/exit seeking behavior, aggression, and falls. On 7/31/21 R1 exited the facility unknowingly to staff. The facility indicates it was believed R1 exited through an alarmed door that was not functioning at the time of the incident. Following the incident staff did not increase R1's supervision until 8/21/21, despite R1 still having wandering behavior. On 8/14/21 R1 was observed in another resident's room, with an injury to his head requiring sutures. Following the incident, the facility did not update R1's plan of care or increase supervision until 8/21/21. On 8/15/21 R1 fell again, required hospitalization and added sutures to the injury obtained on 8/14/21. During the survey R1's call light was observed on the floor and not within reach, as indicated per the resident's plan of care. During the survey the dining room door was observed to be opened with no staff or residents observed in the dining room and not closed, as indicated per the resident's plan of care. Findings include: The facility's Elopement policy and procedure, with an effective date of 7/7/15, states When the patient/resident is located, the Charge Nurse completes a head to toe assessment. The resident is placed on one-to-one supervision until further arrangements are made to ensure the resident's safety (refer to One to One Supervision policy). R1 has diagnoses that include [CONDITION(S)], dementia with behavioral disturbance, impulse disorder, mood disorder due to known physiological condition, mild cognitive impairment, dysphonia, abnormalities of gait and disorder, [CONDITION(S)], [CONDITION(S)], and drug induced dyskinesia. R1's quarterly Minimum Data Set Assessment, with an assessment reference date of 7/8/21, documents R1's cognitive skills for decision making as severely impaired, that wandering behavior occurred daily, and that 2 or more falls with injury (except major) occurred. R1's plan of care includes a focus area for Resident has behavior concerns as manifested by: Resistive to care, non-compliance with wearing of mask, wandering initiated on 4/1/21. Interventions initiated on 4/1/21 include: Elicit family input for best approaches to resident, observe for mental status behavior change as needed, Redirect as able, and Use consistent approaches when giving care. On 8/21/21 the plan of care was revised to include visual on resident when he is not in his room. R1's plan of care includes a focus area for ADL [activity of daily living] self-care deficit as evidenced by: Related to: disease process [CONDITION(S)] Resident at times needs assistance, but frequently declines use of gait belt, wheelchair, staff assistance. Will at times sleep on furniture in resident lounge initiated on 4/2/21 and revised on 6/30/21. Interventions include Resident transfer independently. Resident at times needs assistance, but frequently declines use of gait belt, wheelchair, staff assistance. Resident has issues with staff in his personal space initiated on 4/2/21 and revised on 7/30/21. R1's plan of care includes a focus area for The resident is an elopement risk due to/exhibited by History of wandering, Impaired safety awareness, Neurological impairment, New admission and unfamiliar with surroundings. Wanderguard Right ankle initiated on 4/1/21. Interventions initiated on 4/1/21 include: Distract Resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, magazines; Identify pattern of elopement: Is exit seeking purposeful, aimless, or escapist? Is resident looking for someone, some place or something? If resident exits the building, do not leave unattended- Walk with Resident and/or keep within eye sight; Monitor location closely. Document elopement behavior and attempted diversion interventions in the progress notes and/or behavior log(s); Place WANDER ALERT DEVICE. Note location of device on resident-wanderguard right ankle note the model numbers and battery checks per facility guidelines. Obtain Consent per facility protocols. On 8/22/21 the plan of care was revised to include visual on resident when he is not in his room. R1's plan of care includes a focus area for Resident is at risk for falls r/t Cognition- unaware of safety needs. Deconditioning/weakness. Incontinent. Resident kneels on floor/gets on knees and picks at floor, then gets back up independently. 8/3/21 witnessed fall. 8/15/21 fell on floor and bumped side of face by right eye. Initiated on 4/1/21, and revised on 8/15/21. Interventions initiated 4/1/21 include: Anticipate and meet the Resident's needs. Encourage the Resident to always call for assistance; Education [sic] the Resident on fall prevention measures. Assure Resident that calling for help is not a bother; Follow therapy recommendations for transfers, mobility and ambulation; Place call light or communication device within reach. Answer call light promptly- always; Review information on past falls and attempt to determine cause of falls for prevention and to minimize injuries. Interventions put into place on 7/25/21 include: toilet first HS [hour of sleep] care rounds. Interventions put into place on 7/26/21 include: close dining room doors after meals/activities; and Resident not to be left alone in dining room. Interventions put into place on 8/3/21 include: High back w/c with anti-tip and anti-rollback r/t falling against wall when standing and losing balance; and When resident desires to stand and eat, encourage him to lean against a stable surface and ensure tray table is at an appropriate height. Interventions initiated on 8/4/21 include Encourage to sit down if gait is unsteady. Interventions put into place 8/15/21 include Monitor open area right side face: update MD PRN [as needed]. Apply dressing to area as allows. Progress notes on 7/5/21 document Resident was exit seeking at the start of shift and staff able to redirect resident is now resting in bed will continue to monitor. The surveyor noted no updates to R1's plan of care. Progress notes on 7/22/21 document Resident has been exit seeking during the shift unbale [sic] to sleep in and out of resident rooms became combative with staff with care wouldn't allow staff to change him. Resident was trying to get out of door several times during the shift redirect was unsuccessful this would agitated the resident more will endorse this over to day shift to follow up. Progress notes on 7/22/21 document Resident reviewed in behavior management with IDT [interdisciplinary team] and Pharmacy. Looking to obtain a new weight and changing [MEDICATION(S)] dose to the morning. Will continue to monitor and assist as needed. Progress notes on 7/22/21 document [R1] was sitting in a wheelchair outside medical records room. He was attempting to stand up from his wheelchair and lost his balance hitting his head on doorway from approximately 2 inches above his right eye. Note 1cm red mark above his right eye on the forehead. Progress notes on 7/23/21 document Writer was made aware by dietary that resident's [left] hand was bleeding. Observed an old scab that was bleeding. Resident unable to report what happened. Area was cleansed and covered with [MEDICATION(S)] dressing. Denies pain. Bleeding has stopped. No concerns at this time. Monitor. The surveyor noted no updates to R1's plan of care following this injury. Progress notes on 7/25/21 at 10:15 am document Resident was observed on the floor in the dining room with blood from his head. Had unwitnessed fall. Injury noted to R [right] head, near R eye. Res [resident] was conscious and talking to staff. Unable to obtain VS [vital signs]. Called EMS [emergency medical services] at 0950 [9:50 am], they arrived at 1000 [10:00 am] .EMS assessed and transported to [hospital] at 1012 [10:12 am]. Notified [hospital] ER [emergency room ] about pt [patient] arrival . Progress notes on 7/25/21 2:17 pm document Res returned from [hospital] via stretcher .CT scan negative, 3 sutures above R eye laceration OTA [open to air]. [Hospital] phoned stated they rec [recommend] res use walker also sutures to be DC [discontinued] in 5-days. Lab results showing res with [CONDITION(S)] [urinary tract infection]. Hospital to send order to [Pharmacy]. Progress notes on 7/25/21 at 10:31 pm document Res with aggressive behaviors refusing cares, attempting to hit/kick staff grabbing onto staff, wandering into other res room again difficult to redirect . A root cause analysis action plan, with an event date of 7/25/21 documents a problem statement of Unwitnessed fall in DR. Appears to have hit R side above eyebrow onto table. Causal factors are listed as: not sleeping, loss of balance/unsteady gait, and increased unsteady gait. The form documents Summary statement: Root cause identified- [MEDICATION(S)] [changed] time to ensure better sleeping habits, cause is unsteadiness, refusing wc (wheelchair) at times. Conclusions/recommendations- Keep DR door [closed after] meals, and activities. Sleep study to be initiated as he has not been sleeping. Progress notes on 7/26/21 document Pushed on 1st door of exit by kitchen and alarm sounded, easily assisted away from areas. The surveyor noted no updates related to wandering to R1's plan of care. Progress notes on 7/27/21 document Pushes on 1st exit door by time clock alarm sounded and was easily assisted aware from area. He has not slept this shift. The surveyor noted no updates related to wandering to R1's plan of care. Progress notes on 7/28/21 document Resident at weekly WAR [weekly at risk] meeting re: recent fall on 7/24/21, 7/25/21 sent to ER for eval, Right eye brow has sutures being removed on 7/30, returned from ER with new diagnosis of [CONDITION(S)], being treated with antibiotic. Bruising noted to right eye. Progress notes on 7/28/21 document Resident has shown no overall changes in his mood. Resident continue to express his overall needs as able, staff anticipates and meets all of residents other needs. Continue to structure own leisure time by wandering around the facility .Psych services remain involved. Will continue to monitor and assist as needed. Progress notes on 7/28/21 document .Wandering ad lib per usual behavior. Wanderguard functioning and intact to ankle. Staff redirecting as needed. Continue to monitor and redirect. Progress notes on 7/30/21 at 12:29 pm document Resident is on follow up for: 7/29 res lowered to floor P [after] res lost balance 0 injuries from incident. The current status is Res with abrasions to knees OTA (open to air), multiple sm [small] scabbed areas to upper ext [extremity] . A Root Case Analysis Action Plan, with an event date of 7/29/21, documents Res in bed stood up to go to sink staff encouraged [R1] to sit and eat and was not cooperative, he LOB [loss of balance] and went to floor as staff was not able to get to him on time. Summary statement: Root cause identified- LOB when standing and eating at bedside. Conclusions/recommendations- Encourage him to lean on surface such as wall and adjust tray table to appropriate height when eating tray table. Progress notes on 7/30/21 at 5:15 pm document Resident is on follow up from: [R1] was by the nurses station. Noted blood running down the corner of entry way into the nurse's station on team one side. Also, blood noted on floor in area. Noted resident right elbow area to have (2) 2 cm each open skin tears on right elbow area. Area cleansed with water, steri-strip applied to each area and dressing applied. The current status is dressing dry & intact monitor. Progress notes on 7/31/21 at 6:30 am document Resident is on follow up for: Elopement. The current status is Resident in WC [wheelchair] sitting in hallway. No signs of elopement at this time. Alert and confused per recent baselines. Looking into door alarm situation. Continue to monitor closely as needed. Need maintenance to check door alarms. Progress notes on 7/31/21 at 6:37 am document Resident was reported missing by NOC staff. Approximation of time 20 minutes. All on staff searched facility and premises for resident. Observed resident lying on ground outside on facility patio. No s/s [signs/symptoms] fall. No new injuries noted. Resident unable to describe what he was doing. Confused per baseline with recent dx [diagnosis] of [CONDITION(S)]> Was wearing shoes. Resident assisted into WC [wheelchair] with minimal assist and brought back into building immediately. An Elopement Incident note, with an incident date of 7/31/21, documents This writer came in for AM shift. NOC staff was searching for resident. Reported him not being seen for the last 20 minutes. All staff on floor searched for resident and found resident outside on the patio, laying on the ground by the bushes. Wanderguard was intact to R ankle. Head to toe assessment completed right away. No new injuries noted. Resident got up with minimal assist into wheelchair and brought back into the building. Resident unable to describe what he was doing and where he was going. No door alarms were sounding at time of event. Resident was wearing shoes. Wanderguard was intact to R ankle with no s/s [signs/symptoms] of tampering. Staff statements document Resident was not found in his room around 5:00 during rounds. We checked inside all rooms and he was found approximately 5:30 outside. No alarms went off all night. Another staff statement documents Came onto my shift and was told [R1] was missing. Noc staff looked in all rooms. We found him laying outside next to bushes. We brought him in and the alarms to door did not go off. A root Cause Analysis Action Plan, with an even date of 7/31/21, documents During 5:00 AM Rounds, [R1] was not in room or in hallways. Staff did not hear any alarms + immediately did room searches and checking outside. Res was found laying on ground outside next to bushes (bird room). The form documents Summary statement: Root cause identified- Door by patio malfunctioned it is an alarmed door, that did not latch or sound alarm 50% of time when found door was not latching or alarm not sounding. Adjusted closure of door and now latches. Conclusions/recommendations: All doors leading outside are functioning. All doors to be checked by Maintenance Director and/or designee. Maintenance Director obtaining information on other options of alarm. Was 60 degrees and clear wearing shoes, shorts, shirt. A hand written sheet documents [R1] Synopsis. [R1] wander guard was functioning however, the door that he may have left out of is alarmed but not wander guard alarmed. When checking the functioning of the door 50% of time door did not latch or alarm. Maint. Director adjusted closure of door and is checked daily by Maint Director and/or MOD (manager on duty). All resident with wanderguard devices were functioning when checked after incident 7/31/21. Doors alarmed as well. Maint Director in talks with Project Manager at [Access Control and Wander Management Systems Company] . The surveyor noted no updates to R1's plan of care related to wandering following the incident. On 8/23/21 at 2:10 pm the surveyor interviewed NHA-A. NHA-A informed the surveyor that prior to the incident the facility was checking alarm function weekly, and after the incident began checking alarm function daily, with logs noted to be in place. On 8/23/21 at 2:40 pm the surveyor interviewed Maintenance Director-D. Maintenance Director D informed the surveyor the issue on 7/31 was the door wasn't closing completely. Maintenance Director-D indicated he had adjusted the closing/latching on the door and have had no issues since. Maintenance Director-D indicated the doors were now being checked daily. Progress notes on 8/1/21 document .The current status is Resident continues to be impulsive with decisions, attempts to stand and walk unassisted multiple times this shift. At times takes more than one staff member to assist resident back into bed or wheelchair. Resident often tries to work against staff while being assisted back into bed/chair. Progress notes on 8/1/21 document Writers notes res had increased tripping res struggles to ambulate appears to not be able to move each foot forward does so in a shuffle like motion at times one appears stuck unable to pick up to move forward causing res to become scared stiffen up. When res exhibits theses after mentioned symptoms he begins to trip grab onto objects for balance support however the objects aren't always able to support his weight therefore res has the tendency to fall. Res bumps into objects frequently during each shift as his ability to ambulate declines. Res has been noted to crawl around on the floors. Res becomes increasingly angry with staff during cares, redirection at times with any interaction. Res wanders into other res rooms very difficult to leave out of them. Res crawls on door frequently bumping into objects. Change of condition implemented. Surveyor noted despite staff documenting these observable changes in R1 no changes were made to R1's plan of care. Progress notes on 8/2/21 document Resident was very combative with staff was holding on to staff wrist and trying to punch staff. Resident has stitches in his right eyebrow that need to be removed. Resident is very aggressive and agitated when it comes to care, will endorse over to day shift to attempted stitches removal. Resident continues with ABT [antibiotic] for [CONDITION(S)] with no adverse reactions noted at this time. Progress notes on 8/3/21 document Resident reviewed at weekly WAR meeting re: fall 7/25, new skin injury, and elopement. Unwitnessed fall in dining room 7/25, resident hit head on table causing laceration above right eye. Sent to ER and received stitches. Resident eloped from building 7/31. Intervention in place for fall. Care plan current. Intervention for elopement to fix door, which was done. Door resident exited from had a malfunctioning door alarm. Progress notes on 8/3/21 document Res was walking down the hallways towards writer when it appeared his left leg failed to move forward. Res tripped falling forward onto his L side. Res did not hit his head. Res reports the L side of his leg/hip hurting. Res was seen holding his hand over his L hip. A Root Cause Analysis Action Plan, with an event date of 8/3/21, documents LOB [room number] tripped as his L foot appeared to not able to move forward fell to left side. The form documents Summary statement: Root cause identified- Not able to move forward [with] L foot tripped and fell on to L side. Conclusions/recommendations- After reviews of falls it appears [after] [MEDICATION(S)] was moved to from NOC ->AM's, [increase] #[number] of falls. Will [change] times back to AM's to receive [MEDICATION(S)]. This [change] was to see if he was sleeping. Progress notes on 8/13/21 document [Nurse Practitioner] here, she changed this residents [MEDICATION(S)] order from 7.5mg to 15mg with instructions to monitor for over sedation, fall interventions, monitor for risk of falls, frequent monitoring. She changed this for his increased behaviors with striking out at staff, she is aware that he has a Neurology appointment on August 19, 2021, she feels that this increase will benefit the resident until his neurology appt [appointment] for his aggressing and not sleeping. Progress notes on 8/13/21 document Writer did observe [R1] walk toward the front entrance after being dropped off by family before being redirected by [nurse]. Progress notes on 8/13/21 document Res was monitored closely as he had made several attempts to walk towards front door but was re-directed. Progress notes on 8/14/21 at 10:20 pm document Pushed on 1st exit door by time clock; alarm did alarm. Easily assisted away from area. Progress notes on 8/14/21 at 11:55 pm document Resident was found in another resident room he had a larger lacerations to his eyebrow with bruising to the right side of face. Resident would not allow staff to do a head to toe assessment on him. [Ambulance Service] was called. Resident was last seen by staff in his be [sic] bed at 10:30 pm and was found in another resident room at 11:20 pm. Resident has no other bruise that staff could see without a full assessment monitor for possible bruising later. Resident was picked up ambulance at 11:38 pm and taken to [hospital] . A Root Cause Analysis Action Plan, with an even date of 8/14/21, documents Was in [another resident's room] stating he was climbing a roof. He was attempting to get into bed and LOB [loss of balance] hitting head on head board of bed. Casual factors are listed as dementia, and root cause is documented as loss of balance getting into bed. The form documents Summary Statement: Root cause identified- Sent to ER for stitches. Increase of [MEDICATION(S)] given with potential [increased] falls. Conclusions/recommendations-Attempting to get into a bed LOB hit R side of head on headboard. Attach and related policies or reference material- [Another resident] stated he hit head on head of bed and was bleeding. An incident report for an injury of known origin, on 8/14/21 documents under Incident Description: Resident was found in another resident room and staff notice he had a larger hematoma and laceration to his right side of face on his eyebrow. Under Immediate