Every finding on record at Lincoln Park Nursing and Rehab LLC

Based on interview and record review the facility did not ensure 1 (R86) of 3 sampled residents at risk for falls had interventions in place to prevent a fall with major injury. On 5/23/25 R86 sustained a fall out of bed and was sent to the hospital due to R86 being on a blood thinner and R86 being unable to vocalize if she hit her head. At the hospital R86 was found to have a left subacute infarct of left parietal and frontal lobe with petechial hemorrhage along acute infarct (brain bleed). R86 was at high risk for falls, had right sided weakness from a stroke, had contradictory assessments regarding bed mobility and interventions to be used, was on an anticoagulant and was on an air mattress which are risk factors for a fall. The facility did not assess the various risk factors and the need for possible interventions to prevent a fall with a major injury. Findings include:The facility fall prevention program dated 1/3/23 documents .5. Low/Moderate risk protocols: implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to:Clear pathway to the bathroom and bedroom doors, bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed, call light and frequently used items are within reach, adequate lighting and wheelchairs and assistive devices are in good repair.Implement routine rounding schedule, monitor for changes in resident's cognition, gait, ability to rise/sit, and balance, encourage residents to wear shoes or slippers with non slip soles when ambulating, .High risk protocolsImplement interventions from low/moderate risk protocols, provide interventions that address unique risk factors measured by a risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. Provide additional interventions as directed by the resident's assessment including but not limited to:Assistive devices, increased frequency of rounds, sitter if indicated, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance .R86 was admitted to the facility on [DATE] with diagnoses including hypertension, cerebral infarction with right side hemiplegia, and aphasia.R86's admission Minimum Data Set (MDS) dated [DATE] documents R86 is severely cognitively impaired and dependent with activities of daily living (ADLs). R86 is always incontinent of bladder and bowel. R86 is dependent upon staff for rolling left to right in bed and transferring from bed to a chair. Other mobility assessments including sit to lying, lying to sitting on side of bed, and transfer to toilet were not attempted due to R86's medical condition and/or safety concerns.R86's Care Assessment Area (CAA) for pressure injuries dated 5/10/25 documents: R86 has decreased mobility requiring assistance for her mobility and repositioning which is a contributing issue for potential pressure ulcer development in addition to incontinence issue due to exposure of skin to moisture. (R86) is s/p (status post) hospitalization due to right hemiparesis and aphasia effected (sic) by left cerebral infarction resulting to (sic) generalized weakness and a decline in her functional status.R86's fall risk evaluation dated 5/8/25 documents a score of 7; a score of 5 or above is high risk for falls.The care plan for risk for falls related to right hemiparesis due to stroke, impaired mobility and general weakness dated 5/7/25 documents the intervention, Anticipate and meet the resident's needs. No other interventions are documented to prevent falls or ensure R86's safety due to their risk of falls and diagnoses that contribute to R86's safety risk from falls.R86's Activities of Daily Living (ADLs) Care Plan for the resident has potential for an ADL self-care deficit r/t (related to) generalized weakness initiated 5/7/25 with a goal of improving current level of function through review date initiated 5/8/25, target date 8/5/25. Bed mobility interventions:The resident is an assist of 1 with turning and repositioning in bed. Initiated 5/8/25The resident uses enabler bars to maximize independence with turning and repositioning in bed. Initiated 5/8/25The resident uses (SPECIFY assistive device) to maximize independence with turning and repositioning. Initiated 5/8/25R86's care plan for cerebral vascular accident (stroke) affecting right side of body, aphasia, and intercranial (sic) hemorrhage initiated 5/8/25 with a goal to show improvement to maximum potential to perform ADL's by review date was initiated 5/8/25 with a target date of 8/5/25. This care plan includes an intervention to turn and reposition q (every) 2 hours and PRN (as needed) Keep body in good alignment. Initiated 5/8/25.A nurse's note dated 5/26/25 documents: Writer (Licensed Practical Nurse (LPN) N) was walking back to the nurse's station when the nurse's aide (sic) to the writer to hurry and come into the room. When writer walked into the room the resident was laying on the floor. Resident had RN assess the patient, vital signs were stable. No complaints of pain outside of the resident's baseline. Resident was sent out due to not being able to tell if she hit her head or not and being on blood thinners. POA (power of attorney) and NP (nurse practitioner) were notified, and NP gave writer permission to have her sent out for observation.Hospital record dated 5/26/25 documents R86 had a brain bleed and remained at the hospital until 5/31/25.The Hospital discharge documentation dated 5/31/25 documents for History of Illness/Hospital course: .history of CVA (cerebral vascular accident) causing right sided hemiparesis and aphasia. Patient was rolled onto her side for hygiene purposes and fell out of the bed at the SNF (skilled nursing facility). Patient on aspirin and Eliquis. EMS (emergency medical services) called and patient transported to the ER (emergency room). CT (computerized tomography) head with left subacute infarct of left parietal and frontal lobe with petechial hemorrhage along acute infarct. Kcentra (medication used for the rapid, urgent reversal of acquired blood coagulation factor deficiency caused by vitamin K antagonist (ex. anticoagulant medication) therapy in adults with acute major bleeding.) was given to reverse anticoagulation. admitted to ICU (intensive care unit).On 4/21/26 at 9:44 AM Surveyor spoke to R86's family member-R regarding R86's fall and need to go to the hospital. Family member-R stated they were told (R86) fell out of bed during cares because 1 CNA (certified nursing assistant) was working with (R86) instead of 2. R86 was readmitted to the facility on [DATE].On 4/21/26 at 12:34 p.m. Surveyor interviewed Licensed Practical Nurse (LPN)-N. Surveyor asked LPN-N If she remembers any details of the fall R86 sustained on 5/26/25. LPN-N Referred to her documentation and stated she doesn't remember much about the incident. Review of the facility Fall details dated 5/26/25 at 11:06 am document the above nurse's note as a description of the incident. It is additionally documented the resident was unable to give a description and it was unwitnessed. Immediate action taken documents notified POA, DON (Director of Nursing), and NP. Got order to send her out. Helped put resident back into the bed. The report asks was resident taken to hospital? It is documented N (no). Surveyor noted this is despite R86 being transferred to the hospital.No injuries observed at the time of incident. No pain, Alert and wheelchair bound for mobility. Mental status: oriented to person and situation. Resident does not respond well to questions asked, speech is hard for her. None is documented for predisposing environmental factors. Predisposing physiological Factors document antianxiety use, confused, difficulty with communication, gait imbalance, incontinent, and weakness. Predisposing situation factors are documented as specialty bed.Surveyor noted the risk factors identified as predisposing factors were not assessed or addressed in a care plan prior to this fall. Surveyor noted the documentation does not include any statements or details from staff to accurately determine if the fall was witnessed or not and whether the fall occurred while providing cares as indicated in the hospital documentation.The verification of investigation for R86's fall dated 5/26/25 documents the nursing progress note as documented above regarding LPN-N being called into room while walking back to nurses station. Resident was unable to describe fall, BIMs (brief interview for mental status) 4/15 indicating severe cognitive impairment. Contributing factors and interventions documented include: CVA with affecting dominant right side, able to move independently in bed, high BMW (body mass index; weight (193-202). Modified interventions to the plan of care to prevent re-occurrence: upon return from hospital - staff to position resident with pillows to help identify perimeter of mattress.Summary of factual investigative findings documents: IDT (interdisciplinary team) met regarding fall on 5/26 in resident room. No injury occurred initially noted. Resident is receiving assistance with transfers, toileting, and ADLs (activities of daily living). Resident unable to state what occurred, has BIMs score 4/15. Resident noted to be laying on side of bed. No pain indicators noted. Neuro check negative. NP notified, new orders received to send to ED (emergency department) for eval (evaluation) and treat due to resident on anticoagulant and unable to state if hit head, POA notified. Resident admitted to hospital for intracranial hemorrhage. Resident will benefit upon return from positioning resident with pillows to assist with defining bed perimeter, care plan updated and reviewed.Verification of Investigation: The facility conducted a thorough investigation which included staff interviews, review of clinical records, care plans, mattress settings, and safety interventions in place at the time of the incident. Staff confirmed that the air mattress was appropriately set and functioning as intended and that routine care and monitoring were provided in accordance with the resident's care plan. Staff involved demonstrated understanding of the resident's needs and adherence to established protocols. No environmental hazards or equipment malfunctions were identified. The investigation supports that appropriate interventions were in place, and the incident was not the result of noncompliance or deficient practice. Findings were reviewed with the interdisciplinary team, and opportunities for enhanced monitoring and individualized fall prevention strategies were identified and implemented to mitigate future risk.Root Cause Analysis: A comprehensive root cause analysis was conducted following the resident's fall with injury resulting in intracranial bleeding. The resident, who is capable of independently repositioning, was placed on an air mattress appropriately calibrated to her weight (193 lbs) and comfort level to support an existing wound. Due to clinical contraindications related to both the air mattress and the resident's history of stroke, the use of enablers (eg side rails) was not appropriate. The resident was last provided care and monitoring at approximately 9:30 am and the fall occurred around 11:00 am when the resident rolled out of bed. Emergency protocols were immediately initiated, and the resident was transferred to the hospital approximately 11:24 am. The identified root cause is multifactorial, including the resident's mobility and ability to reposition independently, the inherent reduced boundary support associated with an air mattress, and the inability to utilize restrictive safety devices. There is evidence of staff neglect or failure to follow established care protocols.Surveyor noted the admission MDS for R86 assesses R86 to be dependent upon staff for rolling in bed. A nursing progress note for resident usual performance self-care/mobility charting dated 5/8/25 at 02:10:33 (2:10 am) documented Resident is independent with rolling left and right in the bed. All other mobility areas are noted as not attempted due to medical condition or safety concerns. The MDS was completed 5/10/25. R86's fall occurred 5/26/25. Surveyor also noted R86 was supposed to have interventions in place on the bed to aid in mobility that were not on the bed; according to the post fall investigation. R86's ADL care plan documents interventions for bed mobility including the use of enabler bars to maximize independence with turning and repositioning in bed and the resident uses (assistive device not specified) to maximize independence with turning and repositioning in bed. Surveyor noted the air mattress was not included on R86's care plan until 6/2/25.On 4/21/26 at 12:34 p.m. Surveyor interviewed DON-B. Surveyor asked DON-B if additional interventions were considered to prevent falls prior to R86's fall on 5/26/25. DON-B stated that when someone has a history of falls or are presenting with behaviors that indicate they would fall then different interventions would be considered at that time. On 4/24/26 DON-B submitted additional information to review regarding R86's fall and request the fall be considered unavoidable. The information was reviewed as part of the survey process.

Based on observation, record review, and interview, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety (Wisconsin Food Code) in the main kitchen and the nourishment freezer. *Dietary aide (DA)-O was observed in the main kitchen preparing and handling food without wearing a hair restraint that covered facial hair. *Food debris and sticky floors were observed over several days on the main kitchen floor. *Ground beef patties were observed unwrapped resting directly on the bottom of an opened cardboard box in the main kitchen freezer. *The freezer in the nourishment refrigerator did not have a thermometer or temperature log to ensure freezer food is kept at appropriate temperatures. This deficient practice has the potential to affect all 78 residents who receive food from the main kitchen. Findings include:On 4/20/26 at 8:15 AM, Surveyor conducted an initial tour of the facility's main kitchen with Food Services Director (FSD)-Q. FSD-Q stated the facility follows Wisconsin Food Code for safe food practices. The Wisconsin Food Code documents: . food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles . facilities shall be cleaned as often as necessary to keep them clean . food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. store frozen foods shall be maintained frozen . at any temperature if the food remains frozen. 1. Hair RestraintsOn 4/21/26 at 9:50 AM, Surveyor observed DA-O preparing and handling food in the main kitchen while not wearing a hair restraint for exposed facial hair. On 4/21/26 at 11:29 AM, Surveyor observed DA-O preparing and handling food in the main kitchen while not wearing a hair restraint for exposed facial hair.On 4/21/26 at 1:14 PM, Surveyor shared concern with FSD-Q that DA-O was observed several times not wearing a hair restraint for exposed facial hair while preparing and handling food in the main kitchen, FSD-Q was not aware DA-O should have been wearing a beard restraint and stated FSD-Q would make sure DA-O wears one. 2. Food StorageOn 4/20/26 at 8:15 AM, during the initial kitchen tour, Surveyor observed food debris and sticky floors in the food preparation and cooking area in the main kitchen.On 4/20/26 at 8:24 AM, Surveyor observed several ground beef patties in the main kitchen freezer that were out of the wrapper and resting directly on the bottom of an opened cardboard box. FSD-Q stated FSD-Q would throw the patties away. On 4/21/26 at 11:29 AM, Surveyor observed food debris and sticky floors in the food preparation and cooking area in the main kitchen. On 4/21/26 at 1:14 PM, Surveyor shared concerns with FSD-Q that several ground beef patties were observed unwrapped in the freezer resting directly on the bottom of an opened cardboard box and that Surveyor observed the floor in the main kitchen food preparation and cooking area was sticky and had visible food debris on them over several days. FSD-Q stated FSD-Q did throw away the unpackaged ground beef patties and FSD-Q would educate kitchen staff. On 4/21/26 at 10:39 AM, Surveyor observed the nourishment refrigerator and freezer located behind the nurse's station on the rehab unit. Surveyor observed two boxes of ice cream products labeled with [resident name]. Surveyor was unable to locate a thermometer to measure the freezer temperature or a temperature log for the freezer. On 4/21/26 at 11:56 AM, Surveyor interviewed assistant director of nursing (ADON)-P who stated residents are able to use the nourishment refrigerator and freezer on the rehab unit for any overflow food or freezer food and nursing staff manages the items inside of the nourishment refrigerator and freezer. On 4/21/26 at 1:17 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-N who confirmed nursing staff take care of the resident food items inside of the refrigerator and freezer in the nourishment refrigerator on the rehab unit. LPN-N was not sure if the freezer temperatures are monitored and was only able to locate a temperature log for the refrigerator temperatures. LPN-N was not able to locate a thermometer inside of the freezer. LPN-N confirmed the two boxes of ice cream products are for a resident who is still currently a resident at the facility. On 4/21/26 at 1:38 PM, Surveyor shared the above concerns with Nursing Home Administrator (NHA)-A. No additional information as to why food was not prepared, distributed, and served in accordance with professional standards for food service safety.

Based on interview and policy review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered the facility as having excessively low weekend staffing. This has the potential to affect all 78 residents residing in the facility. Findings include:Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate . Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: 1 October 1 - December 31, (quarter 1) 2 January 1 - March 31, (quarter 2) 3 April 1 - June 30, (quarter 3) 4 July 1 - September 30 (quarter 4) . PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal year Quarter 1 2025 (October 1 - December 31), ran on 4/15/2026, indicates the following: Submitted Weekend Staffing data is excessively low. On 04/20/2026 at 2:10 PM, Surveyor conducted a review of the schedules provided by the facility for the weekends during October- December, 2025. It was noted that there was an RN( Registered Nurse) or LPN (Licensed Practical nurse) on each shift as well as CNAs (Certified Nursing Assistants) designated for each shift and units. If the facility had any unfulfilled hours, they would use agency although this was not frequently a concern. The schedules designated the charge nurse on each shift. Surveyor conducted a review of the facility's Assessment Tool, last reviewed/ updated 2/16/26 ;The facility uses the (name of) Payroll System) which is a time collection system used by hourly and salaried employees. (It) is a fully integrated system that assists the facility in better management of employee time, costs, and performance. Staffing: RN (registered nurse), LPN (licensed practical nurse), LVN (licensed vocational nurse) providing direct care. DON (Director of Nursing): 1 DON RN full time days. ADON (Assistant Director of Nursing) : 1 ADON full-time. UM (Unit Manager): 1 full time days. Wound Nurse: 1 full time days. RN or LPN Charge Nurse- 1 each shift. Direct Care Staff: Direct care staff is calculated based upon acuity of resident needs and ADL (activities of daily living) index scored; flexibility is allowed due to the nature of admissions and discharges for short term and long-term care resident needs reflected in the activities of daily living index reflected on the MDS (Minimum Data Set). Staffing is adjusted based on resident clinical needs.On 04/22/2026 at 9:56 AM , Surveyor interviewed Scheduler-M who has been in this position since December 2025. Scheduler-M stated that she makes the schedule the same for the weekends as during the week. If there is a call-in, they will send out a message for staff to help and a bonus is offered. Scheduler-M stated that she will also help as she is a Certified Nursing Assistant. Scheduler-M stated that the facility will also use agency staffing for last-minute call-ins. Scheduler-M stated that she does not know why the report would indicate there is low weekend staffing. On 4/22/26 at 11:00AM, Surveyor interviewed Administrator- A and Regional Nurse-L regarding the submission of information to the Payroll Based Journal. Administrator- A and Regional Nurse-L stated that this is done at the corporate level and would provide the telephone number for who to talk with.On 4/22/26 at 2:31PM, Surveyor interviewed Director of Acquisitions (Corporate) - K regarding the submission of the Payroll Based Journal information. Director of Acquisitions- K stated that he does not personally submit the information but does review ahead of time. He stated that he felt the staffing was on par with what is required and would need to do a deeper dive into the submissions to find out where the error may have occurred.As of the time of exit, the facility was not able to provide additional information regarding the inaccurate submission of staffing information triggering excessively low weekends from October 1- December 31, 2025.

Based on interview and record review, the facility did not ensure Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) forms were provided in writing and signed for 2 (R2 and R88) of 3 residents reviewed for notification. *R2's Guardian was not given the SNF ABN notice and the NOMNC was not signed before Medicare coverage ended. *R88 did not have a signed SNF ABN or NOMNC before Medicare coverage ended. Findings include: The SNF ABN notice documents: Medicare does not pay for everything, even some care that you or your healthcare provider think you need. The skilled Nursing Facility (SNF) or its Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. Beginning on (insert date), you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The notice provides three options which the resident or resident representative must select one: continue daily skilled services, bill to Medicare, and the resident can appeal to Medicare; continue daily skilled services the resident had been receiving but do not bill Medicare and the resident will be responsible for payment; or do not continue with the care the resident had been receiving and Medicare Part B may cover some of the care for which the resident will be responsible for paying. Signing below means that you have received and understand this notice. You will also get a copy for your records. *If a representative signs for the patient, write '(rep)' or '(representative)' next to the signature. If the representative's signature is not clearly legible, the representative's name must be printed. The NOMNC notice documents: You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continue during the appeal. The notice provides directions on how to request an appeal by providing step by step instructions. The second page of the notice has instructions for providing the information over the phone. Telephone delivery does not require a representative's signature and should only occur when the member is unable to understand the NOMNC and the representative is not available to sing in person. A copy of the annotated NOMNC should be mailed to the representative the day telephone contact is made and a dated copy should be placed in the member's medical file. The following section is to be completed by the provider delivering the NOMNC by telephone. The section contains who delivered the information with title, date and time of call, who was spoken to, their telephone number, their relation to the resident, the last covered date of services, instructions on how to file an appeal, and the date the notice is mailed to the representative which should be the same day the phone call was made. 1.) R2's last covered day of Medicare services was 2/13/2026. No SNF ABN notice was provided to R2 or R2's Guardian and the NOMNC telephone delivery section was completed by Business Office Manager (BOM)-E with a blank line where the date the notice was mailed to the representative. In an interview on 4/22/2026 at 1:31 PM, Surveyor asked BOM-E why R2 did not have a SNF ABN notice and if R2's Guardian was mailed a copy of the NOMNC. BOM-E stated R2 had a Guardian through (name of organization) and they will not appeal the Medicare benefit because the resident will go back to Medicaid payment, so BOM-E did not provide the SNF ABN notice. BOM-E stated BOM-E asks if BOM-E can mail the NOMNC and most times the Guardian or Power of Attorney will not want them mailed so BOM-E does not mail them. 2.) R88's last covered day of Medicare services was 1/25/2026. The SNF ABN notice had handwritten notation by Business Office Manager (BOM)-E that the information on the notice was provided over the phone to R88's activated Power of Attorney (POA) and R88's POA had no concerns. R88's POA did not select one of the three options that was required and there was no signature on the form by R88's POA. R88's NOMNC telephone delivery section was completed by BOM-E with a blank line where the date the notice was mailed to the representative. In an interview on 4/22/2026 at 1:31 PM, Surveyor asked BOM-E why R88's SNF ABN was not signed or have an election of appeal and if R88's NOMNC was mailed to R88's POA. BOM-E stated R88's POA never came in so the notices were not signed. BOM-E stated BOM-E called R88's POA and documented everything but did not get a signature. BOM-E stated BOM-E asks if BOM-E can mail the NOMNC and most times the Guardian or Power of Attorney will not want them mailed so BOM-E does not mail them. On 4/22/2026 at 2:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R2 and R88 did not have signed or mailed SNF ABN or NOMNC notices. NHA-A stated they will have to look into having a process to address the beneficiary notices.

Based on interview and record review, the facility did not ensure proper notification was sent to the State Long-Term Care Ombudsman for 3 (R7, R19, R45) of 8 residents reviewed for transfers or discharges. R7 was transferred from the facility to the hospital on 2/27/26 and 3/8/26, R19 was transferred from the facility to the hospital on [DATE], and R45 was transferred from the facility to the hospital on 3/26/26. The facility was unable to provide evidence the State Long-Term Care Ombudsman was notified in a timely manner of R7's, R19's, or R45's transfers to the hospital. Findings include: 1.) R19 admitted to the facility on [DATE] and had an activated power of attorney (POA) for healthcare decisions. Surveyor reviewed R19's electronic health record (EHR) and located a nursing progress note dated 12/30/25 which documented R19 had critical labs and R19 was sent out to the hospital. R19 was admitted to the hospital with hyperkalemia, acute kidney injury, and acute cystitis with hematuria. R19 returned to the facility on 1/5/26. Surveyor reviewed the list the facility emailed to the State Long-Term Care Ombudsman with notification of residents who transferred or discharged from the facility between the dates of 12/1/25 and 1/7/26 and did not locate R19's hospitalization from 12/30/25 on the list. On 4/21/26 at 3:13 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A that Surveyor was unable to locate evidence the Ombudsman was notified of R19's hospitalization on 12/30/25. NHA-A stated NHA-A would look into it. On 4/22/26 at 8:09 AM, NHA-A stated the wrong reports were being pulled and sent to the Ombudsman and did not include all residents that went out to the hospital. NHA-A fixed the report and now the report includes all residents who have been sent to the hospital. NHA-A stated NHA-A will send the updated reports from the last 6 months to the Ombudsman so that the Ombudsman has accurate information. 2.) R45 admitted to the facility on [DATE] and made their own healthcare decisions. Surveyor reviewed R45's electronic health record (EHR) and located a nursing progress note dated 3/25/26 which documented R45 had abnormal vital signs and a low oxygen level and R45 was sent out to the hospital. R45 was admitted to the hospital with hypokalemia and respiratory failure. R45 returned to the facility on 3/30/26. Surveyor reviewed the list the facility emailed to the State Long-Term Care Ombudsman with notification of residents who transferred or discharged from the facility between the dates of 3/1/26 and 4/7/26 and did not locate R45's hospitalization from 3/25/26 on the list. On 4/21/26 at 3:13 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A that Surveyor was unable to locate evidence the Ombudsman was notified of R45's hospitalization on 3/25/26. NHA-A stated NHA-A would look into it. On 4/22/26 at 8:09 AM, NHA-A stated the wrong reports were being pulled and sent to the Ombudsman and did not include all residents that went out to the hospital. NHA-A fixed the report and now the report includes all residents who have been sent to the hospital. NHA-A stated NHA-A will send the updated reports from the last 6 months to the Ombudsman so that the Ombudsman has accurate information. 3.) On 2/27/2026, R7 was admitted to the hospital for hyperkalemia and a fistula problem (the fistula is the port for dialysis). R7 was readmitted to the facility on [DATE]. On 3/8/2026, R7 was admitted to the hospital for a clogged fistula. R7 was readmitted to the facility on [DATE]. A review of the resident list of discharges that was provided to the Ombudsman did not have R5 listed for the month of February 2026 or March 2026. On 4/21/2026 at 3:09 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R5 was not on the resident list of discharges that was provided to the Ombudsman. NHA-A stated NHA-A would look into why R5 was not on the list because R5 should have been. On 4/22/2026 at 8:09 AM, NHA-A stated NHA-A had been pulling the wrong report to send to the Ombudsman; the list did not include all the residents that went out to the hospital. NHA-A stated NHA-A has gotten clarification on how to pull the report and it now does include all residents.

Based on observation, record review and staff interviews, the facility did not ensure they provided the appropriate treatment and services to 3 out of 4 ( R26, R5, R86) residents reviewed for the development of pressure injuries. R26 was admitted to the facility with a pressure injury to the buttocks. The facility did not complete a comprehensive assessment of the pressure injury upon admission and did not obtain an order for treatment of the pressure injury until 2 days after the admission. R5 was readmitted to the facility after a hospital admission and R5's Stage 4 pressure injury was not comprehensively assessed on the day of readmission. R86 was readmitted to the facility on [DATE] following a hospitalization and the facility did not complete a comprehensive assessment of R86's skin until 6/2/26. Findings include: The facility's policy dated as revised 1/23/26 and titled Pressure Injury Prevention and Management documents: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure injury/injury, prevent infection and the development of additional pressure injuries/injuries. Policy Explanation and Compliance Guidelines(includes) :2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions; and modifying the interventions as appropriate. c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury, Findings will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor pain, tissue type in the wound bed) and treatment and interventions implemented. 1.) R26 was admitted on [DATE] with diagnoses that included Hypertension, acute respiratory failure, Diabetes Mellitus type II and Pneumonia. R26's nursing note dated 4/11/2026 at 7:05 PM and written by Licensed Practical Nurse (LPN)- I documents: (R26) recently admitted w (with)/rehab and strengthening d/t (due to) generalized weakness and deconditioning r/t AMS (altered mental status), hypoxia, tachypneic w/ tachycardia requiring intubation IV (intravenous) [NAME] (antibiotics) and vasopressor therapy. After transferred out of ICU (intensive care unit) pt (patient) found unresponsive w/ mult (multiple) acute infarcts. Alert and oriented; able to make needs known. Skin warm dry w/ adequate turgor. No tenting, dry oral mucosa or obvious signs of dehydration. Dressing to buttocks CDI (clean, dry, intact). Some swelling to bilat (bilateral) upper thighs. No BLE (bilateral lower extremity) edema. INC of B&B (incontinent of bowel and bladder). Requires extensive assist w/repositioning, cares and transfers x2 (2 staff) w/lift. Appetite good; eating 75% of dinner. Currently no indications or c/o (complaints of) increased pain or discomfort. All safety precautions in place per POC (plan of care). PMD (primary medical doctor) updated and all orders verified. Will cont. (continue) to eval (evaluate) and anticipate pt needs. R26's Advanced Clinical admission Assessment, dated 4/11/26 at 7:55 PM documents: (R26) has a skin issue- location: coccyx. Laterality/ Orientation: Medial. Issue type: pressure. Progress: stable. previously deteriorating wound characteristics plateaued. Pressure injury staging: Stage 3 - full thickness skin loss. Wound was present on admission. Length 3.6 cm x 3.4 cm width and 0 undermining. There are no additional characteristics, tissue type, or wound bed details documented. Surveyor reviewed the discharge summary from the hospital dated 4/11/26. Surveyor noted that there were no instructions regarding the care and treatment of a coccyx pressure wound. The hospital problem list did not include R26 having a pressure injury to the coccyx and the discharge medication list did not include any type of treatments for R26. R26's Braden Skin assessment dated [DATE] (assessed the risk of developing a pressure injury) documents a score was 15 points, indicating R26 is at risk for pressure injuries.R26 has potential for impairment to skin integrity r/t (related to) decreased mobility documents: admission: Unstageable; bilateral buttocks Date Initiated: 04/11/2026.The resident will remain free of new skin impairment through the review date. Date Initiated: 04/14/2026.Under the Interventions section it documents: Air Mattress; set to weight and/or comfort level. Initiated: 04/11/2026Monitor skin when providing cares, notify nurse of any changes in skin appearance. Date Initiated: 04/11/2026Use wedge to improve positioning. Date Initiated: 04/11/2026Wheelchair pressure reduction cushion. Date Initiated: 04/11/2026Encourage resident to wear bilateral heel boots when in bed. Date Initiated: 04/18/2026Encourage that heels are elevated while resident is lying in bed. Date initiated: 4/11/26 R26's nursing note dated 4/13/2026 at 08:00; AM documents: Skin Check Skin: Skin warm & dry, skin color WNL and turgor is normal. R26 does not have an external device. Foot evaluation completed. Skin Issues: Skin Issue: 001: New skin Issue. Location: Buttocks - generalized. Laterality / Orientation: Right. Laterality / Orientation: Left. Additional location information: bilateral buttocks (medial) Issue type: Pressure injury / injury. Progress: New: new wound. Pressure injury staging: Unstageable pressure injury / injury. Unstageable injury due to slough and / or eschar. Wound was present on admission. Staged by: In-house nursing. Length (cm): 3.6 Width (cm): 3.4 Depth (cm): 0. Skin Issue: #002: New skin Issue. Location: Front left thigh. Issue type: Other skin issue. Other skin issue description: scabs Progress: New: new wound. Wound was present on admission. R26's physician order dated 4/13/25 at 8:15 AM documents: Buttocks: Cleanse bilateral buttocks with NS, apply xeroform and bordered gauze everyday shift for wound care AND as needed for wound care. R26's physician order dated 4/13/26 at 2:00 PM documents: Monitor bilateral buttocks for changes in skin alteration, report changes to provider every shift for wound care. Surveyor conducted a review of the Treatment Administration Record for April 2026. Surveyor noted that there was no physician order for the treatment of the pressure injury to R26's buttocks until 4/13/26, or two days after R26 was admitted . Surveyor also noted that there was no documentation in R26's TAR for April 2026 that treatment was provided to R26's pressure injury until 4/14/26, or three days after R26 was readmitted to the facility. R26's nursing note dated 4/15/2026 at 11:40 AM documents: Adv - Skin Issues: Skin Issue: #001: Skin issue has been evaluated. Location: Buttocks - generalized. Laterality / Orientation: Left. Laterality / Orientation: Right. Additional location information: bilateral buttocks (medial) Issue type: Pressure injury / injury. Progress: Improving: overall wound characteristics improved. Length (cm): 4.17 Width (cm): 4.53 Depth (cm): 0 Area (cm2): 10.48 Undermining: No. Tunneling: No. Odor after cleansing: None. Surrounding tissue: Intact. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Minimal < 25%. On 4/16/26, R26 had an initial assessment with the Wound Physician. The following was documented: presents with wounds on her/ his left buttock, right buttock and left anterior thigh. Left Buttock-unstageable /necrosis. Present less than 1 day. Measures 6 x 4 x 0.1 cm with a surface area of 24 centimeters. 80% necrotic tissue and 20% granulation tissue. No pain is present and no signs of infection. Treatment: xeroform gauze apply once daily and as needed if saturated soiled or dislodged. Gauze island with border apply once daily and as needed. Debridement procedure. Right Buttock- unstageable due to necrosis. Present less than 1 day. Measures 4 cm x 4 cm x 0.1 cm. Surface area- 16 cm. 80 % necrotic tissue and 20 % granulation tissue. No pain and no signs of infection. Debridement procedure. Treatment same as above. On 4/22/26 at 9:20 AM, Surveyor interviewed DON (Director of Nursing)-B regarding R26 being admitted on [DATE] with a pressure injury to the buttocks. Surveyor asked DON- B about the facility not conducting a comprehensive assessment of the wound on 4/11/26 and also not obtaining a treatment order. DON- B stated that R26's room was already set up for R26's arrival and an air-mattress was in place for R26. DON-B stated that the nurse who admitted R26 to the facility observed a treatment in place on R26's buttocks when completing the head-to-toe assessment. DON- B stated that the nurse removed the dressing and measured the area and then replaced the dressing with a new/clean treatment that R26 had in place upon his arrival to the facility. Surveyor asked DON- B how the nurse knew what treatment was in place prior. DON- B stated that the nurse replaced it with the equivalent in what was in place prior. DON- B stated that typically staff would be expected to call the Doctor/ Nurse Practitioner and either get clarification for a treatment or get a new order for a treatment when a wound is observed. DON- B stated that because there was a dressing in place from the hospital, the nurse just put the same type of dressing back in its place. DON- B also stated that the dressing can be in place for up to 72 hours and this is how long it was going to be before the facility's wound nurse was going to assess the pressure injury. On 4/22/26 at 11:25 AM, Surveyor interviewed Wound Nurse- C regarding R26's pressure injury to the buttocks. Surveyor asked Wound RN- C if a Registered Nurse has assessed R26's pressure injury upon admission on [DATE]. Wound RN- C stated that LPN-I assessed R26 and provided a measurement and staged the area. Wound RN- C stated that the RN on duty probably had other residents to take care of and she was not available to assess R26 on 4/11/26. Wound RN- C stated she told LPN- I to just put a new dressing on and she would assess it on Monday 4/13/26 when she returned to work. On 4/22/26 at 2:12 PM, Surveyor interviewed LPN- I regarding R26's admission on [DATE] and the assessment of the pressure injury to the buttocks. LPN- I stated that she was conducting a head-to-toe assessment of R26 and when the Certified Nursing Assistant and herself turned R26 over she noticed a dressing to R26's buttocks. LPN- I stated that there was nothing in the hospital paperwork that documented R26 had a pressure injury upon discharge from the hospital. LPN- I stated she took the dressing off and cleaned the area. LPN- I stated she then got her measuring tool and measured the area. LPN- I stated that she has been a nurse for 20 years and is familiar with pressure injuries. LPN- I stated she cleansed the wound with normal saline, patted it dry and applied a border gauze because that was what was in place prior. Surveyor asked LPN- I if she had called the Physician or Nurse Practitioner to obtain an order for treatment because there was no order in the hospital paperwork. LPN- I stated that she does not recall if she spoke with Nurse Practitioner or the Physician to get an order. LPN- I stated she had a lot of admissions that day and was very busy. LPN-I stated that she doesn't remember if she asked the Registered Nurse who was also working that shift to assess the area. Surveyor noted that R26's pressure injury did not have a comprehensive RN assessment upon admission and the facility did not document a physician order for treatment of the pressure injury until 4/13/26, or two days after R26 was readmitted to the facility. Despite this, Surveyor noted that R26's pressure injury remained consistent in size and staging. No additional information was provided. 2.) R5 was admitted to the facility on [DATE] with diagnoses of paraplegia, diabetes, chronic pancreatitis, schizophrenia, and chronic obstructive pulmonary disease. R5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R5 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and needed maximum to total assistance with activities of daily living. R5 developed a pressure injury to the left gluteal fold on 4/23/2025. On 7/2/2025 at 11:44 AM in the progress notes, nursing documented R5 was sent to the hospital for evaluation and treatment of the left gluteal fold wound which showed signs of infection with increased pain and foul-smelling drainage. R5 was agreeable to go out and be evaluated. R5 was noted to be non-compliant with offloading which is likely contributing largely to the decline in R5's wound. R5 was continually educated on the importance of offloading and proper nutrition. On 7/11/2025, R5 was readmitted to the facility. On the Nursing Evaluation form, Licensed Practical Nurse (LPN)-G documented in the Skin Integrity section R5 had a decubitus ulcer to the left buttock. No measurements or wound characteristics were documented. On 7/14/2025, R5's left gluteal fold Stage 4 pressure injury was comprehensively assessed by the facility wound Registered Nurse (RN), three days after readmission. On 8/21/2025 at 7:20 AM in the progress notes, nursing documented R5 was using accessory muscles to breathe, and breathing was labored. R5's oxygenation on 3 liters of oxygen was 88%. The nurse increased the oxygen to 10 liters and R5's oxygenation increased to 95-98%. R5 was not arousable with sternal rub prior to the increase in oxygen administration and after the oxygenation increased, R5 was arousable but unable to open eyes. R5's abdomen was distended with no bowel sounds present. R5 was sent to the hospital for evaluation and treatment. On 8/30/2025, R5 was readmitted to the facility. On the Nursing Evaluation form, an LPN documented in the Skin Integrity section R5 had a wound to the left gluteal fold. The LPN documented at 5:11 PM in the progress notes R5 had a wound to the left buttock that measured approximately 4 cm x 3 cm x 6 cm with no drainage and the wound base was beefy red. Surveyor noted the pressure injury was not comprehensively assessed by an RN. On 9/3/2025, R5's left gluteal fold Stage 4 pressure injury was comprehensively assessed by the facility wound RN, four days after readmission. On 9/29/2025, R5 was transferred to the hospital for evaluation and treatment for septic shock. On 10/7/2025, R5 was readmitted to the facility. On the Nursing Evaluation form, an RN documented in the Skin Integrity section R5 had a Stage 4 pressure injury to the left buttock. No measurements or wound characteristics were documented. On 10/8/2025, R5's left gluteal fold Stage 4 pressure injury was comprehensively assessed by the facility wound RN, one day after readmission. On 10/26/2025 at 12:32 PM in the progress notes, nursing documented R5 was being sent to the hospital for evaluation and treatment of a possible bowel obstruction. On 11/2/2025, R5 was readmitted to the facility. On the Nursing Evaluation form, an LPN documented in the Skin Integrity section R5 had a Stage 4 pressure injury to the left gluteal fold. No measurements or wound characteristics were documented. On 11/5/2025, R5's left gluteal fold Stage 4 pressure injury was comprehensively assessed by the facility wound RN, three days after readmission. On 4/20/2026 at 10:03 AM, Surveyor observed R5 lying in bed on an air mattress. Surveyor asked R5 if R5 had any open areas on the skin or any wounds. R5 stated R5 had a wound on the bottom, and it was R5's fault there was a wound there because R5 sits too long in the wheelchair. R5 stated the wound has slowly been getting better after going to the hospital where it was debrided. R5 stated the facility staff changes the dressing daily to the wound. On 4/21/2026 at 10:05 AM, Surveyor observed Wound RN-C assisted by Certified Nursing Assistant (CNA)-D complete the treatment to R5's left gluteal fold Stage 4 pressure injury. Wound RN-C stated Wound RN-C had been working for the facility for a little over a month so did not know the progression of R5's pressure injury. Wound RN-C stated R5 was not compliant but has become much more compliant recently. Wound RN-C thought R5 understands the problem of sitting up in the chair for so long is what is causing the wound to not heal, but R5 is a smoker so Wound RN-C stated the facility has to accommodate R5's wishes as well. In an interview on 4/22/2026 at 9:19 AM, Surveyor asked Director of Nursing (DON)-B what the process was for a newly admitted or readmitted resident that has a skin concern. DON-B stated the nurse on the floor puts the location of the wound in the charting and then the wound nurse will follow up on the resident during weekly wound rounds. DON-B stated the nurses had been documenting a wound as a pressure injury when it is a venous ulcer so the nurses have been instructed to just put the location of the wound on the form and then the wound nurse along with the wound physician would document the etiology of the wound so it was not entered in wrong the first time. Surveyor shared with DON-B the concern R5 was admitted to the hospital four times in the last year with a pressure injury and on readmission to the facility, the wound is not comprehensively assessed for up to four days after readmission. Surveyor shared the concern that without documentation on the day of readmission, the progression of the wound cannot be followed to know if it is improving or declining. DON-B agreed stating the system is broken. On 4/22/2026 at 1:37 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R5's Stage 4 pressure injury was not comprehensively assessed on four readmissions until one to four days after readmission. No further information was provided at that time. 3.) R86 was admitted to the facility on [DATE] with diagnoses that included hypertension, cerebral infarction with right side hemiplegia, aphasia and dysphagia. R86's Minimum Data Set (MDS) dated [DATE] documents that R86 was assessed to be severely cognitively impaired and dependent with activities of daily living (ADL). The MDS also documents that R86 was assessed to be incontinent of bladder and bowel. R86's Care Assessment Area (CAA) dated 5/10/25 documents: R86 has decreased mobility requiring assistance for her mobility and repositioning which is a contributing issue for potential pressure ulcer development in addition to incontinence issue due to exposure of skin to moisture. (R86) is s/p (status post) hospitalization due to right hemiparesis and aphasia effected by left cerebral infaction resulting to generalized weakness and a decline in her functional status.Heels off bed, incontinence care and skin checks will be maintained per facility's protocol. R86's care plan dated 5/7/25 documents potential for skin impairment with an intervention of -Monitor skin when providing cares, notify nurse of any changes in skin appearance. R86's treatment administration record (TAR) for May 2025 documents reposition every 2 hours with start date of 5/7/25. The TAR also documents skin checks completed every Tuesday and Friday. R86's nurses note dated 5/23/25 documents: R86 developed a new open area to the coccyx. R86's Wound MD-H assessment dated [DATE] documents: pressure injury to the sacrum that presents as deep tissue injury (DTI) measuring 12 centimeters (cm) by 7 cm by 0.1 cm. A treatment was ordered for leptospermum honey applied to wound with foam bordered dressing three times a week. R86's nurses note dated 5/26/25 documents: R86 fell out of bed and was sent to the hospital. R86's hospital record dated 5/26/25 documents: R86 sacrum wound as unstageable measuring 10 cm by 4 cm with 10% slough. There is no further documentation from the hospital regarding R86 pressure injury R86 was readmitted to the facility on [DATE] with a readmission physician treatment order that documented: Medihoney with foam bordered dressing to be changed Monday, Wednesday and Friday. Surveyor was unable to locate a comprehensive wound assessment for R86's sacrum unstageable pressure injury that was completed on 5/31/25 when R86 was readmitted to the facility. The facility completed a skin and wound evaluation dated 6/2/25 which documents: R86 sacrum pressure injury is unstageable measuring 13.3 cm by 10.3 cm with 100% slough. Surrounding tissue presents as denunded and erythema. It documents R86 was readmitted from the hospital with her wound to her sacrum substantially deteriorated. R86's care plan documents dated 6/2/25 documents air mattress implemented along with repositioning every 2 hours. R86's nurses note dated 6/2/25 documents: R86 had been refusing to eat and was pocketing crushed medications. R86's Power of attorney (POA) and Nurse practitioner (NP) were made aware. Discussion with R86's POA regarding R86 DNR status and R86 not eating and drinking was conducted. R86's POA was educated on the importance of nutrition and tube feeding was discussed. R86 POA stated R86 did not wish to have a feeding tube. R86's Wound MD-H assessment dated [DATE] documents: R86 sacrum pressure injury as unstageable necrosis measuring 10 cm by 5 cm by 0.1 cm. The assessment also documents (R86) requiring an increase in the level of care. Doxycycline 100 mg (milligrams) po (by mouth) X 14 days, probiotic 2 tabs daily for 30 days for cellulitis. The treatment was changed to cleanse with dakins 1/2 strength and apply alginate calcium followed by foam bordered dressing twice daily. Wound MD-H assessment dated [DATE] documents: R86 sacrum pressure injury as stage 4 measuring 10 cm by 5 cm by 6 cm with 100% necrotic tissue. Wound MD-H documents (R86) requiring an increase in the level of care. Recommendation ER for further evaluation and/or for debridement. The nurses note dated 6/13/25 documents R86 was sent to the hospital for evaluation of the sacrum wound. R86 did not return to the facility after this hospitalization. The hospital record dated 6/13/25 documents WBC (white blood cell) elevated to 23. Lactic acid elevated. Concerns for sepsis. Fluids ordered. Will start broad spectrum antibiotics. On 4/22/26 at 9:22 a.m. Surveyor interviewed DON-B. Surveyor explained to DON-B when R86 was readmitted to the facility on [DATE], a comprehensive wound assessment was not completed. A wound assessment was completed on 6/2/25. DON-B stated the wound nurse that was here while R86 was at the facility no longer works for the facility and DON-B can't answer why an assessment wasn't completed on 5/31/25. Surveyor asked DON-B what contributed to R86 wound deteriorating to the point of needing antibiotics. DON-B stated R86 had a poor appetite and R86's family did not want R86 to have a feeding tube. On 4/22/26 at 9:33 a.m. Surveyor interviewed Wound MD-H. Surveyor asked Wound MD-H what contributed to R86 pressure injury to deteriorate. Wound MD-H stated when R86 returned from the hospitalization on 5/26-5/31/25, R86 wound was brewing an infection deep internally but because they couldn't see the wound base due to the necrotic tissue, it was presenting as cellulitis and the antibiotic was not helping. Wound MD-H stated he recommended R86 be sent to the hospital on 6/13/25 because he could not debride the wound enough at bedside and R86 would need surgical debridement to treat whatever infection was underneath it. Wound MD-H stated he had no concerns with R86 being repositioned and interventions were in place to aid in healing of the pressure injury. On 4/22/26 at 11:19 a.m. Surveyor explained to NHA-A the concern R86 was readmitted to the facility on [DATE] and a comprehensive wound assessment was not completed until 6/2/25.