Action Taken documents Staff attempted to do an assessment on resident he would not allow staff, ambulance service was called to take resident to hospital. MD was phoned and message sent out DON and administrator notified. A statement from a resident documents The resident that witnessed this stated, he was trying to get in that other bed and hit his head on the headboard. A staff statement documents what was resident trying to do, not sure he said he was climbing a roof. Found resident in [another resident room] when closer examined I saw blood on his face and saw eye swollen shut and eyebrow swollen as well went to room and there was a puddle of blood in the middle of room. would not allow anyone to check if he was soiled. Review of R1's plan of care does not document any changes related to the above incident. Progress notes on 8/15/21 at 4:30 am document Resident has returned back from hospital with stitches to his right eyebrow and a non adherent dressing to his face .was very combative with EMT and staff would not allow staff to take his v/s [vital signs] upon his return was given a sandwich and water . Hospital Notes on 8/15/21 document an arrival time on 12:19 am and document Patient was found on floor unknown amount of time large laceration to right eye . Hospital notes document 71 yo [year old] NH [nursing home] resident found down in common area. Unknown down time. Unwitnessed fall. Unknown if he had fallen down stairs or had any other injuries. Was found bleeding with significant injury to the head as well as extensive bruising across entire body surface area .Patient presents with unwitnessed fall at nursing home. Was found in common area unknown how far he had come from his room or whether he had any other falls prior to being down. Was found in a pool of blood. Had obvious head injury as well as contusions to his chest and abdomen Hospital notes document R1 received 4 sutures. Progress notes on 8/15/21 at 9:57 am document Resident was sitting at nurses' station, eating late breakfast. Spilling drinks d/t [due to] being too tired. Refused to go lay down. CNA [certified nursing assisting] attempted to remove tray and cups from resident and resident became combative. MOD [manager on duty] called to situation to remediate. Staff attempting to redirect, but unsuccessful. Resident soiled but refusing cares. Progress notes on 8/15/21 at 10:45 am document Resident wandering unit, going in other residents rooms. Staff continue to redirect resident to his room. Attempting pericare and change of clothes. Res soaked. This writer attempted to clean off blood from prior injury, but he refused. Res at the sink washing himself up. Towels offered. Res closed his door. Will cont [continue] to monitor. Progress notes on 8/15/21 at 8:50 pm document Resident had removed dressing from above right eye. Writer attempted to apply a new dressing and he started punching at writer. He walked over to [another resident room] and took down the door way ribbon and started going into that room. Redirected away from that area. Progress notes on 8/15/21 at 8:58 pm document Punching at CNA when attempted to remove him from the DR [dining room] earlier. Progress notes on 8/15/21 at 9:00 pm document .Resident was walking in the hallway by med cart side 2. He stumbled over his feet and fell on the floor. He bumped the right side of his forehead on the door. Noted bright red blood coming from right side of face near right eye. Note area to be clotting off but still dripping small amounts of blood. Pressure applied and dressing applied. Some resistance with assist. Side of head by right eye continues to bleed even with dressing and pressure applied. The current status is sent to ER . A Root Cause Analysis Action Place, with an event date of 8/15/21, documents Ambulating near nurses station [room number]. Tripped on own feet. fell to floor to R side face area bleeding. Send to ER. Summary Statement: Root cause identified- Res ambulating throughout facility, [increased] agitation and [increased] refusal of cares not sleeping. [R1] did not clean heel -> toe trike and tripped over feet. Falling forward hit R side and bleeding. Did not allow staff to assess. Was sent to ER for follow up. CT neg in wrist restraints at hospital. Hospital Discharge Summary Notes, dated 8/18/21, document [R1] .comes in after suffering an unwitnessed fall. Patient was seen in the emergency room ,d+[DATE] for an unwitnessed fall after being found on the ground with a large laceration above right eye. Patient had been down for unknown amount of time. Imaging showed a large hematoma to his scalp and periorbital region but otherwise imaging was unremarkable. Patient was discharged back to nursing home and presented less than 24 hours later after suffering another unwitnessed fall. It is unknown how long he was on the ground. He has re-injury of laceration to right eye with bleeding noted .Laceration was revised and now has 9 sutures. Patient is being admitted for safety concerns in returning to his current nursing facility given he has had 2 unwitnessed falls in 2 days resulting in injury, multiple abrasions and bruises in various stages of healing, and disheveled appearance. During hospitalization he showed intermittent agitation and confusion with impulsive behavior. Evaluation by geriatric psychiatry agreed with beginning [MEDICATION(S)]. He is scheduled to follow-up with neurology discuss his [CONDITION(S)] regimen. Geriatric psychiatry also felt that a [MEDICATION(S)] dose decrease could be beneficial. Given the progressive nature of his dementia he would also be a candidate for hospice care . Progress notes on 8/19/21 document Res arrived at 1128 [11:28 am] via ambulance from [hospital], .Several attempts to exit building s [without] success, difficulty redirecting . Progress notes on 8/20/21 document Resident a readmit to the facility was a little combative with staff and was able to clam [sic] down staff gave resident space and snacks and fluids on shift and no c/o [complaints of] pain or distress noted on shift. Progress notes on 8/21/21 document Notified family about resident to resident, left a message and requested that the family get a sitter for him due to his increased aggression and agitation. The surveyor noted the facility did not provide a sitter to R1. Progress notes on 8/22/21 document Resident had a res to res that took place on PM shift resident was on his side of the hall and in and out of his room he had no contact with other resident he is very combative with care wouldn't allow staff to clean him up on shift will continue to monitor Review of R1's Behavior Summary Report from 7/5/21-8/23/21 documents wandering behavior occurring on all 3 shifts, every week, during the report time frame. On 8/24/21 at 2:43 pm the surveyor interviewed CNA (certified nursing assistant)-C. CNA-C informed the surveyor R1 wanders every shift, although he is not always exit seeking, and that when he goes out with family he is more likely to exit seek. CNA-C informed the surveyor R1 has aggressive behavior having struck out and has tried to strangle her from behind. CNA-C stated they have talked about redirecting and re-approaching R1. The surveyor asked what interventions CNA-C had been instructed on related to R1's wandering. CNA-C stated normally we are watching him, that they work as a team to keep an eye on R1. On 8/24/21 at 10:01 am the surveyor interviewed Social Worker-E. Social Worker-E informed the surveyor R1 is a handful as he isn't easily redirectable and as day progresses he becomes more agitated. The surveyor asked Social Worker-E what the facility is currently doing for R1's behaviors. Social Worker-E informed the surveyor psych services sees him, they have been working with the pharmacist related to his medication changes. Social Worker-E indicated it has been difficult as R1 doesn't sleep. Social Worker-E indicated R1 loves snacks so will have him come by her or NHA-A and sit and have a snack in the office. Social Worker-E indicated they did a training a couple of weeks ago about dementia approaches as well. On 8/23/21 at 10:18 am, 10:34 am, 10:52 am, and 10:57 am the surveyor observed R1 in bed with the call light on the floor. On 8/23/21 at approximately 9:20 am the surveyor observed the dining room door open with no staff observed in the dining. At 9:33 am the surveyor observed the dining room door remained open with no staff observed in the dining room. On 8/24/21 at 1:18 pm the surveyor interviewed NHA-A. The surveyor asked what the process is when a fall or incident occurs. NHA-A stated the Nurses put it into their risk management, put an immediate intervention in place, and then the IDT reviews for a root cause. The surveyor informed NHA-A of being unable to find updated interventions to R1's plan of care following the elopement on 7/31/21, 8/14/21, and 8/15/21. At 2:33 pm the surveyor met with NHA-A and DON-B. DON-B informed the surveyor the intervention following the 7/31/21 incident was that the door was fixed. NHA-A indicated R1 wouldn't have been on the ground if he hadn't been outside so the door was fixed. NHA-A stated the incident on 8/14/21 was an injury of known origin, indicating it wasn't a fall, and R1 had hit his head on the head board in another resident's room. The surveyor asked what interventions were put in place related to that incident. NHA-A stated staff try to keep an eye on him and out of other residents room. NHA-A started following the incident on 8/15/21 the facility added [MEDICATION(S)] in the hospital, and that following his neurology appointment being canceled while R1 was in the hospital, had been rescheduled to September 7th. DON-B stated she had called R1's daughter and had requested them to pay for a sitter as NHA-A feels it isn't safe, especially with his dementia. NHA-A stated they have all hands on deck for R1, indicating R1 likes food such as sandwiches and chocolate milk and will try to use snacks to redirect. The surveyor noted R1's plan of care was not updated to include increased supervision until 8/21/21 when R1's plan of care was updated to include visual on resident when he is not in his room. On 9/2/21 the facility submitted additional information to review regarding R1 including a timeline of R1's falls and interventions. This information was reviewed by the surveyor as part of their investigation.

Based on record review, interview and observation, the facility did not follow professional standards of practice and its own written policies and procedures designed to help prevent the development and transmission of COVID-19 (Coronavirus Disease 2019), potentially affecting all 29 residents who resided at the facility at the time of the survey. * CNA (Certified Nursing Assistant)-M was not screened upon starting her work shift and later developed signs and symptoms and tested positive for COVID-19. CNA-M was identified by the facility as the index case for the facility's outbreak of COVID-19 that began on 12/23/20. * Facility staff were screened at the start of their shift and found to have signs and symptoms of COVID-19. Despite their signs and symptoms, facility staff members were still allowed into the building to work. These facility staff members were later found to test positive for COVID-19. * Facility staff were not actively screening facility visitors at the entrance to the facility. Funeral home employees were observed to enter the facility without being screened for COVID-19. * The facility experienced an outbreak of COVID-19 that began on 12/23/20 and did not being COVID-19 testing of residents until 12/25/20. The facility completed testing of all residents on 12/26/20. The facility could not provide evidence that it tested all employees for COVID-19 when the outbreak began on 12/23/20. * The facility had one facility staff member test positive for COVID-19 on 11/10/20 and did not begin COVID-19 testing of residents until 11/13/20. * Facility staff were not being tested twice a week per the facility's testing policy and per the county's COVID-19 positivity rate. * The facility could not provide any evidence that it completed contact tracing of employees and residents when facility staff members began showing signs and symptoms of COVID-19 on 11/6/20 and 12/23/20. These facility staff members would later test positive for COVID-19 on 11/10/20 and 12/23/20. The facility's failure to implement an infection prevention and control measures to prevent the spread of COVID-19 created a finding of immediate jeopardy that began on 12/23/20. Senior Director of Clinical Services-E, Director of Clinical Operations-D and Administrator-A were notified of the immediate jeopardy on 1/11/21 at 2:09 p.m. The immediate jeopardy was removed by the facility on 1/11/21. The deficient practice continues at a scope and severity of an F (potential for harm/widespread) as the facility continues to implement its action plan. Findings include: The CDC (Centers for Disease Control)'s recommendation updated on November 20, 2020 and titled, Preparing for COVID-19 (Coronavirus Disease 2019) in Nursing Homes documents, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens, including [MEDICAL CONDITION] . As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). The facility's policy dated as revised 12/21/20 and titled, Suspected or Confirmed Positive COVID-19 Management Policy documents under the Policy section, The center recognizes that as COVID-19 is rapidly spreading across the country, we may have residents and/or staff that develop the disease, The center will strive to adhere to current CDC infection prevention and control recommendations, including universal source control measures, visitor restrictions, screening of residents and HCP and promptly notifying the health department as indicated. As part of our overall Emergency Operations Plan and Pandemic Preparedness and Response Plan, the center's Pandemic Outbreak Planning Committee has established this policy to guide us with our preparation and response in the event COVID-19 virus is suspected or confirmed at the center. On 1/5/21, an FICS (Focused Infection Control Survey) was conducted at the facility. As part of this survey, testing of residents and employees, PPE (personal protective equipment) supply levels and observations of infection control practices were reviewed. On 1/5/21 at 9:29 a.m., Surveyor interviewed VP (Vice President) of Operations-C regarding the infection control status of the building. During this interview, Surveyor was provided with documentation and informed of the following: As of 1/5/21, the facility currently had 25 residents confirmed as COVID-19 positive, 4 confirmed COVID-19 negative residents and had an active outbreak of COVID-19 throughout the building. Since 1/5/21, the facility had 2 residents diagnosed as COVID-19 positive expire and resident hospitalized . As of 1/5/21, the facility had 12 employees whom were confirmed as COVID-19 positive and not working. The facility had a designated COVID-19 section unit that was separated by a plastic barrier and all residents were moved to the appropriate units in the facility based on their COVID-19 status. Surveyor was informed that the facility had been in contact with the Jefferson County Public Health Department and had reported the COVID-19 outbreak to the Jefferson County Public Health, which was in constant communication with the facility regarding measures that could prevent the further spread of COVID-19. Surveyor was informed that the facility did not have any PPE (personal protective equipment) shortages and that the facility was currently under a conventional capacity strategy with their PPE supplies that included gowns, facemasks and gloves. Surveyor was informed that the facility was also under a contingency capacity strategy for the use of PPE supplies that included face shields and or eye protection. An inventory of PPE supplies provided to Surveyor that revealed that as of 1/5/21 the facility had: 550 N95 masks, 350 face shields, 35 eye protection goggles and 1600 disposable gowns available for staff. 1.) Staff Screening The CDC (Centers for Disease Control)'s recommendation updated on November 20, 2020 and titled, Preparing for COVID-19 (Coronavirus Disease 2019) in Nursing Homes documents under the Core Practices section, Have a Plan for Visitor Restrictions. Send letters or email to families reminding them not to visit when ill or if they have a known exposure to someone with COVID-19. Facilitate and encourage alternative methods for visitation (e.g., video conferencing) and communication with the resident. Post signs at the entrances to the facility advising visitors to check-in with the front desk to be assessed for symptoms prior to entry. Screen visitors for fever (T (temperature) ? (greater than or equal to) 100.0 F (degrees Fahrenheit)), symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. Ask visitors to inform the facility if they develop fever or symptoms consistent with COVID-19 within 14 days of visiting the facility. Have a plan for when the facility will implement additional restrictions, ranging from limiting the number of visitors and allowing visitation only during select hours or in select locations to restricting all visitors, except for [MEDICATION NAME] care reasons. The facility's policy dated as revised 12/21/20 and titled, Suspected or Confirmed Positive COVID-19 Management Policy documents under the Procedure section, Monitoring staff: 1) The center will ensure staff are aware of sick leave policies and the requirement that they stay home if they are ill with fever or respiratory/COVID-19 symptoms and if they have been tested for COVID 19 and results are pending; 2) The center will advise employees to check for any signs of illness before reporting to work each day and notify the Executive Director, Infection Preventionist, or designee if they become ill; 3) The center will follow CDC/DPH recommendations regarding the staff screening process for COVID-19. At a minimum, staff will be screened for signs/symptoms of COVID-19 and have their temperature checked at the beginning of their shift. Staff will be instructed to immediately notify their supervisor should they develop symptoms of COVID-19 during a shift and shall be re-screened by nursing supervisor and sent home if screening dictates; 4) Employees will be required to notify the Infection Preventionist, or designee if they have been exposed to someone who has recently traveled outside the state. The Infection Preventionist will refer to CDC guidance for guidance on the employee's ability to work. The facility's infection control listing for employees documents the beginning of the COVID-19 outbreak at the facility as beginning on 12/23/20, when CNA-M first began displaying signs and symptoms of COVID-19. The facility's infection control line listing for December 2020 documents that CNA-M began displaying signs and symptoms of COVID-19 that included headache, stuffy nose and cough on 12/23/20. CNA-M's Kronos time clock log documents that CNA-M worked on 12/23/20 from 3:08 a.m. to 5:55 a.m. Surveyor reviewed the facility's screening logs for 12/23/20 and was unable to locate any documentation or evidence that CNA-M was screened for signs and symptoms of COVID-19 before she began her shift working with residents on 12/23/20. Surveyor reviewed the facility's employee screening tool titled, FACILITY COVID-19 SCREENING TOOL for 12/23/20 and was unable to locate CNA-M's name as having being screened on 12/23/20. Surveyor was unable to locate CNA-M's name and or temperature as taken and reviewed prior to her (CNA-M) entering the building and working her shift on 12/23/20. Per the facility's line listing, CNA-M was confirmed to be COVID-19 positive on 12/25/20 and was found to be the facility's index patient for the COVID-19 outbreak that began on 12/23/20. The facility's infection control line listing for December 2020 documents that CNA-X began displaying signs and symptoms of COVID-19 that included a cough and shortness of breath on 12/26/20. CNA-X's Kronos time clock log documents that CNA-X worked on 12/28/20 from 6:03 a.m. to 7:09 a.m. The facility's screening tool/log titled FACILITY COVID-19 SCREENING TOOL for 12/28/20 documents that CNA-X documented YES as having been exposure to COVID positive person and had shortness of breath or difficulty breathing, congestion or runny nose, headache, sore throat muscle or body aches and cough when CNA-X was screened prior to entering the building and working her shift on 12/28/20. Surveyor noted that CNA-X was tested for COVID-19 with a PCR (Polymerase Chain Reaction) test on 12/28/20. CNA-X's documented test results document that the facility and CNA-X were notified that CNA-X was COVID-19 positive on 12/29/20 at 4:47 a.m. Surveyor noted that CNA-X was screened as having documented signs and symptoms of COVID-19 prior to her entering the building and working on 12/28/20 from 6:03 a.m. to 7:09 a.m. Surveyor was unable to locate any evidence as to why CNA-X was allowed to enter the building and or work with residents after being screened as having documented signs and symptoms of COVID-19 prior to her entering the building and working on 12/28/20. The facility's infection control line listing for December 2020 documents that LPN (Licensed Practical Nurse)-Y began displaying signs and symptoms of COVID-19 that included a cough, myalgia, headache and loss of taste and smell on 12/2920. LPN-Y's Kronos time clock log documents that LPN-Y worked on 12/29/20 from 1:38 p.m. to 6:13 a.m. on 12/30/20. The facility's screening tool/log titled FACILITY COVID-19 SCREENING TOOL for 12/29/20 documents that LPN-Y was found to have headache and cough when LPN-Y was screened prior to entering the building and working her shift on 12/29/20. Surveyor noted that LPN-Y was tested for COVID-19 with a PCR test on 12/31/20. LPN-Y's documented test results document that the facility and LPN-Y were notified that LPN-Y was COVID-19 positive on 1/1/21 at 2:40 a.m. Surveyor noted that LPN-Y was screened as having documented signs and symptoms of COVID-19 prior to her entering the building and working on 12/29/20 from 1:38 p.m. to 6:13 a.m. on 12/30/20 Surveyor was unable to locate any evidence as to why LPN-Y was allowed to enter the building and or work with residents after being screened as having documented signs and symptoms of COVID-19 prior to her entering the building and working on 12/29/20 into 12/30/20. The facility's infection control line listing for December 2020 documents that CNA-I began displaying signs and symptoms of COVID-19 that included a cough on 12/30/20. CNA-I's Kronos time clock log documents that CNA-I worked on 12/31/20 from 1:53 p.m. to 5:45 p.m. The facility's screening tool/log titled FACILITY COVID-19 SCREENING TOOL for 12/31/20 documents that CNA-I was found to have a headache, sore throat and cough when CNA-I was screened prior to entering the building and working her shift on 12/31/20. Surveyor noted that CNA-I was tested for COVID-19 with a PCR test on 12/30/20. CNA-I's documented test results document that the facility and CNA-I were notified that CNA-I was COVID-19 positive on 12/31/20 at 2:37 a.m. Surveyor noted that even after being confirmed to being COVID-19 positive, CNA-I was also screened as having documented signs and symptoms of COVID-19 prior to her entering the building and working on 12/31/20 from 1:53 p.m. to 5:45 p.m. Surveyor was unable to locate any evidence as to why CNA-I was allowed to work with residents after being confirmed to be COVID-19 positive on 12/31/20 at 2:37 a.m. On 1/7/21 at approximately 10:30 a.m.,. Surveyors observed the facility staff open the locked door into the facility for two representatives of the funeral home. Surveyors noted the funeral home representatives were not screened prior to entering the nursing unit where residents resided. On 1/7/21 at 3:14 p.m., during the daily exit, Surveyor informed VP (Vice President) of Operations-C and Senior Director of Clinical Services-E of the above findings. Surveyor requested any information and or evidence as to why the CNA-M was not screened prior to entering the building and working on 12/23/20. Surveyor also asked for any information as to why the above employees were allowed to enter the building and or work when they were screened as having signs and symptoms of COVID-19 prior to entering the building and working with residents on each respective date. VP of Operations-C and Senior Director of Clinical Services-E informed Surveyor that they would attempt gather additional information and would let Surveyor know. On 1/7/20 at 4:26 p.m., Senior Director of Clinical Services-E informed Surveyor that the facility had identified the need to improve their screening process of visitors and or employees and that she (Senior Director of Clinical Services-E) would provide Surveyor with additional information as to the actions the facility had taken to improve their screening process. On 1/11/20 at 10:10 a.m., Surveyor interviewed Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D regarding the screening of employees at the facility. Surveyor asked Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D if the facility had any information and or evidence as to why the CNA-M was not screened prior to entering the building and working on 12/23/20. Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D informed Surveyor that they did not have any information or evidence as to why CNA-M was not screened prior to entering the building and working on 12/23/20. Surveyor asked Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D if the facility had any information as to why the above employees were allowed to enter the building and or work when they were screened as having signs and symptoms of COVID-19 prior to entering the building and working with residents on each respective date. Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D informed Surveyor that they did not have any information or evidence as to why the above employees were allowed to enter the building and or work when they were screened as having signs and symptoms of COVID-19 prior to entering the building and before working with residents on each respective date. No additional information was provided. 2.) COVID-19 Testing The CDC (Centers for Disease Control)'s recommendation updated on November 20, 2020 and titled, Preparing for COVID-19 (Coronavirus Disease 2019) in Nursing Homes documents under the Core Practices section, Create a Plan for Testing Residents and Healthcare Personnel (HCP)for [DIAGNOSES REDACTED]-CoV-2: Testing for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, in respiratory specimens can detect current infections (referred to here as [MEDICAL CONDITION] testing or test) among residents and HCP in nursing homes. The plan should align with state and federal requirements for testing residents and HCP for [DIAGNOSES REDACTED]-CoV-2 and address: Triggers for performing testing (e.g., a resident or HCP with symptoms consistent with COVID-19, response to a resident or HCP with COVID-19 in the facility, routine surveillance); Access to tests capable of detecting [MEDICAL CONDITION] (e.g., polymerase chain reaction) and an arrangement with laboratories to process tests; Antibody test results should not be used to diagnose someone with an active [DIAGNOSES REDACTED]-CoV-2 infection and should not be used to inform IPC action; Process for and capacity to perform [DIAGNOSES REDACTED]-CoV-2 testing of all residents and HCP; A procedure for addressing residents or HCP who decline or are unable to be tested (e.g., maintaining Transmission-Based Precautions until symptom-based criteria are met for a symptomatic resident who refuses testing). The CDC's recommendation updated 1/7/21 and titled, Testing Guidelines for Nursing Homes documents under the Diagnostic Testing section, Perform expanded [MEDICAL CONDITION] testing of all residents in the nursing home if there is an outbreak in the facility (i.e., a new [DIAGNOSES REDACTED]-CoV-2 infection in any HCP or any nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident); A single new case of [DIAGNOSES REDACTED]-CoV-2 infection in any HCP or a nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident should be considered an outbreak. When one case is detected in a nursing home, there are often other residents and HCP who are infected with [DIAGNOSES REDACTED]-CoV-2 who can continue to spread the infection, even if they are asymptomatic. Performing [MEDICAL CONDITION] testing of all residents as soon as there is a new confirmed case in the facility will identify infected asymptomatic residents quickly, in order to assist in their clinical management and allow rapid implementation of IPC (Infection Prevention and Control) interventions (e.g., isolation, cohorting, use of personal protective equipment) to prevent [DIAGNOSES REDACTED]-CoV-2 transmission; When undertaking facility-wide [MEDICAL CONDITION] testing, facility leadership should expect to identify multiple asymptomatic and pre-symptomatic residents with [DIAGNOSES REDACTED]-CoV-2 infection and be prepared to cohort residents. The facility's policy dated as revised 10/2/20 and titled, Skilled Nursing Center COVID-19 Testing Requirements documents under the Procedure section, 1. Testing for COVID-19 will trigger based on the following intervals/instances: a. Symptomatic individual is identified (staff or resident) to have symptoms consistent with COVID-19; b. Any new case is identified within the SNF (outbreak) - test all staff and residents that previously tested negative every 3-7 days until no new cases are identified for a period of at least 14 days since the most recent positive result; c. Routine testing - employees will be tested according to county positivity rate. Outbreak testing: 1. Outbreak testing will occur when there is a new COVID-19 infection in any healthcare personnel or any nursing home-onset COVID-19 infection in a resident. Nursing home onset COVID-19 infections refers to COVID-19 infections that originated in the nursing home; 2. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and resident should be tested , and all staff and resident that tested negative should be retested every 3-7 days until testing identified no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Routine testing of staff: 1. Routine testing of staff is based on the extent of the COVID-19 virus in the community; therefore, centers should use their county positivity rate in the prior week as the trigger for staff testing frequency. a. County positivity rate can be found here: https://data.cms.gov/stories/s/COVID-19 Nursing-Home-Data/bkwz-xpvg/and should be monitored at least every other week. Jefferson County's COVID-19 positive rate from 11/28/20 to 12/25/20 has been above 10 percent and in the red column indicating that employees of the facility should be COVID-19 tested at least twice a week. As part of the infection control survey, Surveyor reviewed the facility's infection control testing log of employees and residents. On 1/7/21 at 9:10 a.m., VP (Vice President) of Operations-C provided Surveyor with a copy of the facility's testing logs for employees and residents since November 2020. On 1/7/21 at 11:50 a.m., Director of Operations-K informed Surveyor that based on the facility's testing policy, the facility currently tested employees for COVID-19 twice a week based on the county's COVID-19 positivity rate. Director of Operations-K informed Surveyor that if the county positivity rate was in the red column, employees should be getting COVID-19 tested twice a week. Director of Operations-K informed Surveyor that the facility only test residents when there is one confirmed case of COVID-19 and/or if they display signs and symptoms of COVID-19. Director of Operations-K informed Surveyor that if there is one confirmed case of COVID-19 in the facility, the facility then tests residents for COVID-19 once a week. Based on Director of Operations-K statement to Surveyor, Surveyor noted that on 11/6/20, CNA-W began displaying signs and symptoms of COVID-19. Per the facility's line listing, CNA-W tested positive for COVID-19 on 11/10/20. Surveyor was unable to find any documentation or evidence in the facility's November 2020 testing log that the facility tested all employees after CNA-W as confirmed to be positive for COVID-19 on 11/10/20. Surveyor noted that all residents at the facility were tested for COVID-19 on 11/13/20 and not on 11/6/20 when CNA-W began displaying signs and symptoms of COVID-19. Surveyor was unable to find any documentation or evidence of contact tracing and or rationale why testing for COVID-19 was delayed for residents after CNA-W began displaying signs and symptoms of COVID-19 on 11/6/20. Surveyor noted that on 12/23/20, CNA-M began displaying signs and symptoms of COVID-19. Per the facility's line listing, CNA-M tested positive for COVID-19 on 12/26/20. Surveyor was unable to find any documentation or evidence in the facility's December 2020 testing log that the facility tested all employees after CNA-M as confirmed to be positive for COVID-19 on 12/26/20. Surveyor noted that all residents at the facility were tested for COVID-19 on 12/26/20 and not on 12/23/20, when CNA-M began displaying signs and symptoms of COVID-19. Surveyor was unable to find any documentation or evidence of contact tracing and or rationale why testing for COVID-19 was delayed for residents after CNA-M began displaying signs and symptoms of COVID-19 on 12/23/20. For the week of 11/28/20 to 12/4/20, per the facility's testing log, Surveyor found that CNA-I was only COVID-19 tested on ce (12/1/20) and not twice weekly based on the county's positivity rate. Surveyor found that CNA-X was only COVID-19 tested on ce (12/1/20) and not twice weekly based on the county's positivity rate. For the week of 12/12/20 to 12/18/20, per the facility's testing log, Surveyor found that CNA-X was only COVID-19 tested on ce (12/14/20) and not twice weekly based on the county's positivity rate. For the week of 12/19/20 to 12/25/20, per the facility's testing log, Surveyor found that CNA-X was only COVID-19 tested on ce (12/21/20) and not twice weekly based on the county's positivity rate. Surveyor found that LPN-Y was not COVID-19 tested for the week of 11/28/20 to 12/4/20. For the week of 12/5/20 to 12/11/20, per the facility's testing log, Surveyor found that that LPN-Y was only COVID-19 tested on ce (12/7/20) and not twice weekly based on the county's positivity rate. Surveyor found that LPN-Y was only COVID-19 tested on ce (12/21/20) and not twice weekly based on the county's positivity rate. Surveyor found that CNA-M was only COVID-19 tested on ce (11/30/20) and not twice weekly based on the county's positivity rate. Surveyor found that CNA-M was only COVID-19 tested on ce (12/9/20) and not twice weekly based on the county's positivity rate. On 1/7/21 at 3:14 p.m., during the daily exit, Surveyor informed VP (Vice President) of Operations-C and Senior Director of Clinical Services-E of the above findings. Surveyor requested any information and or evidence as to why the above staff members were not COVID-19 tested twice weekly on the above dates per the facility's policy and CDC recommendations. On 1/11/20 at 10:10 a.m., Surveyor interviewed Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D regarding the testing of employees at the facility. Surveyor asked Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D if the facility had any information and or evidence as to why the above staff members were not COVID-19 tested twice weekly on the above dates per the facility's policy and CDC recommendations. Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D informed Surveyor that they did not have any information or evidence as to why the above employees were not COVID-19 tested twice weekly on the above dates. Surveyor asked Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D if the facility had any information and or evidence as to why testing of all employees was not completed after the facility had confirmed positive COVID-19 cases of employees on 11/13/20 and 12/26/20. Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D informed Surveyor that they did not have any information or evidence as to why all employees were not COVID-19 tested on [DATE] and 12/26/20. Senior Director of Clinical Services-E and Administrator-A informed Surveyor that the facility had ensured that all facility staff members were COVID-19 tested on [DATE]. Surveyor asked Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D if the facility had any information and or evidence as to why there was a delay in COVID-19 testing of all residents after facility staff began displaying signs and symptoms of COVID-19 on 11/10/20 and 12/23/20. Senior Director of Clinical Services-E, Administrator-A and Director of Clinical Services-D informed Surveyor that they did not have any information or evidence as to why there was a delay in COVID-19 testing of residents after facility staff began displaying signs and symptoms of COVID-19 on 11/10/20 and 12/23/20. No additional information was provided. 3.) COVID-19 Tracing The facility's policy dated as revised 12/21/20 and titled, Suspected or Confirmed Positive COVID-19 Management Policy documents under the Procedure section, 7. Monitoring and management of other residents and staff at the center upon confirmation of a resident or a staff member with a positive COVID-19 status: a. Begin contact tracing; 1) Determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset; (a.) Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCPCOVID-19 testing are known. If the HCP is diagnosed with [REDACTED].) Exposed HCP should be assessed for risk and need for work exclusion.: Surveyor noted that per CNA-I's time clock and the facility's actual work schedules, CNA-I was a full time employee. Surveyor found that CNA-X was only COVID-19 tested on ce (12/1/20) and not twice weekly based on the county's positivity rate for the week of 11/28/20 to 12/4/20. Surveyor noted that per CNA-X's time clock and the facility's actual work schedule, CNA-X was a full time employee, worked at least twice the week of 11/28/20 to 12/4/20 and was not tested twice weekly. Surveyor noted that per CNA-X's time clock records, CNA-X worked at least twice the week of 12/12/20 to 12/18/20. Per the facility's testing log, Surveyor found that CNA-X was only COVID-19 tested on ce (12/14/20) and not twice weekly based on the county's positivity rate. For the week of 12/19/20 to 12/25/20, per the facility's testing log, Surveyor noted that per CNA-X's time clock records, CNA-X worked at least twice the week of 12/19/20 to 12/25/20 Surveyor found that CNA-X was only COVID-19 tested on ce (12/21/20) and not twice weekly based on the county's positivity rate. Surveyor noted from CNA-M's time clock and the facility's actual work schedule that CNA-M was a full time employee and worked at least twice during the week of 11/28/20 to 12/4/20. Surveyor found that CNA-M was only COVID-19 tested on ce (11/30/20) and not twice weekly based on the county's positivity rate. Surveyor found that that per CNA-M's time clock records, CNA-M worked at least twice the week of 12/5/20 to 12/11/20. CNA-M was only COVID-19 tested on ce (12/9/20) and not twice weekly based on the county's positivity rate. Surveyor noted that per LPN-Y's time clock records, LPN-Y worked at least twice the week of 12/5/20 to 12/11/20. For the week of 12/5/20 to 12/11/20, per the facility's testing log, Surveyor found that that LPN-Y was only COVID-19 tested on ce (12/7/20) and not twice weekly based on the county's positivity rate. Surveyor noted that per LPN-Y's time clock records, LPN-Y worked at least twice the week of 12/19/20 to 12/25/20. Surveyor found that LPN-Y was only COVID-19 tested on ce (12/21/20) and not twice weekly based on the county's positivity rate. Surveyor was unable to locate any documentation or evidence and that the facility had system or method in place to ensure that employees whom worked occasionally and not tested twice weekly were tested upon their return to work. Surveyor also noted that per the facility's testing log, there was not system or method in place to track the number of times employees were tested during the facility's one week COVID-19 testing period. Surveyor was unable to locate any evidence in the documentation provided to Surveyor regarding the facility's infection control program that documented that the facility completed contact tracing of employees and residents when facility staff members began showing signs and symptoms of COVID-19 on 11/6/20 and 12/23/20. On 1/6/21 at 1:37 p.m., Surveyor informed Director of Clinical Operations-F of the above findings. Surveyor requested any documentation that documented that the facility began contact tracing of employees and residents when facility staff members began showing signs and symptoms of COVID-19 on 11/6/20 and 12/23/20. On 1/6/21 at 3:29 p.m., during the daily exit, Surveyor informed VP (Vice President) o