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 1 (R45) of 3 residents observed receiving care while on enhanced barrier precautions. During the observation of catheter care for R45, registered nurse (RN)-F did not wear a gown when enhanced barrier precautions (EBP) were in place for R45.Findings include:The facility's policy titled Enhanced Barrier Precautions with implemented date 1/13/23 and revised date 1/26/26 documents: . It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. An order for enhanced barrier precautions will be obtained for residents with any of the following: . indwelling medical devices (e.g., . urinary catheters.) even if the resident is not known to be infected or colonized with a MDRO. PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include: . device care or use: . urinary catheters . Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until . discontinuation of the indwelling medical device that placed them at higher risk. R45 admitted to the facility 1/27/25. R45's quarterly Minimum Data Set (MDS) dated [DATE] documents R45 has an indwelling urinary catheter. R45's indwelling catheter care plan documents the following interventions with an implemented date of 4/18/25:-check tubing for kinks each shift-monitor and document output-monitor for signs/symptoms of discomfort on urination and frequency-monitor/document for pain/discomfort due to catheter-monitor/record/report to doctor for signs/symptoms of urinary tract infection (UTI)R45's physician order dated 7/24/25 documents foley catheter output every shift. R45's physician order dated 5/29/25 documents enhanced barrier precautions due to indwelling catheter and history of MDRO (multi-drug resistant organism) every shift. On 4/20/26 at 9:44 AM, Surveyor observed an Enhanced Barrier Precautions sign posted on R45's door. The sign documents: . Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities. device care or use: . urinary catheter .On 4/22/26 at 8:36 AM, Surveyor observed RN-F complete catheter care for R45. Surveyor observed RN-F complete the process of emptying R45's catheter without donning a gown. On 4/22/26 at 8:39 AM, Surveyor shared concern with RN-F that Surveyor did not observe RN-F wear a gown while providing catheter cares to R45. RN-F stated yes RN-F should have worn a gown and RN-F does not usually care for R45, so the EBP sign must be new. In an interview on 4/22/26 at 8:41 AM with Director of Nursing (DON)-B, DON-B stated all residents with a catheter should be on enhanced barrier precautions, and staff should follow the EBP sign to know what PPE staff should wear when performing cares. DON-B stated staff should wear a gown and gloves when performing catheter cares. Surveyor shared concern with DON-B that Surveyor observed RN-F perform catheter cares for R45 without wearing a gown. DON-B stated RN-F would be educated. On 4/22/26 at 1:26 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A that Surveyor observed RN-F complete catheter cares for R45 without wearing a gown. No additional information was provided.

Based on observation, record review, interview, and facility policy review, the facility failed to maintain infection prevention practices during medication administration for six of six residents (Resident (R) 4, R5, R10, R11, R13, and R15) observed. Two nurses observed placed residents' medications and medical devices on surfaces without cleaning them, failed to clean shared equipment and failed to appropriately put on (don) and doff (remove) personal protective equipment. These deficient practices had the potential to place residents at risk for the spread of infection and cross-contamination and created a risk for an increased potential for infections compromising the health and safety of residents. Findings include:1. Review of R4's Face Sheet provided by the facility revealed R4 was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis that included but not limited to diabetes mellitus due to underlying conditions with diabetic neuropathy. Review of R5's Face Sheet provided by the facility revealed that R5 was admitted to the facility on [DATE] with a diagnosis that included but not limited to heart failure and unspecified asthma.During an observation and interview on 10/01/25 at 4:52 PM, Licensed Practical Nurse (LPN) 1 performed vital checks and administered scheduled medications to R4 and R5 in their shared room. LPN1 performed vital checks i.e. blood pressure and pulse oximeters on R5. Once finished with R5, LPN1 performed vital checks for R4 and applied eye drops to both of R4's eyes. LPN1 failed to don and doff personal protective equipment (PPE) between providing care to the residents. LPN1 returned to the medication cart located in the hall adjacent to the room and attempted to discreetly return R4's white and grey glucometer (a device used to check blood sugar readings) to the medication cart. LPN1 stated staff are to wear gloves during care and perform and hygiene and sanitize the equipment between residents. LPN1 confirmed she did not follow procedure for R4's glucometer, she stated no, I am supposed to wipe it down. LPN1 proceeded to obtain a germicide wipe from the top of the medication cart and quickly wiped the glucometer and returned it to the medication cart, contact time the item must remain wet was not met. Review of the Clorox healthcare bleach germicidal wipes formula container revealed the contact time was 3 minutes.2. Review of R10's Face Sheet provided by the facility revealed R10 was admitted to the facility on [DATE] with a diagnosis that included but not limited to type 2 diabetes.Review of R11's Face Sheet provided by the facility revealed R11 was admitted to the facility on [DATE] with a diagnosis that included but not limited to Type 2 diabetes.Review of R13's Face Sheet provided by the facility revealed R13 was admitted to the facility on [DATE] with a diagnosis that included but not limited to Type 2 diabetes.Review of R15's Face Sheet provided by the facility revealed R15 was admitted to the facility on [DATE] and re-admit on 04/27/25 with a diagnosis that included but not limited to Type 2 diabetes.During an observation on 10/02/25 at 4:13 PM, Registered Nurse (RN) 2 administered afternoon medications on the Rehabilitation unit to R10, R11, R13 and R15. RN2 retrieved and placed a clear plastic container identified as R10's on top of the medication cart. The container housed a glucometer and an insulin pen. RN2 opened the plastic container, removed the glucometer and placed it on to the bare medication cart. RN2 preceded to retrieve a glucometer test strip and lancet, placing both items next to the glucometer. RN2 performed hand hygiene protocol, placed gloves onto her hands, and preceded to the common area where R10 was watching television. RN2 placed the glucometer reader onto a bare table adjacent to where R10 was sitting and performed a blood sugar check. RN2 returned to the medication cart, removed one glove from her right hand, retrieved the Humalog (insulin for diabetes) pen from the plastic container, placed the pen onto the cart. RN2 retrieved a covered needle from the cart, secured it to the pen, placing back on the cart, removed the glove from her left hand, applied sanitizer to her hands and donned a clean pair of gloves. RN2 retrieved R10 from the common area and wheeled him into his room. RN2 exited R10's room, retrieved the insulin pen, returned to the room and administered his insulin. RN2 exited the resident's room, doffed her gloves, and disposed of them in the trash can located on the medication cart. RN2 failed to perform hand hygiene after doffing her gloves. During this same medication pass, RN2 retrieved R11's clear plastic container from the medication cart, sanitized her hands and donned a pair of gloves. She opened R11's plastic container which contained his insulin pen and glucometer placing on to the cart. RN2 retrieved the lancet and placed it on the glucometer gathering the resident's glucometer, test strip, and lancet she preceded to the resident's room. Once in R11's room, RN2 placed the glucometer, strip, and lancet on to the resident's bare bedside table. RN2 performed a blood sugar check, exited the room, doffed her gloves, retrieved R11's insulin pen secured the needle to the pen, placed it on the cart. RN2 sanitized her hands and donned a pair of gloves then returned to R11's room, she administered his insulin, exited the resident's room, and doffed her gloves disposing of the gloves in the trash can on the medication cart. RN2 did not perform hand hygiene after doffing her gloves. During this same medication pass, RN2 retrieved R13's glucometer and test strip placing them on the bare cart. Leaving the resident's medication on the cart, proceeded to R13's room, placed the glucometer on the bare bedside table, prepped R13's finger and checked his blood sugar. She then exited the room, retrieved a vial of insulin, and realized there were no insulin needles in the cart. Left the cart, proceeded to the medication storage room located behind the nurses' station, returned after a few minutes, and drew two units of insulin. RN2 donned gloves after drawing the insulin and proceeded to the resident's room and administered the medications. Returned to the cart and doffed her gloves in the trash can on the medication cart. RN2 did not perform hand hygiene after doffing her gloves. During this same medication pass, RN2 retrieved and placed R15's glucometer, insulin pen, and glucometer on the bare medication cart. RN2 proceeded to check R15's blood sugar, returned to the cart and retrieved the resident's insulin pen. RN2 returned to the resident's room administer his insulin then returned to the cart and doffed her gloves into the trash can located on the side of the trash can. RN2 did not perform hand hygiene after doffing her gloves. During an interview on 10/03/25 at 2:49 PM, RN2 stated donning and doffing, hand hygiene, and Medication Administration trainings were received annually. RN2 continued to state, I probably have been trained to go from clean to clean and dirty to dirty, and now that I am thinking about it, I broke infection control protocol by placing the resident's medication and glucometers on dirty surfaces. RN2 continued to share personal protective equipment (PPE) should be donned and doffed before exiting a resident's room (not at the medication cart) after touching dirty surfaces, before and after patient care. RN2 further stated, leaving the cart unattended not donning and doffing before and after resident's care and not following hand hygiene protocol was not how she was trained she was in a hurry and rushed through the medication pass, due to having a new admission. During an interview on 10/03/25 at 4:00 PM, the Director of Nursing (DON) revealed the expectation of facility staff was to maintain proper infection control protocols and perform proper hand hygiene before and after performing resident's care. Review of the Center for Disease Control and Prevention website, https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html#cdc_generic_section_9-4-7-noncritical-patient-care-equipment, titled Environmental Cleaning Procedures, under section 4.7 table 26 revealed shared non-critical patient care equipment should be cleaned and disinfected before and after each use. Further review of the CDC guidelines titled Recommended practices in healthcare settings, revealed blood glucose meters whenever possible, assign blood glucose meters to a person and do not share . If blood glucose meters must be shared, the device should be cleaned and disinfected after ever use.Review of the facility policy titled, Infection Prevention and Control Program, dated 07/25/25 revealed under Policy, The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environments to help prevent the development and transmission of communicable diseases and infections per national standards and guidelines. The policy further revealed under Standard Precautions: a. all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care and services, b. Hand hygiene should be performed in accordance with the facility's established hand hygiene procedures, under Equipment Protocol, a. all reusable items and equipment . shall be cleaned or disinfection shall be cleaned .Review of the facility policy titled, Hand Hygiene Guidelines, revised 10/30/23 indicated Hand hygiene continues to be the primary means of preventing the transmission of infections . Perform hand hygiene (Soap, water, ABHR [alcohol-based hand rub]), should be readily available . hand hygiene .

Based on interview and record review the facility did not ensure 1 (R9) of 3 residents were free of significant medication errors.*R9 did not receive 2 doses of R9's ordered medications, carvedilol and tramadol. Eliquis was pulled from the Facility's Omnicell (medication dispenser) for R9 on 5/23/2025. R9 was not prescribed Eliquis, per physician orders. Findings include:The Facility's policy titled Administering Medications, with a revised date of May 2025, documents in part, . 3. Medications [NAME] be administered in accordance with the orders, including any required time frame. The Facility's policy titled Automated Medication Dispensing System (AMDS), with a revision date of 06/03/2025, documents in part . 2. Medications removed from the AMDS must have a corresponding Physician/Prescriber's order. R9 was admitted to the facility on [DATE] with diagnoses which include fracture of right fibula, Cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), heart failure and kidney failure.R9's Comprehensive Assessment, Minimum Data Set (MDS), was not completed prior to R9 expiring. Surveyor reviewed R9's Physician orders and noted the following orders:*Carvedilol Oral Tablet - give 6.25 mg (milligrams) by mouth two times a day for hypertension, with a start date of 05/22/2025. *Tramadol HCl Oral Tablet 50 mg- give 50mg by mouth every morning and at bedtime for pain, with a start date of 05/22/2025.Surveyor reviewed R9's Medication Administration Record (MAR) and Treatment Administration Record (TAR) schedule for May 2025. Surveyor noted R9's Carvedilol and Tramadol are marked as 09 in R9's MAR, on 05/23/2025 at 9 AM; indicating Other / See Nurse Notes, per the documents chart codes. Surveyor reviewed R9's progress notes and noted a Nurse note, dated 05/23/2025, documents R9's Carvedilol and Tramadol were not given due to awaiting pharmacy. Surveyor requested a list of medications that are held in contingency (medications available at and a list of medications dispensed through the Facility's Automated Medication Dispensing System (AMDS) for R9 while at the Facility. The Facility provided document, titled Omni Inventory, documents the Facility has the medications, Carvedilol and Tramadol available in contingency.The Facility provided document, titled Omnicell, Transaction by Patient, with a date range of 05/22/2025 through 05/23/2025, documents R9 had a medication, Eliquis 5mg, dispensed on 05/23/2025, at 7:23 PM, by Licensed Practical Nurse (LPN)-C. Surveyor noted that Eliquis is a prescription blood thinner medication used to prevent and treat blood clots. Surveyor noted R9 does not have an order for Eliquis. Surveyor reviewed possible drug interactions (which occur when another substance changes how a medication works, possibly increasing side effects or changing its effectiveness.) using the website drugs.com interaction checker, for R9's current medications with Eliquis. Surveyor noted 3 of R9's medications would have a moderate interaction, indicating Moderate clinical significance, usually avoid combinations and use under special circumstances. Surveyor noted R9's prescribed aspirin showed to be a major interaction, indicating highly clinically significant, usually avoid combination and the risk of interaction outweighs the benefit. On 07/08/2025, at 09:01 AM, Surveyor informed Director of Nursing (DON)-B of the above concerns. Surveyor asked DON-B why R9's Carvedilol was not pulled from contingency on 05/23/2025. DON-B indicated that the Carvedilol in contingency was not the correct dose as ordered for R9. Surveyor noted the Carvedilol in contingency is 3.125 mg, and R9 could receive 2 to achieve R9's prescribed dosage. DON-B indicated that the physician should have been called the to review. On 07/08/2025, at 10:16 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the above concerns. NHA-A indicated the expectation would be to contact the Director of Nursing, Medical Director or pharmacy and the Physician should have been called for clarification for R9's prescribed medications. On 07/08/2025, at 12:01 PM, Surveyor spoke with LPN-C via phone. LPN-C indicated LPN-C does not recall taking out Eliquis for R9 through the AMDS. On 07/08/2025, at 12:40 PM, Survey informed the Facility of the above concerns. No further information provided at time of write up.

Based on observation, interview, and record review, the facility did not ensure 4 (R1, R2, R5, and R6) of 6 residents reviewed received medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. R1 has a diagnosis of Alzheimer's Disease, alcohol abuse, and impaired cognitive function with behaviors demonstrated upon admission. The facility did not obtain information prior to admission that would have been pertinent to understanding R1's behaviors and how to address them. The facility failed to assess R1's behaviors. The facility did not develop and implement individualized psychosocial interventions to address R1's behavior pattern based on assessments and behavior demonstrated in the facility, thus leaving residents residing in the facility vulnerable and at risk. R2 has a diagnosis of psychosis, vascular dementia, and major depressive disorder with behaviors increasing after admission. The facility failed to assess R2's behaviors. The facility did not develop and implement psychosocial interventions to address R2's behavior pattern based on assessments and behavior demonstrated in the facility, thus leaving residents residing in the facility vulnerable and at risk. Review of R2 indicates as early as 1/12/25, R2 was engaging in aggressive behaviors with other residents in the facility and becoming more difficult to care for. Documentation and interviews with Psychiatric Nurse Practitioner (NP)-H indicated as early as January 2025, the facility was aware of R2's increased behaviors and refusals to take medications. Psychiatry NP-H indicated R2's refusals to take medications, Depakote in particular, would have an impact on R2's dementia symptoms along with his behavior symptoms. R1 and R2 engaged in an altercation that resulted in R1 being sent to the hospital with a subdural hematoma. The facility's failure to assess and treat R1 and R2's behaviors created a finding of Immediate Jeopardy, which began on 1/12/25. The facility failed to assess R1 and R2's needs and social history to determine their trauma background in order to treat and complete resident centered plans of care to provide proper care and address behavior concerns. On 5/12/25, at 3:52 PM, Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Nurse-C, and Corporate Consultant-E were informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on 5/12/25. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) related to the additional example regarding R5 and R6 and as the facility continues to implement its action plan. R5 and R6 engaged in multiple resident to resident altercations starting 4/7/25. The facility did not assess R5 and R6's psychosocial needs following the altercations or assess behavioral changes and needs post altercations. Findings include: 1. Surveyor notes the Facility Assessment documents, the facility may accept residents with dementia, residents who may develop dementia, which may include common diseases such as psychiatric and mood disorders, psychosis with hallucinations and delusions, impaired cognition, mental disorder depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, and behaviors that require interventions. Surveyor reviewed R1 and R2's medical record which documents the following: R1 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R1's diagnoses include seizures, Alzheimer's Disease, alcohol abuse, fall, and laceration to the scalp. R1's Discharge Minimum Data Set (MDS) completed on 4/20/25, documents R1 has severe impaired cognitive concerns, short term memory problems, rejection of care concerns, wandering, physical behaviors, and verbal behaviors. R1 requires substantial/maximal assistance with toileting hygiene, showering, and dressing. R1 is independent with transferring and walking. R1 does not require assistive devices while ambulating and ambulates throughout the facility independently. R1 was documented as having a Brief Interview for Mental Status (BIMS) score of 3, indicating that R1 has severe cognitive impairment. On 5/8/25, at 9:51 AM, Surveyor interviewed Assisted Living Facility (ALF) Executive Director-J, ALF Director of Wellness-K, and ALF Assistant Executive Director-L. ALF Director of Wellness-K indicates R1 resided at the ALF for a couple of years. ALF Director of Wellness-K described R1 with severe dementia, PTSD (Post Traumatic Stress Disorder) related to being in the military, delusions of gunfire that were war related, and experiencing hallucinations. ALF Director of Wellness-K stated R1 will calm down immediately after R1 feels safe. ALF Director of Wellness-K indicated R1 was a modest individual and did not like private parts exposed. R1 was a two person assist with one person providing cares, while the other person would assist with calming R1 down during cares. ALF Director of Wellness-K indicated R1 did not like cares being provided by the opposite sex. ALF Director of Wellness-K stated the facility did not reach out to the ALF and records were not requested by the facility. ALF Director of Wellness-K stated she wished the facility would have reached out to them so she could provide report and history along with interventions that would help with some of R1's behaviors. Surveyor noted the facility did not reach out to R1's previous residence (ALF), who could have provided vital information with R1's care plan, behavior monitoring, and treatment plan. On 5/7/25, at 3:29 PM, Surveyor interviewed Hospice Manager of Clinical Services-M who stated she is familiar with R1 who displays behaviors, refusals of care, and displays behaviors with people of the same sex. Hospice Manager of Clinical Services-M stated her team was the only one that could provide cares to R1 as he was familiar with them. Hospice Manager of Clinical Services-M stated Hospice did a lot of work with R1's psychotropic medications to help manage R1's behaviors. Hospice Manager of Clinical Services-M indicated R1 was prescribed Ativan due to R1 consistently wandering which was part of the reason why R1 would have altercations with the same sex. Hospice Manager of Clinical Services-M stated in the times where R1 could not be redirected, Ativan was administered. Hospice Manager of Clinical Services-M stated the referral for admission to the facility came from the hospital. Hospice Manager of Clinical Services-M stated Hospice does not make those type of referrals and Hospice was told by the hospital, R1 was accepted into the facility. Hospice Manager of Clinical Services-M stated Hospice received a phone call on 4/16/25, indicating R1 was being transferred out of the hospital and into the facility. Hospice Manager of Clinical Services-M indicated R1 was redirectable once you got to know R1. Surveyor noted the facility did not reach out or speak with Hospice prior to accepting R1 into the facility. Surveyor noted Hospice had vital information to help guide R1's plan of care with the potential to decrease behaviors with information and interventions the facility was unaware of. On 5/13/25, at 9:36 AM, surveyor spoke with R1's Activated Power of Attorney (APOA) who reported R1 had many behaviors while living at his previous residence, at the ALF. R1 displayed behaviors that were both verbal and physical with other residents while living at the ALF. R1's APOA stated the facility must have accepted R1 blindly because the admission happened so fast and other facilities typically did not accept R1 after interviewing R1. R1's APOA indicated the facility must have accepted him without performing an interview and the facility must not have talked with the nurses at the hospital. R1's APOA indicated R1 has significant PTSD due to training in war and being in the [NAME] Corps. R1 also served time in prison back in 1976. R1 also has a history with alcohol and drug abuse with most recent use approximately two years ago. R1's APOA indicated R1 may have schizophrenia and has never been properly diagnosed. R1 experiences hallucinations and has previously experienced homelessness. Surveyor noted the facility did not reach out to R1's APOA to obtain pertinent psychosocial information that may be beneficial with providing a personalized plan of care and treatment for behaviors. On 5/7/25, at 1:16 PM, Surveyor interviewed Admissions-I who stated she will receive a request for a new admission to the facility and will review the admission paperwork. Admissions-I indicated she will look for red flags such as financials, safe discharge planning, and behaviors. Admissions-I then stated the facility does not have a memory care unit or a unit for residents who elope, and indicated the facility tries to keep it simpler. Admissions-I indicated the facility will get surprises where residents will change after they are admitted . Admissions-I indicated criminal background checks are performed to determine safety risk on all new residents. Admissions-I stated diagnosis and behaviors that are charted will determine if the resident has memory concerns. Admissions-I indicated she has had it happened with one resident recently who was admitted with Hospice care that was not appropriate. Surveyor asked Admissions-I who she was referring to, and Admissions-I indicated R1 was under Hospice care, and everything was good. R1 went to the hospital with behaviors, and behaviors had improved. Admissions-I indicated R1 had a sitter and restraints in the hospital prior to admission. Admissions-I stated the facility got a referral from Hospice and R1's sister-in-law could no longer care for R1. Admissions-I stated Hospice records were reviewed and R1 was accepted based on the Hospice records. Admissions-I indicated she visited R1 in the hospital who displayed agitation, wrist restraints, had a sitter out in the hallway, and described R1 as a restless fish out of water. Admissions-I stated she went back a 2nd time to the hospital and R1 was much calmer, social, talking, asked about lunch, and asked about going home. Admissions-I indicated R1 was 48 hours without restraints or a sitter at the time of her 2nd visit to the hospital. Admissions-I indicated R1 was not wandering in the hospital and started wandering in the facility right away after admission. Surveyor then asked Admissions-I why R1 had a sitter in the hospital, Admissions-I indicated R1 had a sitter due to being aggressive and getting out of bed. Surveyor noted Admissions-I did not receive the referral from Hospice. This was confirmed with an interview with Hospice Manager of Clinical Services-M. Surveyor also noted Admissions-I had already accepted the admission to the facility for R1 prior to visiting R1 in the hospital. R1's care plan documents: R1 is an elopement risk/wanderer related to Alzheimer's Disorder (date initiated 4/17/25). Interventions include: *Photo on wander list (date initiated 4/21/25). *Staff aware of R1's wander risk (date initiated 4/17/25). *Wander alert personal safety device applied to right wrist (date initiated 4/21/25). Surveyor notes 2 of the 3 interventions were initiated 1 day after R1 was discharged from the facility on 4/20/25. Surveyor also notes the intervention indicating R1 wearing the wander alert device on the R1's right wrist was initiated after R1 was discharged from the facility. R1 has potential to be physically or verbally aggressive related to history of alcohol abuse and Alzheimer's Disease with poor impulse control. Verbal aggression occurred 4/16/25, 4/17/25, 4/19/25, and 4/20/25. Physical aggression occurred 4/17/25, 4/19/25, and 4/20/25 (date initiated 4/22/25). Interventions include: *Administer medications as ordered. Monitor/document for side effects and effectiveness (date initiated 4/22/25). *Assess and address for contributing sensory deficits (date initiated 4/22/25). *Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff member when agitated (date initiated 4/22/25). *Monitor/document/report as needed (PRN) any signs/symptoms of R1 posing a danger to self and others (date initiated 4/22/25). Surveyor notes this care plan was initiated 2 days after R1 discharged from the facility on 4/20/25. R1 has a mood problem related to Alzheimer's Disease (date initiated 4/16/25). Interventions include: *Provide a calm and safe environment to allow R1 to express feelings as needed (date initiated 4/22/25). *Provide R1 with area for decreased stimulation as needed (date initiated 4/22/25). Surveyor notes these interventions were initiated 2 days after R1 discharge from the facility on 4/20/25. R1 has potential for a psychosocial well-being problem related to resident-to-resident incident on 4/17/25 and 4/20/25 (date initiated 4/17/25). Interventions include: *Encourage staff to redirect R1 and provide a calm quiet environment; remove high stimulation. R1 prefers the sitting area across from NHA office. To assess and monitor for any triggers or trends in behaviors to mitigate untoward incidents (date initiated 4/17/25). *Monitor mood, behavior, appetite, sleep pattern and usual activities of choice. Report any alterations to provider to determine if any additional interventions are needed (date initiated 4/18/25). *Monitor/document R1's usual response to problems: how R1 makes own changes and expects others to control problems or leaves to fate, or luck (date initiated 4/17/25). *Provide opportunities for R1 and family to participate in care. Continue non-pharmacological interventions to detour and distract from untoward behaviors (date initiated 4/17/25). *Upon readmission to the facility; schedule care conference with Power of Attorney (POA), Hospice, community care, and facility staff to communicate possible alternative placement equipped for residents with dementia (date initiated 4/20/25). *When conflict arises, remove R1 to a calm safe environment and allow to vent/share feelings (date initiated 4/17/25). Surveyor reviewed R1's behavior task list dated 4/16/25 - 4/20/25, which documents: 4/17/25 at 5:59 AM - wandering, yelling/screaming, kicking/hitting, pushing, grabbing, abusive language, threatening behavior, rejection of care 4/19/25 at 3:54 PM - rejection of care Surveyor reviewed the incident description on the facility self-report dated 4/17/25, which documents the following: Prior to the incident, R1 had been wandering the halls and in and out of rooms throughout the night, very agitated. R1 then aggressively approached another resident near the nurses' station, staff was unable to redirect and R2 then struck R1 in the right upper arm twice. Resident description documents, he got in my face. Immediate action taken documents, R1 was given PRN Ativan after non-pharmacological interventions were not effective. Surveyor reviewed staff statement from Licensed Practical Nurse (LPN)-X, dated 4/17/25, which documents the following: R1 was observed wandering hallways and becoming agitated and combative with staff throughout the night. While sitting in front of the nurses' station, R1 aggressively got up and approached R2. R2 then struck R1 in the right upper arm area, twice. R1 and R2 were immediately separated and redirected with the nurse. PRN Ativan was immediately administered without any difficulty. There was no redness/swelling noted to the area however, scattered old bruises were noted throughout R1's bilateral upper extremities. R1 denied any pain. Range of motion was within normal limits. Assistant Director of Nursing (ADON) and DON were notified by staff, POA for R1 was called and notified of the incident, as well as Hospice. Surveyor reviewed staff statement from CNA-V which documents R1 was really restless and confused wandering all night walking in and out of resident rooms and redirected. He was aggressive physically and verbally, abusive towards staff. CNA-V found R1 in a room standing over a resident around 4:00 AM. CNA-V asked R1 what R1 was doing. R1 responded stating R1 was helping the people. CNA-V told R1 that wasn't needed, that is what staff are there for and asked R1 to leave the resident's room with CNA-V because it was not R1's room. R1 told CNA-V no and grabbed something off the table. CNA-V asked R1 to give it to CNA-V, and R1 responded stating it was not R1's and R1 punched CNA-V twice and told CNA-V to leave R1 alone. CNA-V eventually got R1 to walk toward the door and got outside the door. R1 grabbed CNA-V's hand and pulled CNA-V's fingers apart. CNA-V got their hand loose, stepped back, and closed the door. When CNA-V opened the door back up, R1 was gone. CNA-V went to report what happened to the nurse when CNA-V observed R1 again by the nursing station. R1 was walking past R2. CNA-V was close enough to see both R1 and R2, but not to hear them. R1 said something to R2, and R1 stopped, they started to argue, and punches were thrown. Staff immediately intervened and separated R1 and R2. CNA-V does not know who threw the first punch. R2's behavior all night was normal. R2 wandered how R2 usually does, but did not bother anybody. Surveyor reviewed staff statement from CNA-W dated 4/17/25, which documents around 5:50 AM, R1 approached R3 in the TV area and told R3 to shut up because R3 was doing his usual screaming. R2 then told R1, don't talk to R3 like that. R1 walked closer to R2 with R1's fist bald (sic) up punching, R2 swung back at R1 a few times. CNA-W was trying to step in between without being hit. CNA-W separated R1 and R2. A second incident between R1 and R2 occurred three days later. Surveyor reviewed the facility self-report dated 4/20/25, which documents the following: On 4/20/25, around 12:50 AM, R2 hit R1 in the back of the head with a wet floor sign resulting in R1 falling and causing injury. Staff immediately intervened and separated R1 and R2 to maintain safety and conducted nursing assessments. R1 was sent to the hospital for evaluation and treatment. R2 was also sent out to be evaluated by psych and to be admitted inpatient to get R2 the assistance needed. R2 was sent back to the facility from the hospital without a psych work up and without notice. Facility staff notified NHA, DON, POAs, MD, Hospice, R2's PO, APS, ombudsman, and police. R1 sustained injuries as a result of the incident. R1 remained in the hospital. R1 is pending upcoming discharge. Surveyor reviewed staff statement from CNA-Y which documents, CNA-Y was doing rounds, heard a commotion, walked down the hall, and saw R2 hitting R1 with a wet floor sign. CNA-Y and another aid both ran towards the incident to break it up and R2 walked in one direction and R1 walked in the other direction. Surveyor reviewed staff statement from LPN-X which documents, R1 was wandering in and out of rooms, agitating other residents; unable to be redirected. Loud banging noise and yelling heard from unit 4 hall, and R1 was observed on R1's knees on the floor holding R1's face with a large amount of blood dripping from R1's face. R2 was separated from R1 and while walking away with the wet floor sign in hand, R2 admitted that R2 hit R1 several times. Large bumps were noted to the back of R1's head and behind left ear area along with the left side of the face and forehead. R1 was not cooperative with assessment from staff. Seems to be a laceration to left side of upper lip and an approximate 4-centimeter skin tear and redness to the left elbow area, tender to touch. While R1 was being seen by paramedics, R1 turned around and punched LPN-X in the arm/face while attempting to block R1's hit. R1 was placed on the stretcher by the paramedics and taken to the ER. Surveyor reviewed a second staff statement from LPN-X which documents, it was later reported to LPN-X that R1 was struck in the back with the wet floor sign by R2, observed by staff nurse and CNAs. Prior to incident, R1 had been wandering in and out of resident rooms. R2 had been telling staff that R1 killed R2's brother. Staff was attempting to keep the two separate, unsuccessful. The facility did not have pertinent information concerning R1's history and approaches that had been successful to help manage R1's behaviors, such as wandering into and out of other residents' rooms, upsetting them, and being physically aggressive. The initial care plans did not provide sufficient guidance to staff and care plans that were subsequently developed were developed after R1's admission to the hospital with a subdural hematoma that resulted after an altercation with another resident (R2). R2 is an [AGE] year-old resident who was admitted to the facility on [DATE]. R2's diagnoses include intracerebral hemorrhage (a type of stroke where bleeding occurs within the brain tissue), major depressive disorder, psychosis, vascular dementia (a form of dementia caused by damage to blood vessels in the brain, leading to reduced blood flow and oxygen delivery), seizures, and Transient Ischemic Attack (TIA) (temporary blockage of blood flow to the brain, causing similar symptoms to a stroke). R2's Quarterly MDS documents R2 has fluctuating behaviors for disorganized thinking, delusions, and wandering. R2 requires supervision for dressing, bathing, and putting on shoes. R2 is independent with transferring and walking. R2 was documented as having a BIMS of 2 indicating R2 has severe cognitive impairment. R2' care plan documents: R2 has episodes of aggression (date initiated 4/20/25). Interventions include: *Attempt to separate R2 from other residents or staff that R2 has been aggressive with (date initiated 4/20/25). *Monitor R2's whereabouts at all times (date initiated 4/20/25). *Try to redirect resident before he becomes too agitated (date initiated 4/20/25). R2 has a mood and behavior problem related to vascular dementia, unspecified severity, with other behavioral disturbance (example being sexually inappropriate with female residents, exposing self, and poor impulse control). Monitor psychosocial well-being due to peer-to-peer altercation on 4/17 and 4/20. Refusing staff to clean R2's room or letting staff assist R2 in getting dressed. Aggressive behaviors noted towards staff, accepting redirection on 4/1. R2 will refuse medications at times; Risks and benefits explained. R2 will refuse to have lab work done; Risks and benefits explained. (Date initiated 12/11/24). Interventions include: *Provide a calm and safe environment to allow R2 to express feelings as needed (date initiated 12/11/24). *Provide R2 with area for decreased stimulation as needed for negative behaviors (date initiated 12/11/24). *1:1 (one on one staff supervision) initiated and maintained upon return to regular ambulation/wandering (date initiated 4/20/25). *Encourage activated POA to participate in care planning period discuss and review alternate placement options that is a more appropriate setting for R2's progression of disease process (date initiated 4/17/25). *Set up another care conference with POA and psychiatry Nurse Practitioner (NP)-H to collaborate and care planning which is scheduled on 4/22/25 (date initiated 4/17/25). *Activities interview R2 and family to determine interest to care plan meaningful activities. Activities department monitor participation (date initiated 4/21/25). *Collaborate with MD, psych services, pharmacist, Adult Protective Services (APS), ombudsman, parole officer (PO), social services, and Regional Field Operations Director (RFOD) (State Agency) regarding options/interventions/care planning (date initiated 4/21/25). *Request from POA/family information regarding R2's past period extended family support options, likes, dislikes, interests, triggers, or trends. Implement any suggested recommendations if applicable and appropriate (date initiated 4/22/25). *Anticipate and meet R2's needs. Continue to monitor for triggers and any trends (date initiated 12/13/24). *Monitor for any aggressive/intrusive behaviors and report to provider (date initiated 4/11/25). *Monitor psychosocial well-being: mood, behavior, sleep pattern, appetite, and usual activities of choice. Report any alterations and notify provider to determine if any other interventions are recommended (date initiated 4/11/25). *Praise any indication of R2's progress/improvement in behavior (date initiated 2/24/25). *Provide a program of activities that is of interest and accommodates R2's status. Continue to offer nonpharmacological interventions to distract and detour negative incidents. Example: offer snacks, ice cream, chocolates, engage in conversation of preferences, offer meaningful activities, and walk while talking about guitars and music (date initiated 12/11/24). *Utilize psych services if provider deems necessary (date initiated 4/11/25). R2 uses psychotropic, antidepressant medications related to vascular dementia with behaviors, psychosis, and depression. R2 regularly refuses medications (date initiated 3/8/24). Interventions include: *Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift (date initiated 3/8/24). *Consult with pharmacy and MD to consider dosage reduction when clinically appropriate at least quarterly (date initiated 3/8/24). *Educate R2/family/caregivers about risks, benefits and the side effects and/or toxic symptoms (date initiated 11/11/24). *Monitor/record occurrence for target behavior symptoms (date initiated 3/8/24). R2 has a potential psychosocial well-being problem related to resident-to-resident altercation (date initiated 4/17/25). Interventions include: *Attempt to remove and redirect R2 when other residents are calling out to prevent R2 from feeling the need to protect other residents (date initiated 4/17/25). *Initiate referrals as needed or increase social relationships (date initiated 4/17/25). *Monitor/document R2's usual response to problems, how R2 makes own decisions, expects others to control problems or leaves to fate, or luck (date initiative 4/17/25). *When conflict arises, remove R2 to a calm safe environment and allow to vent/share feelings (date initiated 4/17/25). Surveyor reviewed R2's behavior task list dated 4/8/25 - 5/8/25, which documents: 4/19/25 at 4:56 PM - wandering 4/30/25 at 4:56 AM - wandering and rejection of care Surveyor reviewed R2's Medication Administration Record (MAR) which documents R2 is prescribed Seroquel for dementia with behavioral disturbance, Depakote for dementia, Keppra for seizures, and Paxil for depression. Surveyor notes the following missed medications for R2: January 2025 MAR documents the following: *R2 took Seroquel and Paxil one time on 1/10/25. *R2 took Depakote three times on 1/2/25, 1/10/25, and 1/12/25. Surveyor notes R2 took Depakote three times out of 62 opportunities in the month of January 2025. *R2 took Keppra 4 times on 1/2/25, 1/7/25, 1/10/25, and 1/16/25. Surveyor notes R2 took Keppra four times out of 62 opportunities in the month of January 2025. February 2025 MAR documents the following: *R2 took Depakote 21 times out of 56 opportunities. *R2 took Paxil 12 times out of 28 opportunities. *R2 took Keppra 22 times out of 56 opportunities. *R2 refused Seroquel throughout February 2025. March 2025 MAR documents the following: *R2 took Paxil seven times out of 31 opportunities. *R2 took Depakote 12 times out of 62 opportunities. *R2 took Keppra 12 times out of 62 opportunities. April 2025 MAR documents the following: *R2 took Paxil five times out of 30 opportunities. *R2 took Keppra 12 times out of 60 opportunities. *R2 took Depakote 10 times out of 60 opportunities. *R2 was prescribed Rexulti for dementia with a new order dated 4/21/25. Surveyor notes R2 took Rexulti two times out of nine opportunities in the month of April 2025. On 5/8/25, at 1:50 PM, Surveyor interviewed Psychiatry Nurse Practitioner (NP)-H who states she sees R2 every two to three months. Psychiatry NP-H indicated she was told R2 was not taking medications as prescribed as early as January 2025. Psychiatry NP-H stated R2 was not taking Depakote as prescribed and indicated dementia will worsen and behaviors will potentially worsen due to R2 not taking Depakote. Psychiatry NP-H stated things can set off R2 and some of these incidences are racially motivated. Psychiatry NP-H indicated she has not completed evaluations for possible triggers for R2 and is unsure if the facility performed evaluations for possible triggers. Psychiatry NP-H stated she does not think these evaluations to identify possible triggers are a standard of practice for any facility and then stated the facility will deal with the here and now. Psychiatry NP-H stated R2 had recent medication changes, and the facility is to contact her if R2's behaviors worsen, she would possibly adjust medications. Psychiatry NP-H indicated R2 is not a danger to themselves, however R2 is a danger to other residents within the facility if R2 is set off by another irritating factor to them. Psychiatry NP-H stated anybody can be that spark for someone with dementia. Psychiatry NP-H indicated she was not aware of R2's criminal history. The facility did not have a care plan that addressed R2's refusal to take medications. R2 did not consistently begin taking medications until May 2025 when R2's family member began administering them. On 5/8/25, at 2:57 PM, Surveyor interviewed Social Services-D who stated she is aware of the altercations between R2 and R1 that occurred on 4/17/25 and 4/20/25. Social Services-D states the facility has been in contact with R2's POA and family, with care conferences to discuss alternate facilities for R2. Social Services-D stated she was unaware that R2 had a parole officer, and the facility was made aware a couple of months ago when R2's parole officer showed up at the facility with a warrant for R2. Social Services-D indicated she is not aware of why R2 has a parole officer. Social Services-D indicated Admissions-I did not have knowledge of R2 having a parole officer. Social Services-D stated she was not sure what the plan is for the facility moving forward for verifying if residents are on parole with a new admission and directed Surveyor to speak with Admissions-I. Social Services-D indicated Admissions-I was in shock when she ran R2's name through the circuit courts and nothing came up. Social Services-D indicated R2 may have a parole officer due to R2 having convictions in another state. Social Services-D stated R2's care plan is updated to be monitoring R2, and the facility put a plan in for R2 being non-compliant with medications. Social Services-D indicated the facility has attempted to administer R2's medications in chocolate milk, yogurt, and other alternatives without success. Social Services-D stated family is coming in daily to administer R2's medications. Social Services-D indicated she is not sure what would happen if R2 assaults someone again and whether or not there is a plan. Social Services-D stated she feels R2's sister's hands are tied due to R2 getting turned down at other facilities for alternative placement. Social Services-D indicated the family is out of options and have stated numerous times family members will not take R2 home and care for R2 and POA told the facility that the facility can't tell the POA where to move his brother. Social Services-D indicated the facility then reminds R2's POA about the incident that occurred on 4/20/25. Social Services-D indicated she feels the facility should have known that R2 was on parole. Social Services-D indicated the facility tries to tell R2's family that the facility is not the proper setting for R2. Surveyor noted Social Services-D and Admission-I are not aware of why R2 has a parole officer, which helps determine resident needs and plan of care. Social Services-D indicated the facility does not have a plan of action moving forward for residents who are on parole, or if R2 were to display behaviors again including assaulting someone. Surveyor also noted, the facility was unable to indicate R2's previous conviction and ja