Based on interview and record review, the facility did not ensure 1 (R9) of 9 residents reviewed received quality care based on a comprehensive assessment and received treatment and care to help them live to their highest practicable well being. R9 was documented to have had a change in condition on 12/26/20 with concerns for diarrhea that had lasted 9 days. The change in condition was not assessed. On 12/30/20, R9 was documented to have a reduction in food and fluid intake and increased pain. The change in condition was not assessed. Despite R9 being diagnosed with [REDACTED]. On 1/5/21, R9 was documented as confused and yelling out. The change in condition was not assessed. On 1/8/21, R9 was documented to have an unwitnessed fall from bed. R9 was not assessed by a Registered Nurse (RN) following the fall and neurological checks were not thoroughly completed. On 1/8/21, R9 was transferred to the hospital via 911 and diagnosed with [REDACTED]. Findings include: The facility policy, entitled Change of Condition of the Resident (Observing Recording and Reporting), dated December 2016, states: Purpose: To observe, record and report any condition change to the physician so proper treatment can be implemented timely. Definition: Change of condition refers to a deviation from the patient/resident's baseline in physical, cognitive, behavioral or functional domains. The change can be negative or positive. The change in condition may be short lived or an extended for a period of time and presents as a shift from the norm for that specific patient/resident. An acute change of condition refers to a sudden, clinically important deviation from a patient/resident's baseline in physical, cognitive, behavioral or functional domains. It is clinically important that without intervention, the patient/resident may experience complications. Procedure: When a resident presents with a possible change of condition, after a fall or other possible injury, trauma, noted change in mental or physical functioning: 1 Assess the resident's need for immediate care/medical attention. (CNA (certified nursing assistant) to notify nurse, nurse to notify supervisor, etc. (et cetera). Provide emergency care as needed. 3. Assess the resident and notify the attending practitioner of the resident's condition. Compare the resident's condition. Compare the resident's current condition to his/her prior level of functioning. 4. Assessment, monitoring and documentation include, but are not limited to, the following: a. Vital signs, oxygen saturation, blood glucose level .; d. Pain, location, type, intensity, duration, causative factors; e. Personality, behavioral and/or cognitive changes; f. Alteration in level of consciousness, ability to respond; h. Sensory weakness or changes; i. Generalized or localized weakness; . 5. Notify resident's responsible party; 6. Complete INTERACT SBAR, incident/accident report/ risk management as indicated; 7. Monitor resident's condition frequently until stable or transported to a higher level of care, if needed; 8. Add resident and COC (Change of Condition) to the 24- hour report to be reviewed later by the IDT (Interdisciplinary Team). Documentation: 1 Date, time of incident (if applicable), time condition change was identified; 2. Observation of assessment findings; 3. Emergency care provided; if appropriate; 4. Notification of practitioner-include date, time, what was conveyed, any orders received (each time notified); 5. Notification of responsible party-include date, time, what was conveyed, any comments received (each time notified); . Care Plan Documentation: 1 Identify underlying problem causing the condition change; 2. Establish a measurable goal for resolution of condition; 3. Develop a plan to treat the condition. Observe and monitor resident's response to treatment; 4. Document preventative and safety interventions and education provided to the resident (and their response to education); 5. Document observations and reporting of complications. R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 12/24/20, a Brief Interview of Mental Status (BIMS) was completed. R9 scored 13, indicating R9 is cognitively intact. On 12/24/20, a Patient Health Questionnaire was completed. R9 scored 1, indicating no depressive severity indicators. On 12/23/20, a Braden skin risk assessment was completed. R9 received a score of 17, indicating R9 is at moderate risk for developing skin breakdown. R9's Admission Assessment, dated 12/23/20, documents: Severely impaired vision, blind; requires extensive assist of 1 staff for: bed mobility, transfers, toileting and personal hygiene; supervision, cueing and coaching for eating; Braden scale score of 17, moderate risk for skin breakdown, with redness to the coccyx, groin and BLE (Bilateral Lower Extremities) with purple discoloration, heels dry and cracked; no chewing or swallowing problems, on a regular diet consistency and thin liquids; alert and oriented to person, place and time; pain rating of 0, indicating no pain present, no history of falls within the last 30, 60 or 180 days, no agitated behavior demonstrated in the last 7 days. R9's baseline care plan, dated 12/23/20, documents: R9 is alert/oriented; diabetic, but no interventions listed; dietary order: regular, no feeding assistance required, diet is not mechanically altered; vision impaired-blind; behavior concerns-fearful needs; no pain identified, skin intact and not identified at risk for skin breakdown. R9's Care Plan, dated 1/7/21, documents resident's cognitive status is alert with confusion; inappropriate calling out and yelling related to cognitive impairment; 12/24/20, Resident show potential for discharge. R9's care plan does not address R9's [DIAGNOSES REDACTED]. (Cross Reference F656) On 12/23/20, at 22:17 (10:17 PM), R9's medical record documents, R9 arrived at 14:15 (2:15 PM) in a wheelchair with transport.She was hospitalized for [REDACTED]. Transfers with 1 max (maximum) assistance and is alert and oriented to person, place, time and situation. Resident denies pain or discomfort at this time. Head to toe assessment performed with no skin concerns. Resident awake and watching TV with no s/sx (signs or symptoms) of distress. On 12/23/20, at 2:46 PM, R9's Diet Requisition Form, documents: Diet order: regular diet, lactose controlled diet; texture: regular, minced and moist solid consistency diet; liquids: thin. Surveyor is unable to locate documentation this is addressed in R9's Baseline, Comprehensive Care Plan or Certified Nursing Assistant (CNA) care card. On 12/24/20, at 15:00 (3:00 PM), R9's Diet Requisition Form documents: Diet order: regular, lactose intolerance; Texture: Dysphagia Advanced; Liquids: thin; comments: moist-ground meats. Lactose intolerance. Surveyor is unable to locate documentation this is addressed in R9's Baseline, Comprehensive Care Plan or Certified Nursing Assistant (CNA) care card. On 12/25/20, at 12:23 PM, R9's medical record documents: . Dietary approach: Therapeutic diet. The progress note does not address what the therapeutic diet is. On 12/26/20, at 9:08 PM, R9's medical record documents: [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o (complain of) loose stools. Surveyor was unable to locate documentation R9 was assessed for the cause of the loose stools. On 12/26/20, at 22:00 (9:00 PM), R9's medical record documents: Alert and verbal. Pleasant mood. No c/o pain. Uses call light to make needs know. Continent of bowel and bladder. Transfers with 1 A (assist) minimal assist. Took meds (medications) well crushed in applesauce. Fed for meal at 50%. On 12/27/20, at 13:23 (1:23 PM), R9's medical record documents: . Difficulty chewing regular meat trial ground meat in place, assisted with feeding. C/O dysuria increased fluids encouraged. 0 (no) further c/o dysuria. On 12/27/20, at 3:00 PM, R9's Diet Request Form documents: Diet order: not marked; texture: trial ground meat; liquids: not marked. Surveyor is unable to locate documentation this is addressed in R9's Baseline, Comprehensive Care Plan or Certified Nursing Assistant (CNA) care card. On 12/27/20, at 15:39 (3:39 PM), R9's medical record documents: [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9 was assessed for the cause of the loose stools. On 12/28/20, at 19:40 (6:40 PM), R9's medical record documents: [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9 was assessed for the cause of the loose stools. On 12/29/20, at 8:43 AM, R9's medical record documents: : [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9 was assessed for the cause of the loose stools. On 12/30/20, at 9:21 AM, R9's medical record documents: : [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9 was assessed for the cause of the loose stools. On 12/30/20, at 20:49 (8:49 PM), R9's medical record documents: [MEDICATION NAME] Tablet 325 MG, Give 2 tablets by mouth every 4 hours as needed for general discomfort. Surveyor unable to locate documentation R9 was assessed for the cause of the pain. On 12/30/20, R9's medical record documents a reduction in amount of food eaten. 12/30/20: 20:58 (8:58 PM) 0-25% intake for the day. R9's meal intake continues to be limited until discharge to the hospital on [DATE]. R9's meal intake is documented as: 12/31/20, at 9:40 AM, 0-25% eaten; 1/1/21, at 18:55 (6:55 PM), 25-50% eaten; 1/2/21, at 21:04 (9:04 PM), 26-50% eaten; 1/3/21, at 21:53 (9:53 PM), 26-50% eaten; 1/4/21, at 20:37 (8:37 PM), 0-25% eaten; 1/5/21, at 11:06 AM, R9 refused to eat; at 11:30 AM, 0-25% eaten; 21:45 (9:45 PM) refused to eat. 1/6/21, at 11:30 am, refused to eat; 12:28 PM, refused to eat; 20:10 (8:10 PM), refused to eat. 1/7/21, at 20:30 (8:30 PM), refused to eat. Surveyor unable to locate documentation R9 was assessed for the cause of the decreased intake. On 12/30/20, R9's medical record documents a reduction in fluid intake. R9's fluid intake is documented at: 12/30/20, at 21:02 (9:02 PM) 60 cc (cubic Centimeter); 12/31/20, at 9:47 AM, 120 cc; 1/1/21, at 18:57 (6:57 PM), 240 cc; 1/2/21, at 21:04 (9:04 PM), 240 cc; 1/3/21, at 21:55 (9:55 PM), 120 cc; 1/5/20, at 7:30 AM, 240 cc; 11:30 AM, 240 cc, 21:45 (9:45 PM) refused; 1/6/21, at 11:30 AM, refused; 12:24 PM, refused; 20:12 (8:12 PM) 60 cc; 1/7/21, at 20:32 (8:32 PM) refused. Surveyor unable to locate documentation R9 was assessed for the cause of the decreased fluid intake. On 12/31/20, at 9:35 AM, R9's medical record documents: : [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9 was assessed for the cause of the loose stools. On 1/2/21, at 11:30 AM, R9's medical record documents: Pt (patient) positive for Covid today with c/o sore throat, no other complaints at this time. Dr. (doctor) updated and daughter not updated as voicemail was to a man's name. On 1/4/21, at 6:51 AM, R9's medical record documents: [MEDICATION NAME] Tablet 325 MG, Give 2 tablets by mouth every 4 hours as needed for general discomfort. Surveyor unable to locate documentation R9 was assessed for the cause of the pain. On 1/5/21, at 19:41 (7:41 PM), R9's medical record documents: Res (resident) alert confusion noted res laying in bed yelling out would calm when 1 on 1 approach in place then res would start to yell all over. Res would fall asleep in between. Res denied c/o pain offered juice or repositioning, offered to hold hand refused and told writer to get out I just want to go home. Re-educated res that she was sick and that she needed to get stronger for that to happen res would then agree. Appetite poor fluids taken well. Will cont. (continue) to assess, res has dx (diagnosis) of Covid with no noted s/s (signs or symptoms). Surveyor unable to locate documentation R9 was assessed for the reason for the change in condition. On 1/6/21, at 22:04 (10:04 PM), R9's medical record documents: Pt calling out this shift unable to voice needs, did not take medications or meds this shift. Repositioned by staff. Surveyor unable to locate documentation R9 was assessed for the reason for the change in condition. On 1/7/21, at 2:50 AM, R9's medical record documents: [MEDICATION NAME] Tablet 325 MG, Give 2 tablets by mouth every 4 hours as needed for general discomfort. Surveyor unable to locate documentation R9 was assessed for the cause of the pain. On 1/7/21, at 22:47 (10:47 PM), R9's medical record documents: [MEDICATION NAME] Tablet 325 MG, Give 2 tablets by mouth every 4 hours as needed for restlessness. Unable to describe cause of restlessness. On 1/8/21, at 6:31 AM, R9's medical record documents: Received report from NOC (Night) shift that resident had an unwitnessed fall out of bed overnight. Per staff this AM resident had a change in condition. Upon assessment resident minimally responsive, opened eyes to name but not verbalizing, open mouth breathing. B/P (blood pressure) 60/41, HR (Heart Rate) 83, unable to obtain pulse ox (oxygen). Resident is a full code. Called 911 to send resident to hospital. Attempted to call resident's daughter x2 (two times), no option to leave voicemail. Message left for Dr. Surveyor unable to locate documentation of night shift staff assessment of R9 after the fall, the reason for the fall, of an RN assessment of R9 after the fall. On 1/8/21, at 5:28 AM, R9's medical record documents a Post Fall Assessment which documents: the fall occurred 1/8/21 at 4:45 AM; has a history of falling 1-2 times in the last 30 days; no date and time of the most recent falls were documented; assigned care givers, safety measures in place prior to the fall; the time the resident was last seen, who last saw the resident; the position the resident was last seen in; new immediate interventions added to the care plan; re-education provided; referral to IDT staff; care plan updated were all left incomplete on the Post Fall Assessment form. The form is also undated and unsigned. Facility Incident Report, dated 1/8/21 at 5:28 AM, documents, (R9) was found on the floor laying next to the bed. (R9) is confused and didn't know how she fell . Immediate action taken: Patient vitals were taken, patient was assisted back to bed, and head to toe was completed. Resident wasn't taken to the hospital. No injuries observed at the time of the fall. Level of consciousness: Lethargic Drowsy. Mental Status, level of pain, predisposing environmental factors, predisposing psychological factors, predisposing situation factors, agencies and people notified sections of the report were left uncompleted. Surveyor unable to locate documentation R9 was assessed by a RN after the fall. Facility Neurological Assessment Flowsheet, not signed by staff, documents: Neurological Assessments to be completed: q (every) 15 min (minutes) x4 (4 times) until stable, then; q 30 min x4 until stable then; q 1 hr (hour) x4 until stable then; q 4 hr x4 until stable then; q 8 hr. On 1/8/21, at 4:45 AM, Neurological Assessment documents: blood pressure: 142/61; temperature: 97.7; pulse: 102; Respiration: 24; pupil reaction section was incomplete; motor function section: hand grasp section uncompleted, moves all extremities has a dashed line next to it; level of consciousness: a dashed line next to drowsy; pain response: has a dashed line next to inappropriate and 02 (oxygen saturation level): 90. On 1/8/21, at 5:00 AM, Neurological Assessment documents: blood pressure: 138/54; temperature: 98; pulse: 88; Respiration: 20; pupil reaction section was uncompleted; motor function section: hand grasp section were incomplete, moves all extremities has a dashed line next to it; level of consciousness: a dashed line next to drowsy; pain response: has a dashed line next to inappropriate and 02 (oxygen saturation level): 90. On 1/8/21, at 5:30 AM, Neurological Assessment documents: blood pressure: 146/60; temperature: 98; pulse: 86; Respiration: 20; pupil reaction section was incomplete; motor function section: hand grasp section left blank, moves all extremities has a dashed line next to it; level of consciousness: a dashed line next to drowsy; pain response: has a dashed line next to inappropriate and 02 (oxygen saturation level): 91. Surveyor was unable to locate documentation of a neurological assessment completed 1/8/21 at 5:15 AM, per flowsheet directions. On 1/8/21, at 6:00 AM, Neurological Assessment documents: blood pressure: 60/40; temperature: not documented; pulse: 83; Respiration: not documented; pupil reaction section was left blank; motor function section: hand grasp section left blank, moves all extremities has a dashed line next to it; level of consciousness: a dashed line next to drowsy; pain response: has a dashed line next to inappropriate and 02 (oxygen saturation level): not documented. Facility staff calls 911 and has R9 transported to the hospital. On 1/8/21, at 7:12 AM, hospital emergency room documents: Pt (Patient) arrives per EMS (Emergency Medical Services). Pt is drowsy, moaning out. Per EMS pt was minimally responsive and hypoxic. They stated they were not told she had fallen. EMS found her in bed. On MD (Medical Doctor) exam, right elbow abrasion and contusion, bilateral leg scattered contusions noted. Pt is in wet depends full of stool and urine. Pupils: Right 3 mm (millimeters) and sluggish and round. Left pupil irregular shape and non-reactive approx. (approximately) 4 mm. Pt has contusion to right mid lateral back. There is skin break down to coccyx and left buttock and peri-anal area. Lower extremities are cool to the touch and mottles with bilateral medial knee [DIAGNOSES REDACTED] and scattered contusions. Tongue, lips and roof of mouth is dry and covered in thick white substance that will not come off using a wet oral swab. Oral care done. The hospital contacted the facility on 1/8/21 at 8:10 AM. Hospital documents: Facility report provided to hospital by, Registered Nurse ((RN)-U). Hospital documents, (RN-U) stated, Pt came to facility last month for rehab (rehabilitation) after [MEDICAL CONDITION]. Initially (R9) could speak and talk but the last couple of weeks she has declined and only moans and does not talk now. Pt. was positive for COVID on 1/2/21 and since then has declined even more. Pt is a full assist now. Last night the Pt was found by facility staff on the floor in an unwitnessed, supposed fall. Pt was placed back in bed and on day shift (RN-U) noted on her initial assessment to be minimally responsive and staring off. (R9's) blood pressure was 60/40 pulse 83. (RN-U) could not get a saturation. (RN-U) called 911. (RN-U) unable to provide any other information. On 1/12/21, at 10:51 AM, Surveyor called Licensed Practical Nurse (LPN)-V, who was the nurse assigned to R9 on 1/8/21, at the time R9 had an unwitnessed fall from bed. LPN-V did not return the phone call. Surveyor was unable to interview LPN-V. On 1/12/21, at 11:03 AM, Surveyor interviewed Registered Nurse (RN)-U, who stated, she arrived to the facility for the day shift on 1/8/21 and received report from LPN-V. RN-U stated LPN-V informed her, R9 had a fall from bed overnight about 4:45 AM and LPN-V got R9 back in bed and now R9 isn't doing well and will need to be sent out. RN-U stated, she told LPN-V she didn't know R9 and would have to first asses her before sending R9 out. RN-U stated, she arrived to R9's room shortly after 6:00 AM and observed R9 in bed, minimally responsive, staring blankly, not responsive to sternal rub, unable to get pulse oxygen rate. RN-U stated, this was the first time she saw R9 and the CNAs (certified nursing assistance) told her this was a change from R9's usual status. RN-U stated, LPN-V told her R9 just rolled out of bed and nothing more about the un-witness fall. RN-U stated, when she assessed R9 she still had the Hoyer sling under her while in bed. RN-U stated she does not believe any other staff assessed R9 after the fall since LPN-V was the only staff on duty at the time of R9's fall. RN-U stated, company policy for completing neurological checks are, every 15 minutes x4, every 30 minutes x4, every hour x4, every 4 hours x4 then every shift. RN-U stated, LPN-V did not tell her why the neurological checks were not completed per company policy. RN-U stated, LPN-V did not pass along the neurological check form during report however, the Medication Tech on the day shift found the neurological check form when gathering paperwork to send with R9 to the hospital. On 1/12/21, at 12:46 PM, Surveyor interviewed Central Supply/Scheduler (CS/S)-H, who stated, she was not on duty when R9 fell on [DATE] as the facility schedule documents. CS/S-H stated, she did not come into the facility until 7:30 AM on 1/8/21 and did not see R9 on 1/8/21. CS/S-H stated she took care of R9 a few days prior to 1/8/21 and she was in pain due to excoriation on her bottom, muscle aches and pains, called out a lot, did not want to eat or drink and was very different than she was upon admission to the facility. CS/S-H stated, she informed the nursing staff of the changes noted in R9 and they told her they would offer R9 medication for pain. CS/S-H stated, R9 required assist from the staff for meals and staff fed R9 due to her being legally blind and having much difficulty eating and before R9's fall and transfer to the hospital R9 wasn't eating or drinking. On 1/12/21, at 3:49 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Clinical Operations-D, Senior Director of Clinical Operations-E, Interim DON-Q of the concern R9 was not assessed when R9 was documented to have a decrease in food and fluid intake on 12/30/20 through transfer to the hospital on [DATE], diarrhea episodes beginning on 12/26/20, increased pain episodes beginning on 12/30/20, increased agitation on 1/5/21, a fall on 1/8/21; no RN assessment after R9's fall on 1/8/21 and fall investigation documentation is incomplete and does not document a reason for the fall. Surveyor was unable to locate baseline or comprehensive care plans that address R9's dysphagia-oral phase and need for a mechanically altered diet and feeding assistance. No further information was provided. On 1/8/21, after transfer to the hospital, R9 was diagnosed with [REDACTED].