Based on observation, interview, and record review, the facility failed to ensure 2 of 4 residents (R1 and R5) was free from physical abuse. R2 is known to have physical aggression towards residents and staff and was observed to have escalating behaviors. The facility did not ensure R1 was free from abuse by another resident (R2) residing in the facility. On 4/17/25, at 6:45 AM, facility staff observed R2 strike R1 in the arm twice while in the common area. On 4/20/25, facility staff observed R2 strike R1 in the back with a wet floor sign. R2 and R1 were separated by facility staff and escorted to separate units within the facility. Approximately 10 minutes later at 12:50 AM, R2 sought out R1, and R2 hit R1 multiple times in the head with the wet floor sign. R1 sustained a subdural hematoma (a pool of blood between the brain and its outermost covering often associated with a traumatic brain injury) and required an Intensive Care Unit (ICU) stay as a result of being hit in the head by R2 from the wet floor sign. The facility's failure to keep R1 free from physical abuse created a finding of Immediate Jeopardy that began on 4/17/25. On 5/12/25, at 3:52 PM, Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Nurse-C, and Corporate Consultant-E were informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on 5/12/25. The deficient practice continues at a scope and severity (S/S) of a D (potential for harm/isolated) as the facility continues to implement their action plan and based upon the additional example related to R5 and R6. R5 alleges that R6 hit and pinched them in the smoking courtyard. The facility did not prevent this occurrence of abuse or future negative interactions between the residents. Findings include: Surveyor reviewed the facility's Policy and Procedure, Abuse, Neglect and Exploitation, last reviewed 1/5/24, which documents: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. *An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission. *The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment. Existing staff will receive annual education through planned in-services and as needed. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: *Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. *The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. *Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur. *Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services . An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. *Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not destroying evidence). *Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. *Providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: *Responding immediately to protect the alleged victim and integrity of the investigation. *Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. *Increase supervision of the alleged victim and residents. *Room or staffing changes, if necessary, to protect the resident from the alleged perpetrator. *Protection from retaliation. *Providing emotional support and counseling to the resident during and after the investigation, as needed. The facility will have written procedures that include: *Taking all necessary actions as a result of the investigation, which may lead but are not limited to the following: **Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes may be needed to prevent further occurrences. **Defining whether care provision should be changed and/or improved to protect residents receiving services. 1.) Surveyor reviewed R1 and R2's medical record which documents the following: R1 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R1's diagnoses include seizures, Alzheimer's Disease, alcohol abuse, fall, and laceration to the scalp. R1's Discharge Minimum Data Set (MDS) completed on 4/20/25 documents that R1 has severe impaired cognitive concerns, short term memory problems, rejection of care concerns, wandering, physical behaviors, and verbal behaviors. R1 requires substantial/maximal assistance with toileting hygiene, showering, and dressing. R1 is independent with transferring and walking. R1 does not require assistive devices while ambulating and ambulates throughout the facility independently. R1 was documented as having a Brief Interview for Mental Status (BIMS) score of 3, indicating that R1 has severe cognitive impairment. R1's care plan documents: R1 has potential to be physically or verbally aggressive related to history of alcohol abuse and Alzheimer's Disease with poor impulse control. Verbal aggression occurred 4/16/25, 4/17/25, 4/19/25, and 4/20/25. Physical aggression occurred 4/17/25, 4/19/25, and 4/20/25 (date initiated 4/22/25). Interventions include: *Administer medications as ordered. Monitor/document for side effects and effectiveness (date initiated 4/22/25). *Assess and address for contributing sensory deficits (date initiated 4/22/25). *Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff member when agitated (date initiated 4/22/25). *Monitor/document/report as needed (PRN) any signs/symptoms of R1 posing a danger to self and others (date initiated 4/22/25). Surveyor notes this care plan was initiated 2 days after R1 discharged from the facility on 4/20/25. R1 has a history of substance abuse (date initiated 4/22/25). Interventions include: *Notify Medical Director (MD) if R1 appears impaired (prior to administering medications) (date initiated 4/22/25). *Use calm and empathetic approach for communication (date initiated 4/22/25). Surveyor notes this care plan was initiated 2 days after R1 discharged from the facility on 4/20/25. R1 uses antidepressant and antianxiety related to poor prognosis and Post Traumatic Stress Disorder (PTSD) (date initiated 4/22/25). Interventions include: *Administer antidepressant/antianxiety medications as ordered by physician. Monitor/document side effects and effectiveness every shift (date initiated 4/22/25). *Monitor/document/report PRN (as indicated) adverse reactions to antidepressants/ antianxiety therapy R1 uses psychotropic medication related to Alzheimer's Disease (date initiated 4/22/25). Interventions include: *Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift (date initiated 4/22/25). R1 has a mood problem related to Alzheimer's Disease (date initiated 4/16/25). Interventions include: *Provide a calm and safe environment to allow R1 to express feelings as needed (date initiated 4/22/25). *Provide R1 with area for decreased stimulation as needed (date initiated 4/22/25). Surveyor notes these interventions were initiated 2 days after R1 discharge from the facility on 4/20/25. R1 has an alteration in neurological status related to Alzheimer's Disease, history of alcohol abuse, and intracranial bleed/small hematoma to the right side of frontal lobe 4/20/25 (date initiated 4/19/25). Interventions include: *Notify MD/responsible party of changes in neurological status (date initiated 4/19/25). R1 has potential for a psychosocial well-being problem related to resident-to-resident incident on 4/17/25 and 4/20/25 (date initiated 4/17/25). Interventions include: *Encourage staff to redirect R1 and provide a calm quiet environment; remove high stimulation. R1 prefers the sitting area across from NHA office. To assess and monitor for any triggers or trends in behaviors to mitigate untoward incidents (date initiated 4/17/25). *Monitor mood, behavior, appetite, sleep pattern and usual activities of choice. Report any alterations to provider to determine if any additional interventions are needed (date initiated 4/18/25). *Monitor/document R1's usual response to problems: how R1 makes own changes and expects others to control problems or leaves to fate, or luck (date initiated 4/17/25). *Provide opportunities for R1 and family to participate in care. Continue non-pharmacological interventions to detour and distract from untoward behaviors (date initiated 4/17/25). *Upon readmission to the facility; schedule care conference with Power of Attorney (POA), Hospice, community care, and facility staff to communicate possible alternative placement equipped for residents with dementia (date initiated 4/20/25). *When conflict arises, remove R1 to a calm safe environment and allow to vent/share feelings (date initiated 4/17/25). Surveyor notes the Facility Assessment documents, the facility may accept residents with dementia, residents who may develop dementia, which may include common diseases such as psychiatric and mood disorders, psychosis with hallucinations and delusions, impaired cognition, mental disorder depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, and behaviors that require interventions. R2 is an [AGE] year-old resident who was admitted to the facility on [DATE]. R2's diagnoses include intracerebral hemorrhage (a type of stroke where bleeding occurs within the brain tissue), major depressive disorder, psychosis, vascular dementia (a form of dementia caused by damage to blood vessels in the brain, leading to reduced blood flow and oxygen delivery), seizures, and Transient Ischemic Attack (TIA) (temporary blockage of blood flow to the brain, causing similar symptoms to a stroke). R2's Quarterly MDS documents R2 has fluctuating behaviors for disorganized thinking, delusions, and wandering. R2 requires supervision for dressing, bathing, and putting on shoes. R2 is independent with transferring and walking. R2 was documented as having a BIMS of 2 indicating R2 has severe cognitive impairment. R2' care plan documents: R2 has episodes of aggression (date initiated 4/20/25). Interventions include: *Attempt to separate R2 from other residents or staff that R2 has been aggressive with (date initiated 4/20/25). *Monitor R2's whereabouts at all times (date initiated 4/20/25). *Try to redirect resident before he becomes too agitated (date initiated 4/20/25). R2 has a mood and behavior problem related to vascular dementia, unspecified severity, with other behavioral disturbance (example being sexually inappropriate with female residents, exposing self, and poor impulse control). Monitor psychosocial well-being due to peer-to-peer altercation on 4/17 and 4/20. Refusing staff to clean R2's room or letting staff assist R2 in getting dressed. Aggressive behaviors noted towards staff, accepting redirection on 4/1. R2 will refuse medications at times; Risks and benefits explained. R2 will refuse to have lab work done; Risks and benefits explained. (Date initiated 12/11/24). Interventions include: *Provide a calm and safe environment to allow R2 to express feelings as needed (date initiated 12/11/24). *Provide R2 with area for decreased stimulation as needed for negative behaviors (date initiated 12/11/24). *1:1 (one on one supervision from staff) initiated and maintained upon return to regular ambulation/wandering (date initiated 4/20/25). *Encourage activated POA to participate in care planning period discuss and review alternate placement options that is a more appropriate setting for R2's progression of disease process (date initiated 4/17/25). *Set up another care conference with POA and psychiatry Nurse Practitioner (NP)-H to collaborate and care planning which is scheduled on 4/22/25 (date initiated 4/17/25). *Activities interview R2 and family to determine interest to care plan meaningful activities. Activities department monitor participation (date initiated 4/21/25). *Collaborate with MD, psych services, pharmacist, Adult Protective Services (APS), ombudsman, parole officer (PO), social services, and Regional Field Operations Director (RFOD) (State Agency) regarding options/interventions/care planning (date initiated 4/21/25). *Request from POA/family information regarding R2's past period extended family support options, likes, dislikes, interests, triggers or trends. Implement any suggested recommendations if applicable and appropriate (date initiated 4/22/25). *Anticipate and meet R2's needs. Continue to monitor for triggers and any trends (date initiated 12/13/24). *Monitor for any aggressive/intrusive behaviors and report to provider (date initiated 4/11/25). *Monitor psychosocial well-being: mood, behavior, sleep pattern, appetite and usual activities of choice. Report any alterations and notify provider to determine if any other interventions are recommended (date initiated 4/11/25). *Praise any indication of R2's progress/improvement in behavior (date initiated 2/24/25). *Provide a program of activities that is of interest and accommodates R2's status. Continue to offer nonpharmacological interventions to distract and detour negative incidents. Example: offer snacks, ice cream, chocolates, engage in conversation of preferences, offer meaningful activities and walk while talking about guitars and music (date initiated 12/11/24). *Utilize psych services if provider deems necessary (date initiated 4/11/25). R2 uses psychotropic, antidepressant medications related to vascular dementia with behaviors, psychosis, and depression. R2 regularly refuses medications (date initiated 3/8/24). Interventions include: *Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift (date initiated 3/8/24).,, R2 has a potential psychosocial well-being problem related to resident-to-resident altercation (date initiated 4/17/25). Interventions include: *Attempt to remove and redirect R2 when other residents are calling out to prevent R2 from feeling the need to protect other residents (date initiated 4/17/25). *Initiate referrals as needed or increase social relationships (date initiated 4/17/25). *Monitor/document R2's usual response to problems, how R2 makes own decisions, expects others to control problems or leaves to fate, or luck (date initiative 4/17/25). *When conflict arises, remove R2 to a calm safe environment and allow to vent/share feelings (date initiated 4/17/25). Surveyor reviewed R2's Care Area Assessments (CAA)s dated 1/29/25, which document the following: Delirium CAA - R2 has dementia with no acute change in mental status. Cognitive loss/Dementia CAA- R2 has vascular dementia impacting R2's cognitive status at present requiring reminders frequently. R2 is here for long term care due to vascular dementia requiring frequent redirection due to behavior issue and has been refusing medications despite encouragement. R2's condition at present is complicated by recent influenza A which R2 was placed on strict droplet precaution. R2 is mostly independent for R2's ADLs and up ad lib. R2 is able to verbalize needs and wants, when given time. Needs anticipated by staff to maintain safety. Staff to redirect R2 as needed and follow plan of care. Behavioral Symptoms CAA - R2 has vascular dementia with psychosis/behavior triggering this CAA for behavioral symptoms as R2 continues having behavior issue at present. R2 is here for long term care due to vascular dementia requiring frequent redirection due to behavior issue and has been refusing medications despite encouragement. R2's condition at present is complicated by recent influenza A which R2 was placed on strict droplet precaution. R2 is mostly independent with ADL's and up ad lib. R2 is able to verbalize needs and wants, when given time. Needs anticipated by staff to maintain safety. Staff to redirect R2 as needed and follow plan of care. Surveyor reviewed R2's behavior task list dated 4/8/25 - 5/8/25, which documents: 4/19/25 at 4:56 PM - wandering 4/30/25 at 4:56 AM - wandering and rejection of care Surveyor reviewed R2's Medication Administration Record (MAR) which documents R2 is prescribed Seroquel for dementia with behavioral disturbance, Depakote for dementia, Keppra for seizures, and Paxil for depression. Surveyor notes the following missed medications for R2: January 2025 MAR documents the following: *R2 took Seroquel and Paxil one time on 1/10/25. *R2 took Depakote three times on 1/2/25, 1/10/25, and 1/12/25. Surveyor notes R2 took Depakote three times out of 62 opportunities in the month of January 2025. *R2 took Keppra 4 times on 1/2/25, 1/7/25, 1/10/25, and 1/16/25. Surveyor notes R2 took Keppra four times out of 62 opportunities in the month of January 2025. February 2025 MAR documents the following: *R2 took Depakote 21 times out of 56 opportunities. *R2 took Paxil 12 times out of 28 opportunities. *R2 took Keppra 22 times out of 56 opportunities. *R2 refused Seroquel throughout February 2025. March 2025 MAR documents the following: *R2 took Paxil seven times out of 31 opportunities. *R2 took Depakote 12 times out of 62 opportunities. *R2 took Keppra 12 times out of 62 opportunities. April 2025 MAR documents the following: *R2 took Paxil five times out of 30 opportunities. *R2 took Keppra 12 times out of 60 opportunities. *R2 took Depakote 10 times out of 60 opportunities. *R2 was prescribed Rexulti for dementia with a new order dated 4/21/25. Surveyor notes R2 took Rexulti two times out of nine opportunities in the month of April 2025. May 2025 MAR documents the following: *R2 refused Paxil once in May of 2025. *R2 did not refuse Depakote, Keppra, Rexulti and received all prescribed doses in the month of May 2025. Surveyor notes, R2's family started administering medications in May 2025 which improved R2's compliance with taking medications. Surveyor reviewed R2's psychiatric notes dated 1/6/25 and 2/3/25, which document R2 having vascular dementia with behaviors, displays psychosis, hallucinations, and wandering. Psychiatry Nurse Practitioner (NP)-H notes R2 has not been taking medications as prescribed. Surveyor notes, there are no changes, with recommendations to continue to monitor. Surveyor reviewed R2's progress notes dated 4/2/25, which documents the DON (B) contacted Psychiatry NP-H with an update of R2 displaying increased agitation. Psychiatry NP-H stated to continue to monitor R2 and continue to redirect as needed. Psychiatry NP-H indicated she was scheduled to be in the facility on 4/7/25. Surveyor notes Psychiatry NP-H did not see R2 on 4/7/25. R2's next visit with Psychiatry NP-H was on 5/5/25 which documents R2 to continue with Rexulti for dementia that was prescribed on 4/20/25 in the emergency room (ER). The State Agency Received two facility self-reports with resident-to-resident abuse between R2 and R1 occurring on 4/17/25 and 4/20/25. *Surveyor reviewed the facility self-report dated 4/17/25, which documents the following: On 4/17/25, at 6:45 AM, R2 and R1 were documented as wandering the halls throughout the facility and becoming agitated and combative with staff throughout the night. R1 and R2 were in the common area when R1 approached R2. Facility staff attempted to redirect both R1 and R2 however, were unsuccessful. R2 then struck R1 in the right upper arm twice. R2 and R1 were separated. Staff performed skin and pain assessments on both R1 and R2 that were unremarkable. Facility staff contacted the police, NHA, DON, MD, POA's, MCO's (Managed Care Organizations), and Hospice. Surveyor notes facility staff did not contact Parole Officer (PO)-F, who is R2's parole officer. Facility staff interviewed R1 and R2. Neither resident recalled the incident where R2 struck R1 in the right upper arm twice. The facility self-report documents cameras were reviewed, staff statements obtained, and resident statements obtained. The facility self-report documents care plans were updated. *Surveyor reviewed the police report dated 4/17/25, at 7:03 AM, which documents the following: R1 and R2 were in the living room/day room when R1 suddenly stood up and stated what did you say to R2 and aggressively approached R2. R2 then struck R1 in R1's upper right arm. Staff immediately separated the two. The police officer observed R1 who appeared to be fine. Both R2 and R1 are low functioning and the facility states that neither residents would understand what the police was talking about if the police officer were to interview them. Facility staff was advised to file the report to build a paper trail for documentation purposes. For this reason, no incident report will be completed. *Surveyor reviewed the self-report incident notes dated 4/17/25, which documents the following: R2 struck a peer in the upper arm when R2's peer raised their voice to another resident. R2 states R2 was protecting another resident from R1. R2 has no complaints of discomfort and has no alterations to skin integrity that can be seen. R2 is refusing a full skin assessment which is unremarkable. Mood, behavior, sleep pattern, and unusual activities of choice are being monitored for at least 72 hours. R2 remains at baseline. R2's psychosocial well-being and physical status monitoring is ongoing. R2's care plan has been reviewed and updated. The care team will continue to anticipate R2's needs and monitor for any changes. *Surveyor reviewed the incident description on the facility self-report dated 4/17/25, which documents the following: Prior to the incident, R1 had been wandering the halls and in and out of rooms throughout the night, very agitated. R1 then aggressively approached another resident near the nurses' station, staff was unable to redirect and R2 then struck R1 in the right upper arm twice. Resident description documents, he got in my face. Immediate action taken documents, R1 was given PRN Ativan after non-pharmacological interventions were not effective. *Surveyor reviewed staff statement from Licensed Practical Nurse (LPN)-X, dated 4/17/25, which documents the following: R1 was observed wandering hallways and becoming agitated and combative with staff throughout the night. While sitting in front of the nurses' station, R1 aggressively got up and approached R2. R2 then struck R1 in the right upper arm area, twice. R1 and R2 were immediately separated and redirected with the nurse. PRN Ativan was immediately administered without any difficulty. There was no redness/swelling noted to the area however, scattered old bruises were noted throughout R1's bilateral upper extremities. R1 denied any pain. Range of motion was within normal limits. Assistant Director of Nursing (ADON) and DON were notified by staff, POA for R1 was called and notified of the incident, as well as Hospice. *Surveyor reviewed incident notes dated 4/17/25, which documents the following: R1 is monitored by the care team for any delayed injuries from the resident-to-resident altercation. R1's psychosocial well-being is also monitored for at least 72 hours. R1's mood, behavior, appetite, sleep pattern, and unusual activities of choice are unchanged. R1 denies any pain or discomfort. There are no alterations in skin integrity. The care team has notified the provider and all responsible parties. There are no new orders received and there are no recommendations. The care plan is reviewed and updated. R1 is agreeable to spending free time in the lounge across from the NHA office as it is a much calmer environment with less stimuli. R1 did state that R1 needs a quieter environment to decrease agitation/anxiety. R1 is doing well in this area of preference. The care team will continue to anticipate R1's needs and monitor for any changes. *Surveyor reviewed staff statement from Certified Nursing Assistant (CNA)-V which documents R1 was really restless and confused wandering all night walking in and out of resident rooms and redirected. He was aggressive physically and verbally, abusive towards staff. CNA-V found R1 in a room standing over a resident around 4:00 AM. CNA-V asked R1 what R1 was doing. R1 responded stating R1 was helping the people. CNA-V told R1 that wasn't needed, that is what staff are there for and asked R1 to leave the resident's room with CNA-V because it was not R1's room. R1 told CNA-V no and grabbed something off the table. CNA-V asked R1 to give it to CNA-V, and R1 responded stating it was not R1's and R1 punched CNA-V twice and told CNA-V to leave R1 alone. CNA-V eventually got R1 to walk toward the door and got outside the door. R1 grabbed CNA-V's hand and pulled CNA-V's fingers apart. CNA-V got their hand loose, stepped back, and closed the door. When CNA-V opened the door back up, R1 was gone. CNA-V went to report what happened to the nurse when CNA-V observed R1 again by the nursing station. R1 was walking past R2. CNA-V was close enough to see both R1 and R2, but not to hear them. R1 said something to R2, and R1 stopped, they started to argue, and punches were thrown. Staff immediately intervened and separated R1 and R2. CNA-V does not know who threw the first punch. R2's behavior all night was normal. R2 wandered how R2 usually does, but did not bother anybody. Surveyor reviewed staff statement from CNA-W dated 4/17/25, which documents around 5:50 AM, R1 approached R3 in the TV area and told R3 to shut up because R3 was doing his usual screaming. R2 then told R1, don't talk to R3 like that. R1 walked closer to R2 with R1's fist bald (sic) up punching, R2 swung back at R1 a few times. CNA-W was trying to step in between without being hit. CNA-W separated R1 and R2. On 5/7/25, at 12:53 PM, Surveyor attempted to interview R3 who declined to answer questions. On 5/7/25, at 12:56 PM, Surveyor interviewed CNA-P who indicates R3 has severe cognition concerns, and will oftentimes yell out, but R3's yelling out is not directed at anyone. Surveyor reviewed staff statement from RN-N, which documents R2 spends most nights walking around the facility. R2 does go to the long-term care side also. At one-point last night, RN-N had to go over to the long-term care side to look for an item and saw R2 sitting in the lounge by the nursing station. RN-N does not recall what time that was but R2 appear (sic) to be by themselves. R1 spent a lot of time over on the rehab unit last night. RN-N did not witness or hear any incident between R1 and R2. When R1 was on the rehab unit, R1 was being intrusive going near or inside other resident rooms. RN-N had to administer a resident Xanax because it made her anxious. RN-N did not personally see R1 going into other rooms, but that was what RN-N was told by the resident and other staff. *Surveyor reviewed incident notes dated 4/19/25, which documents the following: The care team continues to monitor R2's behaviors and any identifiable trends to mitigate any future untoward incidents. Non-pharmacological interventions are ongoing. The only identifiable trigger is that R2 believes R2 is protecting others, therefore when a peer appears to be distressed, R2 goes into protection mode. The care team will continue to anticipate R2's needs and monitor for any changes. Surveyor reviewed the facility self-report dated 4/20/25, which documents the following: *On 4/20/25, around 12:50 AM, R2 hit R1 in the back of the head with a wet floor sign resulting in R1 falling and causing injury. Staff immediately intervened and separated R1 and R2 to maintain safety and conducted nursing assessments. R1 was sent to the hospital for evaluation and treatment. R2 was also sent out to be evaluated by psych and to be admitted inpatient to get R2 the assistance needed. R2 was sent back to the facility from the hospital without a psych work up and without notice. Facility staff notified NHA, DON, POAs, MD, Hospice, R2's PO (parole officer), APS (adult protective services), ombudsman, and police. R1 sustained injuries as a result of the incident. R1 remained in the hospital. R1 is pending upcoming discharge. *Surveyor reviewed the clinical chart review which documents the following: R1 sustained a subdural hematoma (a type of bleeding in which a pool of blood between the brain and its outermost covering occurs, often associated with a traumatic brain injury). R2 was placed on a 1:1 in the facility indicating one staff member is always with R2. Specific 1:1 instruction for R2 is provided to the 1:1 assigned staff. The care team is currently working with the provider, pharmacist, psych services, APS, ombudsman, POA, medical director, and PO to get R2 properly placed, so R2 can receive the services needed. R2 remains unwilling to take medications as ordered. *Surveyor reviewed staff statement from CNA-Y which documents, CNA-Y was doing rounds, heard a commotion, walked down the hall and saw R2 hitting R1 with a wet floor sign. CNA-Y and another aid both ran towards the incident to break it up and R2 walked in one direction and R1 walked in the other direction. Surveyor reviewed staff statement from LPN-X which documents, R1 was wandering in and out of rooms, agitating other residents; unable to be redirected. Loud banging noise and yelling heard from unit 4 hall, and R1 was observed on R1's knees on the floor holding R1's face with a large amount of blood dripping from R1's face. R2 was separated from R1 and while walking away with the wet floor sign in hand, R2 admitted that R2 hit R1 several times. Large bumps were noted to the back of R1's head and behind left ear area along with the left side of the face and forehead. R1 was not cooperative with assessment from staff. Seems to be a laceration to left side of upper lip and an approximate 4-centimeter skin tear and redness to the left elbow area, tender to touch. While R1 was being seen by paramedics, R1 turned around and punched LPN-X in the arm/face while attempting to block R1's hit. R1 was placed on the stretcher by the paramedics and taken to the ER. Surveyor reviewed a second staff statement from LPN-X which documents, it was later reported to LPN-X that R1 was struck in the back with the wet floor sign by R2, observed by staff nurse and CNAs. Prior to incident, R1 had bee

Based on observation, interview, and record review the Facility did not update the comprehensive person-centered care plan for 2 (R5, R6) of 5 residents to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. * R5 and R6's care plans were not thoroughly updated after a resident to resident altercation to prevent potential further abusive situations. Additionally, R5 and R6's care plan and smoking assessment are not consistent for interventions. Findings include: The Facility Policy titled Care Plans- Comprehensive revised 11/26/16, documents (in part): Policy Statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation . 2. The comprehensive care plan is based on a thorough assessment that includes strengths, goals, life history and preferences, but is not limited to, the MDS (minimum data set). 3. Each resident's comprehensive care plan after each assessment including both the comprehensive and quarterly review assessments is designed to: a. Incorporate identified problem areas and goals for desired outcomes; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strength; d. Reflect the resident's expressed preferences, wishes regarding care and treatment goals including a desire to return to the community; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions . 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process . 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly . The Facility Policy titled Smoking Policy-Residents revised December 2011, documents (in part): Policy Statement This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation . 7. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine any restrictions on a resident's smoking privileges. 8. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 9. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 10. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 11. The staff will review the status of a resident's smoking privileges periodically, and consult as needed with the Director of Nursing Services and the Attending Physician. 12. Smoking articles for residents with independent smoking privileges: a. Residents who have independent smoking privileges shall be permitted to keep cigarettes, pipes, tobacco, or other smoking articles in their possession. b. Residents may only keep disposable safety lighters. All other forms of lighters, including matches, shall be prohibited . 13. Smoking articles for residents without independent smoking privileges: a. Residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etcetera, except when they are under direct supervision . c. Anyone who provides smoking supervision to residents shall be advised of any restrictions/concerns and the plan of care related to smoking. 14. Staff members and volunteer workers shall not purchase and/or provide any smoking articles for residents unless approved by the charge nurse . R5 was admitted to the facility on [DATE] with pertinent diagnoses that include type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), morbid obesity (body mass index (BMI) of 40 or higher), chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed), bipolar disease (mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep), spinal stenosis (a narrowing of the spinal canal, stenosis can cause pressure on your spinal cord), and anxiety disorder (persistent, excessive fear or worry in situations that are not threatening). R5's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/31/25, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R5 is cognitively intact. R5's MDS documents a patient depression questionnaire (PHQ-9) score of 08, indicating mild depression. The MDS documents that R5 is understood and understands others and has clear speech. R5 was assessed to have no behaviors exhibited during the look back period. The MDS documents a high risk drug, categorized as antidepressant, is taken by R5. R5 is responsible for self. Resident to Resident altercation: Surveyor reviewed the Facility Reported Incident dated 4/9/2025 that documents on 4/7/25 around 4:30pm, R5 alleged R6 hit R5 in the courtyard. Residents immediately separated and assessments conducted on both residents. No injuries obtained. Police notified. Investigation started. Surveyor reviewed the Verification of Investigation with the Date of Finding: 4/7/25 that documents within the Summary of Factual Investigative Findings: The care plan has been reviewed and updated. The care team, residents and all parties that were notified are agreeable to the current plan of care.The Plan of Care Update section for R5 and R6 documents Resident provided verbal education of facility rules including to not engage in inappropriate name calling with other residents and to not use the courtyard at the same time as the other resident. Resident counseled to use the courtyard door closest to assigned unit. R5's care plan documents: The resident has a psychosocial wellbeing problem that was initiated on 04/07/2025. The goal is the resident will have no indications of psychosocial wellbeing problem by/through review. (Surveyor noted indications of and definition of what a psychosocial wellbeing problem is for R5 is not specified. Surveyor noted this is an intervention on another care plan for R5 initiated 11/29/24 after a previous resident to resident altercation). Date Initiated: 04/08/2025, Target Date: 07/07/2025 Interventions include: - Consult with: Pastoral care, Social services, Psych (psychology) services, Other: Date Initiated: 04/08/2025 - Encourage participation from resident who depends on others to make own decisions. Date Initiated: 04/08/2025 - Initiate referrals as needed or increase social relationships: (Specify) (Surveyor noted this is not individualized for R5). Date Initiated: 04/08/2025 - When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Date Initiated: 04/08/2025 R5's care plan documents: R5 has a mood problem r/t dx of Bi-polar disorder, hx (history) metabolic encephalopathy, anxiety, depression, history of missing or losing items -Verbally abusive to staff and other residents -loud and disruptive -Invasive to others -problems sleeping 11-29-24 Monitor psychosocial wellbeing due to peer-peer altercation. 12-1-24 Peer-peer that was initiated on 04/27/2020. Interventions include: - SLEEP: Evaluate resident for possible sleeping pattern changes and intervene as appropriate. Date Initiated: 06/09/2020 - Administer medications as ordered. Date Initiated: 04/27/2020 - Attempt to find out the reason or cause for any anxiety; listen to resident to resolve or discuss areas of upset. Date Initiated: 04/27/2020 - Encourage R5 to express feelings. Provide support and reassurance. Date Initiated: 04/27/2020 - Encourage R5 to participate in activities of choice. R5 enjoys adult coloring, tending to R5's plants and collecting stuffed animals. Date Initiated: 04/27/2020 - Engage in relaxation techniques such as deep breathing, grounding in order to reduce anxiety and increase coping Date Initiated: 04/27/2020 - R5 chooses to use west courtyard door to void conflict between other residents. Date Initiated: 01/02/2025 - R5 is encouraged to keep items of high value secured in locked drawer in room Date Initiated: 01/02/2025 - Monitor R5 for changes in behavior such as; expressions of sadness, lack of energy, withdrawn, worry, anxiety, flight of ideas, fast talking and movements. Date Initiated: 08/24/2020 - Provide redirection when inappropriate behaviors exhibited; document behaviors Date Initiated: 01/02/2025 - Re-offer assistance with a referral for behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 04/27/2020 - Work on skills to regulate emotions properly in an effort to reduce making negative statements such as I just want to die. Date Initiated: 10/27/2020 Surveyor noted that the intervention of R5 chooses to use west courtyard door to void conflict between other residents was already initiated on 01/02/2025 and was not effective on 4/7/25 to mitigate conflict that occurred in the courtyard. Surveyor noted the care plan initiated on 4/7/25 is not relevant to the situation of an allegation of abuse. On 5/8/25, at 3:21pm, Surveyor interviewed Social Services (SS)-D regarding what was done after the alleged altercation between R5 and R6 on 4/7/25. SS-D stated that the care plan was updated, and residents were put into separate settings. Staff were advised to supervise R5 and R6 for further issues. On 5/12/25, at 9:27am, Surveyor interviewed Unit Manager (UM)-U who was working when the alleged incident between R5 and R6 occurred. UM-U stated that staff are aware of the issues between R5 and R6. For care plan interventions it was decided that they would keep R5 and R6 apart and use encouragement to help R5 and R6 remain calm. On 5/12/25, at 11:12am, Surveyor interviewed Director of Nursing (DON)-B regarding when a care plan should be updated and was told after a situation occurs. Surveyor asked what was being done to prevent another incident between R5 and R6. Nursing Home Administrator (NHA)-A replied that the residents were educated on policies, options related to other facilities were discussed and it was reinforced that R5 and R6 should go to the courtyard at staggered times so don't run into each other. Surveyor asked if these were added to the care plan and NHA-A replied would have to check. Surveyor noted the interventions staff mentioned of separate settings and keeping R5 and R6 apart were not added to R5's care plan. Surveyor reviewed the Facility Reported Incident dated 4/9/2025 that documents on 4/7/25 around 4:30pm, R5 alleged R6 hit R5 in the courtyard. Residents immediately separated and assessments conducted on both residents. No injuries obtained. Police notified. Investigation started. Surveyor reviewed the Verification of Investigation with the Date of Finding: 4/7/25 that documents within the Summary of Factual Investigative Findings: The care plan has been reviewed and updated. The care team, residents and all parties that were notified are agreeable to the current plan of care. The Plan of Care Update section for R5 and R6 documents Resident provided verbal education of facility rules including to not engage in inappropriate name calling with other residents and to not use the courtyard at the same time as the other resident. Resident counseled to use the courtyard door closest to assigned unit. Surveyor noted that the new Plan of Care Update interventions were not initiated on R6's care plan. Surveyor noted R6's pertinent care plans and interventions were reviewed and none were new on 4/7/25 or after. R6's care plan R6 has a behavior problem issue: Resident chooses not to allow wound care/care/use/wear colostomy supplies, O2, refuses care/showers, refuses appointments/consults, refuses to have weights obtained, uncooperative w/appointments if attends, verbally aggressive w/staff/others, makes racial statements about staff/others, dislikes staff/others, combative w/staff/others @ times, hoards uncovered food, soiled towels/washcloths, throws stool soiled towels/wash cloths against walls, resistive cleaning of room, makes false accusations about staff and other residents was initiated: 08/29/2022. The pertinent intervention of R6 chooses to use east courtyard door to void conflict between other residents was initiated on: 12/19/2023. Surveyor noted that the intervention of R6 chooses to use east courtyard door to void conflict between other residents was initiated on 12/19/23 and did not mitigate conflict that occurred in the courtyard. Surveyor noted while reviewing R6's care plan that 05/23/2024 was the last time an intervention pertinent to R6's behaviors was added to R6's care plan, that is 11 months without new interventions on R6's care plan and no new interventions were noted after the 4/7/25 incident. On 5/8/25, at 3:21pm, Surveyor interviewed Social Worker (SW)-D regarding what was done after the alleged altercation between R5 and R6 on 4/7/25. SW-D stated that the care plan was updated, and residents were put into separate settings. Staff were advised to supervise R5 and R6 for further issues. On 5/12/25, at 9:27am, Surveyor interviewed Unit Manager (UM)-U who was working when the alleged incident between R5 and R6 occurred. UM-U stated that staff are aware of the issues between R5 and R6. For care plan interventions it was decided that they would keep R5 and R6 apart and use encouragement to help R5 and R6 remain calm. On 5/12/25, at 11:12am, Surveyor interviewed Director of Nursing (DON)-B regarding when a care plan should be updated and was told after a situation occurs. Surveyor asked what was being done to prevent another incident between R5 and R6. Nursing Home Administrator (NHA)-A replied that the residents were educated on policies, options related to other facilities were discussed and it was reinforced that R5 and R6 should go to the courtyard at staggered times so don't run into each other. Surveyor asked if these were added to the care plan and NHA-A replied would have to check. Surveyor noted the interventions staff mentioned of separate settings and keeping R5 and R6 apart were not added to R6's care plan. On 5/12/25, at 3:52pm, during the exit meeting with the facility, Surveyor relayed concern of lack of new care plan interventions added after R6 allegedly hit and pinched R5. No additional information was provided regarding R6's care plan interventions being updated after the allegation of abuse occurred on 4/7/25 to prevent future incidences. Smoking Assessments and Care Plan Interventions: R5's care plan documents: R5 is a smoker. - supervised smoker R/T (related to) unsafe behavior. - refuses follow supervised smoking time - resistive to supervised smoking and refuses to allow staff to hold material. - chooses not to follow facility designated smoking location, including doors to enter or exit courtyard as well as smoking policy that was initiated: 04/28/2021. Interventions include: - Instruct R5 about smoking risks and hazards and about smoking cessation aids that are available. Date Initiated: 04/28/2021 - Instruct R5 about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 04/28/2021 - R5 can smoke SUPERVISED. Date Initiated: 04/28/2021 - Monitor oral hygiene. Date Initiated: 04/28/2020 - Notify charge nurse immediately if it is suspected R5 has violated facility smoking policy. Date Initiated: 04/28/2021 Surveyor noted interventions have not been updated since 4/28/2021. On 1/10/25, a Smoking Risk Evaluation was completed for R5. Under Risk Category it is marked that R5 has known history of or current demonstration of unsafe smoking, giving R5 a score of 1. Per the evaluation with a score 1 or greater, risk/IDT (interdisciplinary team) team will review for additional care planning. For the question Is supervision needed? the answer selected is safe to smoke with supervision. For the question Is resident safe to keep any/all smoking materials? the answer selected is yes. For the question Material Storage: the answers selected are resident can keep lighter/matches and resident can keep cigarettes, cigarette materials . Surveyor noted the assessment indicates conflicting information in that it is assessed R5 needs supervision to smoke but that R5 can keep their smoking materials. There is not additional documentation on the assessment to explain assessment responses. On 5/12/25, at 8:34am, Surveyor interviewed Registered Nurse (RN)-S who stated that they try to supervise all smokers but R5 screams about it, won't allow it. On 5/12/25, at 9:27am, Surveyor interviewed Unit Manager (UM)-U regarding the smoking area and if there is supervision. UM-U stated that if a resident needs help someone should be out there with them. On 5/12/25, at 9:45am, Surveyor interviewed R5 about smoking. R5 stated they are not supervised when they go outside to smoke. R5 stated that the facility needs to have more supervision in the smoking area because one lady drops her cigarette butts on the ground then blames R5 and another lady calls R5 the N and B words. Surveyor asked if there were assigned times to smoke with supervision would R5 go out then and was told no, R5 wants to go when R5 wants. Surveyor noted R5's care plan and smoking assessment both indicate R5 needs supervision, however R5 is not supervised to smoke and is allowed to keep their smoking materials. R6's care plan documents R6 is a smoker (supervised), however, Resident chooses not to follow facility designated smoking times as well as smoking policy that was initiated: 04/22/2022. Interventions include: - Resident's smoking materials to be secured by facility staff. Date Initiated: 11/22/2023 - Instruct resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 04/22/2022 - Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 06/13/2022 - Resident chooses not to follow facility designated smoking times as well as smoking policy. Date Initiated: 12/19/2023 - The resident requires SUPERVISION while smoking. Date Initiated: 11/22/2023 Surveyor noted interventions had not been updated since 11/22/2023. On 4/26/24, a Smoking Risk Evaluation was completed for R6. Under Risk Category it is marked that R6 has dexterity problem(s) that could affect smoking, Resident wears oxygen and explain other documents: Cannot always open door but can use door bell to alert staff, giving R6 a score of 2. Per the evaluation with a score 1 or greater, risk/IDT (interdisciplinary team) team will review for additional care planning. For the question Is supervision needed? the answer selected is safe to smoke without supervision. For the question Is resident safe to keep any/all smoking materials? the answer selected is yes. For the question Material Storage: the answer selected is resident can keep cigarettes, cigarette materials . Surveyor noted the smoking assessment indicates risks related to R6's smoking but indicates R6 can smoke & keep materials without supervision. However, R6's care plan indicates R6 requires supervision. Surveyor noted R6's smoking assessment has not been updated/documented as reviewed since 4/26/24. On 5/8/25, at 10:33am, Surveyor observed R6 in the dining room, R6 was not wearing oxygen, which the smoking assessment indicated R6 wore. Surveyor interviewed R6 and asked if they were a smoker to which R6 responded yes. Surveyor asked if they keep their own materials and was told yes, Surveyor asked if they went to the smoking area with supervision and was told R6 is independent and needs no help. On 5/12/25, at 9:27am, Surveyor interviewed Unit Manager (UM)-U regarding the smoking area and if there is supervision. UM-U stated that if a resident needs help someone should be out there with them. Surveyor noted R6's care plan indicates R6 requires supervision and smoking materials are to be secured by facility staff. R6's smoking assessment resulted in a score of 2 yet was coded to not need supervision to smoke and is allowed to keep their smoking materials. On 5/12/25, at 3:52pm, during the exit meeting with the facility, Surveyor relayed concern regarding R5 and R6's care plan and smoking assessments being contradictory.

Based on interview and record review, the Facility did not ensure 1 allegation of resident to resident abuse, involving R5 and R6, of 3 allegations reviewed was reported to the police as a possible suspicion of a crime. R5 made an allegation that R6 hit and pinched them. The Facility reported that the police were called, however, there is no record or documentation to support this occurred. Findings include: Surveyor reviewed the Facility Reported Incident dated 4/9/2025 that documents on 4/7/25 around 4:30pm, R5 alleged R6 hit R5 in the courtyard. Residents immediately separated and assessments conducted on both residents. No injuries obtained. Police notified. Investigation started. Surveyor reviewed the investigation documentation provided by the facility. Surveyor requested the police report involving R5's allegation of abuse from the police department and documentation of the call being made from the Nursing Home Administrator (NHA)-A. The Records Specialist from the [NAME] Police Department reported that there were no calls for service to the address of the facility for the dates of 4/6/25 to 4/8/25. On 5/12/25, at 11:12am, Surveyor interviewed NHA-A regarding the police being contacted. Per NHA-A they cannot locate the sticky note with the documentation of the police call. On 5/12/25, at 3:52pm, during the exit meeting with the facility, Surveyor relayed concern that there is no documentation or evidence that the police were called regarding the allegation of abuse. No additional information was provided regarding the notification of the police regarding R5's allegation of abuse on 4/7/25.

Based on observation, interview and record review the facility did not ensure 1 of 4 residents observed during medication pass had appropriate dispensing of medication that did not break infection control practices. On 3/4/25 at 8:03 a.m. Surveyor observed Registered Nurse (RN)-H dispense R11's medications. RN-H touched each of the pills dispensed for R11 with bare hands. Findings include: The facility's Administering Medications policy with revised date of December 2024. The policy documents . 22. Staff shall follow established facility infection control procedures (e.g handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 3/4/25 at 8:03 a.m. Surveyor observed RN-H dispense R11's medications. Surveyor observed RN-H bare handed open over the counter medications and bare handed touch the medications and placed it in the medication cup. Surveyor observed RN-H pop out medications from the blister pack and into her bare hands then placed it in the medication cup. On 3/4/25 at 1:00 p.m. Surveyor interviewed NHA (nursing home administrator)-A. Surveyor explained the concern RN-H touched medications with her bare hands that were for R11. Surveyor asked if this was proper handling of medications. NHA-A stated this is not the appropriate way to dispense medications.

Based on observation, interview and record review, the Facility did not ensure 1 (R1) of 5 Residents were provided with reasonable accommodations of Resident needs and preferences. *The Facility was aware of R1 having concerns regarding the shower room being too cold for R1 to take a shower, causing R1 to refuse showers. R1 was noted to have 1 documented bed bath in the last 30 days. R1 was not offered or given interventions to allow R1 to stay warm while taking a shower. Findings include: R1 was admitted to the facility on [DATE] with diagnoses which include: excoriation (skin picking disorder), stomatitis, heart failure, dependence on supplemental oxygen and anemia. R1's Annual Minimum Data Set (MDS), dated [DATE], documents R1 has adequate hearing, speech and is able to understand and be understood. R1 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 is cognitively intact. No behaviors exhibited. R1 expressed being able to choose between a tub bath, shower, bed bath or sponge bath, is very important to R1. R1 has no impairment in upper or lower extremities, requires substantial/maximal assistance with shower/bathing. R1 is always incontinent of bladder and has an ostomy device. R1 receives oxygen therapy. R1's quarterly MDS, dated [DATE], documents R1 has verbal behaviors toward others 1 to 3 days, no rejection of care, is supervision or touch assistance with shower/bathing, frequently incontinent of bladder and has an ostomy device. R1 receives oxygen therapy. On 03/03/2025, at 09:35 AM, Surveyor interviewed R1. R1 indicated R1 last had a shower 3 months ago. R1 indicated R1 has been refusing showers due to the shower room being too cold. R1 indicated that R1 has informed staff of this concern and is not offered any solutions or follow up. R1 indicated that R1 will give herself a sponge bath in R1's bathroom but would prefer to take a shower. On 03/03/2025, at 03:13 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-K . CNA-K indicated R1 refuses showers a lot because R1 is cold. CNA-K indicated R1 has not indicated that the shower room is cold, and indicated R1 just says that R1 is cold and refuses to shower. Surveyor reviewed R1's Electronic Health Record (EHR). Surveyor reviewed R1's care plan and noted the following, (R1) has actual for an activities of daily living (ADL) self-care performance/mobility deficit r/t (related to) weakness, Parkinsonism, chronic pain syndrome, RLS (restless leg syndrome), chronic L1 compression fracture, COPD (chronic obstructive pulmonary disorder), chronic respiratory failure. behaviors such as resistance to cares, with interventions that include, Bathing: Physical assist of one. Date Initiated: 05/09/2023 . Locomotion: Uses power Wheelchair-up ad lib in facility, will need assist when getting in and out of the door to courtyard. She also has manual w/c (wheelchair) she is able to propel self with Date Initiated: 09/27/2023 All staff . BATHING/SHOWERING: Resident prefers a shower Date Initiated: 02/21/2023 (R1) has a behavior problem issue: Resident chooses not to allow wound care/care/use/wear colostomy supplies, O2 (oxygen), refuses care/showers, refuses appointments/consults, refuses to have weights obtained, uncooperative w/appointments if attends, verbally aggressive w/staff/others, makes racial statements about staff/others, dislikes staff/others, combative w/staff/others @ (at) times, hoards uncovered food, soiled towels/washcloths, throws stool soiled towels/wash cloths against walls, resistive cleaning of room, makes false accusations about staff and other residents. Date Initiated: 08/29/2022. Surveyor noted Interventions include, . Explain risk and benefits of refusing cares to help resident understand the risk she is taking when refusing cares. Date Initiated: 05/23/2024 . Reapproach if resident refuses cares. Date Initiated: 05/23/2024 (R1) is resistive to care Date Initiated: 06/05/2023 with interventions which include, If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. Date Initiated: 11/06/2023 Surveyor reviewed R1's KARDEX. Surveyor noted R1 shower days are Tuesday and Fridays on PM shift and as needed. Surveyor reviewed the Facility provided document for R1, titled What type of bath did resident receive? with a look back period of 30 days. Surveyor noted R1 should have received showers on 02/04/2025, 02/07/2025, 02/11/2025, 02/14/2025, 02/18/2025, 02/21/2025, 02/25/2025 and 02/28/2025. Surveyor noted on 02/04/2025, 02/07/2025, 02/18/2025 and 02/21/2025 R1 had documented refusals. Surveyor noted on 02/25/2025, R1 received a bed bath. Surveyor noted no information provided as to why R1 refused, if R1 was reapproached, or if risk/benefits were explained to R1 regarding R1's refusal. On 03/04/2025, at 07:20 AM, Surveyor interviewed Maintenance Director-L Maintenance Director-L used Maintenance Director-L's thermometer to measure the temperature of the shower room. Surveyor noted the temperature to read 73.7 degrees Fahrenheit (F). Maintenance Director-L indicated the shower room uses base board radiant heaters and downstairs in the basement is where the master controls are. Surveyor noted Maintenance Director-L took a temperature of the radiant base board, which was 87 degrees F. On 03/04/2025, at 08:23 AM, Surveyor interviewed Maintenance Director-L. Maintenance Director-L indicated Nursing Home Administrator (NHA)-A verbally informed Maintenance Director-L of resident concerns of the shower room being too cold. Maintenance Director-L indicated NHA-A informed Maintenance Director-L of the concerns around January 2025. Maintenance Director-L indicated the shower room heat loss is due to the communal area heating being off and the designated smoking area door open and closing. Maintenance Director-L indicated the Facility was looking into an additional heater for the shower room, and had a contractor come out but are exploring other options as well. On 03/04/2025, at 08:14 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-O. Surveyor asked LPN-O about R1's refusals. LPN-O indicated R1 refuses all cares and showers, weights, everything. LPN-O indicated R1 has expressed concerns regarding the shower room being cold and is why R1 refuses showers. LPN-O indicated LPN-O informed Maintenance verbally regarding R1's concerns of the shower room being cold. LPN-O indicated no interventions can be implemented to assist R1 staying warm to R1's comfort while in the shower room, because R1 just refuses to shower. On 03/04/2025, at 09:56 AM, Surveyor interviewed NHA-A. NHA-A indicated that a couple residents have refused showers due to complaints of the shower room being too cold. NHA-A indicated the Facility has looked into heating lamps for the shower room and has sent information to corporate for options. NHA-A indicated that the temperature in the shower room is being monitored and currently meets regulation. NHA-A indicated the plan moving forward is based on the cost needed to implement a resolution. NHA-A indicated residents could use additional bath blankets and robes going to the shower room. On 03/04/2025, at 02:10 PM, Surveyor informed the Facility of the concerns regarding R1 not receiving a shower in the last 30 days, due to reasonable accommodations not implemented to allow R1 to be warm while taking a shower.

Based on interview and record review the facility did not report 1 (R4) of 2 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. R4 voiced concerns of staff being rough with him. This allegation of mistreatment was not reported to the Nursing Home Administrator or State agency. Findings include: The facility's policy titled, Abuse, Neglect and Exploitation and reviewed/revised 1/5/24 documents under policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section VII Reporting/Response documents A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. R4 was admitted to the facility on [DATE] and discharged on [DATE]. R4's diagnoses includes diabetes mellitus, hemiplegia affect right non dominate side, peripheral vascular disease, depression disorder, atrial fibrillation, and left below knee amputation. R4 does not have an activated power of attorney for healthcare. R4's quarterly MDS (minimum data set) with an assessment reference date of 10/20/24 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R4 is assessed as not having any behavior including refusal of care, eats independently, requires partial/moderate assistance for roll left & right and is dependent for toileting hygiene & chair/bed to chair transfer. R4 is assessed as being frequently incontinent of urine and always incontinent of bowel. On 3/3/25, at 3:24 p.m., Surveyor interviewed Licensed Practical Nurse (LPN)-U regarding R4. LPN-U informed Surveyor she transferred him to the hospital on her shift as he hadn't been taking his medication, hadn't been eating or drinking. LPN-U indicated she asked R4 if it was okay to go to the hospital due to refusals. R4 said yes. LPN-U informed Surveyor she didn't think there were any other issues like his vital signs being off. Surveyor asked LPN-U if R4 complained of knee pain. LPN-U replied yes he had. LPN-U informed Surveyor she made everyone aware and believes the NP (nurse practitioner) gave an order for Voltaren gel. Surveyor inquired if R4 got out of bed. LPN-U informed Surveyor R4 refused to get out of bed, has seen him up but the majority of time he refused. Surveyor asked LPN-U if R4 complained of staff being rough with him. LPN-U replied I think he did due to his pain. LPN-U informed Surveyor sometimes he would refuse anyone to change him and she would have to go in with the CNA (Certified Nursing Assistant). LPN-U informed Surveyor when staff had to check and change R4 he would complain staff was rough due to his pain in his knee. LPN-U informed Surveyor she didn't witness any form of roughness when she would be in with the CNAs. On 3/3/25, at 3:35 p.m., Surveyor interviewed LPN-V regarding R4. LPN-V informed Surveyor R4 didn't do too much, was always in bed and she would go in and speak with him. Surveyor asked LPN-V if R4 complained of staff being rough with him. LPN-V replied yes. Surveyor asked LPN-V after R4 said staff was rough what did you do. LPN-V informed Surveyor she let the girls know if they need assistance to come and get her. LPN-V informed Surveyor she knows she has assisted with cares on the unit when she works. Surveyor asked LPN-V if she reported R4 complained of staff being rough with him. LPN-V replied no. Surveyor asked why she didn't. LPN-V informed Surveyor she put it on the 24 hour report being rough or pairs for cares. On 3/3/25, at 3:37 p.m., Surveyor asked LPN-U if she reported R4 complained of staff being rough to Director of Nursing (DON)-B or anyone else. LPN-U replied no. LPN-U informed Surveyor R4 didn't' want one of the CNAs to take care of him anymore so she replaced that CNA. Surveyor asked LPN-U if she remembers why R4 didn't want the CNA. LPN-U replied no I don't. Surveyor asked LPN-U if she remembers who the CNA was. LPN-U replied no. On 3/4/25, at 10:04 a.m., Surveyor asked Director of Nursing (DON)-B if a resident voices a concern staff is rough to a nurse what should they do. DON-B informed Surveyor they should remove the CNA from care, contact herself or Administrator and then they would do their investigation. Surveyor asked DON-B if anyone reported to her R4 complained of staff being rough with him. DON-B replied no. Surveyor asked if there were any concerns brought to her attention regarding R4. DON-B informed Surveyor he was refusing cares & medication at times and towards the end of his staff he wasn't eating or drinking much. Surveyor informed DON-B of the concern of R4 reporting to LPN-V & LPN-U staff was rough with him. Surveyor asked DON-B no one brought this to your attention? DON-B replied no. On 3/4/25, at 10:59 a.m., Surveyor asked Nursing Home Administrator (NHA)-A if a resident complained of staff being rough what would be done. NHA-A informed Surveyor they would look what occurred, body check, interview. Surveyor asked NHA-A if anyone reported to her R4 complained staff was rough with him. NHA-A replied no. R4's allegation of mistreatment for staff being rough was not report to NHA-A or state agency. No additional information was provided to Surveyor.

Based on interview and record review the facility did not ensure 2 of 2 allegation of abuse, neglect, exploitation or mistreatment involving R4, R9, & R10 were investigated or thoroughly investigated timely. * R4 allegation of staff being rough with him was not investigated. * R9 & R10 resident to resident altercation was not thoroughly investigated. Findings include: The facility's policy titled, Abuse, Neglect and Exploitation and reviewed/revised 1/5/24 documents under policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section V. Investigation of Alleged Abuse, Neglect and Exploitation documents A. An immediate investigation is warranted when allegation of suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s); 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. 1.) R4 was admitted to the facility on [DATE] and discharged on [DATE]. R4's diagnoses includes diabetes mellitus, hemiplegia affect right non dominate side, peripheral vascular disease, depression disorder, atrial fibrillation, and left below knee amputation. R4 does not have an activated power of attorney for healthcare. R4's quarterly MDS (minimum data set) with an assessment reference date of 10/20/24 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R4 is assessed as not having any behavior including refusal of care, eats independently, requires partial/moderate assistance for roll left & right and is dependent for toileting hygiene & chair/bed to chair transfer. R4 is assessed as being frequently incontinent of urine and always incontinent of bowel. On 3/3/25, at 3:24 p.m., Surveyor interviewed Licensed Practical Nurse (LPN)-U regarding R4. LPN-U informed Surveyor she transferred him to the hospital on her shift as he hadn't been taking his medication, hadn't been eating or drinking. LPN-U indicated she asked R4 if it was okay to go to the hospital due to refusals. R4 said yes. LPN-U informed Surveyor she didn't think there were any other issues like his vital signs being off. Surveyor asked LPN-U if R4 complained of knee pain. LPN-U replied yes he had. LPN-U informed Surveyor she made everyone aware and believes the NP (nurse practitioner) gave an order for Voltaren gel. Surveyor inquired if R4 got out of bed. LPN-U informed Surveyor R4 refused to get out of bed, has seen him up but the majority of time he refused. Surveyor asked LPN-U if R4 complained of staff being rough with him. LPN-U replied I think he did due to his pain. LPN-U informed Surveyor sometimes he would refuse anyone to change him and she would have to go in with the CNA (Certified Nursing Assistant). LPN-U informed Surveyor when staff had to check and change R4 he would complain staff was rough due to his pain in his knee. LPN-U informed Surveyor she didn't witness any form of roughness when she would be in with the CNAs. On 3/3/25, at 3:35 p.m., Surveyor interviewed LPN-V regarding R4. LPN-V informed Surveyor R4 didn't do too much, was always in bed and she would go in and speak with him. Surveyor asked LPN-V if R4 complained of staff being rough with him. LPN-V replied yes. Surveyor asked LPN-V after R4 said staff was rough what did you do. LPN-V informed Surveyor she let the girls know if they need assistance to come and get her. LPN-V informed Surveyor she knows she has assisted with cares on the unit when she works. Surveyor asked LPN-V if she reported R4 complained of staff being rough with him. LPN-V replied no. Surveyor asked why she didn't. LPN-V informed Surveyor she put it on the 24 hour report being rough or pairs for cares. On 3/3/25, at 3:37 p.m., Surveyor asked LPN-U if she reported R4 complained of staff being rough to Director of Nursing (DON)-B or anyone else. LPN-U replied no. LPN-U informed Surveyor R4 didn't' want one of the CNAs to take care of him anymore so she replaced that CNA. Surveyor asked LPN-U if she remembers why R4 didn't want the CNA. LPN-U replied no I don't. Surveyor asked LPN-U if she remembers who the CNA was. LPN-U replied no. On 3/4/25, at 10:04 a.m., Surveyor asked Director of Nursing (DON)-B if a resident voices a concern staff is rough to a nurse what should they do. DON-B informed Surveyor they should remove the CNA from care, contact herself or Administrator and then they would do their investigation. Surveyor asked DON-B if anyone reported to her R4 complained of staff being rough with him. DON-B replied no. Surveyor asked if there were any concerns brought to her attention regarding R4. DON-B informed Surveyor he was refusing cares & medication at times and towards the end of his staff he wasn't eating or drinking much. Surveyor informed DON-B of the concern of R4 reporting to LPN-V & LPN-U staff was rough with him. Surveyor asked DON-B no one brought this to your attention? DON-B replied no. On 3/4/25, at 10:59 a.m., Surveyor asked Nursing Home Administrator (NHA)-A if a resident complained of staff being rough what would be done. NHA-A informed Surveyor they would look what occurred, body check, interview. Surveyor asked NHA-A if anyone reported to her R4 complained staff was rough with him. NHA-A replied no. NHA-A & DON-B were unaware of R4's complaint of staff being rough and therefore no investigation was conducted prior to R4 being discharged on [DATE]. No additional information was provided to Surveyor. 38829 2.) R9 was admitted to the facility on [DATE], with diagnoses of Memory Deficit, Following Nontraumatic Intracerebral Hemorrhage, Dysarthria, Essential Hypertension, Vascular Dementia, Major Depressive Disorder, and Unspecified Psychosis. R9 has an activated Health Care Power of Attorney (HCPOA). R9's 5 day Minimum Data Set (MDS) completed 2/19/25 documents R9's Brief Interview for Mental Status (BIMS) score to be a 4 indicating R9 is severely impaired for daily decision making. R9 has no mood or behaviors documented. R9 has no range of motion concerns. R9 is occasionally incontinent of bladder and always incontinent of bowel. R9 is independent with transfers and mobility and is ambulatory. R10 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Unspecified Atrial Fibrillation, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Chronic Kidney Disease, Peripheral Vascular Disease, Vascular Dementia, Major Depressive Disorder, and Anxiety Disorder. R10 has an activated Health Care Power of Attorney (HCPOA). R10's MDS completed 2/1/25 documents R10's BIMS score to be 3, indicating R10 is severely impaired for daily decision making. R10 has no mood or behaviors documented. R10 has no range motion concerns. R10 requires partial/moderate assistance for transfers and mobility. R10 is always incontinent of bowel and bladder. R10 uses a wheelchair for locomotion. Surveyor reviewed the Misconduct Incident Report submitted on 1/17/25. The report documents that on 1/12/25, R9 struck R10 in the face at approximately 2:30 PM. Staff intervened and separated R9 and R10 to maintain safety. Assessments were completed and the police were notified. R10 was noted to have a chin abrasion and slight swelling to the left side of R10's face. Surveyor notes the Misconduct Incident Report submitted does not contain any names of witnesses to the incident. There is 1 statement from Housekeeper (HSK)-F that documents HSK-F was coming down the hall by the activity room and HSK-F saw R9 strike R10 in the face. HSK-F took R10 to R10's room and a CNA took R9 away. There are no other staff statements. Surveyor received the working schedule for 1/12/25 to review. It is unclear who was assigned to R9 and R10 as the shift assignment details are blank for all 3 shifts. Surveyor notes there is documentation in the report of where R9 and R10 reside and what staff was assigned to either or both of R9 and R10 on that day, prior to and at the time of the altercation. Registered Nurse (RN)-G documented in R9's progress notes that RN-G was informed by staff on Unit 2 that R9 slapped another Resident on the other unit. Interventions were for R9 to be placed on 1:1 supervision on the PM shift and conduct a 2 day sleep study. Sleep study indicated R9 is awake and wanders throughout the facility mid-morning through PM shift. The care plan was reviewed and updated. Director of Nursing (DON)-B documented that DON-B sent an email to activities to update R9's activity preference and increase offering preferred activities during high wandering times. Surveyor reviewed R9's comprehensive care plan. 1.) (R9) has little or no activity involvement due Resident wishes not to participate-Initiated 3/5/24 -The last intervention was initiated on 6/5/24. -No interventions were updated since the 1/12/25 Resident to Resident altercation 2.) (R9) is resistive to care, refuses medications, treatments due to memory deficit-Initiated 8/15/24 -The last intervention was initiated on 12/2/24. -No interventions were updated since the 1/12/25 Resident to Resident altercation 3.) (R9) has a behavior problem due to refusing staff to clean room, or letting staff assist with getting dressed-Initiated 12/11/24 -Praise any indication of Resident's progress/improvement in behavior-Initiated 2/24/25 4.) (R9) has a mood problem due to vascular dementia. ie. being sexually inappropriate with female Residents(exposing self). Monitor psychosocial wellbeing due to peer-peer altercation-Initiated 2/28/24 -Monitor psychosocial wellbeing. Report any altercations and notify provider to determine if any other interventions are recommended-Initiated 1/13/25 Surveyor notes the 2 updated interventions for R9 are challenging given R9's cognitive status is severely impaired for daily decision making. Surveyor reviewed R9's psychiatric notes. On 1/6/25, Psychiatric Nurse Practitioner (PsychNP)-M documented that R9 has become more difficult again. Refusing medication and wanders the halls ambulating independently. Staff reports no physical or verbal behaviors and difficult to redirect at times. PsychNP-M recommends to continue current medications. On 2/3/25, PsychNP-M documented staff report behaviors have better. R9 had a peer to peer interaction and is not taking medications consistently. Recommendation was to monitor for symptoms of psychosis and visual or auditory hallucinations. On 3/4/25, at 10:52 AM, Surveyor reviewed R9 and R10's Misconduct Incident Report with Nursing Home Administrator (NHA)-A. NHA-A confirmed NHA-A is the abuse coordinator. NHA-A does not remember what nurse reported the altercation between R9 and R10. NHA-A initially indicated that HSK-F was an agency employee and does not know who it was. Surveyor shared the concern that there are no witnesses listed in the Misconduct Incident Report, however, HSK-F witnessed the altercation between R9 and R10. Surveyor shared that there are no other staff statements describing R9's behavior before, during, and after the altercation in order to get a grasp of what may have triggered R9 to strike R10. There are no staff statements of what R10 was doing at the time or describing R10's behaviors before, during, and after the altercation. Shared that the investigation of R9 and R10 was not a thorough investigation with a root/cause analysis of the altercation. On 3/4/25, at 12:01 PM, NHA-A shared with Surveyor that neither R9 or R10 recalled the incident. NHA-A informed Surveyor that technically we didn't have to report based on the Resident to Resident diagram guidelines. We reported out of good faith. Surveyor notes that R9 hitting R10 on the side of the face meets the definition of willful and R10 suffered physical injury as indicated in the incident report that R10 sustained a chin abrasion and swelling to the left side of R10's face. At this time, the facility has not provided additional information.

Based on interview and record review the facility did not ensure 1 (R7) of 8 residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the residents choice. * On 3/3/25 R7 was not wearing tubigrips according to R7's physician orders and plan of care. Findings include: R7's diagnoses includes hemiplegia and hemiparesis following cerebral infarction, aphasia, vascular dementia, anxiety disorder, and paranoid schizophrenia. R7's actual ADL (activities daily living) self-care performance/mobility deficit care plan initiated documents an intervention * Dressing: Physical Assist of 1 -Tubigrips on in AM (morning) off HS (hour sleep) -Wears glasses. Initiated 9/9/22. R7's physician order dated 5/16/23 documents Tubigrips on in the AM and off at HS. In the morning for edema on and in the evening for edema off. R7's quarterly MDS (minimum data set) with an assessment reference date of 1/27/25 has a BIMS (brief interview mental status) score of 3 which indicates severe impairment. R7 is assessed as being dependent for lower body dress and putting on/taking off footwear. R7's Certified Nursing Assistant (CNA) Kardex as of 3/3/35 under the section Dressing/Splint Care documents * Dressing: Physical Assist of 1 -Tubigrips on in AM (morning) off at HS (hour sleep) - wears glasses. * Apply tubigrips. * Remove tubigrips. On 3/3/25, at 9:30 a.m., Surveyor observed R7 with his eyes closed & wearing glasses, leaning towards the right in a wheelchair at a table in the dining room with the TV. Surveyor observed R7 is wearing beige grippers socks and slippers. Surveyor observed R7 is not wearing tubigrips. On 3/3/25, at 9:59 a.m., Certified Nursing Assistant (CNA)-S approached R7 who was sitting in a wheelchair in the dining room stating to R7 she going to take your weight. CNA-S wheeled R7 away from the hallway and down the hallway. Surveyor observed R7 is not wearing tubigrips. On 3/3/25, at 10:29 a.m., Surveyor observed R7 continues to be sitting in a wheelchair in the dining room with his head towards the right and eyes closed. Surveyor observed R7 continues to be wearing beige gripper socks with slippers. R7 is not wearing tubigrips. On 3/3/25, at 11:33 a.m., Surveyor observed CNA-S wheel R7 out of the dining room, down the hallway, and into R7's room. From 11:36 a.m. to 11:46 a.m. Surveyor observed CNA-S and [NAME] Clerk Secretary/CNA-R transfer R7 from the wheelchair onto the toilet using a sit to stand lift, provide continence care for R7, and transfer R7 back into the wheelchair. Surveyor observed during this observation R7 was not wearing tubigrips. On 3/3/25, at 12:19 p.m., Surveyor observed Licensed Practical Nurse (LPN)-P provide R7 with his lunch. Surveyor observed R7 is still not wearing tubigrips and has beige gripper socks with slippers on his feet. On 3/3/25, at 1:48 p.m., Surveyor observed R7 sitting in a wheelchair at a table in the dining room. R7 continues to be wearing beige gripper socks with slippers and does not have tubigrips on. On 3/3/25, at 3:39 p.m., Surveyor observed R7 rolling back & forth in the wheelchair in the dining room with the TV. Surveyor observed R7 still does not have tubigrips on. On 3/4/25, at 7:27 a.m., Surveyor observed R7 dressed for the day being wheeled down the hallway. Surveyor observed R7 is wearing tubigrips. On 3/4/25, at 7:28 a.m., Surveyor asked CNA-T when is R7 suppose to have tubigrips on. CNA-T informed Surveyor R7 gets them on during the day and is suppose to come off at night. On 3/4/25, at 9:58 a.m., Surveyor asked Director of Nursing (DON)-B is the expectation staff follow a residents care plan and Kardex. DON-B replied yes. Surveyor informed DON-B Surveyor noted R7's care plan and Kardex documents tubigrips on AM and off HS. Surveyor did not observe R7 having the tubigrips on yesterday (3/3/25). DON-B informed Surveyor there is also an order for the nurses. On 3/4/25, at 10:15 a.m., Surveyor reviewed R7's March 2025 TAR (treatment administration record). Surveyor noted tubi grips are checked & initialed as being on in the AM and checked & initialed as off on 3/3/25. On 3/3/25 R7 did not have tubigrips on.

Based on observation, interview, and record review the facility did not ensure 1 (R2) of 1 Residents reviewed with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. *R2 was observed not wearing R2's right hand splints to prevent further decrease in range of motion. Findings Include: Surveyor reviewed the facility policy and procedure Range of Motion Exercises revised 10/2010 which documents: .Documentation The following information should be recorded in the Resident's medical record: 4. Whether the exercise was active or passive. 7. Any problems or complaints made by the Resident related to the procedure. 8. If the Resident refused the treatment, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. Reporting 1. Notify the supervisor refuses the exercises. 2. Report other information in accordance with facility policy and professional standards of practice. R2 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Chronic Obstructive Pulmonary Disease, Essential Hypertension, Alcohol Dependence, Depression, and Anxiety Disorder. R2 is currently his own person. R2's Quarterly Minimum Data Set (MDS) completed 1/6/25 documents R2's Brief Interview for Mental Status (BIMS) score to be 13, indicating R2 is cognitively intact for daily decision making. R2's Patient Health Questionnaire(PHQ-9) score is 1 indicating minimal depression. No behaviors are documented for R2. R2 is always incontinent of bladder and occasionally incontinent of bowel. R2 has range of motion (ROM) impairment on 1 side of both upper and lower extremity. R2 requires set-up for eating, and is dependent for showers, lower dressing, hygiene, and transfers. R2 is substantial/maximum for upper dressing and mobility. R2's MDS does not document R2 has splint or brace assistance. On 3/3/25, at 9:25 AM, Surveyor observed R2 in a wheelchair with a significantly right hand contracture. All of R2's fingers are contracted in except for the second finger, the index. R2 is not wearing a splint on the right hand. R2's Kardex as of 3/3/25 does not document R2 has a right hand splint. Surveyor reviewed R2's current comprehensive care plan. -R2 has actual for an activities of daily living (ADL) self-care performance/mobility deficit due to CVA right side weakness/hemiplegia. 12/28/21 This focused problem does not document an intervention for R2 to wear a splint on the right hand. R2's Occupational Therapy (OT) Discharge Summary dated 1/28/25 and signed by Occupational Therapist (OT)-E documents: Skilled Interventions Provided: Manual stretch to right upper extremity(RUE) to facilitate joint extension and prevent contractures, assessment of RUE hand splint fit, tolerance and establishment of restorative RUE ROM program, splint program, caregiver education in splint application, wear schedule and precautions. Patient Progress: (R2's) functional performance has improved as a result of instruction in compensations, modifications and adaptations. Communication: Reviewed (R2's) plan of treatment and treatment services with interdisciplinary team members. Discharge Recommendations and Status: Right hand splint wear recommended during waking hours as tolerated to enhance finger extension. Caregivers shall provide Upper Extremity ROM during cares, routine hand washing and skin and nail assessment during routine cares. ROM program established and trained on right hand splint wear. Splint and Brace program established on right hand splint wear. Prognosis: Prognosis to maintain current level of functioning=good with consistent staff follow-through. Caregivers verbalize understanding of right upper extremity ROM and splinting application, care and wear schedule. Surveyor notes that OT notes documented R2 tolerated wearing the right hand splint. The Therapy Referral to Restorative Nursing Program or Functional Maintenance Program Form dated 1/28/25 and signed by Occupational Therapist (OT)-E documents: Recommended Program-ROM and Splint/Brace Precautions-Monitor nail length and skin integrity Range of Motion Extremity-Right Upper-Passive ROM-2 sets of 10 repetitions 2 times a day. Splint/Brace Right Upper-right hand-ROM during routine cares, assess skin/nail length -right hand splint as tolerated during waking hours Surveyor reviewed R2's resolved comprehensive care plan. (R2) is at risk for developing impairment in functional joint mobility due to generalized weakness, discomfort when moving, poor motivation, inactivity related to history of CVA. (R2) has a contracture note to right upper extremity and requires passive range of motion (PROM). 8/24/23 Initiated 2/10/25 Resolved Interventions: -Assess skin/nail length when applying/removing splint. Cut fingernails as needed. Initiated 1/30/25 Resolved 2/10/25 -PROM-maintain good body alignment. Provide PROM to right shoulder/elbow/wrist/hand as tolerated. Perform in slow and smooth motion. Initiated 8/9/24 Resolved 2/10/25 -Right hand splint as tolerated during waking hours Initiated 1/30/25 Resolved 2/10/25 Surveyor notes there is no documentation as to why OT-E recommends the right hand splint to maintain current level of functioning for the contracture on 1/28/25 and R2's care plan documents wearing the right hand splint is resolved on 2/10/25. On 2/25/25, MSN/APRN/FNP (MAF)-I completed a comprehensive assessment on R2 and documented: .(R2) has a splint for (R2's) right hand to wear daily. Encouraged to wear daily to prevent contractures. Assisted with placing splint onto (R2's) right hand. No changes made to plan of care. Diagnostic Statement: Contracture, right hand Plan: Contracture right hand due to past stroke with hemiplegia on right side. Plan of care: Continue splint use daily. Follow-up with Physiatry department as recommended. OT as needed. Keep nails short. Continue ROM exercises daily. On 3/3/25, at 10:25 AM, Surveyor did not observed R2 wearing a splint on the right hand. On 3/3/25, at 12:05 AM, Surveyor asked R2 if R2 has a right splint. R2 stated, I think it doesn't fit and I have to get a new one. Surveyor notes R2 does not have splint on the right hand, but observed a splint on R2's counter in R2's room. On 3/3/25, at 1:02 PM, OT-E confirmed that R2 has a splint for the right hand and should be wearing the splint. Staff should know to put the splint on. OT-E stated R2 occasionally will not wear the splint. On 3/4/25, at 7:43 AM, Surveyor observed R2 not wearing the right hand splint. Surveyor observed the hand splint on R2's counter next to the closet in R2's room. On 3/4/25, at 8:16 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C. ADON-C stated that the care plan to wear the right hand splint was resolved because R2 refused to wear the splint on a regular basis. Surveyor shared the concern there is no documentation that R2 was refusing to wear the right hand splint and no documentation of interventions to re-approach R2 to wear the splint. ADON-C stated ADON-C will look for documentation. On 3/4/25, at 8:35 AM, Surveyor interviewed Social Worker (SW)-J in regards to R2. SW-J stated that SW-J is unaware of any recent behaviors and has been compliant with cares. On 3/4/25, at 9:35 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D in regards to R2. CNA-D confirmed CNA-D provides cares to R2 on a regular basis. CNA-D confirmed that R2 has a splint for R2's right hand. CNA-D stated that when R2 has refused to wear the right hand splint, CNA-D has informed the nurse, but not everytime. On 3/4/25, at 9:47 AM, Surveyor interviewed R2. Surveyor asked R2 if R2 would wear the right hand splint. R2 stated that R2 would wear the right hand splint, but they have to help me put it on. I can't do it. I don't want it to get worse. Surveyor asked R2 if they offered today to put on the right hand splint and R2 stated, No. Surveyor observed all fingers are significantly contracted in on the right hand except for the index finger. R2's nails appear to be making significant contact with R2's inner palm. On 3/4/25, at 10:41 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated if a Resident refuses cares, the CNA updates the nurse. The nurse updates the physician of refusals and it is placed on the 24 hour board or in the Resident progress notes. It should be documented. On 3/4/25, at 10:52 AM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R2 has not been wearing R2's right hand splint during the survey process and there is no documentation that R2 has been refusing to wear the right hand splint. On 3/4/25, at 2:09 PM, Surveyor again shared the concern with NHA-A and DON-B the concern that R2 has a right hand contracture and has not received appropriate treatment and services to prevent further decrease in range of motion by observations of R2 not wearing the right hand splint.