Based on interview and record review, the facility did not ensure 1 (R9) of 9 resident's physician was consulted with or notified of a change in the resident's physical, mental or psychosocial status and the need to alter the treatment plan. R9 was documented to have had a change in condition on 12/26/20 with concerns for diarrhea that lasted 9 days. The physician was not notified of this change in condition. On 12/30/20, R9 was documented to have a reduction in food and fluid intake and increased pain. The physician was not consulted with regarding this change in condition. On 1/5/21, R9 was documented as confused and yelling out. The facility did not consult with the physician regarding this change in condition. On 1/8/21, R9 was documented to have an unwitnessed fall from bed. The physician was not notified. On 1/8/21, R9 was transferred to the hospital via 911 and diagnosed with [REDACTED]. Findings include: The facility policy, entitled Change of Condition of the Resident (Observing Recording and Reporting), dated December 2016, states: Purpose: To observe, record and report any condition change to the physician so proper treatment can be implemented timely. Definition: Change of condition refers to a deviation from the patient/resident's baseline in physical, cognitive, behavioral or functional domains. The change can be negative or positive. The change in condition may be short lived or an extended for a period of time and presents as a shift from the norm for that specific patient/resident. An acute change of condition refers to a sudden, clinically important deviation from a patient/resident's baseline in physical, cognitive, behavioral or functional domains. It is clinically important that without intervention, the patient/resident may experience complications. Procedure: When a resident presents with a possible change of condition, after a fall or other possible injury, trauma, noted change in mental or physical functioning: .3. Assess the resident and notify the attending practitioner of the resident's condition. Compare the resident's condition. Compare the resident's current condition to his/her prior level of functioning . 6. Complete INTERACT SBAR, incident/accident report/ risk management as indicated; .Notification of practitioner-include date, time, what was conveyed, any orders received (each time notified) . R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 12/24/20, a Brief Interview of Mental Status (BIMS) was completed. R9 scored 13, indicating R9 is cognitively intact. On 12/24/20, a Patient Health Questionnaire was completed. R9 scored 1, indicating no depressive severity indicators. On 12/23/20, a Braden skin risk assessment was completed. R9 received a score of 17, indicating R9 is at moderate risk for developing skin breakdown. R9's Admission Assessment, dated 12/23/20, documents: Severely impaired vision, blind; requires extensive assist of 1 staff for: bed mobility, transfers, toileting and personal hygiene; supervision, cueing and coaching for eating; Braden scale score of 17, moderate risk for skin breakdown, with redness to the coccyx, groin and BLE (Bilateral Lower Extremities) with purple discoloration, heels dry and cracked; no chewing or swallowing problems, on a regular diet consistency and thin liquids; alert and oriented to person, place and time; pain rating of 0, indicating no pain present, no history of falls within the last 30, 60 or 180 days, no agitated behavior demonstrated in the last 7 days. R9's baseline care plan, dated 12/23/20, documents: R9 is alert/oriented; diabetic, but no interventions listed; dietary order: regular, no feeding assistance required, diet is not mechanically altered; vision impaired-blind; behavior concerns-fearful needs; no pain identified, skin intact and not identified at risk for skin breakdown. On 12/23/20, at 22:17 (10:17 PM), R9's medical record documents, R9 arrived at 14:15 (2:15 PM) in a wheelchair with transport.She was hospitalized for [REDACTED]. Transfers with 1 max (maximum) assistance and is alert and oriented to person, place, time and situation. Resident denies pain or discomfort at this time. Head to toe assessment performed with no skin concerns. Resident awake and watching TV with no s/sx (signs or symptoms) of distress. On 12/26/20, at 9:08 PM, R9's medical record documents: [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o (complaint of) loose stools. Surveyor was unable to locate documentation R9's physician was informed of the change in condition. On 12/27/20, at 15:39 (3:39 PM), R9's medical record documents: [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9's physician was informed of the change in condition. On 12/28/20, at 19:40 (6:40 PM), R9's medical record documents: : [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9's physician was informed of the change in condition. On 12/29/20, at 8:43 AM, R9's medical record documents: : [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9's physician was informed of the change in condition. On 12/30/20, at 9:21 AM, R9's medical record documents: : [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9's physician was informed of the change in condition. On 12/30/20, R9's medical record documents a reduction in amount of food eaten. 12/30/20: 20:58 (8:58 PM) 0-25% intake for the day. R9's meal intake continues to be limited until discharge to the hospital on [DATE]. R9's meal intake is documented as: 12/31/20, at 9:40 AM, 0-25% eaten; 1/1/21, at 18:55 (6:55 PM), 25-50% eaten; 1/2/21, at 21:04 (9:04 PM), 26-50% eaten; 1/3/21, at 21:53 (9:53 PM), 26-50% eaten; 1/4/21, at 20:37 (8:37 PM), 0-25% eaten; 1/5/21, at 11:06 AM, R9 refused to eat; at 11:30 AM, 0-25% eaten; 21:45 (9:45 PM) refused to eat. 1/6/21, at 11:30 am, refused to eat; 12:28 PM, refused to eat; 20:10 (8:10 PM), refused to eat. 1/7/21, at 20:30 (8:30 PM), refused to eat. Surveyor was unable to locate documentation that R9's physician was updated on the reduction of oral intake/change in condition. On 12/30/20, R9's medical record documents a reduction in fluid intake. R9's fluid intake is documented at: 12/30/20, at 21:02 (9:02 PM) 60 cc (cubic Centimeter); 12/31/20, at 9:47 AM, 120 cc; 1/1/21, at 18:57 (6:57 PM), 240 cc; 1/2/21, at 21:04 (9:04 PM), 240 cc; 1/3/21, at 21:55 (9:55 PM), 120 cc; 1/5/20, at 7:30 AM, 240 cc; 11:30 AM, 240 cc, 21:45 (9:45 PM) refused; 1/6/21, at 11:30 AM, refused; 12:24 PM, refused; 20:12 (8:12 PM) 60 cc; 1/7/21, at 20:32 (8:32 PM) refused. Surveyor was unable to locate documentation that R9's physician was updated on the reduction of fluid intake/change in condition. On 12/31/20, at 9:35 AM, R9's medical record documents: : [MEDICATION NAME] HCI Tablet 2 MG (Milligrams), give 1 tablet by mouth every 8 hours as needed for diarrhea, c/o loose stools. Surveyor was unable to locate documentation R9's physician was informed of the change in condition. On 1/5/21, at 19:41 (7:41 PM), R9's medical record documents: Res (resident) alert confusion noted res laying in bed yelling out would calm when 1 on 1 approach in place then res would start to yell all over. Res would fall asleep in between. Res denied c/o pain offered juice or repositioning, offered to hold hand refused and told wrier to get out I just want to go home. Re-educated res that she was sick and that she needed to get stronger for that to happen res would then agree. Appetite poor fluids taken well. Will cont. (continue) to assess, res has dx (diagnosis) of Covid with no noted s/s (signs or symptoms). Surveyor unable to locate documentation R9's physician was informed of the change in condition. On 1/6/21, at 22:04 (10:04 PM), R9's medical record documents: Pt calling out this shift unable to voice needs, did not take medications or meds this shift. Repositioned by staff. Surveyor unable to locate documentation R9's physician was informed of the change in condition and refusal to take medication. On 1/8/21, at 6:31 AM, R9's medical record documents: Received report from NOC (Night) shift that resident had an unwitnessed fall out of bed overnight. Per staff this AM resident had a change in condition. Upon assessment resident minimally responsive, opened eyes to name but not verbalizing, open mouth breathing. B/P (blood pressure) 60/41, HR (Heart Rate) 83, unable to obtain pulse ox (oxygen). Resident is a full code. Called 911 to send resident to hospital. Attempted to call resident's daughter x2 (two times), no option to leave voicemail. Message left for Dr. Surveyor unable to locate documentation of night shift staff assessment of R9 after the fall, the reason for the fall, an RN assessment of R9 after the fall or if R9's physician was updated on the fall. (Cross Reference F684) On 1/12/21, at 10:51 AM, Surveyor called Licensed Practical Nurse (LPN)-V, who was the nurse assigned to R9 on 1/8/21, at the time R9 had an unwitnessed fall from bed. LPN-V did not return the phone call. Surveyor was unable to interview LPN-V. On 1/12/21, at 11:03 AM, Surveyor interviewed Registered Nurse (RN)-U, who stated, she arrived to the facility for the day shift on 1/8/21 and received report from LPN-V. RN-U stated LPN-V informed her, R9 had a fall from bed overnight about 4:45 AM and LPN-V got R9 back in bed and now R9 isn't doing well and will need to be sent out. RN-U stated, she told LPN-V she didn't know R9 and would have to first asses her before sending R9 out. RN-U stated, she arrived to R9's room shortly after 6:00 AM and observed R9 in bed, minimally responsive, staring blankly, not responsive to sternal rub, unable to get pulse oxygen rate. RN-U stated, this was the first time she saw R9 and the CNAs (certified nursing assistance) told her this was a change from R9's usual status. RN-U stated, LPN-V told her R9 just rolled out of bed and nothing more about the unwitnessed fall. RN-U stated, when she assessed R9 she still had the Hoyer sling under her while in bed. RN-U stated she does not believe any other staff assessed R9 after the fall since LPN-V was the only staff on duty at the time of R9's fall. RN-U stated, LPN-V did not tell her she updated R9's physician about the fall. Surveyor unable to locate documentation R9's physician was updated on R9's unwitnessed fall out of bed. On 1/12/21, at 12:46 PM, Surveyor interviewed Central Supply/Scheduler (CS/S)-H, who stated, she was not on duty when R9 fell on [DATE] as the facility schedule documents. CS/S-H stated, she did not come into the facility until 7:30 AM on 1/8/21 and did not see R9 on 1/8/21. CS/S-H stated she took care of R9 a few days prior to 1/8/21 and she was in pain due to excoriation on her bottom, muscle aches and pains, called out a lot, did not want to eat or drink and was very different than she was upon admission to the facility. CS/C-H stated, she informed the nursing staff of the changes noted in R9 and they told her they would offer R9 medication for pain. CS/S-H stated, R9 required assist from the staff for meals and staff fed R9 due to her being legally blind and having much difficulty eating and before R9's fall and transfer to the hospital R9 wasn't eating or drinking. On 1/12/21, at 3:49 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Clinical Operations-D, Senior Dir of Clinical Operations-E, Interim DON-Q of the concern R9 was not assessed and physician was not notified of the changes in condition when R9 was documented to have a decrease in food and fluid intake on 12/30/20 through transfer to the hospital on [DATE], diarrhea episodes beginning on 12/26/20, increased pain episodes beginning on 12/30/20, increased agitation on 1/5/21 and fall on 1/8/21 until after R9 was sent to the hospital via 911 over 2 hours after the unwitnessed fall. No further information was provided. On 1/8/21, after transfer to the hospital, R9 was diagnosed with [REDACTED].