Based on observation, interviews and record review the facility did not ensure 1 (R1) of 1 residents reviewed for colostomy, urostomy or ileostomy services, received care consistent with professional standards of practice. *R1 was not provided ostomy supplies and R1 ordered ostomy supplies from (community pharmacy name) & R1 was provided the incorrect ostomy supplies, per R1's order. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], documents R1 has verbal behaviors toward others 1 to 3 days, no rejection of care, is supervision or touch assistance with shower/bathing, frequently incontinent of bladder and has an ostomy device. R1 receives oxygen therapy. On 03/03/2025, at 09:35 AM, Surveyor interviewed R1. R1 indicated The Facility ran out of R1's ostomy supplies. R1 indicated that Staffing Coordinator/CNA-N indicated to R1 that the supplies were stolen. R1 indicated that R1 had to make an order for delivery from (community pharmacy name) for R1's ostomy supplies, and is waiting for the order to arrive. R1 indicated R1 is currently using paper towels and washcloths in place of ostomy supplies. R1 indicated R1 last had a shower 3 months ago. R1 indicated R1 has been refusing showers due to the shower room being too cold. R1 indicated that R1 has informed staff of this concern and is not offered any solutions or follow up. Surveyor reviewed R1's Electronic Health Record (EHR). Surveyor reviewed R1's care plan and noted the following, . has actual for an activities of daily living (ADL) self-care performance/mobility deficit r/t (related to) weakness, Parkinsonism, chronic pain syndrome, RLS (restless leg syndrome), chronic L1 compression fracture, COPD (chronic obstructive pulmonary disease), chronic respiratory failure. behaviors such as resistance to cares, with interventions that include, -Bathing: Physical assist of one. Date Initiated: 05/09/2023 . Locomotion: Uses power Wheelchair-up ad lib in facility, will need assist when getting in and out of the door to courtyard. She also has manual w/c (wheelchair) she is able to propel self with Date Initiated: 09/27/2023 All staff . BATHING/SHOWERING: Resident prefers a shower Date Initiated: 02/21/2023 . has a behavior problem issue: Resident chooses not to allow wound care/care/use/wear colostomy supplies, O2 (oxygen), refuses care/showers, refuses appointments/consults, refuses to have weights obtained, uncooperative w/appointments if attends, verbally aggressive w/staff/others, makes racial statements about staff/others, dislikes staff/others, combative w/staff/others @ (at) times, hoards uncovered food, soiled towels/washcloths, throws stool soiled towels/wash cloths against walls, resistive cleaning of room, makes false accusations about staff and other residents. Date Initiated: 08/29/2022. Surveyor noted Interventions include, . Explain risk and benefits of refusing cares to help resident understand the risk she is taking when refusing cares. Date Initiated: 05/23/2024 . Reapproach if resident refuses cares. Date Initiated: 05/23/2024 . is resistive to care Date Initiated: 06/05/2023 with interventions which include, If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. Date Initiated: 11/06/2023 . has an ostomy to RLQ (right lower quadrant) r/t hx (related to history of) bowel obstruction Date Initiated: 04/22/2022, interventions include, Resident chooses not to follow correct protocol for ostomy care. Removes her ostomy bag catching her stool with towels and paper towels causing her skin irritation, incontinence. Date Initiated: 07/11/2023 . prefers to self-care of her colostomy. Offer assist of 1/help if she appears to be struggling. Date Initiated: 05/24/2023. On 03/03/2025, at 10:45 AM, Surveyor checked back in with R1. At this time R1 expressed being uncomfortable due to the paper towels and wash cloth R1 was using in place of R1's colostomy supplies. Surveyor observed R1 had bowel contents that leaked through onto R1's gown. R1 indicated that R1 does not refuse to wear R1's colostomy bags but does refuse staff assistance with the care of R1's colostomy. On 03/03/2025, at 11:50 AM, Surveyor interviewed Staffing Coordinator/CNA-N. Staffing Coordinator/CNA-N indicated The Facility does not have a stock supply of colostomy supplies, and indicated only 2 residents in the Facility require ostomy supplies. Staffing Coordinator/CNA-N indicated Staffing Coordinator/CNA-N only orders supplies for 1 of the 2 residents. Staffing Coordinator/CNA-N indicated R1's ostomy supplies come through (name of supplier) and are on auto order around the beginning of the month every month. Staffing Coordinator/CNA-N indicated R1 likes to use 4-5 bags per day and is always requesting a new one, which has caused R1 to run out early. Staffing Coordinator/CNA-N indicated once R1's supplies come in Staffing Coordinator/CNA-N will bring them to the nurses station and R1's ostomy supplies are kept behind the nurses station. Staffing Coordinator/CNA-N indicated Staffing Coordinator/CNA-N was unsure who would be responsible to call and request a quantity increase for R1's ostomy supplies. Staffing Coordinator/CNA-N indicated Staffing Coordinator/CNA-N is unsure of how many ostomy supplies R1 has at this time. On 03/03/2025, at 12:01 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-P. Surveyor asked LPN-P to show Surveyor where R1's ostomy supplies are kept. LPN-P indicated R1's ostomy supplies are kept in Staffing Coordinator/CNA-N's office and indicated R1 currently does not have any ostomy supplies in the nurses station or medication room. LPN-P indicated R1 should receive 1 ostomy bag per shift. LPN-P indicated that Agency staff have given R1 a whole box in the past and R1 would go through them too fast. On 03/03/2025, at 12:03 PM, Surveyor interviewed LPN-O. LPN-O indicated R1's colostomy supplies are kept in the schedulers office. LPN-O indicated R1 goes through colostomy supplies frequently and is suppose to be given 2 per day. On 03/03/2025, at 12:41 PM, Surveyor interviewed Staffing Coordinator/CNA-N. Staffing Coordinator/CNA-N indicated Staffing Coordinator/CNA-N does not have any ostomy supplies for R1 in Staffing Coordinator/CNA-N office at this time. Staffing Coordinator/CNA-N indicated that Staffing Coordinator/CNA-N called (name of supplier) this morning and is now waiting on insurance. Staffing Coordinator/CNA-N indicated R1 last received R1's colostomy supplies, about 1 month ago. On 03/03/2025, at 12:49 PM, Surveyor interviewed LPN-O. Surveyor asked LPN-O if R1 had been given an ostomy supplies yet. LPN-O indicated that the R1 had not asked for any supplies and LPN-O did not give R1 any supplies. On 03/03/2025, at 12:52 PM, Surveyor was in R1's room and noted R1 to have light brown, liquid matter, on R1's gown in the area of R1's colostomy. R1 indicated R1 should be receiving R1's (community pharmacy name) order for R1's colostomy supplies by this evening. LPN-P then came into R1's room with a single system colostomy bag. LPN-P indicated R1's colostomy supplies were located on another unit, and R1 has 2 bags left. R1 confirmed the single system colostomy device provided by LPN-P, is the same that R1 has been using. Surveyor reviewed R1's orders and noted the following, Please provide 2 pouch ostomy supplies every shift for ileostomy encourage to keep the wafer in place and change the ostomy bag only if soiled. CHANGE Wafer every 7 days -Order Date- 02/11/2025 1743. Surveyor reviewed the Facility provided document, titled *eMar - Medication Administration Note, dated 03/01/2025, and documents not available. Surveyor noted progress note was written by LPN-O. Surveyor reviewed the Facility provided document, titled Delivery Ticket/ DME (durable medical equipment) Certification Receipt Form, documents R1 received 1- Ostomy skin powder, 30-One-piece drainable pouch, cut to fit stoma and 25- skin barrier wipes on 02/04/2025. On 03/04/2025, at 08:14 AM, Surveyor interviewed LPN-O. LPN-O indicated R1 was given the last of R1's ostomy supplies last night. Surveyor asked LPN-O about LPN-O 's progress note on 03/01/2025, that indicated R1's ostomy supplies were not available. LPN-O indicated R1 did not have ostomy supplies available at that time. LPN-O informed Surveyor that R1 doesn't even use a wafer system as per R1's order. Surveyor asked LPN-O what LPN-O would do if LPN-O had questions regarding an order. LPN-O indicated LPN-O would ask Director Of Nursing (DON)-B or the provider who put in the order. LPN-O indicated LPN-O did not ask DON-B or the provider regarding R1's order. Surveyor asked LPN-O about R1's refusals. LPN-O indicated R1 refuses all cares and showers, weights, everything. On 03/04/2025, at 08:33 AM, Surveyor interviewed DON-B and Assistant Director Of Nursing (ADON)-C. DON-B indicated R1's colostomy order indicates to change R1's wafer every 7 days and supply 2 pouch system every shift. DON-B indicated R1's insurance will only cover 1 pouch per day. DON-B indicated that if R1 needs an increase in quantity, nursing staff is responsible for contacting community care. DON-B indicated staff should use Facility stock ostomy supplies for a resident if the resident runs out of ostomy supplies. Surveyor indicated to DON-B that Surveyor was informed by Staffing Coordinator/CNA-N that the Facility does not have a stock supply of ostomy supplies. DON-B indicated the Facility should have stock ostomy supplies and would look into it. DON-B then indicated that R1 does not use a wafer and uses the single system ostomy device. DON-B indicated DON-B would need to clarify the order and get back to Surveyor. On 03/03/2025, at 08:50 AM, DON-B came to Surveyor and informed Surveyor that Nurse Practitioner (NP)-Q would like to speak with Surveyor via phone. NP-Q informed Surveyor that NP-Q put in the order for R1 to be provided a wafer and bag, a 2 device system, for colostomy supply. NP-Q indicated NP-Q ordered R1 to have the 2-part system, with a wafer to encourage R1 to allow R1 to keep the wafer on to promote skin integrity, while allowing R1 to just change the bag of the device. NP-Q indicated R1 has reoccurring cellulitis around R1's stoma. NP-Q indicated R1 needs to be provided education regarding the importance of using the 2-system device to encourage R1's independence and promote skin integrity. NP-Q indicated using the 2-system device would hinder R1 from having to repeatedly rip off the 1 system device each time to change the bag. On 03/04/2025, at 09:56 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A indicated that R1's insurance covers 1 ostomy bag per day. NHA-A indicated nursing staff is responsible for ensuring ostomy supplies are ordered. On 03/04/2025, at 02:10 PM, Surveyor informed the Facility of concerns regarding R1 not having ostomy supplies, having the ordered ostomy supplies and R1 having to order ostomy supplies. DON-B indicated R1's order has been updated and community care has been contacted to update R1's order to the correct ostomy supplies.

Based on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and do not develop pressure ulcers for 2 (R37 and R71) of 7 residents reviewed for pressure injuries. * R37 was admitted from the hospital on 11/16/23 with multiple deep tissue pressure injuries from a medical device. On 11/17/23, the wound MD ordered treatment for the deep tissue pressure injuries which was not entered into R37's medical record until 11/20/23 with treatments not being signed out as completed until 11/27/23. The November and December Treatment Administration Record (TAR) indicated 8 of the 13 days where treatment was not signed as being completed. R37 was noted to have a 20 pound weight discrepancy between the hospital discharge paperwork and R37's admission weights, with a total 32.2 pound weight loss which was not address by the dietitian. (Cross Reference F692) The hospital notes also indicated R37 was moderate assist with bed mobility. The facility initiated care plans addressing Activities of Daily Living and Actual Impaired Skin Integrity however the facility did not implement interventions to assist with turning and repositioning R37. On 12/14/23, developed an Unstageable pressure injury to the left gluteal, treatment was ordered along with an order for an air mattress. Nursing staff documented on the functioning of the air mattress every shift from 12/14/23 until 12/20/23 even though the air mattress was not placed on R37's bed until 12/20/23. *R71 was admitted with a Stage 4 pressure injury to the right heel that was not comprehensively assessed weekly from 11/1/2023 until 11/10/23. There was no assessment of the pressure injury readmission on 11/16/23 until 11/20/23. There was no treatment order in the record from 11/16/23 (readmitted ) until 11/22/23 however LPN IP-P indicated she did treatment to the pressure injury sometime between 11/16-11/20/23 based off of a previous podiatry order. R71's record did not document as to what date between 11/16 and 11/20/23 this treatment was done. Findings include: The facility policy and procedure entitled Wound Care from MED-PASS (C)2001 revised October 2010 states: Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which he resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. The facility policy and procedure entitled Pressure Ulcer Documentation Guidelines undated states: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. When charting a description of a pressure ulcer, the following components should be a part of you weekly charting. 1. LOCATION 2. STAGE: Indicate the stage as I, II, III, IV, Unstageable or Suspected Deep Tissue Injury (DTI). This staging system should be used to describe pressure ulcers ONLY. 3. DIMENSIONS: Always measure length, width, and depth and document it in that order. Always recorded in centimeters. 5. WOUND BASE DESCRIPTION: describe the wound bed appearance. If the wound base has a mixture of these, use the percentage of its extent (i.e., the wound base is 75% granulation tissue with 25% slough tissue). 11. NOTIFICATION: Notify the Physician/NP, Interdisciplinary Team and Family/Designee when a pressure ulcer develops, shows no improvement in 2-4 weeks, declines or heals. 1. R37 was admitted to the facility on [DATE] with diagnoses of left knee hemarthrosis, anxiety, depression, rheumatoid arthritis, osteoporosis, and anemia. R37's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R37 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had four deep tissue pressure injuries (DTI) on admission. R37 had a brace to the left knee which caused the DTIs on the left leg and the right leg DTIs were from the right leg pressing up against the brace on the left leg. R37's hospital discharge paperwork stated R37 presented to the hospital with left knee pain after a fall at home and was unable to bear weight due to the pain. X-ray imaging indicated hemarthrosis and R37 was brought in for observation due to inability to ambulate with premorbid challenges with ambulation. Physical and Occupational Therapy worked with R37 and identified the need for placement in a skilled nursing facility for short-term rehab. The hospital Physical Therapy note stated R37 was moderate assist with bed mobility to bring lower extremities to the edge of the bed and back due to pain. R37 was unable to transfer due to pain. R37's hospital weight was 165 pounds. On 11/17/2023, R37 weighed 185.7 pounds and on 11/19/2023, R37 weighed 185.4 pounds. Surveyor noted the discrepancy of 20 pounds between the hospital weight (165 pounds) and the facility weight (185.4 pounds). R37's Activities of Daily Living Care (ADL) Plan was initiated on 11/16/2023 with the focus that R37 was non-weight bearing to the left lower extremity and no interventions were implemented for the level of assistance needed for bed mobility. R37's Actual Impairment to Skin Integrity Care Plan was initiated on 11/16/2023 with the following interventions: -Evaluate and treat per physician's orders. -Evaluate resident for signs/symptoms of possible infections. Surveyor noted R37 did not have an intervention to address turning and repositioning even though the hospital discharge notes indicate R37 was moderate assist with bed mobility and that R37 was noted to have an Actual Skin Impairment care plan, an ADL care plan indicating R37 was non-weight bearing to the left lower extremity. On 11/16/2023 on R37's Nursing Evaluation (Admit/Readmit, Qtly, Annual, Sig Change) on the Skin Integrity section of the form, Licensed Practical Nurse (LPN) Supervisor (Sup)-O documented R37 had two small DTIs to the right shin, a DTI to the left shin, and a DTI to the right rear calf. On 11/16/2320 on R37's Wound Evaluation form, LPN Infection Preventionist (IP)-P documented DTIs to the following areas: right medial calf, front right lateral lower leg distal, right shin, and front left lateral lower leg. In an interview on 12/21/2023 at 1:53 PM, LPN IP-P stated LPN IP-P takes a picture of each wound that records measurements and Wound Physician-J sees R37 the following day and takes their own measurements of the area. LPN IP-P stated LPN IP-P goes back to the previous day's facility assessment and adds Wound Physician-J's measurements to the Wound Evaluation form in the notes section. LPN IP-P stated the picture measurement is different from Wound Physician-J's measurements because LPN IP-P was not sure what the camera actually captures. On 11/17/2023, R37 was seen by Wound Physician-J for the initial visit and each of the four wounds was comprehensively assessed. Wound Physician-J documented the treatment plan for each DTI was to apply border foam three times a week. Surveyor noted treatment orders for the four DTI pressure wounds were not entered into R37's medical record until 11/20/2023 and the treatments were not signed out as completed until 11/27/2023, ten days after admission. Review of the November and December TAR had treatments to the four DTI pressure injuries signed out as completed 5 times out of 13 days treatments were due to be administered; 8 of the 13 days treatments were due were blank on the TAR. Wound Physician-J comprehensively assessed R37's pressure injuries weekly except on 11/30/2023 when R37 was out of the facility for an appointment. On 11/29/2023 LPN IP-P obtained measurements of the DTIs with the camera. No documentation was found indicating the wounds were assessed by and Registered Nurse or Wound Physician. R37's Activities of Daily Living Care Plan (ADL) was revised on 11/20/2023 with the following interventions: -Bed Mobility: quarter side rail or enabler/assist bar to improve mobility. -Bed Mobility: independent. Surveyor noted R37's care plan did not have an intervention to address turning and repositioning even though the ADL care plan indicated R37 needed quarter side rail or an enabler/assist bar to improve bed mobility which they also indicated as independent. On 12/4/2023, R37 weighed 153.4 pounds, a 32.3 pound weight loss, or 17.4%. Registered Dietician (RD)-I requested a re-weight on 12/6/2023. Surveyor noted no further weights were documented. On 12/14/2023 at 8:47 PM in the progress notes, nursing charted R37 had a new open area to the left buttock that measured 0.25 cm x 1 cm. R37 was unaware of the wound. There was no assessment of the wound bed. The Nurse Practitioner was notified, and the area was cleaned with normal saline and foam border dressing was applied. An air mattress was ordered. The nursing order to check the air mattress for function was entered onto the TAR on 12/14/2023 with nursing signing out the air mattress was functioning every shift. Surveyor noted each shift was signed out on the TAR by nursing staff indicating they were checking the air mattress. On 12/15/2023, R37 was seen by Wound Physician-J via telemedicine. The Unstageable pressure injury to the left buttock measured 1.11 cm x 0.72 cm x 0.1 cm with 100% slough to the wound bed and moderate serous drainage. The note attached to the measurements stated the measurements were obtained by the facility's nursing staff using third party wound imaging technology and may have been obtained prior to the date of service. A treatment for xeroform gauze to the wound three times weekly was ordered. There was no revision to R37's care plan to establish a turning and repositioning program even though R37 developed an unstagable pressure injury. On 12/18/2023 at 10:45 AM, Surveyor observed R37 working with therapy with a brace to the knee, gripper socks on using a gait belt and walker with two therapists. On 12/18/2023 at 11:55 AM, Surveyor asked R37 how they were doing. R37 stated they are non-weight bearing for another four weeks after they tumbled and fractured the bones in the knee and cannot move the foot. R37 stated they had difficulty with range of motion due to rheumatoid arthritis. On 12/18/2023 at 2:10 PM and on 12/19/2023 at 7:51 AM and 11:59 AM R37 was observed to be lying in bed on their back. On 12/20/2023 at 8:41 PM in the progress notes, nursing charted R37 finally agreed to have an air mattress. Maintenance swapped out the regular mattress with an air mattress. Surveyor noted nursing staff had been signing out they were checking R37's air mattress when R37 did not have an air mattress in place. Surveyor also note there was no reference to R37 refusing the air mattress from 12/14 through 12/20/23. On 12/21/2023 at 12:09 PM, Surveyor observed R37 lying in bed on their back. An air mattress was in place. R37 stated they wear a brace on the left leg but now R37 does not have to wear it when R37 is in bed. R37 stated Wound Physician-J was in that morning and told R37 the wounds were looking better. Surveyor asked R37 how they got the pressure injuries. R37 stated the leg wounds were caused by the leg brace and the wound to the back side was caused by a bed pan. On 12/21/2023 at 12:17 PM, Surveyor asked Wound Physician-J to describe R37's wounds and how they developed. Wound Physician-J stated R37 currently has DTIs to the left shin, right proximal shin, the right distal shin, the left calf, and the left buttock. Wound Physician-J stated the DTIs were mechanically related and they were calling the orthopedic clinic to see about the leg brace. Wound Physician-J stated R37 sticks to the bed pan and is not able to move very well due to the brace on the leg. LPN IP-P stated R37 finally agreed to have the air mattress put on the bed. Surveyor noted R37's care plan was not updated to include a turning and repositioning program even though Wound Physician-J indicated R37 sticks to the bed pan and is not able to move very well due to the brace on his leg. On 12/21/2023 at 1:53 PM, Surveyor asked LPN IP-P if they were wound care certified. LPN IP-P stated no. LPN IP-P stated LPN IP-P does all the wound care for all the residents Monday through Thursday. Surveyor asked LPN IP-P what the process was for assessing pressure injuries. LPN IP-P stated Wound Physician-J comes to the facility on Thursdays so on Wednesday LPN IP-P takes a picture of the wounds with the facility camera that measures the wounds and attaches a picture to the evaluation. LPN IP-P stated Wound Physician-J looks at all the wounds for a complete assessment. Surveyor asked LPN IP-P why no treatments were in place on admission with the DTI wounds. LPN IP-P stated they would have to look into that. Surveyor shared the concern with LPN IP-P that Wound Physician-J thought the Unstageable pressure injury to the left gluteal was from a bed pan. LPN IP-P stated R37 thought that might be where the wound came from, not Wound Physician-J. LPN IP-P stated R37 does not really get up, just lies flat in bed. When repositioning is offered, R37 has stated they only want to stay on their back. LPN IP-P stated they just got the order to remove the brace when in bed. On 12/21/2023 at 2:07 PM, Surveyor shared with Director of Nursing (DON)-B the concerns R37's treatments were not consistently signed out, R37 had a weight loss that was not addressed prior to developing an Unstageable pressure injury to the left gluteus, and R37's care plan states R37 is independent with bed mobility, yet staff are saying R37 has difficulty moving in bed due to pain and the brace on the leg and the care plan was not revised to address R37's immobility. No further information was provided at that time. On 12/27/2023 via email, the facility provided a revised Actual Impairment to Skin Integrity Care Plan with the following interventions that were implemented on 12/21/2023, after being brought to their attention by Surveyor: -Pain: Evaluate R37 for changes in pain level and if appropriate request a scheduled pain medication from physician. -Educate R37/family/caregivers of causative factors and measures to prevent skin injury. -Encourage good nutrition and hydration in order to promote healthier skin. --Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to physician. -R37 needs pressure relieving/reducing mattress to protect the skin while in bed. -Use a draw sheet or lifting device to move R37. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The facility also provided an Unavoidable Pressure Injury worksheet dated 12/21/2023 that has R37's name, they are NOT at end of life, NOT on hospice, had a history of healed skin problems to the sacrum, and has current wounds to the front lateral lower leg, right second toe, right shin, front right lateral lower leg, right medial calf, left gluteus, and left lateral calf. The form states: The resident has two or more of the following diagnosis with cast or splint that can't be removed checked and no other diagnosis checked. A Braden of 17 indicating at risk for pressure injury and the form is signed by the physician on 12/21/2023. The form does not show the pressure injury to the left gluteus was unavoidable. 46517 2. R71 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus type 2, heart failure and renal failure. R71 was admitted with an unstageable pressure injury to their right heel. R71's admission Minimum Data Set, dated dated [DATE], documented R71 had a Brief Interview for Mental Status of 15, indicating R71 was cognitively intact and R71 had one unstageable pressure injury. R71's care plan, entitled, R71 has actual skin impairment to skin integrity .pressure ulcer to right heel with diagnosis of DM (Diabetes Mellitus) and Venous insufficiency, date initiated 06/16/23, had interventions including, Low air loss mattress, evaluate and treat per physician's orders, ensure that heels are off-loaded while resident is lying in bed . R71's active physician's orders included, Wound to Right Heel: Cleanse with Normal Saline, pat dry, apply calcium alginate followed by ABD (Abdominal) pad and secure with kerlix, every evening shift Monday, Wednesday and Friday. On 12/18/23 at 9:34 AM, Surveyor observed R71 lying in bed on back. R71 informed Surveyor they were admitted in June 2023 and had an ulcer to their right heel that occurred at home during a fall. R71 stated the staff assist R71 with putting on the pressure relieving boots and per R71, R71 wears them in bed all the time. At this time R71 pulled up the blanket and showed Surveyor the prevalon boots. R71 thought the staff were changing the dressing every other day. Surveyor reviewed R71's wound documentation and noted R71 was being followed the facility's wound physician until 10/26/23 and then R71 began to see an outside podiatrist. R71's wound measurements were completed weekly from 06/15/23 to 10/26/23. On 06/15/23, R71's right heel wound was documented as unstageable due to necrosis with measurements of 4.48 cm (centimeters) by 3.47 cm. On 10/26/23, R71's right heel was classified as a stage 4 with 90% slough and measured 1.5cm x 1cm x 0.1cm. After 10/26/23, Surveyor could not locate a comprehensive wound assessment until 11/20/2023. Surveyor reviewed R71's Electronic Medication Administration Record (EMAR) for the month of November 2023 and noted R71 had an order for wound treatment to the right heel (Wound to Right Heel: Cleanse with Normal Saline, pat dry, apply calcium alginate followed by ABD (Abdominal) pad and secure with kerlix, every evening shift Monday, Wednesday and Friday) that was documented as completed on 11/08/23, but then was not on the EMAR again until 11/22/23. Surveyor reviewed R71's Electronic Medical Record (EMR) and noted R71 was sent to the hospital on 11/10/23 and readmitted to the facility on [DATE]. Surveyor could not locate a comprehensive wound assessment upon re-admission on 11/16/23 nor wound care orders until 11/22/23. On 11/20/23 R71's stage 4 PI measured 2.18 cm x 1.69 cm. This wound care assessment has pictures attached and the wound was without signs/symptoms of infection. The treatment on this assessment was documented as Normal Saline followed by Calcium Alginate. On 11/22/23, R71's stage 4 PI measured 4.77 cm x 2.21 cm. These measurements have pictures attached and the wound currently appears without signs/symptoms of infection. The treatment on this assessment was documented as Normal Saline followed by Calcium Alginate. R71's wound was measured weekly after 11/22/23 and the most current measurements on 12/20/23 were 1.02cm x 0.78cm. On 12/20/23 at 12:54 PM, Surveyor interviewed Wound Care Licensed Practical Nurse (LPN IP)-P. Per LPN IP -P, R71 was followed by [name of wound physician] but is now followed by podiatry. LPN IP -P informed Surveyor R71 was sent to the hospital on 11/10/23 and then readmitted on [DATE]. Surveyor asked about a comprehensive wound assessment upon re-admission. LPN IP-P reviewed R71's EMR and showed Surveyor a nursing evaluation from 11/16/23 which documented right plantar foot/ulcer. Surveyor noted there was not a comprehensive assessment of R71's pressure injury such as measurements or description of the wound bed tissue in this documentation. Per LPN IP-P, the nursing staff should do a skin assessment if the resident was gone for more than 24 hours. Surveyor asked if R71's heel pressure injury (PI) had always been there or had it healed and then re-opened. Surveyor pointed out that R71's PI was classified as In House. Per LPN IP-P, that was a mistake on her part. LPN IP-P informed Surveyor R71's right heel PI was always there, it had not healed. Surveyor asked about a lack of wound care orders in R71's EMAR from re-admission on 11/16/23 to 11/22/23. LPN IP-P stated she would need to look into it and get back to Surveyor. On 12/20/23 at 3:00 PM during the end of the day meeting with Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A, Corporate Personnel (CP)-Y Surveyor shared the concern of a lack of a comprehensive assessment of R71's right heel PI from 10/26/23-11/22/2023 and a lack of a treatment order from 11/16/23 to 11/22/23. At this time, DCO-C stated the team had additional information and would speak with surveyor after the meeting. On 12/20/23 at 3:39 PM, Surveyor interviewed DON-B, LPN IP-P, and CP-Y. LPN IP-P showed Surveyor measurements of R71's right heel PI from 11/01/23. Surveyor asked if R71's wound was measured from 11/01/23-11/22/23. Per LPN IP-P, R71 was in the hospital from 11/10/23-11/16/23, and R71 was at an appointment on 11/08/23 which is the day LPN IP-P does the picture measurements. Surveyor asked about measurements and a treatment order upon re-admission on 11/16/23 to 11/22/23. Per LPN IP-P, when R71 was readmitted (11/16/23) the PI treatment order was discontinued. LPN IP-P stated she saw R71's wound and did the treatment between 11/16/23 and 11/20/23. Surveyor asked what treatment order did LPN II-P follow if there was no order in R71's EMR? Per LPN IP-P, R71 had previously seen podiatry and they said to continue with the current treatment of calcium alginate followed by ABD pad followed by Kerlix. Surveyor noted there was no indication on the Medication Administration Record or the Treatment Administration of the treatment being performed between 11/16 and 11/20/23. Surveyor asked why were no measurements taken until 11/20/23? Per LPN IP-P, when she saw the wound prior to 11/20/23 it was not on a Wednesday. LPN IP -P stated Wednesdays are when she takes pictures. Surveyor asked what the expectation is for wound assessments upon re-admission. Per CP-Y it would be the expectation wounds would be measured upon admission. Surveyor explained the concern of a lack of a comprehensive wound assessment from 11/16/23 to 11/20/23 and a lack of a treatment order from 11/16/23 to 11/22/23. On 12/27/23 the facility submitted information for review. Surveyor reviewed all the information provided and noted information submitted did not reflect a comprehensive wound assessment was conducted on R71 upon readmission into the facility on [DATE].

Based on observations, record review and staff interviews, the facility did not always ensure that they provided adequate supervision and an environment that remains as free of accident hazards for 3 out of 4 residents reviewed for accident hazards and/or falls. * On 10/10/23, R5 is to be transferred with the assistance of 2 staff members and a hoyer lift. R5 was being transferred using a hoyer lift with only 1 facility staff member when R5's ankle was bumped, resulting in a fracture. R5 went out the the hospital and returned in a soft cast. R5 experienced an increase in daily pain as a result of the fracture. * According to the 9/4/23 Minimum Data Set (MDS) R41 has occasional urinary incontinence. Documentation revealed R41 to be incontinent of urine 18 times in September. Even though R41 was known to be occasionally incontinent of urine, with noted urinary incontinent episodes in September, and known to be at risk for falls, the facility did not care plan for an individualized routine toileting program. On 9/23/23, R41 had a fall in his bathroom resulting in multiple rib fractures. The facility updated R41's care plan after the fall in the bathroom however the updated care plan does not address a routine toileting program. Additionally, R41's care plan has a documented intervention for one person assist with ambulation and toileting. During survey, R41 was observed multiple times walking the unit unassisted and going to the bathroom unassisted. * R43 has had multiple falls which included a review of 14 falls since June of 2023. Surveyor noted 10 of the 14 falls lacked a thorough investigation into them in order to determine a root cause analysis and to evaluate whether identified fall prevention interventions were implemented and whether they were effective or not. This is evidenced by: 1. Surveyor reviewed the facility's policy Full Body Mechanical Lift Equipment and Guideline with an effective date of 3/22/2018. The Full Body Mechanical Lift Equipment and Guideline states in part; Operating the full body mechanical lift will require 2 caregivers. Surveyor conducted a review of the facility's self-reported incident involving R5 which the facility became aware of on 10/12/23. The Facility submitted DHS (Department of Health Services) form F- 62617 (Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report) on 10/12/23 regarding R5 having a bruise to her ankle. Date discovered was 10/12/23. An X-ray was obtained, and a fracture was noted. Allegation type is: Injury was not observed and is suspicious because of the extent or location. The facility's interview with R5 states that on 10/10/23, she was transferred via hoyer lift with 1 staff member and her ankle was bumped. Multiple staff interviews were conducted, along with observation of facility cameras of the evening in question. Based upon the viewing of the facility cameras, it was determined R5 was transferred with 1 assist. The facility was able to rule out abuse as R5 remains safe in the facility and that this appears to be an unintentional accident, possibly due to not following facility policy and protocols, The facility took action regarding Certified Nursing Assistant (CNA) - V for violation of facility policy and an action plan was started. Surveyor conducted a review of R5's electronic medical record (EMR) for additional information pertaining to the event that occurred on 10/10/23, including a review of R5's care plan. R5's care plan for Actual Activities of Daily Living (ADL) self-care performance deficit related to Impaired Mobility, Muscle Weakness, Refuses ADLS to perform at times includes an intervention dated 4/26/23 which states, Transfers: Resident requires Total/Hoyer mechanical lift X2. R5's medical record includes in part; 10/11/2023 at 5:01 p.m., Health Status Note (nurses note): Resident (R5) complained of pain to left lower shin/ankle/foot and toes. Resident has multiple stories of why foot/ankle/shin and toes are hurting her she stated she possibly bumped it or moved a certain way during transfer with hoyer lift yesterday. Writer reported to NP (Nurse Practitioner) and asking for X-ray. NP gave order for X-ray to left foot/ankle. Order processed and noted. 10/12/2023 at 03:17 a.m., Health Status Note (nurses note): R5 offers complaints of LLE (Left Lower Extremity) pain. Prn (as needed) Tylenol administered. BLE (Bilateral Lower Extremity) elevated on pillow. 10/12/2023 at 6:48 p.m., Health Status Note (nurses note): Forwarded foot and ankle X-ray to NP. 10/12/2023 at 7:10 p.m., Health Status Note (nurses note): NP called regarding X-ray fx to L ankle. She is asking her to go to ER (emergency room ) but she is refusing to go. R5 is her own person. Contacted her family but they were not able to convince her either. NP, ADON (Assistant Director of Nursing) notified. R5 stated she will go to ER in the morning or to ortho. NOR (New order received) for Tylenol 1000 mg q (every) 8 hours prn. 10/13/2023 at 7:42 a.m., Discharge/Transfer Summary Note Text: R5 has a fracture to left ankle. Resident c/o pain 10/10 on a numerical scale. She has bilateral non pitting edema in both ankles. Resident refused all medications this AM including pain meds stating that she may throw up if taking medication, and she will take meds when returning from acute care setting. Resident has an order to be sent out and treated after X-ray reveals left ankle fracture. For Pain management through the night resident has been using ice packs, keeping left ankle elevated. Resident has been cleaned of incontinence, and ready for EMT. 10/13/2023 at 8:13 a.m., Health Status Note (nurses note): EMT arrival at facility @ 0810 (8:10 am) to take resident ( R5) to [name of hospital]. Report given to Charge Nurse @ 0817 (8:17 am) by writer. 10/13/2023 at 1:19 p.m., Health Status Note (nurses note): Patient (R5) returned from hospital with new order for Vicodin and Ibuprofen. Has fx in left foot, soft cast on. Is to follow up with ortho asap. 10/16/2023 at 10:28 a.m., Health Status Note (nurses note): Resident (R5) is complaining of pain to left ankle due to fracture. Resident is out of Narco. Writer reached out to NP and she will not refill prescription. Writer is reaching out to ER DOC (Doctor) who prescribed pain medication for a refill. 10/16/2023 at 12:41p.m., Health Status Note (nurses note): Primary MD came to visit with resident. MD wants us to follow up with ortho regarding resident's pain management for fracture they're now managing fracture with follow up. 11/3/2023 at 10:58 a.m., Health Status Note (nurses note): Dr. was contacted in regards to Hydrocodone 5-325 refill as the residents pain is not being relieved by Tylenol/ Ibuprofen. It was stated that a request will go to the team and a call back would be done regardless of if the medication is filled or not. Resident had a follow up on [DATE]st which she attended and NNO were placed. Next appt is [DATE]th @ 14:30 (2:30 p.m.) Resident was given PRN medication to help alleviate pain, as well as a cold compress and repositioning--which are only slightly effective. 11/16/2023 at 6:56 p.m., Health Status Note (nurses note): R5 back from appt. with Dr. R5 no longer needs to be in splint, but to utilize off loading boots at all times. And continue being cautious with LLE. Follow up in 4 weeks and transportation notified. endorsed. Although the facility did conduct re-education on 10/12/23 to facility staff about the proper use of the hoyer lift and that 2 staff must assist during this type of transfer, during the survey observations were made of current residents without safety interventions in place. 22692 2. Surveyor reviewed the facility policy titled Fall Evaluation Safety Guideline with an effective date of November 28, 2017. Documented (in part) was: Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible. Purpose: To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately. To achieve each resident's maximum potential of physical functioning. To prevent or reduce injuries related to falls. To enhance resident dignity and self-worth. To rehabilitate residents to their fullest potential of function. To Individualize interventions for each resident. Procedure: A fall risk evaluation will be completed at the following times: upon admission/readmission to the facility, quarterly, and with a significant change of status and as needed. If the evaluation finds the resident at risk, implement resident specific interventions/precautions. Initiate, review and revise the fall care plan as appropriate, with new or discontinued interventions . Recommendations for strategies on managing falls . Fall related to toileting needs: Provide a night light. Bed is locked and in lowest position. Clear pathway to the bathroom. Footwear to prevent slipping such as socks with grippers. Evaluate for mobility supportive devices. Assistive device within reach (but not an obstacle). Toilet schedule . Post fall action: Team huddle-a post fall gathering to review a fall. Post fall investigation (review recent medications, vital signs, toileting schedule, changes in mood or behavior . increase assistance with activities of daily living (ADL's), footwear, environment. Root cause analysis-determine casual factors of fall. Evaluate resident and re-evaluate risk. Evaluate effectiveness of interventions. R41 was admitted to the facility on [DATE] with diagnosis (in part) of: Metabolic encephalopathy, Type 2 Diabetes, Communication deficit, Muscle weakness, Difficulty in walking, Chronic Kidney disease, Overactive bladder. R41's most recent quarterly Minimum Data Set (MDS) assessment, dated 12/5/23, documented that R41 had a Brief Interview for Mental Status (BIMS) of 7, indicating that R41 has a severe cognitive impairment. R41's Admission MDS assessment dated [DATE] documented that R41 required one-person physical assist for transfers, walking in and out of the room and locomotion on and off the unit. R41's Urinary and Bowel incontinence was assessed as occasionally incontinent. The MDS documented that there was no urinary toileting program in place. Surveyor reviewed the Fall Risk assessment dated [DATE] at 9:30 PM. Documented was: This evaluation is being completed related to Admission. Fall Risk Score is: 7. Fall risk scored above 5, resident is at a HIGH risk for falls. Surveyor reviewed R41's Fall risk Care plan with an initiation date of 8/28/23. The resident is [at] risk for falls [related to] decreased mobility and medication usage [status post] hospitalization due to hypoglycemia contributing to metabolic encephalopathy . causing generalized weakness and a decline in his functional status, impaired balance, cognitive loss, fall [history], recent falls. Goal: The resident will be free of minor injury through the review date. Interventions include the following: Anticipate and meet the resident's needs. Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The resident needs a safe environment with: (floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in lowest position, personal items within reach.) Surveyor reviewed R41's Activities of Daily Living (ADL) Care plan with an initiation date of 8/29/23. The resident has actual ADL self-care performance deficit [status post] hospitalization due to hypoglycemia contributing to metabolic encephalopathy . causing generalized weakness and a decline in his functional status . Interventions documented (in part) -Transfers: Resident requires physical assist X 1 staff with 2 wheeled walker. Toileting: Resident requires physical assistance with toileting of 1 staff. Surveyor reviewed R41's Bladder Care plan with an initiation date of 8/29/23. The resident has risk for bladder incontinence [related to] Overactive bladder. Interventions documented: Provide skin care with each incontinent episode. Evaluate resident for [signs and symptoms of Urinary tract infection]. Clean peri-area with each incontinence episode. Ensure resident has unobstructed path to the bathroom. Surveyor reviewed R41's Certified Nursing Assistant (CNA) Kardex. Listed under safety was documented: Encourage to call for assist, Resident has been known to self-transfer and ambulate on his own despite being encouraged to ask for assistance. Reacher to be within reach. Listed under Transferring was documented: Resident requires physical assist X 1 staff with 2 wheeled walker. Listed under Mobility was documented: Locomotion: [R41] does not have [wheelchair], utilizes 2 [wheeled walker] with [stand-by-assist] of 1 for ambulation. Listed under Restorative Nursing was documented: Ambulation: Apply gait belt. Assist to standing position, provide assistive devices for walking. May pull/follow with [wheelchair] for safety. Allow periods of rest when needed. Encourage to walk to meals, and activities/bathroom. Surveyor reviewed a progress note from 9/23/23 at 1:47 PM. LPN-FF documented, [R41's] roommate yelled help down the hallway. [R41] found on his bathroom floor. This was an unwitnessed fall. Resident did not have his walker with him, also had house shoes on his feet that were too big for him. Upon assessment resident stated he had pain at a 4 in his right posterior elbow that had a scant amount of blood noted. He denied hitting his head. Skin check showed erythema to right rib area. Complete set of vitals completed at that time. [LPN-FF] grabbed an aide who assisted with getting resident back into his chair. Resident brought down to bistro to have lunch. During lunch he had [complained of shortness of breath] with breathing in and a pain at a 4 [out of 10] in his right rib. I contacted [R41's Power of Attorney] who request he be sent out for further care at this time. [Nurse Practitioner (NP)/Director of Nursing (DON)] Case Manager updated. Surveyor reviewed the fall investigation completed by the facility. R41's fall occurred at 11:45 AM. Within the fall investigation, there was no time listed when R41 was last toileted. LPN-FF documented in the fall report that R41 had the following predisposing physiological factors: Balance problem, Confused, and Gait Imbalance. LPN-FF documented that the predisposing situation factors included: Ambulating without assist and Improper footwear. R41 was sent to the Emergency Department for evaluation. R41 was diagnosed with closed fracture of multiple ribs on his right side. Surveyor reviewed documentation revealing that R41 was incontinent of urine a total of 18 times in the month of September. R41 did not have a toileting plan in place other than R41 requiring physical assistance with toileting of 1 staff, provide skin care with each incontinent episode, evaluate resident for [signs and symptoms of Urinary tract infection], clean peri-area with each incontinence episode and ensure resident has unobstructed path to the bathroom. Surveyor noted there was no toileting schedule addressed in R41's care plan, even though the facility is aware of R41 transferring himself unassisted. Surveyor reviewed R41's Fall Comprehensive care plan. After the fall on 9/23/23, the facility added the following interventions: Encourage resident to wear proper footwear when ambulating. Reminder sign to call for assist and use walker. Resident med to be reviewed by Cardiology to ensure drops in BP are not medication related. Encourage to call for assist, Resident has been known to self-transfer and ambulate on his own despite being encouraged to ask for assistance. Non-skid socks/footwear. On 9/26/23 additional interventions were added: AMBULATION: Resident has self-care deficit in ambulation related to history and recent falls, unsteady gait. Resident is able to ambulate 150 feet. Locomotion: [R41] does not have [wheelchair], utilizes [2 wheeled walker] [with stand by assist] of 1 for ambulation. Contact family and request for different shoes. Surveyor reviewed R41's Ambulation Comprehensive care plan that was initiated on 9/26/23. Resident has self-care deficit in ambulation related to history and recent falls, unsteady gait. Resident is able to ambulate 150 feet. Goal: Resident will walk with 2 wheeled walker 3 times a day to the dining room/bathroom with supervision of 1 staff with gait belt to maintain functional ambulation skills by next review date. Resident will ambulate to meals at least once a day through next review date. Interventions: Apply gait belt. Assist to standing position, provide assistive devices for walking. May pull/follow with [wheelchair] for safety. Allow periods of rest when needed. Encourage to walk to meals and activities/bathroom. Surveyor noted that the updated Fall and Ambulation Comprehensive Care plans did not address any toileting schedule for R41 even though he was found in the bathroom unassisted without walker while in the bathroom on 9/23/23. On 12/18/23 at 1:18 PM, Surveyor observed R41 walking unassisted. R41 had gripper socks on and was using a 2 wheeled walker. Surveyor noted R41 was not being provided with physical assist with 1 person with a 2 wheeled walker per the ADL care plan intervention dated 8/29/23. On 12/18/23 at 1:22 PM, Surveyor observed R41 walking unassisted to the front desk and speaking to the receptionist. R41 had gripper socks on and was using a 2 wheeled walker. Surveyor noted R41 was not being provided with physical assist with 1 person with a 2 wheeled walker per the ADL care plan intervention dated 8/29/23. On 12/18/23 at 1:32 PM, Surveyor observed R41 walking unassisted in the hallway around the office area. R41 had gripper socks on and was using a 2 wheeled walker. Surveyor noted R41 was not being provided with physical assist with 1 person with a 2 wheeled walker per the ADL care plan intervention dated 8/29/23. On 12/19/23 at 11:40 AM, Surveyor observed R41 in common area across from nurse's desk/station. R41 had gripper socks on, and his 2 wheeled walker was positioned in front of him. R41 got up from chair and used his 2 wheeled walker to walk back to his room unassisted. Surveyor noted R41 was not being provided with physical assist with 1 person with a 2 wheeled walker per the ADL care plan intervention dated 8/29/23. On 12/19/23 at 11:46 AM, Surveyor observed R41's roommate entered the room and left the door open. Surveyor walked by resident room and noted that R41's 2 wheeled walker was located by R41's bed. R41 was not seen in bed or in the room, however R41's bathroom door was shut with the light on. On 12/19/23 at 11:48 AM, Surveyor observed R41 coming out of the room without walker. R41 returned to get walker and walked unassisted with 2 wheeled walker back to the common area to watch tv. Surveyor noted R41 was not being provided with physical assist with 1 person with a 2 wheeled walker per the ADL care plan intervention dated 8/29/23. In an interview on 12/20/23 at 11:56 AM, Surveyor asked CNA-GG how they would identify a resident's mobility and transfer status. CNA-GG stated they would look on Kardex and the care plan. CNA-GG stated if she had any other questions, she would ask the nurse. Surveyor asked what the current ambulation/mobility status is for R41. CNA-GG stated that R41 can move around on his own, but they would like a standby with him. Surveyor asked if R41 would allow a staff member to be a standby assist. CNA-GG stated that R41 was sweet, and he would allow it, but R41 likes to move around on his own. In an interview on 12/21/23 07:55 AM, Surveyor asked LPN-HH what R41's mobility/ambulation/standby orders are currently. LPN-HH stated that they would get back to the surveyor on that one. Surveyor asked if LPN-HH had worked with R41 in the past. LPN-HH stated yes. Surveyor asked, what do you do to prevent him from falling? LPN-HH stated they remind R41 to use his call light and that R41 has a sign in his room to remind him to use his call light. LPN-HH stated that R41 is pleasantly confused. Surveyor asked How well does R41 ambulate? LPN-HH stated that R41 is pretty steady on his feet and has not had a fall since they have been here. LPN-HH stated that R41 does well with his walker. On 12/21/23 at 10:15 AM, LPN-HH returned to surveyor to state that R41 is up with one standby assist and a gait belt. In an interview on 12/21/23 at 08:56 AM, Surveyor asked LPN-O what the mobility/ambulation status is on R41. LPN-O stated that R41 is independent with ambulating and uses a 2 wheeled walker. Surveyor asked if LPN-O recalled any falls for R41. LPN-O stated they had no concerns with any falls recently. LPN-O stated that R41 is not as weak as he was in September. Surveyor asked what was in place to prevent R41 from falling. LPN-O stated that R41 needs reminders to ask for help but that R41 had all the interventions he needs to keep from falling in place. On 12/21/23 at 11:22 AM, LPN-O returned to surveyor. LPN-O stated that they looked in the medical record for R41. LPN-O stated that she noticed that R41 is not independent and that she misspoke. LPN-O stated that they went to speak to the PT-II about R41's ability to ambulate independently and R41's current status. LPN-O stated that PT-II has written an updated note to communicate that resident is able to ambulate with 2 wheeled walker as desired without assistance. LPN-O stated that based on info provided from PTII, LPN-O will update R41's care plan. In an interview on 12/21/23 at 12:51 PM, Surveyor informed DON-B about concerns with R41's fall and that R41 was observed multiple times ambulating unassisted which was contrary to what is listed in R41's care plan. Surveyor asked, how often should a care plan be updated? DON-B stated that they adjust the care plan as needed based off the resident's needs. If there are changes to the care plan and the CNA needs to know we print out a new Kardex. Surveyor asked, if a care plan is not being followed, what should staff do? DON-B stated that if the care plan is not appropriate, we will change the care plan. DON-B stated that with R41's situation, we did talk to therapy because R41 does not follow direction well. PT-II stated to DON-B that R41 was capable to be up and around the unit as needed. DON-B stated that R41's care plan was updated to reflect this change. Surveyor informed DON-B of the continued concern that the care plan was not being followed. Surveyor reviewed R41's updated care plan. On 12/21/23 the facility changed R41's transfer intervention to the following: Resident is up ad lib in facility with 2 wheeled walker. R41's Toileting intervention remains the same: Resident requires physical assistance with toileting of one staff. In an Interview on 12/21/23 at 1:57 PM, Surveyor informed Consultant-EE of the concerns with R41's fall on 9/23. Surveyor informed Consultant-EE that there was concern because this fall happened in the bathroom. There was nothing in the fall investigation documented when R41 was last toileted and there was no toileting plan in place. 46517 3. R43 was admitted to the facility on [DATE] on hospice care and had diagnoses including Vascular Dementia, unspecified severity, without behaviors; Parkinson's Disease; cognitive communication deficit and muscle weakness. R43's most recent quarterly Minimum Data Set (MDS) assessment, dated 9/22/23, documented R43 had a Brief Interview for Mental Status of 3, indicating R43 had severe cognitive impairments; R43 required maximum staff assistance for transfers and was dependent on staff for toileting, and R43 had two or more falls with minor injuries since the last assessment date. R43's care plan, entitled R43 has high risk for falls r/t (related to) actual falls without injury r/t, weakness, confusion, hx (history) frequent falls, impaired balance, dementia, anxiety, Parkinson's disease, psychotropic medication use, dated 4/17/22 with interventions including; Ensure bed brakes are locked; Hospice increase visits; Therapy to eval WC (wheelchair); Med review; Meet needs; Behavior of sliding self out of broda chair; Bed at safe height when transferring; Encourage up in common area; Gripper socks; Meals in dining room; Lay down after lunch; Get up for afternoon activities; Personal items within reach; Pillows for positioning; Call light within reach; Bed next to wall per preference; Fall mat; Snack prior to bed; Activity after dinner; Lay down between meals-04/24/23; Recline broda chair; Psych services; Reg mattress and Laid down after lunch which was initiated on 7/11/23. Surveyor noted multiple interventions which were the same such as lay down after lunch, lay down between meals and then laid down after lunch again. Surveyor asked Nursing Home Administrator (NHA) - A and Director of Clinical Operations (DCO)-C for R43's fall investigations from June 2023 forward. Surveyor was given 14 fall investigations from June 2023 forward. Surveyor reviewed these investigations and noted the following: Surveyor noted a lack of a thorough investigation with the following falls: On 7/15/23 at 7:00PM R43 slid out of the recliner and was incontinent. The intervention was to toilet after meals, however R43's incontinence care plan states to toilet every two hours. The fall investigation does not document when R43 was last toileted. On 8/7/23 at 4:00PM R43 slid from R43's broda chair and the root cause was R43 has a behavior of sliding herself from the chair. The investigation does not include whether R43 was continent, when the last time R43 was toileted, or whether the other fall interventions were followed such as offering to lay down after lunch, which was an intervention from 4/24/23 and 7/11/23. On 9/26/23 at 7:58 PM R43 was found on the floor on the landing mat in R43's room. The fall investigation is confusing because it states R43 was found on floor mat from low bed but then the investigation also stated the root cause analysis was resident continues to climb out of chair and all current interventions are appropriate. The investigation was not clear as to whether R43 fell from bed or the chair and did not include if R43 was continent, when R43 was last toileted, or when R43 last had something to eat. Surveyor never received clarification on this fall. On 10/21/23 at 7:15 PM R43 fell out of chair the broda chair. Per the investigation the nurse saw R43 begin to slide out of broda chair, but could not get there fast enough, however, this investigation also stated the fall was unwitnessed and the unit nurse was on break during that time. This investigation had an area for a Certified Nursing Assistant (CNA) statement and in that spot it was documented the CNA acknowledged the need for a statement but refused to do so. This investigation did not include whether current fall interventions were in place such as toileting R43 after meals or offering to lay down after meals. The investigation does not include whether R43 was incontinent or when R43 was last toileted. On 11/01/23 at 1:53 PM, R43 was found on the mat by R43's bed. Per R43's roommate, R43 did not fall but placed self on the mat. The root cause stated the team reviewed R43's life story which included information that R43 used to work on a hobby farm and maybe R43 goes onto the floor to get closer to the animals. Surveyor did not find this information anywhere else in R43's EMR. Surveyor could not locate documentation the facility attempted to integrate animal care somehow into R43's daily activities. This investigation does not include whether all fall interventions were followed such as toileting, or if R43 was out of bed for lunch, or if R43 had just laid down. On 11/20/23 at 10:22PM, R43 had a fall out of bed. The root cause stated R43 was maybe restless due to incontinence, however the fall investigation does not state if R43 was offered a snack prior to bed, which was a previous fall intervention. On 11/30/23 at 10:22 PM, R43 had a fall from bed which stated R43 may have been restless due to being incontinent. This investigation does not address if R43 was offered a snack which was a previous fall intervention. The intervention for this fall was to ensure R43 was wearing gripper socks. R43's most recent MDS on 9/22/23 documented R43 needed maximum assistance from staff to stand and did not walk 10 feet due to safety concerns. On 12/10/23 at 9:33 PM, R43 had a fall out of bed. The root cause analysis stated R43 was having behaviors and crawling out of bed and all current interventions remain appropriate. This investigation does not address if R43 was offered a snack prior to bed or when R43 was last seen or toileted, or if R43 was incontinent. On 12/15/23 at 4:45PM, R43 was attempting to get out of bed and unit nurse tried to redirect but was unsuccessful and R43 ended up on the floor. R43 stated R43 needed to get out of there. The root cause was restlessness, but the investigation did not determine when R43 was last seen or last toileted, if R43 was incontinent, or when R43 last ate something. On 12/16/23 at 13:14 PM, R43 was found on the floor by R43's bed. The root cause stated R43 was incontinent. This investigation does not address if R43 was toileted after lunch per care planned interventions and does not address when R43 was last seen. On 12/20/23 at 10:20 AM, Surveyor interviewed Unit Manager Registered Nurse (RN)-D. Surveyor asked RN-D what the facility's fall process is. Per RN-D if someone falls one person stays with the resident, we find an RN and assess the resident; we do a skin check, new pain evaluation and vital signs. RN-D stated we would ask the resident what they were doing. Surveyor asked if staff members are interviewed. Per RN-D, just recently the facility started interviewing staff. RN-D stated R43 only had one or two falls since RN-D became the manager and RN-D was not that familiar with R43 prior to becoming manager in late October of this year. Per RN-D the facility's fall investigations have gotten more thorough like asking staff when the resident was last toileted or if the resident was incontinent. Surveyor reviewed the above fall investigations with RN-D and asked RN-D if she had any additional information such as staff statements. RN-D stated she would look into it and get back to Surveyor. On 12/20/23 at 11:00 AM, Surveyor interviewed Director of Nursing (DON)-B, and Corporate Personnel (CP)-Y. Surveyor reviewed the above fall investigations and asked if the facility had any additional information such as staff statements that included when the resident was last since, last toileted and if the R43 was incontinent at the time of the fall. CP-Y stated when she started at the facility sometime in Sept/Oct, she realized the facility's fall investigations were lacking that information and she started having the facility fill out fall packets that would include all of that information. Surveyor asked to view any of the fall packets the facility may have regarding any of the above falls for R43. On 12/20/23 at 3:00 PM, during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Clinical Operations (DCO)-C, DON-B, and CP-Y, Surveyor brought up concerns with the above fall investigations and a lack of a thorough investigation that included information such as whether or not current fall interventions were in place at the time of the falls. DCO-D informed Surveyor the team had additional information to provide after the meeting. On 12/20/23 at 03:47 PM, Surveyor interviewed DON-B and CP-Y. DON-B provided Surveyor with information that clarified some of R43's falls (those falls were not included in this citation because Surveyor did not have an issue with the investigation.) Surveyor explained needing that type of information for all of the above mentioned falls. [TRUNCATED]

Based on interview and record review, the facility failed to ensure 2 of 3 residents (R2 and R11) reviewed for weight loss had their nutritional care needs recognized, evaluated, and addressed to provide adequate parameters of nutritional status. 1. R2 was admitted to the facility for rehab at 180.8 pounds taken on 6/25/22. By 7/4/22 R2 had lost 9.4 pounds and weighed 171.4. The Registered Dietician (RD) assessed the resident on 7/5/22 and noted the weight loss from admission and only added interventions that were already in place prior to assessment, noting the resident was overweight per Basic Metabolic Index (BMI). There was no care plan put in place for nutrition or weight loss. R2 continued with minimal food intake and only drank Ensure nutritional shakes and weighed 164.2 on 7/15/22. R2's Activities of Daily Living (ADLs) started to decline as R2 was weak and fatigued. Nursing noted the weight loss but R2 was not reassessed and was discharged to home 7/18/22. After another hospitalization and admission on 7/28/22 it was documented R2 weighed 157.6 on 7/31/22 and 155.2 as of 8/6/22. R2 continued to refuse meals and had poor food intake. Despite having a care plan in place, no supplements were ordered until 8/9/22 when the significant weight loss triggered. The RD put the order for Ensure three times a day back in place but still noted him as overweight, despite the unwanted weight loss. The Nurse Practitioner (NP) was not made aware of the weight loss until 8/16/22 and added an appetite stimulant, a multivitamin, and an additional supplement. No other RD assessments were completed and no increase in weight monitoring was completed. No reassessments were completed to assess the added interventions, R2's continued refusal of meals and poor food intake, or reweigh until 9/3/22 when R2 weighed 145.8. R2 was now not getting out of bed and needed extra assist with ADLs. On 9/8/22 R2, his wife, and the facility agreed to a feeding tube (G-tube) but there was a delay in making the appointment. The appointment was not scheduled until 9/15/22 and made for 9/20/22 but due to a transportation issue on the facility's part the appointment was canceled and rescheduled for 9/26/22. On 9/21/22 R2 was dehydrated and required intravenous fluids (IVF.) R2 went out to the appointment for the G-tube on 9/26/22 but it was not able to be placed due to R2's anatomy and would need to be surgically placed. On 9/27/22, R2 and his wife requested he be transferred to the hospital and he was admitted for Severe Protein Calorie Malnutrition and Failure to Thrive. 2. R11 was admitted to the facility 9/27/22 with a diagnosis of Severe Protein Calorie Malnutrition and at high risk for weight loss. R11 weighed 178.4 lbs. on 9/28/22. R11 weighed 174.3 on 10/4/22, 174.4 on 11/1/22 and 156.0 on 12/13/22. R11 had a significant weight loss that was not identified by the facility and no assessment or new interventions were put in place at that time due to no Registered Dietician (RD) in the facility. The facility identified the weight loss 1/9/23 but R11 was not assessed by the RD until 1/23/23 when interventions were put in place. Findings include: Surveyor reviewed facility's Nutritional Status Management with a revision date of 4/2/2018. Documented was: .Purpose: It is the practice, in accordance with advanced directives to provide interventions to maintain, improve and respond to nutritional needs. Measures will be taken to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balances, unless the residents clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The facility will both evaluate and record meal intake and document within the medical record. The interdisciplinary team together with the resident and / or resident representative will identity, evaluate risk factors and individualize interventions to meet the nutritional needs of the residents and determine through monitoring of health status the effectiveness. Nutritional status will be evaluated, using the Comprehensive Nutrition Assessment, upon admission and with a significant change in condition. It will be reviewed quarterly and annually. The Mini Nutritional Assessment may be completed quarterly. The interdisciplinary team will collaborate to meet individualized goals with meeting nutritional needs. Responsible Party: Nursing, Dietary, Therapy 1. Identification Potential and actual areas for risk factors will be identified by the interdisciplinary team through review of the following documentation: o Skin observations o Nursing Assistant documentation o Medication Administration Records o Admission Evaluations o Nursing documentation o Skin integrity evaluations o Resident summaries o Weights and weight variances o Routine nutritional evaluations 2. Nutritional disorders will be identified and evaluated: o Anemia o Confusion o Dehydration o Delayed wound healing o Edema o Fractures o Hypotension o Impaired cognition o Malnutrition o Obesity o Pressure injuries o Unintended weight gain / loss o Urinary tract infections 3. Meal intake will be recorded and review for: o Intake patterns o Refusals 4. Identification and evaluation of the following risk factors as they apply to the resident, but not limited to: o Acute or chronic pain o Alcohol / drug abuse o Alterations in taste, dry mouth o Arthritis o Cancer o Chronic blood loss o Confined to bed or chair o Constipation o Decreased physical activity; immobility o Decreased sensation of smell, taste and sight o Dementia o Depression o Diarrhea o Diminished appetite and / or eating ability o Hyperthyroidism o Impaired digestion o Impaired functional status (inability to feed self) o Impaired hearing or vision o Impaired respiratory status (i.e. COPD) o Impaired swallowing o Increased physical activity, wandering o Infection o Iron deficiency o Kidney disease o Lack of access to culturally acceptable foods o Lactose intolerance o Malabsorption syndrome o Medications (i.e. Diuretics, laxatives, cardiovascular agents) o Nausea / vomiting o Oral health concerns o Radiation / chemotherapy o Social isolation o Slow pace consumption resulting in unpalatable food 5. Evaluation for malnutrition: o Bilateral edema o Cachexia o Dull eyes o Fatigue o Muscle wasting o Pale skin o Poor skin turgor o Swollen and / or dry tongue with [NAME] or magenta hue o Swollen gums or lips o Weakness 6. Development and Implementation of individualized interventions based on interdisciplinary evaluations, resident and / or resident representative goals to promote the highest level of function and dignity which may include, but not limited to: o Encourage consumption of foods and fluids during meals o Encourage energy conservation techniques o Identification of food allergies o Implementation of non-pharmaceutical and / or pharmacologic interventions to decrease o depression / anxiety o Offer and encourage fluids with meals, medication passes, snacks and while awake o Offer ethnic, cultural and religious food preferences o Provide food substitutions as needed o Off replacements of similar nutritive value for uneaten food items o Identification of meal frequency, meal location and times o Modification of fluid containers, utensils, cups and serve ware as needed catering to fine motor skills and abilities o Monitor meal consumption o Lab values o Pharmacy consults o Psychological consults o Therapy evaluations and involvement o Determination of more frequent weight monitoring o Nutritional supplementation o Additional fluids o Enhanced foods o Liberalized diet o Finger foods o Restorative program o Review food preferences o Additional non-food fluid items 7. Dietician consultation should follow: o A trend indicating a 5% weight gain or loss o All residents receiving gastrointestinal feedings or total parental nutrition for review and recommendations regarding orders o Completion of a nutritional evaluation and consultation with the resident, physician and resident representative if indicated o Evaluation of new or chronic associated risk factors o Modify, with the interdisciplinary team, including the resident and resident representative the plan of care with interventions to address risk factors and restore desired weight goals o Monitor the effectiveness of the modified plan of care 8. Care planning: Must address, the extent possible, identified causes of impaired nutritional status, reflect the resident personal goals, preferences and identify specific interventions, timeframes and parameters for monitoring. o There should be a documented clinical basis for any conclusion that nutritional status or significant weight change are unlikely to stabilize or improve. (e.g. physician's documentation to why weight loss is medically unavoidable) o The resident and / or resident representative involvement to ensure goals and preferences Examples of goals include: o A target weight range o Desired fluid intake o The management of an underlying medical condition (diabetes, kidney disease, wound healing, heart failure or infection) o The prevention of unintended weight loss or gain Interventions: o Diet liberalization o Weight related interventions o Environmental factors o Functional factors o Medications o Food intake o Fluid balance o Feeding tubes o [Total parental nutrition (TPN)] Monitoring: o Interviewing o Observing o Reviewing specific factors o Evaluating. Surveyor reviewed facility's Weight Monitoring Guideline with a revision date of 7/1/2019. Documented was: Purpose: The facility measures and records weights to ensure accuracy and provide information for the evaluation of clinical status unless clinically contraindicated with physician justification. To provide guidance on timely consultation and weight parameters . Responsible Party: Nursing, Dietary Residents will be weighed; documentation will be recorded in [point click care (PCC)]: o Upon admission and re-admission. Hospital weights should be verified and compared to facility admission and / or re-admission weight. o Daily for three days o Weekly for four weeks post admission and / or until the weight is determined to be stable. Monthly by the 7th of each month. o Anytime as needed with a change in condition or specified by [nutrition at risk (NAR)] committee. o As specified by the physician or mid-level practitioner. The Licensed Nurse: o Will verify the accuracy of the weight by comparing the weight with the most recently recorded weight. o Direct a re-weight for variances < or > 5 pounds. o Consult with the physician and dietician / designee with a confirmed 5 % weight variances in 30 days and 10% in 6 months and / or as ordered by the physician with weight parameters. o For residents on daily weights for fluid volume overload prevention and monitoring weight notification parameters should be discussed with the physician and at minimum consultation should be completed with a 5 pound weight change in 1 week for residents with heart failure or fluid volume overload risk. o Monitor weight reports produced inside PCC for significant changes and for gradual insidious changes that may indicate a risk factor for nutrition or hydration status and / or clinical condition. Dietitian: o Review significant weight change reports daily for review and evaluation o Review weight reports at least weekly to ensure residents with weight variances of 5% in 30 days and 10% in 6 months are reviewed and evaluations for nutritional risk and timely interventions is completed. o Review weight reports for significant weight changes following the 7th of the month. Refer residents with significant weight changes to the NAR committee for review. 1.) R2 was admitted to the facility on [DATE] with diagnoses that included Neurofibromatosis, Muscle Weakness, Difficulty in Walking, Repeated Falls, Hyperparathyroidism, Vitamin D Deficiency, Chronic Lymphocytic Leukemia (CLL) of B-Cell Type not having Achieved Remission, COVID-19, and Dysphagia. Surveyor reviewed Physician Discharge Summary from hospitalization [DATE] through 6/24/22 for weakness and falls. Documented was a weight of 183 lbs. 2.5 oz. Discharge Instructions and Follow-Up documented: Activity: activity as tolerated with fall precautions Physical and Occupational Therapy per plan of care with the intention of the patient hopefully being able to return home in the next 1 to 2 weeks Diet: General diet with Ensure nutritional supplement (not chocolate) with lunch and dinner . Surveyor reviewed R2's MD orders. Documented with a start date of 6/24/22 was Weights: one time only for 1 Day AND every day shift for 3 Days AND every day shift every 7 day(s) for 3 Weeks AND every day shift starting on the 1st and ending on the 7th every month and Regular diet, Regular texture, Thin consistency. [Ensure] Nutritional supplement (not chocolate) with lunch and dinner for regular diet. Surveyor reviewed R2's weights. Documented on 6/25/22 and 6/26/22 was 180.8 lbs. Surveyor reviewed Physical Therapy (PT) Baseline Assessments from 6/26/22. Documented was, Pt will perform transfers with [stand by assist (SBA)] to progress toward [prior level of functioning (PLOF)]: [Caregiver Assist (CGA)]. Pt will ambulate with [two wheeled walker (2ww)] and CGA for 150 ft to progress functional mobility: 2ww and CGA for 50 ft. Surveyor reviewed the Admission Minimum Data Set (MDS) with an assessment reference date of 6/28/22 for R2. Documented under Section C, Cognition was a Brief Interview for Mental Status (BIMS) score of 12 which indicated cognitively intact. Documented under Section G, Functional Status for Bed Mobility and Transfer Status was 2/2 which indicated Limited Assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance; One person physical assist. Documented under Walk in Room and Walk in Corridor was 7/2 which indicated Activity occurred only once or twice - activity did occur but only once or twice; One person physical assist. Documented under Locomotion On Unit and Locomotion Off Unit was 2/2 which indicated Limited Assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance; One person physical assist. Documented under Mobility Devices was Walker. Documented under Section K, Swallowing/Nutritional Status was Height and Weight Height: 69 inches. Weight: 181 pounds. Documented under Weight Loss and Weight Gain was No, or unknown. Surveyor also reviewed R2's Care Area Assessments (CAA) with an assessment date of 6/29/22. The CAA for Nutritional Status documented under Nature of the Problem/Condition [R2] has a BMI of 26.7 which is considered overweight. Documented under Care Plan Considerations was Will Nutritional Status - Functional Status be addressed in the care plan? Yes. If care planning for this problem, what is the overall objective? Avoid complications, Minimize risks. Describe impact of this problem/need on the resident and your rationale for care plan decision. (Include complications and risk factors and the need for referral to other health professionals) Will [continue] to provide a regular diet to meet nutritional needs. Surveyor reviewed R2's Comprehensive Care Plan with an initiation date of 6/28/22. There was no Nutritional Status care plan for R2. Documented in R2's Progress Notes on 6/30/2022 at 1:29 PM was resident did not eat either meal this shift, [Certified Nursing Assistant (CNA)] offered to feed resident he declined, writer will inform family, np (nurse practitioner) updated. Surveyor reviewed CNA documentation for R2's Amount Eaten for June 2022. Documented were 18 entries for the month that included: 76% - 100%: 2, 51% - 75%: 0, 26% - 50%: 5, 0% - 25%: 3, and Resident Refused: 7. MD Orders were updated for R2 on 7/1/22 and the Ensure nutritional shakes were increased to 3 times a day. R2's weight was taken on 7/4/22 and was documented as 171.4 lbs. Surveyor noted a 9.4 lbs. loss in 9 days. R2's weight was taken on 7/9/22 and was documented as 168.8 lbs. Surveyor noted a total of 12 lbs. weight loss, down 6.6% since 6/25/22. Surveyor reviewed R2's Nutrition Assessment with an assessment date of 7/9/22 completed by Former RD-BB. Documented was: .Labs . Albumin: 3.3 . Assessment: [R2] . [admitted ] on a regular diet. Res has poor meal intakes with multiple meal refusals. Res is receiving nutritional shakes [three times daily (TID)] to provide additional [calories] and [protein] to help meet nutritional needs. Current wt: 171.4#, BMI: 25.3 (overweight). Weight maintenance is desired. Hosp wts: 200.0# (6/21/22) and 182.8# (6/22/22). Most recent labs noted above . Nutrition Diagnosis: overweight Nutrition Intervention: Cont on a regular diet with nutritional shakes Nutrition Monitoring and Evaluation: Will monitor weight, intakes, and labs. Surveyor reviewed Physical Therapy (PT) Discharge Assessments from 7/14/22. Documented was Pt will perform transfers with SBA to progress toward PLOF (prior level of functioning): CGA (contact guard assist). Pt will ambulate with 2ww and CGA for 150 ft to progress functional mobility: 2ww (wheeled walker) and CGA for up to 40 ft. Surveyor noted no improvement in transfers and ambulation for R2. R2's weight was taken on 7/15/22 and was documented as 164.2 lbs. Surveyor noted a total of 16.6 lbs. weight loss, down 9.2% since 6/25/22. Documented in R2's Progress Notes on 7/16/2022 at 6:02 PM was Additional education provided: Poor nutritional intake. Resident is not eating. Refusing all meals. Maybe fair intake of liquid. Resident [complaint of (c/o)] of not having a [bowel movement (bm)]. Educated on the importance of eating at least vegetables and fruits to have regular bowel movements and increase water intake. Documented on 7/17/2022 at 7:36 PM was Reported to writer that resident is refusing meals. Writer tried encouraging. Writer encouraged wife to encourage resident to eat dinner. Took two bites at that point. Resident says his taste buds are gone and everything smells and taste bad. He says he doesn't have an appetite either. Wife says he has not been eating much even before coming here. NP aware. Per NP, will see resident sometime this week to discuss appetite stimulant. Continue to monitor. The resident was not seen by the NP due to R2 discharging to home on 7/18/22. Surveyor reviewed CNA documentation for R2's Amount Eaten for July 2022. Documented were 55 entries of intake for the month that included: 76% - 100%: 2, 51% - 75%: 4, 26% - 50%: 5, 0% - 25%: 25, and Resident Refused: 19. After R2 was discharged home on 7/18/22, he was hospitalized again from 7/20/22 through 7/28/22 for Physical Deconditioning and admitted back to the facility for a second time on 7/28/22. Documented in Hospital Report was .appetite remains significantly poor, discussed with RD, tolerating snacks and supplements wife brings from home . CLL: stable . R2's Progress Notes documented on 7/28/2022 at 4:10 PM .[R2] arrived via stretcher with wife at bedside. Resident alert oriented times four denies any complaints of pain or discomfort at this time . Was admitted into hospital for generalized weakness [history (Hx)] of COVID two months ago not covid vaccinated. Here for therapy strengthening and nutritional support. Np aware of patient arrival and med review was done. No new orders at this time. A Comprehensive Care Plan was put in place for R2 for Nutrition on 7/28/22. Documented was: Focus: [R2] has an altered nutritional status [related to (r/t)] poor meal intakes Goals: Resident will consume adequate energy to maintain weight Interventions: o Obtain and document weights per MD orders and facility protocol. o Monitor/record/report to MD [as needed (PRN)] [signs/symptoms (s/sx)] of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. o Provide and serve supplements as ordered o Provide, serve diet as ordered. Monitor intake and record [every (q)] meal. o RD to evaluate and make diet change recommendations PRN. Surveyor reviewed R2's MD orders. Documented with a start date of 7/28/22 was Weights: one time only for 1 Day AND every day shift for 3 Days AND every day shift every 7 day(s) for 3 Weeks AND every day shift starting on the 1st and ending on the 7th every month and Regular diet, Regular texture, Thin consistency. Documented with a start date of 7/29/22 was Get up in chair for meals three times a day. There was no order to restart the Ensure. R2's weight was taken on 7/29/22 and was documented as 158.4 lbs. Surveyor noted R2 lost an additional 5.8 lbs. while out of the facility. Surveyor reviewed Physical Therapy (PT) Baseline Assessments from 7/29/22. Documented was Pt will perform transfers with SBA (stand by assist) to progress toward PLOF (prior level of functioning): CGA. Pt will ambulate with 2ww and CGA for 50 ft to progress functional mobility: 2ww and CGA for 20 ft. R2's weights were taken on 7/31/22 through 8/4/22 and were documented as: 7/31/22: 157.6 lbs. 8/1/22: 157.0 lbs. 8/2/22: 158.4 lbs. 8/3/22: 158.4 lbs. Surveyor reviewed the Admission MDS with an assessment reference date of 8/3/22 for the second admission for R2. Documented under Section C, Cognition was a BIMS score of 12 which indicated cognitively intact. Documented under Section G, Functional Status for Bed Mobility was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two+ persons physical assist. Documented under Transfer Status 3/2 Extensive Assistance - resident involved in activity, staff provide weight-bearing support; One person physical assist. Documented under Walk in Room and Walk in Corridor was 8/8 which indicated Activity did not occur - activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period; [activity of daily living (ADL)] activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period. Documented under Section K, Swallowing/Nutritional Status was Height and Weight Height: 66 inches. Weight: 158 pounds. Documented under Weight Loss and Weight Gain was No, or unknown. Surveyor noted a significant decline in ADLs since the Admission MDS on 6/28/22. Also noted was Weight Loss coded as No, or unknown when R2 had a significant weight loss since 6/25/22 of 22.4 lbs. and 12.4% total. Surveyor also reviewed R2's CAA with an assessment date of 8/3/22. The CAA for Nutritional Status documented Describe impact of this problem/need on the resident and your rationale for care plan decision. (Include complications and risk factors and the need for referral to other health professionals): The resident has potential altered nutritional status [related to (r/t)] poor meal intake. The goal is the resident will consume adequate energy to maintain weight by having diet served as ordered, provide and serve supplements, monitor intake, monitor weight, and RD to evaluate and make diet change recommendations as needed to maintain current level of functioning. R2's weights were taken on 8/4/22, 8/6/22 and 8/7/22 and were documented as: 8/4/22: 158.4 lbs. 8/6/22: 155.2 lbs. 8/7/22: 155.4 lbs. Documented in Progress Notes on 8/9/2022 at 2:48 PM by Former RD-BB was Res triggered for a [significant] wt change. Current wt: 155.2# (pounds), which is a wt loss of 13.6# (8.1%) x1 mo. BMI: 25.0 (overweight). Res cont on a regular diet. Meal intakes are poor. Res states he has no appetite. Will discuss appetite stimulant. Will also add nutritional shakes TID (three times daily). Will cont to monitor weight, intakes, and labs. There was no assessment by Former RD-BB on 8/9/22, no assessment of the weight loss since admission of 25.6 lbs. (14.2%) and continues to address the resident as overweight on the BMI scale but does not address the significant weight loss. MD Orders were updated for R2 on 8/9/22 and the Ensure nutritional shakes were put back in R2's orders and scheduled for 3 times a day but the appetite stimulant was not addressed and no order was put in for R2. MD Orders were updated for R2 by NP-CC. Added on 8/17/22 was Mirtazapine Oral Tablet 7.5 MG (Mirtazapine) Give 7.5 mg by mouth at bedtime for appetite stimulant. Added on 8/18/22 was Multivitamin Men Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet by mouth one time a day for supplement. Added on 8/20/22 was House Nutritional Frozen Pudding two times a day Supplement. On 1/31/23 at 10:37 AM, Surveyor interviewed NP-CC. Surveyor asked about the orders put in for R2 in August. NP-CC stated this was because she had been updated on the significant weight loss. Surveyor asked if she was ever made aware prior to 8/17/22. NP-CC stated no, she was unaware but she should have been updated when R2 first started having significant weight loss (5% or more.) Surveyor reviewed CNA documentation for R2's Amount Eaten for August 2022. Documented were 89 entries of intake for the month that included: 76% - 100%: 3, 51% - 75%: 3, 26% - 50%: 2, 0% - 25%: 35, and Resident Refused: 35. There were no reweighs for R2 or any assessments by Former RD-BB after 8/9/22 that addressed the resident's poor appetite and refusal of meals. R2's weight was taken on 9/3/22 and was documented as 145.8 lbs. Surveyor noted R2 lost an additional 9.4 lbs. since 8/7/22 and since NP-CC added interventions. No one assessed the effectiveness of these interventions. Total weight loss since 6/25/22 was 35.0 lbs. (19.4%) and 12.6 lbs. (8.0%) since 7/29/22. Documented in Progress Notes on 9/4/2022 on 9:47 AM was No longer on PT/[occupational therapy (OT)], or covid isolation. Refusing to get up for staff, frequently refuses meals. Will drink ensure/supplements offered. This morning he said he couldn't eat breakfast because it was cold it was scrambled eggs, sausage and a muffin. Offered to warm it up which he refused. He again refused the meal. Documented on 9/5/2022 at 10:02 AM was Resident continues to refuse the food here, does drink the ensure supplements his wife brings in as well as the food she brings here. Documented in Progress Notes on 9/8/2022 at 11:34 AM was Writer spoke to resident's wife and resident - They would like a g-tube placed if possible but wants to ensure insurance will cover it. Advised will notify MD and will let social services know for follow up. Documented 9/8/2022 at 12:20 PM was Writer made [NP-CC] aware of G-tube request. Documented in Progress Notes on 9/9/2022 at 11:15 AM by Former RD-BB was Res triggered for a sig wt change. Current wt: 145.8#, which is a wt loss of 12.6# (8.0%) x1 mo. BMI: 23.5 (normal). Cont on a regular diet with magic cups and nutritional shakes. Intakes are very poor (0-25%). Low dose [Mirtazapine] started recently to stimulate appetite. Res and wife discussed and requested g-tube placement. Will cont to follow up. There was no assessment by Former RD-BB on 9/9/22, no assessment of the weight loss since the first admission. There were no reweigh orders to assess the continued weight loss. Documented in Progress Notes on 9/15/2022 at 3:43 PM was Writer met with the wife and son in regards to their desire to take [R2] home if he is not having the procedure done soon. Writer did state that the appointment has been made and writer needs to get clarification as writer does not want to provide the wrong information. Writer did let the wife know that his appointment to get the tube in place will be on Tuesday September 20th, leaving here at 9 am. Surveyor noted there was no follow-up by the facility to make the G-tube appointment until 9/15/22. Documented in Progress Notes on 9/20/2022 at 2:39 PM was Resident continues to refuse food at meals but will drink his supplements. Missed his appointment for G tube placement due to transportation issues . The facility was responsible for ensuring transportation to the appointment. The appointment was rescheduled for 9/26/22. Surveyor reviewed R2's visit note from 9/21/22 with NP-CC. Documented was .[R2] states he feels it is hard to swallow and his voice is weaker . Mirtazapine . resident still has noted weight loss. supplements are being given. resident is encouraged to get out of bed for meals. psych consult made. Referral to GI for consideration of g-tube placement was made 9/8. [Speech Therapy (ST)] eval made 9/21 for complaints of dysphagia and weak voice. Will also place PIV and start 0.9NaCI IVF at 50ml/hr x1L to help with hydration . Documented in Progress Notes on 9/23/2022 at 10:56 AM was Resident ate less than 25% or refused meals for 24/hr. Resident continues to have very poor meal intake, does drink the supplements his wife brings in. GT placement is Monday 9/26/22. Documented in Progress Notes on 9/26/2022 at 3:08 PM was Resident returned from appointment for gtube/peg tube placement. They were NOT able to place either type of tube due to his stomach being too high under the ribs/xyphoid process. No changes made to orders. Surveyor noted R2 needed an appointment scheduled with General Surgery to place the G-Tube. Documented in Progress Notes on 9/27/2022 at 4:45 PM by Director of Nursing (DON)-B was Writer had meeting with [Social Services], [NP-CC] and wife via phone to discuss discharge plan and goals of care this afternoon. Resident continues to have decreased oral intake, continues to decline to get out of bed and has had overall decline in function. Received IV fluids last week X 2 liters. Resident unable to get G tube placed yesterday d/t anatomy and per wife needs a surgical consult. [NP-CC] discussed safety concerns with wife regarding [discharge]. Wife replied All he is doing is sitting there in bed. You are just changing his diapers and giving him meds. I can do that. Writer discussed overall clinical concerns with underlying CLL, deconditioning and monitoring of labs for fluid purposes. Resident would need to be evaluated by PT for current transfer status as resident has declined to get up and participate in ADLs. Wife requested resident be sent out to hospital at this time if resident is agreeable due to above ongoing concerns. Resident agrees to go to ER for eval and treat . Writer called 911 for transport d/t other services unavailable for transport . Surveyor reviewed PT Discharge Assessments from 9/26/22. Documented was Pt will perform transfers with SBA to progress toward PLOF: Previous (9/25/22): refused to attempt. Discharge (8/26/22): has not been willing to stand. Pt will ambulate with 2ww and CGA for 50 ft to progress functional mobility: Previous (9/25/22): refused to ambulate. Discharge (8/26/22): no ambulation. Surveyor noted the severe decline in transfers and ambulation for R2 since original admission and second admission. Surveyor reviewed CNA documentation for R2's Amount Eaten for September 2022. Documented were 94 entries of intake for the month that included: 76% - 100%: 2, 51% - 75%: 4, 26% - 50%: 0, 0% - 25%: 23, and Resident Refused: 65. There were no reweighs for R2 or any assessments by Former RD-BB that addressed the resident's poor appetite and refusal of meals or non-effective interventions in September 2022. R2 was admitted to the hospital on 9/27/22 with Failure to Thrive and Severe Protein Calorie Malnutrition. Surveyor reviewed Hospital RD assessment with a date of 9/29/22. Documented was a weight of 133 lbs. 2 oz. Documented under Subj