Based on observation, interview, and record review, the facility did not ensure 2 (R4 and R5) of 3 Residents at risk for falls received the necessary services/interventions and supervision to prevent an injury from a fall. *Per care plan/care card, R5 was to have call light in place, sign posted to remind to ask for assistance, and foot rests on R5's wheelchair. On 8/25/20, during onsite observation, R5 did not have these interventions in place. R5 has had a total of 12 falls since admission to the facility. The last fall on 8/3/20 resulted in R5 sustaining a right femoral neck fracture. Contrary to facility policy, the facility did not do a comprehensive assessment of each fall or do a root cause analysis of each fall. *Per care plan/care card, R4 was to be in a low bed and have foot rests on R4's wheelchair. On 8/25/20, during onsite observation, R4 did not have these interventions in place. R4 has had 2 falls since admission to the facility. Findings Include: Surveyor reviewed the Fall Prevention and Management Guidelines Policy and revised 5/20/19 and noted the following applicable: Details of Key Elements A. Assessments 1. Admission fall risk assessment completed within 24 hours of admission 2. If indicated, repeat fall risk assessment within 14-21 days after admission 3. Frequency of reassessment a. Upon a fall b. Significant change c .Quarterly and annually d. Anytime the Interdisciplinary Team(IDT) deems it is necessary or of potential benefit 4. Continence protocol a. Toilet schedule 5. Mental status assessment 6. Pain assessment 7. Review record of [DIAGNOSES REDACTED]. 8. Pharmacological assessment and review 9. Environment assessment 10. Analysis/assess level of risk assessment B. Dynamic Treatment Plan 1. Specific interventions based on results of fall assessments and individual Resident's preferences. 2. As information is updated, it needs to be communicated to the staff, Resident and family C. Evaluation 1. Completed post fall evaluation after every fall or near fall or assisted fall a. A fall investigation and post fall assessment must be completed. These need to include: 1. Physical assessment 2. All contributing factors to the fall 3. Medication changes 4. Mental status changes 5. New diagnoses 2. Activate reporting mechanism/tracking of falls within the facility b. Actions of the IDT 1. Timely modifications to the treatment plan and re-inservicing of staff 2. Physical adaption to room,wheelchair,and/or walking devices 3. Collective review, identification, and analysis of trends in Resident falls throughout the facility 3. Facility protocol must include falls management review and analysis by one or more of the following: the safety committee, falls committee, IDT, quality improvement committee, or established IDT group Surveyor noted that the facility did not have a policy and procedure on supervision for Residents at risk of falls. 1) R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R5 has an activated Health Care Power of Attorney (HCPOA). R5's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R5 to have short and long term memory impaired and demonstrated severely impaired skills for daily decision making. The MDS also documented that R5 required extensive assistance with 1 person assist for bed mobility, transfers,dressing, and toileting. The MDS indicated that R5 had 2 or more falls with 1 sustaining a major injury. Surveyor was unable to review a Care Area Assessment (CAA) for R5's falls. Surveyor reviewed R5's Admission Evaluation dated 4/29/20, locked 4/30/20 and noted that it is documented that R5 was at risk for falls and a fall care plan was implemented. Surveyor reviewed R5's care plan and noted the following for at risk for falls due to cognition, unaware of safety needs, and deconditioning/weakness,disease process; initiated 4/30/20, revised 7/20/20: Interventions: .Education the Resident on fall prevention measures. Assure Resident that calling for help is not a bother-initiated 4/30/20 .Place call light or communication device within reach. Answer call light promptly-always when in bed put in lowest position-initiated 4/30/20, revised 5/9/20 .Resident to wear gripper socks-initiated 5/9/20, revised 8/5/20 .Place bed at lower position-initiated 5/20/20 .Keep Resident in view-initiated 6/9/20 .Floor mat-initiated 6/15/20 .Anti roll back to wheelchair and therapy to review-initiated 6/22/20 .Sign placed to ask for assistance to use bathroom--initiated 7/2/20 .Encourage to be toileted every 2 hours/as needed-initiated 7/13/20 .Due to COVID Resident eats in room, once done eating encourage to leave room to be more visible-initiated 7/16/20 .Stay in bathroom with Resident-initiated 7/24/20 Surveyor reviewed R5's current care card and noted the following related to R5's fall interventions 1. 2 assist with gaitbelt for transfers 2. Wheelchair with footrests 3. Gripper socks 4. Anti-rollback 5. Bilateral repositioning bars 6. Low bed with a floor mat Surveyor noted that no initial fall assessment was completed for R5 upon admission. However, on 7/31/20 a fall risk assessment was completed for R5 and it was documented a score of 16, meaning R5 was at moderate risk for falls. On 8/14/20, another fall risk assessment was completed with R5 scoring 18, again, making R5 at moderate risk for falls Surveyor reviewed R5's falls from admission to current. The following was documented in R5's electronic medical record for the 12 falls R5 had while at the facility. 1. 5/2/20-Fall with no injury. Found sitting on the floor by the bed. Per care plan intervention implemented was to put call light or communication device within reach. Answer call light promptly-always when in bed, but in lowest position-initiated 5/9/20 2. 6/8/20-Fall with no injury. Found sitting on bottom next to bed. Per care plan, intervention implemented was keep R5 in view-initiated 6/9/20 3. 6/13/20-Fall with no injury. Found laying on the floor. Per care plan, intervention implemented was floor mat next to bed-initiated 6/15/20 4. 6/18/20-Fall with no injury. Found laying supine on left side in hallway Per care plan, intervention implemented was activities to provide puzzles-initiated 6/19/20. 5.6/20/20-Fall with no injury. Found laying on back on floor by nurse's station, wheelchair by R5. No intervention implemented. 6. 6/21/20-Fall with no injury. Found on left side on floor, near closet, wheelchair in front of R5. Per care plan, intervention implemented was anti-roll back to wheelchair and therapy to review-initiated 6/22/20. Surveyor noted for falls 1-6, there was no fall investigation initiated or completed including witness statements from staff who had observed R5 before, after, or at the time of R5's fall. 7.6/23/20-Fall with no injury. Found on right side laying on floor, wheelchair by R5. Intervention implemented was to re-organize in room for easier access-initiated 6/23/20. No witness statements obtained of R5's fall. 8.7/7/20-fell on floor. Per care plan intervention implemented was to keep snack and drink within reach.-initiated 7/8/20. No witness statements obtained of staff who had observed R5 before, after, or at the time of R5's fall. 9.7/11/20-Witnessed fall. Standing at copy machine room, holding on to the rail and fell . Per care plan intervention implemented was to encourage R5 to be toileted every 2 hours/as needed.-initiated 7/13/20. No fall investigation was initiated or completed including witness statements of staff who had observed R5 before, after, or at the time of the fall. 10.7/15/20-Attempted to transfer self from wheelchair to bed and fell on the floor. Intervention implemented was to keep R5 in the hallway and in sight of staff until the meal arrives and serve just inside the door.-initiated 7/15/20. 1 witness statement obtained from staff. 11. 7/23/20-fell in bathroom. Intervention implemented was R5 was not be left in the bathroom by herself. Staff to remain as R5's legs are not reliable. 1 witness statement obtained. 12. 8/3/20-fell in hallway in front of door. R5 sustained a right femoral neck fracture. Per care plan, intervention implemented was for R5 to wear gripper socks.-initiated 6/5/20. 3 witness statements obtained. Surveyor also noted that the facility was unable to provide any documentation that the physician or the activated HCPOA had been notified of the fall. Surveyor noted there was no comprehensive fall investigation for each of R5's falls including no root cause analysis of each fall. On 8/25/20 at 10:05 AM, Surveyor observed R5 in wheelchair in doorway of room. R5 can not be seen from the nurse's station or in line of view of staff in the hallway. On 8/25/20 at 10:10 AM, Surveyor observed R5 in wheelchair with no footrests on the wheelchair. On 8/25/20 at 10:25 AM, Surveyor observed no sign in R5's room reminding R5 to ask for assistance. Surveyor also observed R5's call light not within reach of R5. On 8/25/20 at 10:40 AM, Surveyor observed R5 in R5's room, not within in sight of any staff. On 8/25/20 at 10:10 AM, Surveyor interviewed Licensed Practical Nurse (LPN-D) in regards to R5's fall on 8/3/20 in which R5 sustained a right femoral neck fracture. LPN-D stated LPN-D was on shift when R5 fell . LPN-D stated it was change of shift and occurred around 6 AM. LPN-D stated R5 had been in bed prior to the fall. R5 ambulated to the hallway and fell outside the copy room door. On 8/25/20 at 11:10 AM, Surveyor interviewed Certified Nursing Assistant(CNA-F). CNA-F informed Surveyor that 'keeping a Resident in view' means to keep a Resident within sight by staff at all times. CNA-F stated that if R5 is in the doorway, R5 must be in line of view at all times. On 8/25/20 at 1:45 PM, Surveyor interviewed Director of Nursing(DON-B) who agreed that 1 witness statement of a fall is not enough to do a root cause analysis of a fall. DON-B agreed that there was lack of comprehensive fall investigation that included a root cause analysis of each of R5's falls. On 8/25/20 at 3:50 PM, Surveyor shared the concern with Administrator (NHA-A) and DON-B of R5's repeated falls, the last resulting in an injury. Shared the concern that Surveyor had observations of R5's fall interventions not in place during the onsite survey. Also shared the concern of fall investigations not being comprehensive including not identifying root cause analysis of each of R5's falls. No further information was provided at this time. 2.) R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4 is R4's own person. R4's Admission Minimum Data Set((MDS) dated [DATE] documented R4 had a Brief Interview for Mental Status(BIMS) of 12, indicating moderately impaired skills for daily decision making. R4's MDS also documented that R4 required extensive assistance with 2 for bed mobility, transfers, and toileting. Surveyor reviewed R4's CAA dated 7/14/20 for falls and noted the following was documented:at risk for falls due to decreased mobility due to multiple comorbidities including but not limited to post hemorrhagic [MEDICAL CONDITION], Type 2 diabetes, dementia, [MEDICAL CONDITION]. Care plan initiated and interventions include: anticipated needs. Surveyor reviewed R4's Admission Evaluation dated 7/10/20, locked 7/11/20 and noted that it is documented that R4 was at risk for falls and a fall care plan was implemented. Surveyor reviewed R4's care plan and noted the following for at risk for falls due to cognition, unaware of safety needs, and deconditioning/weakness,gait balance problems, pain,recent illness; initiated 7/13/20, revised 8/20/20 Interventions: .Anticipate and meet the R4's needs. Encourage R4 to always call for assistance-initiated 7/10/20 .Educate R4 on fall prevention measures. Assure R4 that calling for help is not a bother-initiated 7/10/20 .Place call light or communication device with reach. Answer call light promptly always-initiated 7/10/20 .Follow therapy recommendations for transfers, mobility and ambulation-initiated 7/10/20 .Floor mat-initiated 8/11/20 .Place bed at lowest position-initiated 8/11/20 .No gripper socks when in bed-initiated 8/21/20 Surveyor reviewed R4's current care card and noted the following related to R4's fall interventions. 1. Wheelchair with footrests 2. Low bed with floor mat 3. Bilateral repositioning bars Surveyor noted that no initial fall assessment was completed for R4 upon admission. The following was documented in R4's electronic medical record for the 2 falls R4 had while at the facility. 1.7/12/20-R4 found laying on floor at about 2:30 AM. Per report, intervention implemented was low bed, however, Surveyor noted low bed per care plan was not initiated until 8/11/20. Surveyor noted a fall report was completed with 3 witness statements obtained of staff before, after, and of actual fall of R4. However, Surveyor was not provided a root cause analysis of R4's fall. 2.8/20/20-R4 found laying the floor on left side. Per report, intervention of low bed was not in place. Surveyor noted there was no witness statements obtained from staff before, after, and of actual fall of R4. Surveyor was not provided a root cause analysis of R4's fall. On 8/25/20 at 9:55 AM, Surveyor observed R4 in bed with head of bed slightly elevated and R4's bed was not in the lowest position. On 8/25/20 at 9:55 AM, Surveyor interviewed LPN-D who verified that R4's bed was not in the low position. On 8/25/20 at 10:30 AM, Surveyor observed R4 in wheelchair with anti-tippers on and no foot rests on the wheelchair. On 8/25/20 at 3:50 PM, Surveyor shared the concern with NHA-A and DON-B that Surveyor had observations of fall interventions for R4 not in place during the onsite survey. Also shared the concern of fall investigations not being comprehensive including not identifying root cause analysis of each of R4's falls. No further information was provided at this time.

Based on a complaint received at the Southeastern Regional Office, record review and interview the Facility did not immediately consult with a Resident's physician upon a significant change in the resident's physical status and a need to commence a new form of treatment for 1 (R1) of 6 Residents reviewed. * On 9/12/18, RN (Registered Nurse)-G faxed R1's physician office (R1) is c/o (complaining of) pain from catheter site. Area is hot to the touch, very hard surrounding the area, and has a foul smelling yellow pussy drainage coming from the skin by the opening. I'm afraid it may be infected. Please advise. Thank you. There was no nursing note written regarding R1's suprapubic site, this information was not placed on the 24 hour report, and the Facility did not follow up until the next day as R1's wife was taking R1 to the hospital. R1 was admitted to the hospital and as of the survey exit has not returned to the Facility. Findings include: The physician notification policy and procedure dated 6/2017 documents under procedure, The physician will be notified of any changes in the resident's condition that deviated from the established base line and/or results of laboratory test, therapist evaluations, dietary/pharmacy recommendations, medication errors, resident refusal or non-compliance with the plan of care. Should the attending physician not be available within an hour, the physician should be re-contacted (or the on call or alternative physician). If unavailable, the Medical Director should be notified. The licensed nurse will document in the clinical record any calls/faxes or other communication from the physician and if any orders were received. A nurse will notify the physician of any resident experiencing a clinically unstable condition and/or life threatening event. Should the physician not be available, the nurse should attempt to notify the Medical Director asap (as soon as possible), but may send the resident to the emergency room without a physician order [REDACTED]. The nurse will document routine calls or faxes made to the physician listing the date, physician notified, reason for notification, time of notification and response. The physician should respond on that shift for the next. Documentation will be reviewed at change of shift to inform the oncoming shift of any calls or faxes waiting a response from the physician. All staff will be aware and watching for a change in a resident and will immediately report this to staff nurse. R1 was admitted to the facility on [DATE] and discharged on [DATE]. The admission MDS (Minimum Data Set) with an assessment reference date of 8/24/18 and signed as complete on 9/12/18 documents a BIMS (brief interview mental status ) score of 15 which indicates cognitively intact. R1 requires extensive assistance with one person physical assist for bed mobility, transfer, ambulating in room, and toilet use. R1 is checked as having an indwelling catheter. The nurses note dated 8/18/18 documents, Alert & verbal. Denies pain or discomfort. Lungs clear. No SOB (shortness of breath). Bowel sounds active x (times) 4. Abdomen is soft, round and non-tender. No [MEDICAL CONDITION]. S/P (suprapubic) catheter is patent and draining clear yellow urine. Slept well this shift. The skin review-weekly with an effective date of 9/8/18 is checked for redness and new. Under site documents, 14) abdomen and under description documents s/p (suprapubic) site with redness. Surveyor reviewed the 24 hour report/change of condition report and noted the following documentation for R1: 9/9/18 new diabetic shoes, senna now prn (as needed) 1-2 tabs open area back upper scrotum. 9/10/18 24 hour sheet not provided to Surveyor. 9/11/18 prn senna 1-2 tabs open sore scrotum start derma synlag wound gel BID (twice daily) to scrotum (P) (plan) Dc (discharge) home Fri (Friday. 9/12/18 PRN senna 1-2 tabs open sore scrotum start derma synlag wound gel BID to scrotum possible d/c Friday. Surveyor noted there is no documentation on the 24 hour report regarding R1's suprapubic catheter. 9/13/18 new open area posterior upper scrotum. Spouse brought res (resident) to Meriter Hospital ER for eval (evaluation) S/P (suprapubic) site. The skilled care daily summary dated 9/12/18 at 9:36 a.m. documents under site, 14) abdomen Under description documents S/P (suprapubic) site slight tenderness with cleansing. The Facsimile cover sheet dated 9/12/18 to Physician-L or RN (Registered Nurse) documents, (R1) is c/o (complaining of) pain from catheter site. Area is hot to the touch, very hard surrounding the area, and has a foul smelling yellow pussy drainage coming from the skin by the opening. I'm afraid it may be infected. Please advise. Thank you. RN-G. There is a handwritten notation, faxed 9-12-18 RN-G. There is another handwritten notation on the facsimile cover sheet which documents, MD (medical doctor) office phoned updated (up arrow) 9/13 spouse assisted res. (resident) at ER (emergency room ). There is no documentation in R1's medical record on 9/12/18 regarding R1's catheter site being hot to the touch, surrounding area very hard, and having foul smelling yellow pussy drainage. Nor is there documentation in the record R1's physician was sent a fax regarding this. The skilled care daily summary dated 9/13/18 at 9:18 a.m. documents under site, 14) abdomen Under description documents, S/P (suprapubic) site slight tenderness with cleansing. The nurses note dated 9/13/18 documents, Physician-L/Physician-M office phoned updated spouse transported res (resident) to Merriter's hospital ER (emergency room ) for eval (evaluation). R1 was admitted to the hospital and has not returned to the Facility as of the exit on 11/20/18. On 11/20/18 at 10:14 a.m., Surveyor spoke to CNA (Certified Nursing Assistant)-N regarding R1. Surveyor asked CNA-N if she remembered R1 and if she took care of R1. CNA-N informed Surveyor that she remembered R1 and that when she was taking care of R1 there was green oozing from the suprapubic and she reported this to LPN-H. CNA-N informed Surveyor in her position she can only pass information to her supervisor. Surveyor asked when this was. CNA-N informed Surveyor she thinks it was on the day R1's wife took him to the hospital. CNA-N informed Surveyor R1 asked her (CNA-N) to call his wife on the day he was discharged which she did and R1 informed his wife he wasn't feeling well and was having urinary symptoms. On 11/20/18 at 10:03 a.m., Surveyor spoke with LPN (Licensed Practical Nurse)-H regarding R1. LPN-H informed Surveyor she vaguely remembers R1. LPN-H informed Surveyor R1's wife took him to the hospital. Surveyor asked LPN-H if she knew why. LPN-H informed Surveyor R1's doctors are in Madison. LPN-H informed Surveyor R1's wife wanted an eval (evaluation) for him. Surveyor asked for what. LPN-H informed Surveyor R1's suprapubic site was a little red and she was concerned about it, R1 had a low grade temperature of 100. LPN-H informed Surveyor before the doctor was able to respond the wife was taking R1 out. LPN-H informed Surveyor when the doctor called back she let the doctor know he was on his way out to see his doctor. On 11/20/18 at 12:31 p.m., Surveyor asked LPN-H when she called R1's physician to update them would she document this in a note. LPN-H replied, Yes. LPN-H informed Surveyor she called R1's physician to tell them what was going on but R1 was already heading out the door. Surveyor asked if this was on the 13th. LPN-H indicated it was. Surveyor asked LPN-H did anyone report to her drainage from R1's catheter. LPN-H replied, Yes and we were keeping it clean and dry and there's a treatment. Surveyor asked if LPN-H remembers who told her about the drainage. LPN-H replied CNA-N maybe. On 11/20/18 at 12:35 p.m., Surveyor asked Interim DON (Director of Nursing)-B if she remembered R1. Interim DON-B informed Surveyor she wasn't familiar with R1 and former DON-O was at the Facility. Surveyor read Interim DON-B the fax that was sent to Physician-L on 9/12/18 and asked if she would expect staff to contact the physician if he didn't respond. Interim DON-B informed Surveyor she wouldn't have faxed something that's urgent. Interim DON-B informed Surveyor the nurse should have followed up with a phone call to make sure the doctor reviews it. Surveyor asked when the nurse sends a fax to the doctor how would another nurse know a fax has been sent. Interim DON-B informed Surveyor it should be charted in the Resident's record and put on the 24 hour report so the incoming nurse could follow up on it. Surveyor informed Interim DON-B Surveyor was not able to locate a note and it was not placed on the 24 hour report. Surveyor informed Interim DON-B Surveyor also was not able to locate a change of condition form for R1. Interim DON-B reviewed R1's electronic medical record and informed Surveyor she does not see one. Interim DON-B continued to review R1's electronic medical record and stated, No I didn't find one. On 11/20/18 at 12:55 p.m., Surveyor telephoned RN (Registered Nurse)-G to speak to her about the fax she wrote on 9/12/18 regarding R1's suprapubic catheter. RN-G did not return Surveyor's call. On 11/20/18 at 2:21 p.m., Surveyor received a call from Physician's RN-P to inquire when the Facility contacted Physician-L regarding R1. Surveyor informed Physician's RN-P Surveyor had noted RN-G had sent a fax on 9/12/18 regarding R1's suprapubic catheter site. Physician's RN-P informed Surveyor they received a call from Lake Mills on 9/12/18 regarding the patient planned to discharge on Friday and to please call them back. Physician RN-P informed Surveyor they called Lake Mills back and spoke with RN-G and informed her they couldn't give any orders regarding the discharge until he was examined and to let the family know. Surveyor asked if they received the fax RN-G sent them on 9/12/18. Physician RN-P informed Surveyor she didn't know if they received a fax or not. Physician RN-P informed Surveyor they received a call on 9/13/18 from R1's wife with a concern of potential systemic infection, fever, chills and something around R1's belly button. Physician's RN-P informed Surveyor R1 had an appointment on the 14th and they recommended be seen for further investigation. Physician's RN-P informed Surveyor Lake Mills called urology on the 13th. Physician's RN-P indicated LPN-H called about the suprapubic site and spoke with the nurse at Physician-M's office informing her the suprapubic site has been pink for a week, had a temperature of 100 degrees gave 650 mg of [MEDICATION NAME], rechecked the temperature and it was 99.4, warm to touch, yellow drainage and painful to touch. Physician's RN-P indicated the urology nurse paged Physician-M's physician's assistant. Surveyor inquired if Physician-L is following R1 at the hospital. Physician's RN-P replied No, he's followed by hospitalist. Surveyor inquired about the fax that RN-G sent on 9/12/18 again. Physician's RN-P informed Surveyor she wouldn't know when a fax came in and she doesn't see any notes or a telephone encounter regarding the fax. Physician RN-P informed Surveyor the only other encounter was on 9/10/18 when R1's wife called regarding the wound on R1's scrotum. On 9/20/18 at 2:45 p.m., Administrator-A and Interim DON-B were informed of the above. On 11/26/18, Administrator-A e-mailed Surveyor additional information which included the Facsimile cover sheet dated 9/12/18 to Physician-L, the skilled care daily summary dated 9/13/18, health status note dated 9/13/18, a page from R1's MAR (Medication Administration record) and R1's temperatures. Surveyor had previously reviewed all this information during the survey.