Based on observations, interviews and record reviews, the facility's water management program (WMP) is inaccurate, incomplete and is not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, the CDC Toolkit and the Wisconsin State Plumbing Code SPS 382.50, creating a potential for all 65 facility residents to be infected by Legionella. The facility's Water Management Program failed to: Include water management team members who were knowledgeable about the facility's water system Describe the building water system using text and an accurate flow diagram of the system Identify all locations where Legionella could grow and spread, Identify where control measures should be applied based on where Legionella could grow and spread and identify how to monitor them Identify acceptable ranges of control limits (disinfectant levels, temperature ranges) and corrective actions to take when control limits are not met, Include a process to confirm the WMP is being implemented and is effective Identify what actions should be taken to protect all residents when a resident is diagnosed with Legionnaires disease or when environmental samples identify the presence of Legionella in the water. These failures contributed to R6 acquiring Legionella while residing in the facility. The facility learned on [DATE] that R6 tested positive for Legionella but didn't take any action beyond collecting environmental samples to protect other residents until [DATE] when the Local Public Health Department directed the facility to stop using their water. R6 died on [DATE] from acute kidney injury secondary to septic shock secondary to Legionella. Failure to take action to prevent the growth of Legionella in the water system created a finding of immediate jeopardy, which began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator), DON B (Director of Nursing), MNT C (Maintenance) and SA E (Senior Administrator) of the immediate jeopardy on [DATE] at 3:40 PM. The immediate jeopardy was removed on [DATE]. However the deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as the facility continues to implement its action plan and monitor its effectiveness. Findings include: The [DATE] revised CMS Quality, Safety and Oversight Letter ,d+[DATE] titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) states Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Maintains compliance with other applicable Federal, State and local requirements. The [DATE] CDC Toolkit titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings identifies the key elements of a water management program for healthcare facilities to include: 1. Establish a water management program team 2. Describe the building water systems using text and flow diagrams 3. Identify areas where Legionella could grow and spread 4. Describe where control measures should be applied and how to monitor them 5. Establish ways to intervene when control limits are not met 6. Make sure the program is running as designed and is effective 7. Document and communicate all the activities The CDC toolkit identifies locations in a buildings water system where Legionella can grow and spread to include but not limited to: Hot and cold water storage tanks Water heaters Water Filters Electronic and manual faucets Aerators Shower heads and hoses Pipes, valves and fittings Infrequently used equipment including eye wash stations Ice machines Hot tubs The CDC toolkit identifies factors internal to buildings that can lead to Legionella growth to include: Biofilm Scale and sediment Water temperature fluctuations: Provides conditions where Legionella grows best (77°-108°F) Water pressure changes PH Inadequate disinfectant: Does not kill or inactivate Legionella Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant The Wisconsin State Plumbing Code Chapter SPS 382.50(3)(b)6 requires a nursing homes hot water system to be installed and maintained to provide bacterial control by one of the following methods: Water stored and circulation initiated at a minimum of 140°F and with a return of a minimum of 124°F Water chlorinated at 2mg/L residual Another disinfection system approved by the department On [DATE] at 10:05 am, NHA A provided Surveyor with a document titled Lincoln Park Time Line for Legionella that noted the following: [DATE] - Regular Legionella testing completed in facility and the results on [DATE] were positive for Legionella. The facility hired IWC (Innovative Water Consulting) who sanitized / chlorinated the facility water. Retesting was completed on [DATE] and results on [DATE] indicated no detectable traces of Legionella. Installed first disinfectant machine and point of use filters on showers. Water testing was conducted ,d+[DATE] and again in ,d+[DATE] however the time line doesn't identify that Environmental Testing was completed on [DATE] and IWC test results on [DATE] were positive for Legionella in the East and West staff bathrooms. The time line doesn't include IWC test results dated [DATE] which were again positive for Legionella in the East and West staff bathroom. [DATE] IWC test results were positive for Legionella in the following locations: Hot water tank, basement mop sink, East and West shower rooms, employee entrance sink, and the front desk sink. IWC Sanitized- Hydrotreat Sanitization on [DATE]. Retested water on [DATE] 1 positive (East Shower Room). Periodic flushing was started. Retesting was completed [DATE]and and IWC tests results dated [DATE] were positive for Legionella in the incoming water and negative at other sites; hot water return, hot water holding tank, shower room east and west . MNT C completed Legionella testing using IWC supplies - MNT C reported this occurred on [DATE]. Results received on [DATE] and Legionella was detected in Rooms 17, 33, 38, 82, and 91. Legionella was not detected in the East and West Shower Room or room [ROOM NUMBER]. On [DATE] between 9:15 am and 10:30 am, Surveyor interviewed NHA A and MNT C (director of environmental services) regarding Legionella in the facility's water system. MNT C indicated that back in 2018, the Corporate Maintenance person told him that CMS Centers for (Medicare and Medicaid Services) said the facility had to test their water for Legionella. Circulator pump does not run continuously. MNT C stated that there were two domestic hot water heaters to raise the municipal water temp to a set point of 140 degrees F, and one water heater for the Kitchen. He stated that a pump in the water heater room pumped water to a holding tank in an adjacent room. He further stated that the facility had circulator pump set to run when there was a demand of water in the building, which he later clarified via email on [DATE] that the pump runs until it reaches a set point which is 110 degrees then turns off and if the temp drops down on the return side it kicks on again. MNT C stated that the mixing valve in the holding tank room maintained outlet water temperature between 105 and 115 degrees F. MNT C further stated that since he started working at the facility in 2003, the circulator pump was not set up to run continuously until the site visit by the State Plumbing Inspector on [DATE]. It should be noted that not having the circulator pump set to run continuously leads to water stagnation, reduced temperatures and unequal distribution of disinfectant which all contribute to Legionella growth. Water temperature in return lines is below 124 degrees and water chlorination is not monitored at fixtures. The facility did not meet the ASHRAE Guideline found in the following website address https://www.montcopa.org/DocumentCenter/View/1036/ASHRAE?bidId= notes: SPS 382.50(b) 6. Hot water distribution systems shall be installed and maintained to provide bacterial control by one of the following methods: a. Water stored and circulation initiated at a minimum of 140°F and with a return of a minimum of 124°F. The WI State Plumbing Code requires the temperature on the return line to be 124°F. b. Water chlorinated at 2 mg/L residual. c. Another disinfection system approved by the department. These requirements were not met, as follows: On [DATE] at 11:01 am, Surveyor and MNT C observed the temperature gauge to read 100°F (not 124° as required) on the return water line identified by MNT C. On [DATE] at 2:35 pm, MNT C reported that once the second disinfection system was installed on [DATE], he stopped manually checking the chlorine level. When asked how the chlorine level was monitored he stated there was a digital display but he wasn't quite sure as he has nothing to do with it since IWC installed the system. (It should be noted that once MNT C stopped manually checking the chlorine levels, the facility no longer had a system to ensure its water was chlorinated at 2mg/L residual as required by the WI State Plumbing Code) On [DATE] between 9:15 and 10 am, review of documents including IWC email of [DATE]th 8:32 am received from MNT C via email on ,d+[DATE] and ,d+[DATE], and interview with NHA A on [DATE] at 8:32 am revealed that the facility's disinfectant system installed in the holding water tank room in basement indicated Free Chlorine of 4.0 ppm (4.0 mg/L) at that location, but the facility did not have hot water samples taken at plumbing fixtures in resident care areas far away from the injection location to check for compliance with the minimum 2 mg/L Residual chlorine requirement in the system in accordance with the Wisconsin state plumbing code SPS 382.50(3)(b), and the ASHRAE Guideline ,d+[DATE] Section 4.1.6. The IWC email document further revealed that the state plumbing inspector required those distal levels that MNT C will be testing in the bathroom to be at least 0.5ppm (0.5mg/l) with no more than 4.0ppm (4.0mg/l) as defined by the SDWA (Safe Drinking Water Act) limits. Facility did not meet the elements described in the CDC tool kit The [DATE] CDC Toolkit titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings (as identified above) identifies, in part, the following elements in a water management program: 1. Establish a water management program team 2. Describe the building water systems using text and flow diagrams 3. Identify areas where Legionella could grow and spread 4. Describe where control measures should be applied and how to monitor them 5. Establish ways to intervene when control limits are not met . On [DATE] and [DATE], Surveyor reviewed the facility's WMP and noted: * Document is a template and Lincoln Park is filled in at Facility Name. The document contains no dates as to when it was developed or reviewed. On [DATE] at 1 pm, NHA A reported the WMP was created in 2017 however the document identifies NHA A as part of the Water Management Program Team even though she reported she's only been at the facility for four weeks. NHA A was unable to tell Surveyor when the document was updated. * There is no text description of the WMP as recommended by the CDC toolkit and the water system diagram is inaccurate per interview with MNT C on [DATE] between 9:15 and 10:30 am. MNT C reported the facility had three water heaters however the water system diagram identifies four water heaters and the hot water holding tank and kitchen are not included. During a follow up interview with MNT C at 3:50 pm, he confirmed the diagram was not accurate. MNT C was unable to explain the flow of water through the facility system even though the WMP identifies him as a member of the WMP Team and responsible for knowledge of the water systems and monitoring and documenting control locations and limits. * The water system diagram titled Potential Hazardous Locations does not identify all locations within the facility's water system where Legionella can grow and spread to include the bed pan sprayers in all resident rooms as identified in the [DATE] IWC Sanitation Report, hot water storage tank also identified in the [DATE] IWC report, hot water heater, and respiratory equipment. The diagram indicates stagnation applies to the ice machine, sinks, showers and Jacuzzi tubs. * The water system diagram titled Control Monitoring identifies visual temperatures as the only control measure for the following locations municipal water main, disinfectant system, sinks, showers, Jacuzzi tubs, water heaters, blending valves, and the laundry, however it doesn't identify the specific control limits (acceptable temperature ranges) for each of the areas identified for control monitoring. The diagram doesn't identify what control measures (testing disinfectant, flushing) and control limits (acceptable level of disinfectant, frequency and duration of flushing) will be used to address stagnation as well as disinfection as required by the WI State Plumbing Code * The WMP includes two text pages for Monitoring that conflict with each other. One page is computer generated titled Monitoring and the other page is handwritten titled Control Monitoring and is not signed or dated. o Computer generated Monitoring Page Water temperatures are to be taken (or read from an in line thermometer) and recorded on a monthly basis. Locations of required temperature recordings can be found on the Control Monitoring Flow Charts (pages). Acceptable ranges can be found in the Notes section of the flow chart. Surveyor review of the WMP flow charts identified in facility WMP as water system diagrams does not include locations of required temperature recordings and acceptable ranges. Bed pan sprayers - Not included despite recommendations in [DATE] IWC Sanitation Report, which noted The bed pan sprayers are of high concern as they are being flushed on a bi-weekly protocol. It was noted during the sanitization that we saw a lot of black, brown and greenish colors coming from these lines. These are notable of biologically growth. We would recommend that these be completely removed if possible or to place them on a weekly flushing protocol. Chlorine monitoring - Not included despite WI State Plumbing Code Jacuzzi tubs - Not included despite being identified on the facility water system diagram as a potentially hazardous location due to stagnation of water. Hot water storage tank - Not included despite water from the storage tank testing positive for Legionella on [DATE] and recommendations in [DATE] IWC Sanitation Report. The above conflicts with the following: o Hand written Control Monitoring page Water temperatures - Take weekly water temps throughout building but doesn't include specific locations to include but not limited to the hot water holding tank, hot water heaters and acceptable temperature ranges. Bed pan sprayers - Weekly flushing of bed pan sprayers Chlorine monitoring - Not included Jacuzzi tubs - Not included. Hot water tank - Monthly flushing of hot water tank Flushing not done as often as needed On [DATE] at 3:50 pm, Surveyor discussed concerns with facility WMP noted above with MNT C. MNT C reported he is the author of the hand written Control Monitoring page. He reported the weekly flushing of bed pan sprayers and monthly flushing of the hot water tank were added in 2018. When asked about how long it takes to flush all of the bed pan sprayers he reported his assistant MNT I shared weekly flushing. MNT C identified three Jacuzzi tubs, one located in physical therapy, one located in the Unit 1 central bath and one located in the Unit 3 central bath. He indicated the tubs are included in the weekly flushing. Surveyor reviewed the computerized log for flushing titled Bedpan Sterilizer generated by the facility on [DATE] for dates [DATE] through [DATE]. The log notes flushing was not completed weekly as indicated in the WMP and reported by MNT C. Flushing occurred at an interval ranging between 11 - 17 days. On [DATE], the log noted only able to do the non-COVID patient rooms On [DATE] at 7:05 AM, Surveyor and NHA A went into the Spa room to look at their whirlpool tub. NHA A indicated this was the only tub they had and they rarely use it. Surveyor asked NHA A how often the tub is cleaned/flushed as there's black debris in the bottom of the tub. NHA A indicated she would check and get back to Surveyor. On [DATE] at 8:06 AM, Surveyor interviewed PT H (Physical Therapist) at this time regarding the tub. PT H indicated there is a tub in the bathroom. Surveyor went into the Physical Therapy Gym bathroom to look at the tub. Surveyor observed the tub to be a standard bathroom tub, with a commode shower chair within it. The tub had a thick layer of black debris that the surveyor was able to run her fingers through and fingers became coated in the black debris. Surveyor interviewed PT H at this time regarding cleaning of the tub. PT H indicated housekeeping cleans it as they only use it for transfer practice. PT H indicated the water is never ran in that tub. On [DATE] at 10:20 AM, Surveyors interviewed MNT I, who stated that he and MNT E were flushing the water system on a regular basis. When asked how often, MNT I stated they flushed whirlpools once per week and bedpan hoses every other week. MNT I was unaware if CNAs were using the bedpan hoses and did not recall maintenance staff giving nursing any guidance on whether they should be using them or not. MNT I stated resident bathroom sinks and the bath/shower in physical therapy were not being flushed. Water temperatures are too low Surveyor reviewed the computerized log generated by the facility on [DATE] for testing the hot water temperatures in the facility. The log indicates temperatures were taken on a weekly basis as identified in the WMP and the temps were taken in the same eight locations each time but did not include the hot water storage tank, or hot water heaters. The log notes low temperatures between 105 - 108 are recorded at multiple locations on ,d+[DATE]//20, [DATE], [DATE] and [DATE]. According to ASHRAE Guideline ,d+[DATE], water temperature is a significant factor that influences the survival of and growth of Legionella. The optimal temperatures for Legionella growth are generally between 85°F and 108°F. Outcome R6 was a [AGE] year-old woman who was admitted on [DATE]with an abdominal wound and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Admission MDS (minimum data set) dated [DATE], indicates R6 has a BIMS (Brief Interview of Mental Status) of 14 out of 15 indicating R6 is cognitively intact. On [DATE] R6's Nurse Practitioner Visit note, indicates R6 is not having any signs of Respiratory symptoms based on the Review of Systems. R6 looks well-nourished and well-groomed. Assessment/Plan indicates CBC (complete blood count) ordered related to recent bleeding and lethargy . 10. [CONDITION(S)] -stable CXR (chest x-ray) ordered, supplemental O2 (oxygen) prn (as needed), monitor respiratory status . On [DATE] at 1:03 PM, R6's CBC results showed high white blood cell count (Leukocytosis) of 14.9 with a reference range of 3.,d+[DATE].2. R6 also had low hemoglobin (protein responsible for transporting oxygen in the blood) and a low red blood cell count. R6's labs on [DATE] indicated a BNP (B-type Natriuretic Peptide (heart hormone)) of with a reference range of less than or equal to 449. R6's CMP (Complete Metabolic Panel) showed a BUN (Blood Urea Nitrogen) of 110 which is high and a creatinine of 3.35 which is also high with a GFT (Glomerular Filtration Rate) of 13. On [DATE] at 1:32 PM R6's Nurses Note states in part: labs from [DATE] faxed to NP, awaiting call back. New labs ordered today have not received the results yet. UA (urine analysis) was collected 12:20 pm via straight cath (catheter) via sterile technique and sent with lab personnel that was here obtaining STAT (immediate) labs at 12:30 pm . On [DATE] at 5:31 PM, R6's Nurses Note states in part: Updated NP with lab results. Orders received to send to (hospital name) ER (emergency room ) for AKI (acute kidney injury), dehydration, and CHF (congestive heart failure) exacerbation. On [DATE] at 7:26 PM, R6's Emergency Department Note, states in part: Patient here in the emergency department from her living facility with report of increased shortness of breath and report of acute renal failure found on labs done today. Patient arrives emergency department awake and alert . she has no complaints and per the ambulance crew she did not wish to be transported to the emergency department . Pulmonary: Comments: Patient with diminished breath sounds and crackles in bases, mild to moderate increased work of breathing at rest.Assessment: Principal Problem: Acute Renal Failure. Active Problems: Urine retention, acute on chronic diastolic CHF (Congestive Heart Failure) . Mild [CONDITION(S)] and recent onset cough, rule out COVID-19 infection. On [DATE] at 11:24 PM, R6's COVID-19 Swab was negative while at the Hospital. On [DATE] R6's urine tested positive for Legionnaires [MEDICATION(S)]. On [DATE] at 9:59 AM, R6's Nurses Note states in part: Received call from guardian (name), coming to pick up resident's personal items. (Name) was informed from nursing staff at (hospital) that residents not expected to make it . On [DATE] at 10:48 AM, a fax from the Hospital regarding R6 was sent containing Hospital records from [DATE] at 7:25AM that states in part: Assessment and Plan: #AKI (Acute kidney injury) Etiology: ATN (acute tubular necrosis or AKI) secondary to septic shock in the setting of Legionella and Pneumococcal pneumonia .#Septic Shock: ,d+[DATE] (secondary to) Legionella, pneumococcus, mycoplasma? signed by a Physician on [DATE]. (Septic shock is a wide spread infection that causes organ failure. Legionella is the bacteria which causes Legionnaires 'disease, which grows in stagnant water systems, air conditioning units and central heating systems.) Per LPH (local public health) R6 passed away in the Hospital, Hospital discharge date of [DATE]. On [DATE] at 1:15 PM Surveyor interviewed LPH F (Local Public Health) regarding R6 and the facilities Legionnaires outbreak. LPH F indicated it was reported to them that R6 had legionnaires on [DATE]. LPH F indicated she tried to reach R6 at her home address and later discovered on [DATE] R6 had been at a Nursing Home Facility. LPH F indicated they got hold of (Admissions personnel) on [DATE]. LPH F indicated she is unaware of when the facility was first informed as R6 was in the ICU (intensive care unit) and LPH was unable to speak with her. LPH F indicated that R6 was at the Nursing Home Facility during her entire incubation time from the 12th to the 27th. LPH F indicated that R6 had signs and symptoms of pneumonia on [DATE]. LPH F indicated they found out during an email that the facility had a legionella concern. LPH F indicated LPH went to the facility on [DATE] to check water samples. LPH F indicated the facility had taken water samples earlier in February 2021 also but sent those tests to their water management company. LPH F indicated the facility had several types of legionella bacteria indicated when LPH took their own samples. LPH F indicated the facility was recommended on [DATE] to stop the use of their water and to stop showers at that time. LPH F indicated LPH had verbal communication with the facility and concerns were voiced about multiple strains. LPH F indicated she dropped off sputum sample containers and was informed by DON B that the facility does not have the capacity to test for sputum cultures and that a Respiratory therapist from their corporation would need to do it. LPH F indicated the facility had three other Residents with symptoms (R8, R10, and R11). LPH F indicated she recommended the facility do sputum cultures on any resident with pneumonia symptoms. LPH F indicated LPH would have recommended stopping the use of water once the facility had a positive result as the facility only had filters on the ice machines and shower heads. LPH F indicated the facility water management company made recommendations and LPH F doesn't think the facility made the changes as there were concerns with water temperatures and the holding tank. LPH F indicated 15 swabs came back positive and 11 water samples also came back positive for legionella. LPH F indicated the facility should have taken action when they found out positive for legionnaires. LPH F indicated they took water samples and have a water plan, but she does not know where they are with flushing as they called their water consultant company. LPH F indicated in [DATE] the facility put a second sanitization system in and did not let DSPS know and altered the plumbing without a back flow prevention plan and without approval from DSPS. LPH F indicated the facility has had legionella in the past. LPH F indicated that flushing water access for thirty seconds to a minute at a time is not long enough to flush out the system. LPH F indicated that the facility water management plan should tell the staff how long it takes to flush the system and how long it takes water to get from one corner of the building to every water fixture in the building. LPH F indicated in an older building the plumbing should have more maintenance. LPH F indicated the ice machines had multiple organisms of legionella and the facility was unable to say when the ice machine was last cleaned or when the filter was changed. LPH F indicated the facility is not to use their ice machine until they can maintain and clean the ice machine per manufacturer recommendations. LPH F indicated on [DATE] she spoke with NHA A regarding the different types of legionella strains. LPH F indicated the facility completed a system flush with chlorination of the system with their water consultant company on [DATE] and were to take further water samples to be sent to their water management company. LPH F indicated that the facility's second water system is not in their water plan and was not approved to be put in and there was no back flow prevention system in place. LPH F indicated that the water coming in showed legionella and if issues arise the city will take samples and all the samples in the surrounding area (gas station etc.) of the facility were negative for legionella and had adequate chlorine levels. LPH F indicated she asked for sputum cultures on R8, R10 and R11 and the testing would have been done by LPH and were never provided to LPH. There is no indication that staff tried to obtain sputum cultures on R8, R10 or R11 like LPH recommended. Failure to ensure that all necessary steps were being taken to prevent the growth of Legionella created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when the facility began implementing the following: On [DATE] the facility initiated the following interventions based on [NAME] Health Department recommendations: o Discontinued use resident sinks and shower rooms o Halted Admissions o Ice Machine turned off o Purchased ice and bottled water In addition to these immediate interventions, the facility began implementing the following: 1. Resident (R6). Is no longer in the facility. 2. Emergency QAPI Meeting held to review Legionella Outbreak and the steps taken so far to remediate the immediacy of the concern. A RCA is being completed to determine systemic gaps in monitoring the Water Management System to prevent legionella outbreaks. The QAPI Team will meet to discuss the RCA and implement immediate corrective actions. During facility audits any discrepancies to the Water Management Plan will be immediately taking to the QAPI team so immediate correction actions can be implemented. 3. All sinks within the facility have been covered until such time that they are safe for resident use. 4. Facility Water Management has been updated to meet CDC recommendations. 5. Facility circulating pump has been set to continuous run. 6. A review a of previous water management plan was conduct and the following was updated on the plan immediately a. Created a flow diagram to reflect the current water system in the facility b. Deadlegs, incoming water, disinfection system, water temperatures were added as potential hazards. c. A control monitor plan was developed to include the flushing of deadlegs per the CDC guidelines. d. A Review of the CMS QSO-,d+[DATE] and the CDC Legionella Toolkit was conducted to highlight areas of improvement for our updated water management plan. e. Added in guidance for what to do if the local health department is not available or responding to give their recommendations 7. Educate Facility maintenance team to test chlorine levels weekly to ensure appropriate levels to kill legionella and to concur or refute electronic system measuring system. 8. All staff have been educated on facility Legionnaires Guideline and specifically on the following: 9. No use of facility faucets, bed pan washers, ice machine, kitchen faucets/sprayers and any other water sources. 10. Nebulizer, [CONDITION(S)], Bi-Pap, and respiratory equipment to be rinsed with sterile water. 11. If an outbreak occurs, monitoring residents for respiratory symptoms daily. 12. Proper use of ABHR for hand hygiene for staff and residents, utilizing bottled water for hand washing if hands are visibly soiled. 1 bottle per person per use. 13. Use of bottled water for drinking, hand washing, brushing teeth, and rinsing items (i.e. bed pans, basins, and denture cups). 14. All residents in the facility have the potential to be affected. 15. The following measures have been taken: 16. Emergency QAPI Meeting held to review Legionella Outbreak and steps taken so far to remediate the concern. 17. All sinks within the facility have been covered until such time that they are safe for resident use. 18. Facility will revise and update water management plan so it meets the criteria outlined in CMS QSO-,d+[DATE] and the CDC Legionella Toolkit including, but not limited to an efficient plan to monitor the controls and what to do if an issue is identified. 19. A Root Cause Analysis is being completed to determine systemic gaps in monitoring the Water Management System to prevent legionella outbreaks. The QAPI team will meet discuss the Root Cause Analysis and implement immediate corrective actions 20. All staff have been educated on facility Legionnaires Guideline and specifically on the following: 21. No use of facility faucets, bed pan washers, ice machine, kitchen faucets/sprayers and any other water sources. 22. Nebulizer, [CONDITION(S)], Bi-Pap, and respiratory equipment to be rinsed with sterile water. 23. If an outbreak occurs, monitoring residents for respiratory symptoms daily. 24. Proper use of ABHR for hand hygiene for staff and residents, utilizing bottled water for hand washing if hands are visibly soiled. 1 bottle per person per use. 25. Use of bottled water for drinking, hand washing, brushing teeth, and rinsing items (i.e. bed pans, basins, and denture cups). 26. Facility staff will not work until they have been educa[TRUNCATED]

Based on interview and record review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies to prevent a legionella outbreak. This has the potential to affect all 65 Residents residing within the facility. Facility was aware of having positive legionella in their water supply from tests in 2018 and 2019 and starting again on [DATE]. The facility failed to implement corrective actions to prevent a legionella outbreak, resulting in a Resident's hospitalization and death due to Legionella. Facility failure to develop and implement corrective actions to prevent a legionella outbreak, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator), DON B (Director of Nursing), MNT C (Maintenance) and SA E (Senior Administrator) of the immediate jeopardy on [DATE] at 3:40 PM. The immediate jeopardy was removed on [DATE]. However the deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as the facility continues to implement its action plan. This is evidenced by: Facility Policy entitled 'QAPI Guideline,' states in part: Purpose: The process will ensure that proactive quality care and services are provided to each resident on a continuous basis that meets requirements of practice consistent with standards of practice. Practice standards and reviews will include clinical care, quality of life and resident choice.Guideline . Systematic Process Analysis and action: addresses at a minimum: addresses all systems of care and management practices. Includes clinical care, quality of life and resident choice. Utilizes the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents. Identifies, reports, tracks, investigates and analyzes to prevent adverse outcomes at minimum with accident reporting, infection control, medications, pharmacy services and trending of key quality indicators.maintains formal written documentation as evidence of on-going quality management. Quality improvement Team Guide. Root Cause Analysis Questions: 1. What/why is the area of concern? 2. What is the desired outcome or goal? 3. What are all the road blocks/barriers toward achieving our goal? 4. What tool or activities will be needed to further identify the area of concerns? .5. Write a statement of causation (cause and effect) of the problem. 6. What approaches/actions will be used to achieve our desired goal? 7. How will we measure our progress toward our goal? 8. What date do we expect to achieve our desired outcome? 9. How will this be communicated to the rest of the team? The goal of a Root Cause analysis is to find out what happened, why and/or how it happened, what do you do to prevent it from happening again . According to the Centers for Disease Control and Prevention (CDC), Legionella is a type of bacterium found naturally in [NAME] environments, like lakes and streams. It can become a health concern when it grows and spreads in human-made building water systems like Showerheads and sink faucets . Hot water tanks and heaters Large plumbing systems . People can get Legionella when breathing in small droplets of water that contain the bacteria. According to the CDC, Most healthy people exposed to Legionella do not get sick. People at increased risk of getting sick are: People [AGE] years or older Current or former smokers People with a chronic lung disease (like chronic obstructive pulmonary disease or emphysema) People with weak immune systems or who take drugs that weaken the immune system (like after a transplant operation or chemotherapy) People with cancer People with underlying illnesses such as diabetes, kidney failure, or liver failure https://www.cdc.gov/legionella/about/causes-transmission.html The CDC indicates that one in ten healthy people who get sick from Legionella will die; one in four people in healthcare facilities who get sick from Legionella will die. On [DATE] at 10:05 am, NHA A provided Surveyor with a document titled (facility name) Time Line for Legionella that noted the following: On [DATE] the facility had positive test results for legionella On [DATE] the facility had positive test results for legionella On [DATE] the facility had positive test results for legionella in their hot water tank, basement mop sink, east and west shower rooms, employee entrance sink and the front desk sink. On [DATE] the facility had one positive test result in the east shower room. On [DATE] the facility had positive test results for legionella in their incoming water supply. On [DATE] the facility was informed by LPH (Local Public Health) that R6 had tested positive for Legionella in her urine culture on [DATE]. On [DATE] the facility had positive test results for legionella in rooms 17, 33, 38, 82 and 91. Legionella was not detected in either East or West shower room at this time. R6 died at the hospital on [DATE]. On [DATE] at 3:40 PM, Surveyor asked NHA A for any indication that the QA committee discussed the facility's Legionella concerns since [DATE] along with their QAPI (Quality Assurance Performance Improvement) Plan or PIP (Performance Improvement Plan) regarding Legionella. Surveyor interviewed SA E (Senior Administrator) and NHA A (Nursing Home Administrator) regarding QA (Quality Assurance Committee). NHA A indicated the team is scheduled to meet and discuss February's findings this month ([DATE]). NHA A indicated the QA Committee met about legionella in November or December of 2020 and the QA committee meets monthly. On [DATE] at 4:10 PM, Surveyor was provided QA meeting information from NHA A from [DATE] through February 2021 which indicates the following: [DATE] Facility QA Committee met, no indication of Legionnaires being discussed. [DATE] Facility QA Committee met, no indication of Legionnaires being discussed. [DATE] Facility QA Committee met, no indication of Legionnaires being discussed. On [DATE] Facility QA Committee met to review the month of January. Under Infection Control indicates COVID-19 outbreak in the month of January, indicating three respiratory infections two of which were COVID-19 and one pneumonia. There is no indication that Legionnaires was discussed at this time despite knowing of a positive Legionnaires case on [DATE] for R6. There is no evidence the QA Committee met once a Legionnaire's outbreak was brought to their attention on [DATE], to ensure their Water Management Plan was effective or new interventions were implemented given their extensive history with having positive legionella testing. The Facility has not provided evidence/documentation of a QAPI or PIP to show the Facility's QA committee was making prompt efforts to implement and make corrective actions to their Water Management Plan to prevent a Legionella outbreak since detection of Legionella in their water samples in October of 2020. The failure to develop and implement corrective water management plan to prevent a legionella outbreak created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: 1. Resident (R6). Is no longer in the facility. 2. Emergency QAPI Meeting held to review Legionella Outbreak and the steps taken so far to remediate the immediacy of the concern. A RCA is being completed to determine systemic gaps in monitoring the Water Management System to prevent legionella outbreaks. The QAPI Team will meet to discuss the RCA and implement immediate corrective actions. During facility audits any discrepancies to the Water Management Plan will be immediately taking to the QAPI team so immediate correction actions can be implemented. 3. All sinks within the facility have been covered until such time that they are safe for resident use. 4. Facility Water Management has been updated to meet CDC recommendations. 5. Facility circulating pump has been set to continuous run. 6. A review a of previous water management plan was conduct and the following was updated on the plan immediately a. Created a flow diagram to reflect the current water system in the facility b. Deadlegs, incoming water, disinfection system, and water temperatures were added as potential hazards. c. A control monitor plan was developed to include the flushing of deadlegs per the CDC guidelines. d. A Review of the CMS QSO-,d+[DATE] and the CDC Legionella Toolkit was conducted to highlight areas of improvement for our updated water management plan. e. Added in guidance for what to do if the local health department is not available or responding to give their recommendations 7. Educate Facility maintenance team to test chlorine levels weekly to ensure appropriate levels to kill legionella and to concur or refute electronic system measuring system. 8. All staff have been educated on facility Legionnaires Guideline and specifically on the following: 9. No use of facility faucets, bed pan washers, ice machine, kitchen faucets/sprayers and any other water sources. 10. Nebulizer, [CONDITION(S)], Bi-Pap, and respiratory equipment to be rinsed with sterile water. 11. If an outbreak occurs, monitoring residents for respiratory symptoms daily. 12. Proper use of ABHR for hand hygiene for staff and residents, utilizing bottled water for hand washing if hands are visibly soiled. 1 bottle per person per use. 13. Use of bottled water for drinking, hand washing, brushing teeth, and rinsing items (i.e. bed pans, basins, and denture cups). 14. All residents in the facility have the potential to be affected. 15. The following measures have been taken: 16. Emergency QAPI Meeting held to review Legionella Outbreak and steps taken so far to remediate the concern. 17. All sinks within the facility have been covered until such time that they are safe for resident use. 18. Facility will revise and update water management plan so it meets the criteria outlined in CMS QSO-,d+[DATE] and the CDC Legionella Toolkit including, but not limited to an efficient plan to monitor the controls and what to do if an issue is identified. 19. A Root Cause Analysis is being completed to determine systemic gaps in monitoring the Water Management System to prevent legionella outbreaks. The QAPI team will meet discuss the Root Cause Analysis and implement immediate corrective actions 20. All staff have been educated on facility Legionnaires Guideline and specifically on the following: 21. No use of facility faucets, bed pan washers, ice machine, kitchen faucets/sprayers and any other water sources. 22. Nebulizer, [CONDITION(S)], Bi-Pap, and respiratory equipment to be rinsed with sterile water. 23. If an outbreak occurs, monitoring residents for respiratory symptoms daily. 24. Proper use of ABHR for hand hygiene for staff and residents, utilizing bottled water for hand washing if hands are visibly soiled. 1 bottle per person per use. 25. Use of bottled water for drinking, hand washing, brushing teeth, and rinsing items (i.e. bed pans, basins, and denture cups). 26. Facility staff will not work until they have been educated on the facility Legionnaires Guideline (as outlined above). 27. Facility Water Management plan to be updated to address current risk areas to ensure safe use of facility water. 28. New employees will receive education on the facility Legionnaires Guideline in orientation. 29. Facility Administrator to ensure identified water management issues are reviewed by the facility QAPI Committee. 30. Audits of facility staff will be completed 3x per week for 1 month and monthly for 2 months to ensure compliance with education. 31. Audits of facility sinks to be completed daily to ensure they are either covered or safe for resident use. 32. Recirculating pipe audit 1x daily to ensure it meets appropriate temperature. 33. Facility to review and update the Water Management Plan Annually and as needed. 34. Facility will use routine monitoring of chlorine levels, water temperatures, flushing of deadlegs as control measure to ensure the efficacy of the program. If a concern was identified, the facility will immediate discuss discrepancy, take action, and put a plan in place to correct. 35. During facility audits any discrepancies to the Water Management Plan will be immediately taking to the QAPI team so immediate correction actions can be implemented. Please reference F880.

Based on a complaint investigation, medical record review, resident observations and staff interview, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 2, (R2 &R4) of 6 residents identified as being at risk for falls. *R2 had multiple falls including 1 fall with a major injury. R2's falls plan of care specified R2 was to wear appropriate footwear/gripper socks at all times. Review of progress notes documentation and fall incident reports revealed R2 was not wearing appropriate footwear and fell on [DATE], sustaining a [MEDICAL CONDITION]. R2 had falls without injury on 5/23, and 5/24/18 while not wearing appropriate footwear. On 11/12/18, the surveyor reviewed additional documentation (staff statements) submitted by the facility on 11/8/18, at 4:43p.m. Review of the statements revealed multiple facility staff were aware R2 preferred to wear hunting socks and his backless slippers rather than appropriate footwear/gripper socks. The statements indicate R2 would often refuse to wear his gripper socks. Despite staff being aware R2 had been refusing to wear gripper socks, his fall plan of care had not been updated to acknowledge R2's refusals or offer other footwear options in an attempt to decrease R2's risk for falling. *R4 who has been identified as a high risk for falls had a falls care plan intervention to have his bed in the low position while he was in bed. R4 was observed in bed on multiple occasions on 11/7/18, with his bed not in a low position. Findings include: 1.) The surveyor reviewed R2's closed medical record on 11/5-11/7/18, as part of a complaint investigation alleging R2 had had multiple falls with injuries. R2 had [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed R2 to be severely cognitively impaired and R2 required a minimum assist of 1 for transfers and ambulation. Progress Note documentation revealed many instances of R2 self-transferring and ambulating with or without his walker, without putting on his call light or waiting for staff assistance. Progress Note documentation on 4/26/18 at 3:14p.m. indicates, Resident found sitting on floor in doorway of bedroom by writer at approx. 1:25p.m. Asking writer to get him up. Resident had heavy hunting socks on. Backless slippers were found next to resident's bed. Resident's walker was found in closed bathroom . R2 had no injuries as a result of this fall. Review of a fall investigation/incident report concerning this fall revealed under section What footwear was in use at the time of the event by the resident? that R2 had been wearing regular heavy hunting socks. The Fall Scene Investigation Report under section 1. Factors observed at the time of fall: indicated slid out of slippers. Review of R2's falls plan of care initiated on 8/21/17 revealed the facility updated the plan following R2's fall on 4/26/18, to include an intervention of, appropriate footwear/gripper socks on at all times, discourage hunting socks. Progress Note documentation on 5/3/18 at 9:45a.m. indicates, Found resident sitting on floor in hallway at approx. 8:35a.m. Walker next to side. No one heard thud from fall .Writer went to do vitals resident c/o (complained of) left hip pain .Order to send to ER for evaluation . It was found R2 sustained a left [MEDICAL CONDITION] as a result of this fall. Review of a fall investigation/incident report concerning this fall revealed under section What footwear was in use at the time of the event by the resident? that R2 had been wearing slippers. The Fall Scene Investigation Report under section 10. Footwear at the time of fall indicates slippers without backs. The surveyor spoke with Licensed Practical Nurse (LPN)-B on 11/7/18 at 9:45a.m. LPN-B was the nurse who completed the Progress Note and fall investigation/incident report concerning R2's fall on 5/3/18. LPN-B confirmed that at the time of R2's fall on 5/3/18 he had been wearing slippers with no backs on them. LPN-B also stated the slippers R2 was wearing did not have an anti-slip/skid surface on the soles. LPN-B stated she felt the slippers R2's was wearing on 5/3/18 were not appropriate footwear for the resident. LPN-B also indicated she believes R2 was wearing gripper socks inside the backless slippers. Progress Note documentation on 5/23/18 at 10:29p.m. indicates, Resident fell to the floor trying to transfer to the bathroom. Didn't put on call light. No injury. Review of a fall investigation/incident report concerning this fall revealed under section What footwear was in use at the time of the event by the resident? that R2 had been wearing regular socks not appropriate footwear/gripper socks. Progress Note documentation on 5/24/18 at 2:45p.m., indicates, Resident fell on floor trying to transfer from bed to bathroom. Background-Resident uses a walker to get up from bed and for walking. No injuries. Review of a fall investigation/incident report concerning this fall revealed under section What footwear was in use at the time of the event by the resident? that R2 had been wearing his slippers, not appropriate footwear/gripper socks. Facility staff did not ensure R2 was wearing appropriate footwear as per his falls plan of care leading to a fall on 5/3/18 in which R2 sustained a fractured left hip. On 11/12/18, the surveyor reviewed additional documentation (staff statements) submitted by the facility on 11/8/18, at 4:43p.m. Former Director of Nursing (FDN)-G's statement dated 11/8/18 indicates, Writer oversaw the care of R2 as the DON between the dates on (of) 3/23/2018 and 6/22/2018 . Resident would wear very heavy, wool type socks and refused other footwear. Resident would not wear gripper socks or shoes because he felt they were too constricting. Writer and staff had spoken with wife and daughters frequently about his falls and his noncompliance with self-transferring and refusing proper footwear. Certified Nursing Assistant (CNA)-H's statement dated 11/7/18 indicated that she cared for R2 approximately 5 times per week. CNA-H indicated R2 liked to wear his slip on slippers and hunting socks and refused to wear his gripper socks. CNA-I's statement dated 11/8/18, indicated that R2 refused to wear his gripper socks. CNA-J's statement dated 10/8/18, indicated R2 liked to wear his house slippers and that R2 preferred his hunting socks rather than the gripper socks. Despite staff being aware R2 had been refusing to wear gripper socks because he preferred hunting socks and his slippers, his fall plan of care had not been updated to acknowledge R2's refusals or offer other footwear options in an attempt to decrease R2's risk for falling. 2.) The surveyor reviewed R4's medical record on 11/6-11/7/18. Review of R4's falls plan of care and indicated he is at high risk for falls. A fall intervention in the plan of care and also on the Certified Nursing Assistant (CNA) Care Card located in R4's bathroom is Bed in low position. On 11/7/18, the surveyor observed R4 in bed with the bed not in the low position at 7:40a.m., 8:05a.m., 9:08a.m., and 10:53a.m. At 10:55a.m., the surveyor informed Corporate Consultant (CC)-A that R4 was observed in bed all morning with his bed not in a low position.