Based on observation, interview, and record review, the facility did not ensure that a resident having pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents reviewed for treatment and prevention of pressure ulcers (Resident 5). R5 (Resident 5) was admitted to the facility without a pressure ulcer and was identified to be at risk for development. On 11/14/16 R5 developed a scratch on his back/buttock. On 11/22/16 the facility documented that R5's wound had a slough filled center. The presence of slough indicates the pressure ulcer was a stage 3. The Physician was contacted via fax and ordered Santyl (a wound [MEDICATION NAME] ointment) to be applied twice daily. One week later, on 11/29/16, Surveyor observed R5's dressing change. During the dressing change, Director of Nursing (DON) B identified the wound as an unstageable pressure ulcer and noted it had doubled in size from the previous week and is now on the right ischium as well. R5 had a Panacea Clinical Foam Mattress in place. The manufacturer guidelines for the mattress indicate that that the mattress is not intended for stage III or IV pressure ulcers. R5 was receiving dressing changes to his right buttock twice daily from 11/23 - 11/29/16. The facility did not do the following: 1. Document the pressure ulcer as a stage 3 on 11/22/16 when it presented with slough. 2. Document the decline of the pressure ulcer from 11/23/16 - 11/28/16, despite the treatment being done twice daily. 3. Contact R5's Physician from 11/23 - 11/28/16 to notify him of the decline of the pressure injury. 4. Add a mattress that was appropriate to promote healing and prevent new ulcers from developing. 5. Position R5 off of the pressure ulcer while laying in bed on his back. Surveyor observed R5 sleeping in bed on his back and laying directly on the pressure ulcer on the Panacea Clinical mattress. This is evidenced by: The facility policy entitled Wound Prevention and Treatment dated 7/2015 states as follows: The center strives to ensure that a resident entering the center without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates unavoidable skin breakdown. The center will consider all residents as at risk for skin impairment and will implement the following interventions to prevent the development of pressure ulcers: Reduce occurrence of pressure over bony prominence to minimize injury. Protect against the adverse effects of external mechanical forces (pressure, friction, shear). Increase the awareness of pressure ulcer prevention through educational programs. Staging of Pressure Ulcers The following pressure ulcer staging system is consistent with the recommendations of the National pressure Ulcer Advisory Panel (NPUAP) . Pressure ulcers are staged using the system below:*Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. *Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined . Note: The center acknowledges NPUAP, Wound, Ostomy and Continence Nurse (WOCN) recommendations; However, The center will comply with Medicare and Medicaid documentation requirements. Wound Prevention and Treatment Progression of wound healing will be documented by length, width and depth measurements. Nursing will remove the dressing, evaluate and document the condition of the wound. The facility policy Therapeutic Support Services Guidelines includes the following for mattress requirements based on the stage of the pressure ulcer: Multiple Stage 1 pressure ulcers: Foam mattress Stage 2 or Stage 3: Alternating pressure Mattress (AIRDYNE-BARI, MA65B42, MA65B48) Multiple Stage 3 or Stage 4: Low Air Loss and Alternating Pressure Mattress MA65B42, MA65B48, MA85B42, MA85B48) R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R5's admission Braden assessment, dated 10/20/16, indicates Resident 5 scored 18 indicating Resident 5 was at risk for pressure injury development. The facility's Braden risk score indications are as follows: At Risk: 15-18, Moderate Risk: 13-14, High Risk: 10-12, Very High Risk: 9 or below. The Braden assessment was again completed 10/27/16 with a score of 19 (not at risk), 11/3/16 and 11/10/16 with a score of 18 at risk. R5's admission Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) was completed with Resident 5 scoring a 13 indicating he is cognitively intact. Section M0150 the MDS indicates R5 is not at risk for developing pressure ulcers. Section G0110, Activities of Daily Living (ADL's) indicates R5 requires 2 staff and extensive assist for bed mobility and transfers. A Care Area Assessment (CAA) worksheet states, Braden score is 18. Resident is at risk for developing pressure ulcers due to immobility. He was admitted with shearing on the right coccyx. He is extensive assist with bed mobility, transfers. He has a pressure reducing cushion for W/C (wheelchair) and mattress. R5's comprehensive care plan for Skin Integrity Assessment Prevention and Treatment Care Plan indicates the following areas of impairment: Right coccyx-shear - present upon admit, treated upon admit - Resolved 11/1/16 Right hip surgical incision (femur fracture) - present upon admit - Resolved Deep Tissue Injury Right Heel - Facility acquired on 10/28/16 - Unresolved, improving Scratch Right Back/Buttock - Facility acquired on 11/14/16 - Worsening Goals: Blister will heal without signs/symptoms of infection in 90 days; surgical site will heal without signs/symptoms in 90 days, Blister right heel without signs/symptoms of infection in 90 days. Monitor wound weekly and as needed (PRN), Provide treatment per medical Doctor (MD) order, Update MD within 2 weeks if no evidence of healing, heel boot bilateral while in bed (discontinued 11/29/16), Santyl ointment to area twice a day (BID) cleanse with normal saline, cover with gauze. Braden Risk Assessment Score: At Risk (15-18): Frequent turning, Maximal Remobilization, Protect Heels, Manage Moisture, Nutrition, Friction and Shear, Pressure Reducing Support Surface if Bed or Chair-Bound, Protect Heels, Pressure Reducing Surface, Turn and Reposition every 2 hours, Keep Head of Bed at or below 30 degrees. Braden Score: 18 R5's Low Back/Buttock (Ischium) pressure injury recorded on the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other: 11/14/16: 1.1 x 0.7 x 0 Sites - Other: Scratch 11/22/16: 1.6 x 1.3 x 0 - Stage: N/A 11/29/16: 3.0 x 3.0 x 0 Unstageable R5's Nurses Notes state as follows: 11/14/16: .Is continent of B and B (bowel and bladder), very small amount of drng (drainage) to the R (right) heel. No c/o (complaint of) pain with dressing change. +1 [MEDICAL CONDITION] noted in BLE (bilateral lower extremities) Res (Resident) is two assist with walker in room to bed and toilet. Is hard for him to stand up. He continues with the bruised bumps to the Right upper buttocks, no c/o pain . 11/15/16 10:00 AM: Skin barrier applied to R (right) buttock. 11/22/16 at 10:30 AM: Open area on Right Upper Buttock- slough filled center, medial edges surrounding tissue red - hardness surrounding open area. Wound measurements 1.6 x 1.3. Faxed Physician's office asking for [MEDICATION NAME] ointment. Will wait for response. 11/22/16 at 5:30 PM: Orders from Physician for right upper buttock noted. Resident aware. 11/23/16 at 9:55 AM: .yellow slough middle of OA (open area) on R buttocks. 11/23/16 at 3:00 PM: .dressing change right buttock wound bed yellow slough 11/25/16 at 8:50 AM: .Treatment to buttock done . 11/26/15 at 10:00 AM: .Dressing to coccyx changed scant amount of serous drainage . 11/28/16 at 2:35 PM: Area of right butt (buttock) had large amount of serosanguineous drainage; treatment done per MD order. On 11/29/16 at 9:25 AM, Surveyor observed the treatment to R5's unstageable pressure injury to his low back/buttock (ischium). During the treatment Director of Nursing (DON) B stated that what started as a scratch is now a pressure ulcer and it is larger than when she last saw it two weeks ago. As DON B was assessing the pressure ulcer of R5's low back/buttock (ischium), Surveyor asked DON B what stage is the pressure ulcer. DON B stated, Unstageable. DON B stated they will start having R5 lay down between meals. On 11/29/16 at 10:20 AM, Surveyor and License Practical Nurse (LPN) G entered R5's room to check the type of mattress on R5's bed. LPN G pulled back the covers and Surveyor observed the mattress name as Direct Supply Panacea Clinical. On 11/29/16 at 10:25 AM, Surveyor asked DON B for the manufacturer recommendations for the Direct Supply Panacea Clinical mattress. DON B provided the manufacturer guidelines for the Panacea Clinical mattress to Surveyor . The guideline states the following - Panacea foam Mattress are intended to be used as part of your care plan to help treat or prevent decubitus ulcer (pressure injuries) by providing a presuure redistributing support surface. Panacea mattress are designed as part of, but not replacement for your comprehensive care plan. WARNING: This mattress is not intended for stage 3 or 4 ulcers. Resident specific assessment could alter your particular usage of these mattresses. On 11/29/16 after the dressing change, the facility sent a fax to R5's Physician that stated as follows: Area to R (right buttock is now large and unstageable. Peri-wound is pink and intact, mod (moderate) sersang (serosanguineous) drainage. R5 denies pain/discomfort. Will continue to use N.S. (Normal Saline) cleanse, skin prep to peri-wound, Santyl to wound bed, cover with gauze and secure with [MEDICATION NAME]. Will change daily (this was changed from twice daily). R5's Physician signed the fax stating, Ok on 11/29/16. On 11/29/16 at approximately Noon, DON B then added a Roho cushion and Alternating Pressure Mattress to R5's skin interventions. DON B also stated she will be contacting the nurses to determine when the pressure ulcer started to worsen between 11/23 and 11/28/16. On 11/29/16 at 12:55 PM. Surveyor completed a resident interview with R5. Surveyor asked R5 if there are any positions he is uncomfortable in or does not like to sleep in. R5 replied, No. Surveyor asked R5 if he ever declines staff offers to reposition or turn him while in bed. R5 replied, No. R5 stated he does not recall staff offering to turn him while in bed, but could not remember for certain. R5 stated, if I asked, I'm sure they would turn me. On 11/29/16 at 2:50 PM, Surveyor observed R5 sleeping in bed and laying directly on his back on the Panacea Clinical mattress. It is important to note that the facility did not do the following in order to promote healing and prevent new injuries from developing: 1. Document the pressure injury as a stage 3 on 11/22/16 when it presented with slough. The facility did not recognize this as a stage 3 pressure injury, thereby delaying a new treatment (decreasing the Santyl from two time a day to once daily) and care plan interventions (Roho cushion and Alternating Air Mattress were not put in place until after Surveyor observed R5's wound treatment on 11/29/16) that could have promoted healing, prevented infection and prevent new ulcers from developing. 2. Recognize and document the decline of the pressure injury from 11/23/16 - 11/28/16, despite the treatment being done twice daily. The nurses note on 11/28/16 at 2:35 PM indicated that the pressure injury had large amount of serosanguineous drainage which was an increase in drainage previously noted. The MD was not contacted. 3. Contact R5's Physician from 11/23 - 11/28/16 to notify him of the decline of the pressure injury (increase in size/location and drainage). 4. Add a mattress that was appropriate to promote healing and prevent new ulcers from developing. R5's mattress was not appropriate for the stage of his pressure ulcer. 5. Surveyor observed R5 sleeping in bed and laying directly on his back on the Panacea Clinical mattress. On 11/30/16 at 1:15 PM and 1:45 PM, Surveyor spoke with DON B. Surveyor asked DON B if she would have expected R5's pressure ulcer to go from a scratch to an unstageable pressure ulcer. DON B stated with using Santyl that it's possible because R5's skin is thin especially over the ischium. Surveyor asked DON B if there is documentation of any nurse(s) contacting the Physician between 11/23-11/28/16 when the pressure ulcers was worsening. DON B stated, I don't believe so. Surveyor asked DON B if she would expect the nurse to call the Physician when a pressure injuries worsens. DON B replied, Yes. DON B stated it is her expectation that the nurse would also call her with any new wound or worsening wound and she would give further direction. DON B stated she would have expected to be called.

Based on interview and record review the facility did not ensure each resident received 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 7 sampled residents (Resident 1). This has the potential to effect 10 out of 32 residents in the facility who are full-code. Resident 1 desired to receive CPR (Cardiopulmonary Resuscitation). Resident 1 was found without a pulse and the facility did not verify code status thus did not immediately begin CPR. CPR was started approximately 30 minutes later after it was discovered Resident 1 was a full code. When the CPR was started Resident 1 was in bed and a backboard was not in place per CPR standards. Failure to immediately begin CPR created a finding of Immediate Jeopardy, which began on [DATE]. The Nursing Home Administrator was notified of the immediate jeopardy on [DATE] at 2:45 PM. The facility removed the immediacy on [DATE], however the deficient practice continues at a severity/scope level of E (no actual harm /pattern) as the facility continues to implement its removal plan. This is evidenced by the following: The facility's policy for CPR, revised [DATE], includes the following: Unless a decision not to initiate CPR has previously been made by the resident and stated guidelines are in place, CPR will be initiated on any resident that experiences a witnessed or unwitnessed cardiopulmonary arrest while in the center. The applicable CPR consent form will be reviewed and signed by the resident on admission or during their stay if they choose to change their original decision. Procedure: -Determine if an arrest has occurred and call for assistance. -All CPR certified persons report to the area of the cardiopulmonary arrest, or suspected cardiopulmonary arrest. -Determine if a code status has been established and documented using the CPR Consent form. --File original copy in the Advanced Directive section of the resident's medical record. -Gather the equipment and take to the site of the cardiopulmonary arrest. -Assign the responsibility of notifying the following person (s) simultaneous with the initiation of CPR: --Emergency Medical Services (EMS) (911 where applicable) --Physician --Family/legal representative -Initiate CPR, if using Automated External Defibrillator (AED) follow AED verbal instructions. -Continue CPR until Emergency Medical Services arrive or the physician orders [REDACTED]. The facility has a Green Light through the call system for emergencies. This is can be activated in all resident rooms and where there is a nurse call button. When pushed a green light flashes in the hall and an alarm sounds at the nursing station and can be heard throughout the 1st floor. Resident 1 was [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was alert and oriented and her own decision maker. On [DATE] Resident 1 signed the facility's Cardiopulmonary Resuscitation Consent (CPR) form. Resident 1 indicated she desired to have CPR and/or external defibrillation performed in the event of [MEDICAL CONDITION]. Resident 1's physician orders [REDACTED]. Resident 1's Progress Notes include: -[DATE], Ambulated into facility. Did note shortness of breath. Ambulating in room on own without oxygen. Continent of bowel and bladder. Temperature 97.7, pulse 107, respirations 20, blood pressure ,[DATE], oxygen saturation 96% with oxygen at 2 liters. Lungs diminished in lower lobes. -[DATE] at 7:50 AM, Green light sounded and Certified Nursing Assistant (CNA) running down the hall yelling for nurse. Went into Resident 1's room to find her lying sideways on bed, feet dangling. Incontinent of urine. Ash color. No pulse, respirations or blood pressure. Repositioned Resident 1 in bed. By Registered Nurse (RN) C. -8:00 AM, Resident 1's physician called and updated on death. Time of death 7:50 AM. Order received to release body to funeral home. By RN C. -8:10 AM, 911 called and paged out await arrival. CPR started and AED and crash cart retrieved. By RN C. -8:30 AM, EMS arrived on scene. AED advised no shock, CPR continued. AED advised no shock two times. EMS called CPR, time of death 8:35 AM. -10:00 AM, spoke with family, Resident 1 was last seen at 7:00 AM getting dressed. Resident 1 found at 7:50 AM with no pulse or respirations. Resident 1's Notice of removal of a human corpse from a facility, completed by RN C, indicates death was pronounced on [DATE] at 7:50 AM. 7:50 AM is crossed out and 8:35 AM is written next to it. Following the incident the facility conducted an investigation and submitted a self-report to the State Agency. The investigation includes the following statements: CNA F--Stated she looked at the clock when she pushed the emergency green light it was 7:50 AM. Resident 1's curtain was pulled, could see her feet. She had sandals on and her toes were purple, but this is normal. CNA F and CNA G were in room cutting up food for roommate and said to Resident 1 going down for breakfast? CNA F pulled the curtain and saw Resident 1 had fallen back in bed and had been incontinent. CNA F told CNA G to run and get Licensed Practical Nurse (LPN E). RN C showed up first and checked pulse. LPN E was behind RN C with the vitals machine. There was no heart rate, no pulse. CNA H came in and was asked to get linens. CNA F cleaned Resident 1 up and put a gown on her. At approximately 8:30 AM, the nurses ran back to the room. CNA G--Around 7:45 AM would have been passing trays down that side of the building. Took tray to Resident 1's roommate and was helping her. CNA F pulled the curtain and pushed the green light. CNA G ran to get LPN E, waving her hands for her to come. RN C went into the room. RN C checked vitals then went and made phone calls. CNA G went back to passing trays with RN C, LPN E, CNA F and CNA H still in the room. CNA H--Came up on floor about 7:45 AM. CNA H helped with another resident transfer then another staff member came in and said Resident 1 had passed. At approximately 8:00 AM went to Resident 1's room to see if they needed anything. RN C left to make calls and CNA H helped CNA F get Resident 1 and room ready for family. This took until estimated 8:15 AM. RN C--I was sitting at nurse's station and heard CNA G say Resident 1 was gone. LPN E, LPN E stated she's gone. RN C stated she ran to room and the clock indicated it was 7:50 AM. RN C had grabbed the vitals machine on the way to the room. CNA G and CNA F were in the room and LPN E came in behind her. Resident 1 was sideways on the bed with her feet dangling over. Resident 1's oxygen nasal cannula was sitting next to her on the bed. Resident 1 was fully dressed, pants were unbuttoned. Resident 1 was cold to the touch, blue fingers and toes. Took vitals and there was no pulse apically or radially, no blood pressure, no respirations. LPN E was there and confirmed. CNA F and RN C remained in the room and repositioned Resident 1 into bed. This was around 7:55 AM. RN C went to nurse's station and called physician's office around 7:55 AM to 8:00 AM. Physician gave order for release of body. Physician did not ask about Resident 1's code status. RN C then called Resident 1's daughter and left a message around 8:10. RN C then checked the chart and went and told NHA A Resident 1 was a full code. RN C called 911 estimated at 8:15 AM. NHA A called corporate nurse consultant then told RN C to start CPR. LPN E and someone grabbed crash cart. NHA A brought AED. LPN E used the ambu bag while RN C did CPR. EMS arrived at 8:25 AM estimate. EMS called time of death at 8:35 AM. RN C was asked why she didn't grab the chart and RN C stated spur of the moment;[MEDICATION NAME]. LPN E--At 7:30 AM there was a green light. Resident 1 had obviously passed when they got there and she went back to passing medications. Then she and another staff grabbed the crash cart and went to Resident 1's room. RN C was already doing compressions; this was around 8:00 AM. EMTs came and used our AED, indicated no shock. EMTs declared Resident 1 deceased at about 8:25AM to 8:30 AM. LPN E was asked what she would normally do in this situation: LPN E stated she normally would have someone grab the chart. LPN E stated that was not done in this case right away. The facility investigation concluded that the nurses failed to follow center policy and procedure as they did not check Resident 1's chart to identify code status. It was also identified that RN C's CPR certification expired on [DATE]. The facility at that time re-educated all nurses on the CPR policy, CPR drills were conducted on all shifts, CPR certification audits were conducted. On [DATE] at 10:25 AM, Surveyor interviewed CNA F regarding her involvement with Resident 1 on [DATE]. CNA F stated she entered Resident 1 room at approximately 7:45 AM, CNA F stated she was bringing in Resident 1's roommate breakfast tray. CNA F stated she saw Resident 1's feet under the curtain, and she called over to ask if Resident 1 was going to breakfast. CNA F stated she did not answer so I looked around the curtain and found her laying across the bed with her feet hanging off the side and her arms were spread out, CNA F demonstrated how she found Resident 1. CNA F stated Resident 1 was cold and her feet were blue. CNA F went on to say Resident 1 feet were always blue I think it is from circulation problems. CNA F stated she pushed the green button and when no one came CNA G went out into the hall to get a nurse. CNA F stated RN C entered the room and took Resident 1's vitals. LPN E entered the room after RN C was already in the room. RN C took LPN E's stethoscope and listened to Resident 1's heart. RN C then left the room and stated she was going to call the Physician and the family. CNA F stated she started to clean Resident 1 up because she had been incontinent of urine and her family would be coming. Surveyor asked CNA F if RN C indicated she was a full code or that she was going to check to see what her code status was. CNA F stated no she just stated she was calling the physician and family. CNA F stated she gave Resident 1 a complete bed bath and changed her entire linens before leaving the room. CNA F stated CNA H is the only person who came into the room after RN C left the room. CNA F stated no one else ever came into the room while she was performing cares. Surveyor asked CNA F is she has any way to identify if a Resident is a full code or DNR. CNA F stated no, the nurse is to do that we just inform the nurse when we find someone. Surveyor asked if the CNA's carry a care card for all residents. CNA F stated yes, but it does not indicate anyone's code status. Surveyor and CNA F reviewed the CNA care card; there is no indication on the care card for code status. CNA F stated we do not look in the chart that is for the nurses to do. They did not look in her chart and she was a full code. CNA F stated after she left the room she did not come back to Resident 1's room. Surveyor asked CNA F if she heard a code called over the intercom after she left Resident 1's room. CNA F stated a code was not called and she did not hear one. CNA F stated no one asked CNA F and CNA G to get the chart so the nurses could look to see if she was a full code. On [DATE] at 11:00 AM Survey interviewed CNA H regarding Resident 1 on [DATE] when Resident 1 expired. Surveyor asked CNA H to describe how she was involved with Resident 1. CNA H stated she was on the floor helping get breakfast trays to the residents in their rooms. CNA G came to her and stated they had just found Resident 1 passed away in her room. CNA H stated I told her I would finish here and go see what I can do to help. CNA H stated she entered the room and CNA F and RN C were in the room. RN C was finishing taking vitals when CNA H entered the room. CNA H stated RN C stated as she was walking out of the room you can help CNA F clean Resident 1 up while I go and call the family and the Physician. Surveyor asked CNA H what time she entered the room. CNA H stated it was around 7:50 or so, I was starting to pass trays around 7:45 and I had just started. CNA H stated she and CNA F gave Resident 1 a complete bed bath and changed her entire bed before leaving the room. Surveyor asked CNA H if any other nurse entered the room while you were assisting CNA F. CNA H stated no one came in to the entire time after RN C left the room. CNA H stated she finished doing post mortem care at approximately 8:10 or 8:15 AM. CNA H stated she left the room and went to the nurse's station. RN C was at the nurse's station and the other nurses were on the hallways passing medications. Surveyor asked CNA H if she ever was called back in to the room. CNA H stated she never re-entered Resident 1's room or even walked by Resident 1's room. Surveyor asked CNA H if RN C called a code over the intercom after you left Resident 1's room. CNA H stated no, she never called a code over the intercom for Resident 1. Surveyor asked CNA H if she had any other information related to Resident 1. CNA H stated she seen the EMT in the facility at around 8:35 AM for Resident 1. On [DATE] at 11:15 AM Surveyor interviewed CNA G regarding her involvement with Resident 1 on [DATE]. CNA G stated she and CNA F entered the room to give Resident 1's roommate her breakfast tray. Resident 1's feet were visible under the curtain. CNA F asked Resident 1 if she was going out to breakfast. It was already 7:50 AM and Resident 1 is usually in the dining room by now. CNA G stated CNA F looked around the curtain and Resident 1 was lying across the bed with arms spread. CNA F stated I think she has passed. CNA F pushed the green button (emergency button to call help to the room). CNA G stated no one was coming when she looked out the door. CNA G left the room and saw LPN E standing at her medication cart passing medications. CNA G yelled and waved for LPN E to come to the room. CNA G stated LPN E looked at CNA G and LPN E asked what do you want now. CNA G stated LPN E did not leave her medication cart so I had to run down the hall to tell her Resident 1 had died . CNA G stated she turned around and started to run back to the room. As she passed the nurses station RN C was on the other side of the nurse's station and asked CNA G what was going on. CNA G informed RN C that Resident 1 looks dead. CNA G stated RN C grabbed the vital machine and followed CNA G to the room and LPN E was walking behind them to the room. RN C then checked Resident 1's pulse and checked for a heartbeat; there was none. LPN E came into the room and just stood there watching RN C, she did not assist or say anything just watched. LPN E left the room while RN C finished the vitals. RN C stated she was walking out of the room and stated I have to go make some calls; she was going to call the Physician and the family. CNA G stated she left the room and found CNA H and told her Resident 1 had died . CNA H was then going to help CNA F clean up Resident 1. CNA G stated LPN E was already back at her medication cart passing medications when she exited the room. CNA G stated she went back to the room approximately at 8:15 AM to see if they needed anything and they were just finishing post mortem cares for Resident 1. At 8:30 AM CNA G stated they were going back in to start CPR; apparently no one had checked the chart to see if Resident 1 was a full code until after the cares were completely done. LPN E ignored the whole situation. She went back to her cart and never came back to the room or checked the chart; she was Resident 1's nurse so she should have checked the chart. CNA G stated at approximately 8:30 AM she went back to the room and the crash cart was in the room, CNA G stated she could see Resident 1 and she was still lying in the bed and no one had started CPR at that time On [DATE] at 11:30 AM Surveyor asked CNA G how Resident 1 looked. CNA G stated Resident 1 was completely dressed for the morning. Resident 1 had her make up already on and her hair was combed. CNA G stated Resident 1's legs and feet were blue in color, but they always were, here legs have been that color since she was admitted to the facility. On [DATE] at 12:42 PM, Surveyor interviewed RN C. RN C stated she was alerted to the situation via the green light and a CNA yelling down the hall. This was about 7:,[DATE]:50 AM. There were 2 other nurses at the nurse's station too. RN C went to Resident 1's room and LPN E followed her in. Resident 1 was lying crossways in bed and was ashen gray. Resident 1 was not breathing, was blue around the lips and was cool to the touch. Her oxygen cannula was lying next to her on the bed; Resident 1 did not have her oxygen on. RN C checked Resident 1's vitals and there were none. RN C helped CNA F reposition Resident 1 back onto the bed and went to the nurse's station to call the physician and let him know Resident 1 had passed. RN C also left a message for Resident 1's daughter. RN C then went to chart the events in the nursing notes and saw Resident 1 was a full code. It was about 8:10 AM at the time and RN C called EMS and alerted NHA A. RN C grabbed LPN E and the crash cart and went to Resident 1's room and started CPR at approximately 8:10. RN C provided chest compressions while LPN E used the ambu bag. EMS arrived in the room and used the facility's AED machine which indicated no shock. CPR was continued until instructed by EMS to stop. RN C stated in a code situation she would typically grab the vitals machine and the resident's chart but her [MEDICATION NAME] was rushing and it slipped my mind. On [DATE], at 3:40 PM, Surveyor interviewed LPN E. LPN E stated on [DATE] she was working the morning shift and doing her medication pass at the opposite end of the hallway. LPN E saw the green light and a CNA running down the hall. LPN E responded and as she was passing the nurses station RN C was getting up to respond also. When LPN E entered the room Resident 1 was lying on the bed and her color was not good. Resident 1's eyes were fixed and open, face was bluish pale and she was cold to the touch. RN C checked Resident 1's vitals and stated Resident 1 was gone. RN C instructed LPN E to return to her medication pass. Later, just before 8:00 AM, LPN E heard RN C state Oh my she was a full code. RN C called 911 and returned to Resident 1's room. LPN E grabbed the ambu bag and went to Resident 1's room. Upon re-entering Resident 1's room, around 8:00 AM, Resident 1 was in bed, staff had completed post mortem cares and RN C was doing compressions. RN C did not have a backboard under Resident 1. Surveyor asked if you need a backboard when doing CPR in a bed. LPN E responded absolutely, but RN C had already started so she did not check at the time. LPN E began using the ambu bag until EMS arrived. LPN E stated she did not hear a code blue paged but could not be positive. Surveyor asked if LPN E checked Resident 1's code status. LPN E stated she did not think to check the chart as Resident 1 was obviously gone. LPN E stated this was her first experience with a code and she was in shock. On [DATE], at 2:25 PM, Surveyor interviewed EMS Personnel L. EMS Personnel L stated the county paged out EMS to the facility on [DATE] for Resident 1 at 8:19 AM. On [DATE], Surveyor interviewed other staff, not involved in this event, to determine their understanding of the facility's procedures when a cardiac event occurs. On [DATE], at 7:56 AM, Surveyor interviewed RN J. RN J stated she works part-time and works all over the building days and evening shifts. RN J stated if a CNA reports a resident is not breathing she would go and assess the resident and check for respirations and pulse. RN J would then check the chart for the resident's code status which is located in the front of the chart. If the resident is full code she would go back to the room and activate the green light and start CPR and when the other nurse responds have them call 911 and have a CNA get the crash cart. RN J stated if she was the only nurse in the building she should have to call 911 first and then go start CPR. RN J stated the CNAs cannot call 911 but they can meet the EMS at the door and let them in. On [DATE], at 8:02 AM, Surveyor interviewed LPN M. LPN M stated she works primarily day shift. LPN M stated if someone reports that a resident is not breathing she will go to the resident grabbing the crash cart on the way and assess the resident. LPN M then would check the resident's chart to determine code status. If they are a full code she would call the code overhead and delegate a CNA to call 911 as she went to start CPR. LPN M stated it is the nurse's responsibility to check the chart for code status, call the code overhead, delegate to CNA to call 911 and go start CPR. On [DATE], at 8:15 AM, Surveyor interviewed RN K. RN K stated she works the night shift and at night there is typically 1 RN and 2 CNAs in the building. RN K stated if staff report a resident is not breathing she would go and assess the resident and ask someone to bring the chart down to the room so she could check the code status. If the resident is full code she would announce the code overhead, call 911 and then start CPR. RN K would ask the CNAs to get the crash cart and meet the EMS at the door. RN K stated the CNAs cannot call 911, it has to be done by the nurse. On [DATE], at 4:04 PM, Surveyor again interviewed NHA A and DON B. DON B stated in the event of a code staff should call Code Blue then 911. DON B stated the nurse can delegate any staff to call the code or 911 as the nurse goes to the room to begin CPR. When entering the room the AED should be placed and check if a shock should be administered and then start compressions. DON B confirmed if a resident is in bed they need to put a backboard, which is on the crash cart, under the resident before starting compressions. DON B stated she was not aware if RN C used a back board or not for Resident 1. The failure to immediately provide CPR to Resident 1 created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when they conducted chart audits to verify code status and forms were completed and up to date, began re-education for all nurses on the CPR policy and procedure with the expectation that CPR is initiated upon verification of code status, began re-education for all staff that all staff have the ability to announce a code blue and call 911 and the use of a back board in addition to crash cart and AED prior to next shift and the expected immediate response to visual or audio of green light prior to their next shift. CPR drills have been conducted on all shifts. CPR certification audit was completed. The facility will continue with CPR drills weekly times four weeks then monthly and conducting ad hoc QAPI on incident and corrective action taken. On [DATE], at 9:54 AM, Surveyor interviewed NHA A about the above incident. NHA A stated following the incident all staff were re-educated before their next shift on the CPR protocol/policy. NHA A stated they also conducted an audit of all nurses CPR certification and noted RN C's certification had expired on [DATE]. NHA A stated they have also been completing CPR drills.