Based on observation, interview, and record review, the facility did not ensure that 1 (R14) of 5 residents reviewed for unnecessary medications had adequate monitoring and was free of adverse consequences from [MEDICAL CONDITION] medications which indicate the dose should be reduced or discontinued. R14 was observed to have potential side effects of [MEDICAL CONDITION] medications and the facility was unaware until it was brought to their attention by the Surveyor. Findings include: R14 has [DIAGNOSES REDACTED]. Medications include: [MEDICATION NAME] ER 500 mg daily (an anticonvulsant) for [DIAGNOSES REDACTED] with [MEDICAL CONDITION]/convulsions, [MEDICATION NAME] 75 mg daily (an antipsychotic) for borderline personality disorder (increased on 1/5/2018 from 50 mg daily), [MEDICATION NAME] 0.5 mg every 12 hours as needed (an antianxiety) and was receiving it almost daily (order discontinued on 1/5/2018), and [MEDICATION NAME] 0.5 mg daily (an anti-tremor) for [MEDICAL CONDITION]. R14's plan of care for antidepressant medication related to depression was initiated on 4/12/2017. The interventions listed were to administer antidepressant medications as ordered by physician, monitor/document side effects and effectiveness as appropriate; monitor/document/report as needed adverse reactions to antidepressant therapy; change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in activities of daily living ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/[MEDICAL CONDITION]; fatigue, [MEDICAL CONDITION]; appetite loss, weight loss, nausea/vomiting, dry mouth, or dry eyes. R14's plan of care for anti-anxiety medications related to anxiety disorder was initiated on 4/21/2017. The interventions listed were to administer anti-anxiety medications as ordered by physician, monitor for effects and effectiveness every shift (initiated 7/16/2017); monitor/document/report as needed any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision; unexpected side effects to include mania, hostility, rage, aggressive or impulsive behavior, hallucinations; monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol (initiated 7/18/2017). R14's plan of care for [MEDICAL CONDITION] medications was initiated on 7/16/2017. The interventions listed were to administer [MEDICAL CONDITION] medications as ordered by physician, monitor for side effects and effectiveness (initiated 4/21/2017); monitor/document/report as needed any adverse reactions of [MEDICAL CONDITION] medications: [REDACTED]. R14's plan of care for depression related to dementia was initiated on 8/21/2017. The interventions listed were to arrange for psychiatric consult, follow up as indicated; assist the resident in developing and/or provide the resident with a program of activities that is meaningful and of interest, encourage and provide opportunities for exercise, physical activity; discuss with the resident/family/caregivers any concerns, fears, or issues regarding health and placement concerns. The facility policy and procedure entitled [MEDICAL CONDITION] Medication Management dated 11/28/2017 states: Purpose: it is the practice of this facility that a resident will not receive unnecessary medications including psychoactive medications, unless non-pharmacological interventions have failed to sufficiently modify a resident's target behavioral, mood, or sleep disturbance. Each psychoactive medication will be given to treat clearly defined targeted conditions and to promote or maintain highest practicable physical, functional, and psychosocial well-being. Residents prescribed psychoactive medications will receive adequate monitoring and will have gradual dose reductions attempted, unless clinically contraindicated. PSYCHOACTIVE MEDICATION DATA COLLECTION PR(NAME)EDURE: 1. Review resident record to assist with potential causal factors for mood/behavior or sleep concerns including but not limited to: a. History and Physical, b. [DIAGNOSES REDACTED].> c. Medications, d. Consults, e. Interdisciplinary progress notes, f. MD/NP (Medical Doctor/Nurse Practitioner) Progress notes, g. Resident evaluations (i.e., pain, social services data collection and history, admission data collection, etc .), h. Most recent MDS, i. Overall review for changes in condition from baseline, j. Therapy notes, k. Care plan. 2. Interview resident, family or resident representative for insight into potential casual factors of mood, behavior or sleep issues/changes. 3. The interdisciplinary team will complete the Behavior and [MEDICAL CONDITION] Medication Evaluation prior to initiation of a psychoactive medication. 4. If resident is currently receiving a psychoactive medication, the data collection and completion of the Behavior and [MEDICAL CONDITION] Medication Evaluation will be completed after admission, reviewed quarterly, with a change in condition. ADVERSE CONSEQUENCES (UNNECESSARY DRUGS) - The information that is collected depends on therapeutic goals, detection of potential or actual adverse consequences, and consideration of risk factors, such as: Medication-medication, medication-food interactions; Clinical condition (for example [MEDICAL CONDITION]); Properties of the medication; Black-box warnings; and History of adverse consequences related to a similar medication. DEFINITIONS: . Tardive Dyskinesia - Tardive Dyskinesia refers to abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected. ADVERSE CONSEQUENCE PR(NAME)EDURE: 1. Residents on psychoactive medications are monitored daily for adverse consequences. 2. Side effects may include but are not limited to; allergic reaction, sedation, acute onset of signs or symptoms or worsening of chronic disease, involuntary movements, behavioral distress, decline in function or cognition, addition or discontinuation of medications and/or non-pharmacological interventions, addition or discontinuation or care and services such as enteral feeding, significant change in diet that may affect absorption of medication. 3. Abnormal Involuntary Movement Scale (AIMS) will be performed on residents receiving antipsychotic medications to screen for tardive dyskinesia every 6 months in PCC (Point Click Care). 4. Contact MD/NP regarding any medication-related adverse consequences. On 1/5/2018 at 1:05 PM in the progress notes, nursing charted a message was left for R14's family member to inform them of a new order to increase the [MEDICATION NAME] to 75 mg at night. On 1/6/2018 at 3:23 PM in the progress notes, nursing charted: Resident did not verbalize to writer initially that he was having any hallucinations until writer inquired about it. Resident stated that he is see(ing) multiple people who are unknown to him and they are scaring him. When asked what these people are doing he stated they are making faces at him and other weird things, unable to elaborate any further. Resident did verbalize that these people are not real but yet he still sees them. (Psych) NP was at facility yesterday and aware of the hallucinations and made medications adjust at that time. From 1/6/2018-1/8/2018 nursing documented every shift that no hallucinations were reported by R14. There was no more documentation regarding hallucinations. On 1/16/2018 at 2:03 PM in the progress notes, social services charted a late entry for 1/5/2018 stating: Resident was seen by Psych NP for possible dose reduction in [MEDICATION NAME]. Resident had reported to NP that he was experiencing hallucinations that he had not reported to staff. [MEDICATION NAME] was increased due to this report of hallucinations. Meds will be reviewed monthly and as needed. On 1/22/2018 at 2:35 PM during a conversation with R14, Surveyor observed R14 to have very pronounced mouth movements. On 1/23/2018 at 8:24 PM in the progress notes, nursing charted: Denies any hallucinations; reports 'hasn't had any since yesterday which is unusually (sic) since they are usually there all day.' No documentation was found showing R14 was having hallucinations since the nursing entry on 1/6/2018. On 1/24/2018 at 10:05 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F regarding monitoring of behaviors and side effects of [MEDICAL CONDITION] medications. LPN-F stated Behavior Solutions is involved with any residents that need [MEDICAL CONDITION] medications. When the order comes for a [MEDICAL CONDITION] medication, the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) would put behavior monitoring into the Medication Administration Record [REDACTED]. LPN-F looked in R14's MAR indicated [REDACTED]. LPN-F stated there wasn't any monitoring in the MAR for R14. On 1/24/2018 at 1:47 PM, Surveyor interviewed DON-B regarding monitoring of behaviors and side effects of [MEDICAL CONDITION] medications. DON-B stated the monitoring of behaviors is in the Certified Nursing Assistant (CNA) charting and if behaviors are noted, the CNA would inform the nurse on the unit. The nurse would then chart in the progress notes the behaviors that were observed. Surveyor described the excessive mouth movement observed during conversation with R14. DON-B stated she was unaware of any abnormal movements at present and had done an Abnormal Involuntary Movement Scale (AIMS) last October and there weren't any mouth movements at that time. DON-B stated she would have another AIMS done. R14 was observed on 1/23/2018, 1/24/2018, and 1/25/2018 by Surveyor in the facility. During observations, R14 was in the hallway and lounge area off of the nurses' station on the long term care unit ambulating with a wheeled walker. During all observations throughout the survey, R14 had pronounced mouth movements. CNA charting on behaviors was reviewed. CNA's charted every shift on behavior symptoms in a check-the-box format from 12/26/2017-1/24/2018. The behaviors listed as options that could be checked were: frequent crying, repeats movement, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate, rejection of care, none of the above observed, resident not available, resident refused, and not applicable. For all shifts, CNA's charted none of the above were (sic) observed or not applicable. Surveyor noted there is no indicator related to hallucinations. It was not until 1/26/2018 that an AIMS was completed on R14 showing severity level of 4 (on a 0-4 scale with 4 being the most severe) due to mouth movements. Surveyor noted this was despite sharing the concerns regarding R14's mouth movements earlier in the survey on 1/24/18. Surveyor also noted The facility's policy also indicates: DEFINITIONS: Tardive Dyskinesia - Tardive Dyskinesia refers to abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected. ADVERSE CONSEQUENCE PR(NAME)EDURE: 1. Residents on psychoactive medications are monitored daily for adverse consequences. R14's 1/26/18 AIMS was completed as follows by Assistant Director of Nursing (ADON)-G: Ask resident about the current condition of their teeth. Ask resident if they wear dentures. Do teeth or dentures bother resident now? (response) Currently has upper and lower dentures. States he uses upper denture but not lower plate related to improper fitting.(back to loose and front to tight) Ask resident whether he/she notices any movements in mouth, face, hands, or feet. If yes, ask to describe and to what extent they currently bother resident or interfere with his/her activities. (response) Yes, my mouth Stated that the movement with him mouth makes it difficult to eat. Have resident sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at entire body for movements while in this position). (response) Continuous movement of mouth, no other body movement noted. Ask resident to open mouth. (Observe tongue at rest within mouth.) Do this twice. (response) Resident able to do without difficulty; movement of mouth appeared to have stopped. Ask resident to stand up. (Observe in profile. Observe all body areas again, hips included.) (response) No abnormal movement with again exception of mouth. Ask resident to extend both arms outstretched in front with palms down. (Observe trunk, legs, and mouth.) (response) Mouth is continuously moving; no other body movement observed. The psychiatric NP was notified on 1/26/2018 of the AIMS result and a new order was obtained to increase R14's [MEDICATION NAME] to twice a day from once a day. On 1/26/2018, monitoring for signs of increasing fear, anxiety or agitation related to hallucinations and document the number of hallucinations every shift was added to R14's MAR. R14's plan of care for use of [MEDICAL CONDITION] medications was revised to include R14 uses [MEDICATION NAME] for borderline personality disorder with visual hallucinations. The interventions added to the plan of care included: communication - provide a calm and safe environment to allow resident to express feelings and fears as needed, encourage healthy habits to optimize functioning - maintain medication regimen as prescribed, maintain regular sleep pattern, maintain self-care, monitor/document/report signs of increasing fear, anxiety or agitation related to the hallucinations, administer [MEDICATION NAME] as ordered by physician, monitor for side effects and effectiveness, and consult with pharmacy/physician to consider dosage reductions when clinically appropriate, monthly and as needed. On 1/29/2018 at 11:35 AM, Surveyor interviewed DON-B, ADON-G, and Regional Director-H regarding the monitoring of side effects of [MEDICAL CONDITION] medications for R14 when the [MEDICATION NAME] was increased on 1/5/2018. DON-B stated R14 had told the psychiatric NP that he had been having hallucinations. ADON-G confirmed R14 was having visual hallucinations. DON-B stated R14 had never told anyone in the facility that he was having hallucinations and the NP must have known the right questions to ask, because that is why she increased the [MEDICATION NAME]. DON-B stated there was documentation in the progress notes that there weren't any hallucinations after the increase and when someone has a change in dosage of a [MEDICAL CONDITION] medication, that information is passed on by using the 24-hour report so the nurses know to monitor the resident. Surveyor asked for clarification in the facility's policy and procedure on [MEDICAL CONDITION] Medication Management where it states: The interdisciplinary team will complete the Behavior and [MEDICAL CONDITION] Medication Evaluation Surveyor asked where this evaluation was documented. Regional Director-H stated the facility doesn't use that tool; it was put in the policy by corporate, but it hasn't been implemented and staff hasn't been trained on it. Surveyor had alerted the facility to the abnormal involuntary movement of R14's mouth. R14's plan of care for [MEDICAL CONDITION] medications had the intervention to monitor, document, and report any adverse reactions of the [MEDICAL CONDITION] medications such as tardive dyskinesia. The facility policy and procedure for [MEDICAL CONDITION] Medication Management states to monitor resident daily for any adverse consequences such as tardive dyskinesia. No documentation was found showing monitoring for adverse effects of the medications; despite R14 expressing difficulty eating due to the movements. On 1/29/2018 at 5:17 PM, Surveyor discussed the concerns regarding R14's lack of monitoring for adverse side effects of [MEDICAL CONDITION] medication during the exit conference with the Nursing Home Administrator (NHA), DON-B, ADON-G, and Regional Director-H. Surveyor is the one who brought the mouth movements to their attention. No further information was provided at that time. On 1/30/2018, NHA provided R14's hospital discharge summary dated 4/12/2017, and NP visit notes dated 9/13/17 and 1/9/18. On the 4/12/17 discharge summary, Tardive Dyskinesia (TD) was listed as a diagnosis. In the general appearance section of the summary, there was no documentation of any abnormal movements. On the 9/13/17 NP visit note, she writes R14 has some [DIAGNOSES REDACTED]s from [MEDICAL CONDITION] along with some obvious TD symptoms from his antipsychotic medications. There is no description of the TD symptoms. TD was listed as past medical history from 10/25/12. In the medication list, the order for [MEDICATION NAME] is 50 mg nightly and then in parenthesis it states R14 is taking differently: taking 100 mg nightly. R14 was taking 50 mg of [MEDICATION NAME] at that time. In the description for general appearance in the musculoskeletal section, it states R14 has left [MEDICAL CONDITION] and [DIAGNOSES REDACTED]s of upper extremities and some TD present. There is no indication where the TDs are or to what extent. The description of the HEENT (head, ears, eyes, nose, and throat) has no mention of abnormal movement or TDs. On the 1/9/18 NP visit note, she writes R14 has some [DIAGNOSES REDACTED]s from [MEDICAL CONDITION] along with some obvious TD symptoms from his antipsychotic medications. There is no description of the TD symptoms. TD was listed as past medical history from 10/25/12. In the medication list, the order for [MEDICATION NAME] is 50 mg nightly and then in parenthesis it states R14 is taking differently: taking 100 mg nightly. R14 was taking 50 mg of [MEDICATION NAME] at that time. The description of the HEENT states R14 has TD movements of his tongue and mouth with lip smacking and tongue thrusting and rolling. The visit was on 1/9/18, the note was printed up on 1/22/18 and noted was hand-written on the bottom of the last page on 1/23/18. Surveyor reviewed this information. The NP documentation was not provided to the facility for thirteen days after the visit. With a previous history of tardive dyskinesia, more vigilant monitoring would be expected. The facility did not document any monitoring of R14 for side effects of the [MEDICAL CONDITION] medications on a daily basis as per their policy and plan of care.

Based on record review and interview, the facility did not ensure that 1 of 4 residents (R386) reviewed for falls received adequate supervision and assistance to prevent falls. R386 had 2 falls. On one occasion the facility did not follow the care plan interventions and R386 fell . On a second occasion, R386 was tired. The nurse directed the Certified Nursing Assistant (CNA) to put R386 to bed. There was a delay and the CNA did not attend to R386 until 50 minutes later. As the CNA propelled the wheelchair she had to hold R386 by her shoulder, as R386 was leaning forward in her wheelchair. When the CNA let go of R386 to open the door to her room, R386 fell forward and broke her right elbow. Findings include: R386's medical record was reviewed 1-29-18. R386 was [AGE] years old. Prior to her admission to the facility, R386 had a fall at home which resulted in multiple subarachnoid hemorrhages. (A subarachnoid hemorrhage is bleeding in the space between the brain and the surrounding membrane - the subarachnoid space). R386 was admitted to the facility for rehab on 11-24-17. The facility identified that R386 was at risk for falls and on 11-24-17 implemented a falls care plan. The care plan interventions included: bed in low position when R386 was in bed, walker within reach when in bed, and bed brakes locked. FIRST FALL 11-30-17 The facility completed an Occurrence Report on 12-1-17. R386 was found on the floor when she fell out of bed on 11-30-17 at 2:45 PM. Although she complained of back pain, R386 sustained no other injury. CNA - C provided the following written statement. CNA - C found R386 on the floor in her room. CNA - C documented that, Her (R386) bed was in normal height when I found her. This indicated that R386's care plan - to keep her bed in the low position - was not implemented. Additionally, the Occurrence Report did not evaluate if the other care plan interventions were in place. Neither keeping the walker within reach when in bed nor locking the bed brakes was addressed in the report. On 1-29-18 at 12:28 PM DON (Director of Nursing) - B was informed of these findings. No additional information was provided to the survey team. SECOND FALL 12-12-17 The facility completed an Occurrence Report on 12-13-17. On 12-12-17 at 7 PM, CNA - E reported that R386 fell forward out of her wheelchair and on to her right side. On 12-12-17, RN - D wrote the following statement. At 6:00 PM, I asked CNA - E to assist R386 to bed, therapist had tried to feed R386 but she was too fatigued. At 6:50 PM, R386 was still in lounge. CNA - E was in breakroom. I again said when your (sic) done will you assist R386 to bed. At 7:00 PM, CNA - E came to Unit 2 to tell me R386 was on the floor. she (CNA - E) was propelling her (R386) to her room, R386 was leaning forward and she (CNA - E) was assisting her to sit back. She (CNA - E) said she reached to open the Resident's room door and R386 fell forward out of wheelchair, CNA stated only one foot rest was on wheelchair, the right one. On 12-12-17 CNA - E also provided a written statement. CNA - E said that she pushed R386 from the common area, holding her shoulder back as she was leaning forward. When they arrived, R386's room door was shut. CNA - E said that she let go of R386 to open the door and at that time R386 slid forward out of the chair and landed on the floor. R386 was transferred to the hospital for evaluation. She had sustained a fracture to her right elbow. The preceding information was shared with DON - B on 1-29-18 and additional information was requested. On 1-29-18 at 1:57 PM, DON - B indicated that she had just spoken with CNA - E to review the fall. DON - B provided the following information. CNA - E told DON - B that she remembered that both foot pedals were on R386's wheelchair. DON - B was asked about CNA-E and RN - D's statement at the time of the fall, indicating that both foot pedals were not on the wheelchair. DON - B reported that RN - D no longer worked at the facility. DON- B was asked why there was a 50 minute delay to get R386 to bed and CNA - E was found in the break room at that time. DON - B reported that when CNA - E was initially asked to put R386 to bed, she was assisting residents on another unit who had Dementia. CNA - E told DON - B that she might have stopped in the break room. DON - B was asked why the CNA let go of R386 to open the door when CNA - E already knew that R386 was at risk for falling out of the wheelchair as CNA - E held R386's shoulder as she pushed the wheelchair down the hall. DON - B reported that CNA - E did not think that R386 would fall out of the chair. In summary, the facility failed to anticipate and meet R386's needs when R386 was fatigued and needed to be put to bed as identified by RN - D. R386 had to wait 50 minutes to be put to bed. CNA - E knew that R386 was leaning forward and at risk for falling out of the chair and CNA - E did provide assistance by holding R386's shoulder. However, CNA- E did not provide supervision and assistance to R386 when CNA - E let go of R386's shoulder and R386 fell out of her wheelchair and fractured her right elbow. On 2/1/18 the facility submitted additional information regarding F386's second fall. Surveyor noted that this information was collected on 1/31/18 after Surveyor shared concerns regarding R386's fall. Review of the information indicates the facility had determined both on 11/24/17 and 12/8/17, R386 was at risk for slipping from her wheelchair as non-slip material was to be placed under the wheelchair cushion as of 11/24/17 and eventually a change in seat was made to the chair on 12/8/17. The additional information also includes details indicating it was not unusual for R386 to go to bed at this time due to her eating and assistance needs however, the fall investigation and statements from the time of the fall indicate F386 was fatigued, requesting to go to bed and requiring physical assist to maintain position in the wheelchair all which increased the need for greater safety measures and supervision to prevent a possible fall. Also included within the additional information the facility poses the question of whether the injury was an actual acute fracture or older based upon Resident diagnoses. Surveyor noted review of records indicate R386 sustained a fracture to her right elbow on 12-12-17 diagnosed after the fall occurred.

Based on a complaint received at the Southeastern Regional Office, observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries resulting in deterioration which created an immediate jeopardy situation for Residents #3 and #5. Resident #3 developed an avoidable Stage 2 pressure injury on her right stump. While this pressure injury deteriorated the Facility did not reassess the pressure injury, did not consult with the physician, and did not revise the care plan. Resident #3 was hospitalized and surgery was perform which resulted in a right above the knee amputation. Resident #5 developed shearing to the left buttocks which was not assessed when it was identified and developed an avoidable Stage 3 pressure injury to the right buttocks. The shearing deteriorated to an infected Stage 4 pressure injury. Resident #5's pressure injuries were not reassessed timely and the plan of care was not revised. The Facility's failure to provide the necessary care and services to Resident #3 and #5 created a finding of Immediate Jeopardy beginning on 7/25/16. Administrator-A, Interim Director of Nursing (DON)-B, RN (Registered Nurse)-C, Corporate Consultant-F and Director of Nursing (DON) from Villa at River Parkway-G were informed of the Immediate Jeopardy on 10/10/16 at 3:02 p.m. The Immediate Jeopardy was removed on 10/11/16. The deficient practice continues at scope/severity of E (potential for harm/pattern) as the Facility continues to implement its action plan and for Resident #4, who is at risk for pressure injury and did not have her heels floated according to the plan of care. Findings include: The Pressure Ulcer Treatment policy and procedure revised October 2010 documents under general guidelines; 1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s). b. Managing tissue loads. c. Pressure ulcer care. d. Managing bacterial colonization and infection. e. Operative repair of the pressure ulcer(s). f. Education and quality improvement. The section documentation indicates, The following information should be recorded in the resident's medical record: 1. The type of treatment and resident response. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the care. 5. Any change in the resident's condition. 6. All assessment data (i.e., color, size, pain, drainage, etc.) when inspecting the wound. 7. Resident tolerance of the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. Resident refusal of the treatment and the reason(s) why, and that risks of not complying, benefits of complying and alternatives explained. 10. The signature and title of the person recording the data. 1. Surveyor # reviewed Resident #3's medical record on 10/3/16 to 10/6/16. Resident #3 was admitted to the facility on [DATE] following heart surgery for [REDACTED].#3's [DIAGNOSES REDACTED]. The resident admission assessment dated [DATE] includes a body diagram of the left foot which has the heel circled with a handwritten notation of 2 x 2 cm (centimeter) necrotic area. The nursing admission note dated 4/5/16 documents, Resident has multiple skin issues, right [MEDICAL CONDITION], large open wound to chest with scant amount of slough to area, see admission skin assessment for further details. Surveyor # noted that Resident #3's left heel is not documented in this note. The Braden assessment dated [DATE] has a score of 14, which indicates moderate risk. The CNA (Certified Nursing Assistant) Careplan Kardex dated 4/5/16 located behind Resident #3's bathroom door under the section skin care documents, Report any skin issues to nurse. Under special needs/precautions documents, Heel to be floated and under the section ambulation/transfer documents, RBA (right below amputation) Prosthetic to be worn with transfers. The ADL (activities of daily living)/mobility deficit care plan dated 4/11/16 has an intervention also dated 4/11/16 of SKIN INSPECTION: The resident requires SKIN inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. The skin integrity care plan dated 4/11/16 includes the following interventions which are all dated 4/11/16 of Assess/record/monitor wound healing. Measure length, width and depth where possible, Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD., Educate the resident/family/caregivers as to the causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, Follow facility policies/protocols for prevention/treatment of [REDACTED]. Serve diet as ordered, monitor intake and record, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes, The resident has pressure reducing device: bed/chair. Air mattress to bed; check function, The resident needs reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested, The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing, and Treat pain as per orders; offer prior to treatment/turning etc. to ensure The resident's comfort. The admission MDS (Minimum Data Set) with an assessment reference date of 4/12/16 and signed as complete on 4/18/16 documents a BIMS (brief interview mental status) total score of 15, which is cognitively intact. Resident #3 requires extensive assistance with two plus person physical assist for bed mobility, transfers and toilet use, and does not ambulate. Resident #3 is at risk for developing pressure injuries and is coded as having one or more unhealed pressure ulcer(s) at Stage 1 or higher. Resident #3 is coded as having one unstageable pressure injuries with the the pressure injury length as 2.0 cm (centimeter) and width as 2.0 cm. The most severe tissue type is coded as eschar. Pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer care, surgical wound care and applications of ointments/medications other than to feet are checked for skin and ulcer treatments. The pressure ulcer CAA (Care Area Assessment) dated 4/18/16 under analysis of findings documents, Actual alteration in skin due unstageable area that was present upon admit, risk for further skin breakdown due to assist with bed mobility, refusal of treatment plan and has incontinence. Under care plan considerations documents, Recently admitted after prolonged hospital stays; admitted to facility with unstageable area to right heel. At risk for further breakdown due to assist with bed mobility, refusal of treatment plan (per nurses notes 4-8-16) and has incontinence. She was also admitted with 2 surgical wounds with treatment plan in place. She is receiving nutritional supplement, staff assists with mobility and incontinent cares rendered. Has pressure relieving device bed and w/c (wheelchair). The weekly wound charting dated 4/18/16 documents, Resident remains with unstageable ulcer to left heel. Area measures 3 x 2 x less than 0.1. Area is not open and no odor or exudate present. Edges are loose. Resident denies pain to area. Continue with current treatment, resident has alternating air mattress, and heel to be floated and offloaded. Surveyor # noted this is the first assessment (13 days later) of Resident #3's left pressure injury since she was admitted . Surveyor # also noted that although the size of the open area has increased there is no change in Resident #3's skin integrity care plan. Podiatrist-GG progress note dated 5/16/16 documents, New ulcer to left heel. fu (follow up) 3 weeks. The Facility assessed Resident #3's left heel weekly from 4/18 to 5/23/16. The skin/wound weekly note dated 5/23/16 documents, site/location Left heel. Stage/lengthxWidthxDepth 2 x 2 x less than 0.1. Edges are slightly loose, wound bed is 100% necrotic tissue, no odor noted and trace serous exudate noted on dressing. Periwound is WNL (within normal limits). Tx (treatment)/interventions will continue with current treatment and alternating air mattress and floating heel when in bed and no shoe on left foot. Summary/outcomes: Area is improved will update PMD (primary medical doctor) on progress. APNP (Advance Practice Nurse Prescriber)-U progress note dated 6/7/16 documents, Has had BKA (below knee amputation) due to [MEDICAL CONDITIONS] probably DM (diabetes mellitus) and recently this week had (R) (right) leg prosthetic adjusted and now has developed a small wound on top of right stump that is currently open. Has some discomfort from this. Also, she is unable to see or treat area due to location. Under physical exam documents, skin: has abrasion on right and left shin. Slight [DIAGNOSES REDACTED] no warmth present. Has unstageable left heel ulcer with black eschar present in crater wound. Has small .5 cm (centimeter) open area on right stump. No [DIAGNOSES REDACTED] or drng (drainage) noted. Under assessment documents, non-healing wound of amputation stump. Decubitus ulcer, heel, left unstageable. APNP-U recommended Resident #3 stop wearing the prosthetic until the wound heals. This open area healed on 7/7/16. Podiatrist-GG progress note dated 6/7/16 documents, fu (follow up) 2 weeks ulcer (L) (left) posterior heel. The nurses note dated 6/10/16 documents, Resident vision highly impaired, uses magnifying glass for reading small print. Wound to chest superficial, dressing changed this AM (morning) as ordered. No active drainage from site. Heel ulcer dressing changed this AM as well, mild brown drainage noted. Resident refuses to off load heel despite many attempts. Wheelchair. Limb/Prosthesis. Cardio/Respiratory status stable. Skin warm and dry, lungs sound clear. Abdomen soft with bowel sounds x (times) 4. Denies [MEDICAL CONDITION], dizziness of feelings of malaise. No [MEDICAL CONDITION] noted to extremities. Continues with incontinence of B & B (bowel and bladder). Denies pain at this time. The skin/wound weekly note dated 6/13/16 documents, Site/location: Unstageable ulcer remains to left heel. Ulcer was present on admission. Stage/LengthxWidthxDepth: 2.7 x 2.5 x less than 0.1. Edges are slightly loose from 12 to 6. Wound bed is 100% eschar. Trace serous exudate noted on old dressing. No odor present and resident denies pain to area. Tx/Interventions: Continue with current treatment of [REDACTED]. Resident also has alternating air flow mattress in place. Summary/Outcomes: Resident updated on progress of wound and NP updated. Surveyor # noted this assessment was 21 days after the last assessment which was conducted on 5/23/16. The pressure injury has increased in size, and there were no changes made to Resident #3's skin integrity plan of care. The nurses notes dated 7/1/16 documents, Area to left heel showing signs of improvement, necrotic area starting to peel off, resident sternal area has healed, dry scabbing noted to area, [MEDICATION NAME] applied to area. Area on stump dry, Tx (treatment) done and intact. Old peg tube site with mild drainage, no s/sx (signs/symptoms) of infection to any areas. Wheelchair. VSS (vital signs stable), no concerns at this time. No c/o (complaint of) chest pain or palpitations. The PT/OT/ST (physical therapy/occupational therapy/speech therapy) recommendation to caregivers dated 7/4/16 documents, High risk of skin breakdown. The skin/wound weekly note dated 7/7/16 documents, site/location: left heel and right stump. Stage/Length x Width x Depth: Left heels measures 4 x 3 x 0.1, edges are attached and regular, wound bed is 90% granulation with 10% eschar. No odor present and trace serous exudate noted. Right stump is healed. Tx/Interventions: DC (discontinue) treatment to right stump, and prosthesis was re-fitted. Continue current treatment for [REDACTED]. Summary/outcomes: MD and resident updated on progress. The nurses note dated 7/11/16 documents, Left heel area continues with treatment, Necrotic area spongy about to fall off. The Braden assessment dated [DATE] has a score of 17, which indicates low risk. Podiatrist-GG progress note dated 7/12/16 documents, ulcer (L) heel fu (follow up) 3 weeks. The skin/wound weekly note dated 7/13/16 documents, Site/Location: left heel and right stump. Stage/Length x Width x Depth: Left heel measures 3.4 x 2.2 x 0.1. Edges are attached and regular. Wound bed is 50% granulation tissue with 50% dark eschar. No odor present and small amount serous exudate noted. Right stump is recurring area is stage 2 and measures 2 x 1 x less than 0.1. Edges are attached and regular. Wound bed is 100% granulation tissue. No exudate or odor noted. Tx/Interventions: Will continue with current interventions and treatment for [REDACTED]. Summary/outcomes: MD updated on progress and will continue to follow. Surveyor # noted the right stump stage 2 was not added to Resident #3's skin integrity care plan and the care plan has not been updated. The skin/wound weekly note dated 7/20/16 documents, Site/location: Resident was admitted to facility with unstageable area to left heel and developed a Stage 2 ulcer to right stump. Stage/Length x Width x Depth: Left heel measures 2 x 2 x less than 0.1. Edges are attached and regular, wound bed is 70% slough and 30% granulation tissue. Moderate exudate noted on old dressing with some odor present. Right stump measures 2 x 2 x less than 0.1. Edges are slightly irregular and attached. Wound bed is 100% granulation tissue and no exudate or odor present. Tx/Interventions: Will continue with current interventions and NP also seen and assess areas and new orders received for resident to follow up with wound clinic due to unhealing wounds related to DM (diabetes mellitus) and poor vascular circulation. APNP-U progress note dated 7/20/16 documents, During her time at speciality hospital developed unstageable pressure wound of left heel. This continues today and is treated by podiatry in Kenosha. Unable to stand on left leg due to pressure wound and pain. Wound has become mushy under scan and has a faint odor to it today. She is agreeable to going to wound clinic that she was seen at in the past St. Cats wound clinic in Kenosha. Has had BKA (below knee amputation) due to [MEDICAL CONDITIONS] probably due to DM and recently this week had right leg prosthetic adjusted and now has developed a small wound. The shape of a horseshoe on the tip of the right stump. It is painful to touch and has an area of slough at the bottom of the horseshoe wound. No drng. (drainage) present. No surrounding [DIAGNOSES REDACTED] present. Under physical exam documents, Skin: Has unstageable left heel ulcer with black eschar present in crater wound scabbed area on heel mushy with slight odor present. Has small horseshoe shaped open area on right stump. Has slight [DIAGNOSES REDACTED] with slough noted on bottom of wound bed. No drng. (drainage) present. Under assessment documents, 1. Decubitus ulcer of heel, left unstageable 2. Decubitus ulcer of lower extremity, Stage II (2). Under plan documents, 1. Will refer to wound clinic in Kenosha for heel and stump wounds along with abd (abdominal) wound. 2. Will continue with same treatments till seen at wound clinic. This wound clinic appointment was canceled by Podiatrist-GG. Surveyor # noted that APNP-U is assessing the right stump pressure injury as having slough and the nursing assessment documents 100% granulation. On 10/6/16 at 10:58 a.m., Surveyor # asked APNP-U why the description of Resident #3's pressure injury to her right stump on 7/20/16 is different that the nursing assessment. APNP-U stated, mine is right and explained that she distinctly remembers the wound. The skin/wound weekly note dated 7/25/16 documents, Site/location: Left heel and right stump. Stage/Length x Width x Depth: Left heel measures 2 x 2 x less than 01 edges are attached and regular and wound bed is 70% dark slough with 30% granulating tissue Moderate amount of serous exudate noted on old dressing and odor has improved. Right stump area measures 2 x 2 x less than 01 Edges are attached and regular, no odor or exudate present. Tx/Interventions: Will continue with current treatments and update PMD. Summary/outcomes: Continue to monitor. The nurses note dated 7/27/16 documents, Resident Lt (left) foot wound has strong odor coming from wound, 2+ [MEDICAL CONDITION] noted to the top of foot and toes of Lt. foot, pulses in Lt. foot extremely weak, difficult to palpate, sensation to foot has decreased, resident stated she does feel when writer is rubbing sole of foot, slight feeling in all toes to Lt. foot. Writer called resident Podiatrist-GG, MD updated on condition of foot and wound measuring approx. 4.2 cm x 3 cm depth unknown at this time necrotic area covering partial area of wound, the necrotic area is mushy yet intact to bed wound treatment completed as ordered. MD gave verbal orders to start resident on [MEDICATION NAME] 875/135 mg BID (twice daily) until resident is to see MD. MD appt. (appointment) moved up to August 1, 2016 at 1430 (2:30 p.m.) scheduler updated and made aware of appt. change. There was no revision to Resident #3 skin integrity plan of care. The nurses note dated 8/1/16 documents, missed appointment with foot doctor today. The nurses note dated 8/5/16 documents, Left heel area continues with treatment. Requires mod (moderate) assist with ADLs (activities of daily living)/Personal cares. Writer spoke with Podiatrist-GG office, verbal order received to start resident on [MEDICATION NAME] 875/125 mg BID x 14 days for foot infection. First dose given, resident tolerating ATB (antibiotic) therapy at this time. Magnifying glass used for right eye worse than left. Resident started on ATB for foot infection for 14 days. Tolerating ATB at this time. Dressing changed as ordered this afternoon. [MEDICAL CONDITION] noted to LLE (left lower extremity), pressure dressing applied, new medication started to decrease [MEDICAL CONDITION] in LE (lower extremity). Walker. Wheelchair. Limb/Prosthesis. Treatment to BLE completed as ordered, no drainage noted from either site. Area on stump tender to touch, redness noted, again ATB started on infection to stump open area. Resident #3's physician was not consulted with regarding the right stump and there is conflicting documentation as to whether the antibiotic is for Resident #3's left foot or right stump. The nurses note dated 8/7/16 documents, Continues on ABT/foot infection. No adverse reactions noted. No c/o (complaint of) pain thus far this tour. The nurses note dated 8/10/16 document, Continues with daily wound care treatments to abdomen, right stump to RLE (right lower extremity) and left foot/heel. Left foot with dressing, CDI (clean dry intact). Continues on ABX [MEDICATION NAME] 875 mg for right stump wound infection/[MEDICAL CONDITION]. No adverse effects from ABX noted. 1.) Surgical wound old peg tube site 0.4 cm x 0.7 cm x 0.2 cm wound bed red with white edges. Has small amount of bleeding at site. 2.) Pressure area to right stump 2.3 cm x 3.1 cm , area discolored black/purple with peri wound reddened. Is scheduled for surgical debridement on 08/25 with vac placement. 3.) Diabetic ulcer to left heel 2.1 cm x 2.3 cm x 0.3 cm wound with tan stringy eschar, wound edges white macerated in appearance. Incontinent of stool during night. Incontinent of urine during night. Right BKA has prosthetic not in use at this time d/t (due to) pressure ulcer to stump. Resident#3's physician was not consulted regarding the change in Resident #3's right stump pressure injury and this assessment is 16 days after the previous assessment (7/25/16). Surveyor # noted the facility did not revise Resident #3's skin integrity plan of care. The skin/wound note dated 8/11/16 documents, 1.) Surgical wound old peg tube site 0.4 cm x 0.7 cm x 0.2 cm wound bed red with white edges. Has small amount of bleeding at site, no odor noted. 2.) Pressure area to right stump 2.3 cm x 3.1 cm area discolored black/purple with peri wound reddened. Is scheduled for surgical debridement on 08/25 with vac placement. 3.) Diabetic ulcer to left heel 2.1 cm x 2.3 cm x 0.3 cm wound with tan stringy eschar, wound edges white macerated in appearance no drainage or foul odor noted. Resident #3's physician was not consulted regarding change in Resident #3's right stump pressure injury and there was no revision to Resident #3's skin integrity plan of care. The nurses note dated 8/14/16 documents, Pressure area to right stump 2.3 cm x 3.1 cm, area with gray edges and black center and discoloration of peri wound which is purple in color. Is scheduled for surgical debridement on 08/25 with vac placement. 3.) Diabetic ulcer to left heel 2.1 cm x 2.3 cm x 0.3 cm wound with tan stringy eschar, wound edges white macerated in appearance. Resident #3's physician was not consulted with regarding the deterioration of the right stump pressure injury and there was no revision to Resident #3's skin integrity plan of care. Surveyor # noted this is the last nursing assessment that Surveyor # was able to locate in Resident #3's medical record for Resident #3's left heel and right stump pressure injuries. The nurses note dated 8/18/16 documents, Resident is being treated for [REDACTED]. The nurses note dated 8/21/16 documents, DM, just finished ABT/right stump infection. extensive assist of one for transfers and ADL's. Glasses and magnifying glass for fine print. Daily dressing to left heel diabetic ulcer, right stump and peg tube. incontinent wears brief incontinent of urine, wears brief unable to wear prosthesis d/t stump too sore Wheelchair. Sleeping well after PRN (as needed) for pain given. No further c/o pain. The nurses note dated 8/25/16 documents, Resident has very poor eyesight wounds (sic) wheelchair. VSS (vital signs stable) no s/s (signs/symptoms) distress or complaints. Pt. (patient) had surgical procedure today--no complications observed or reported. The nurses note dated 8/27/16 documents, Continues with daily wound care treatments to abdomen, right stump to RLE (right lower extremity) and Left foot/heel. S/P (status [REDACTED]. Continues to participate with OT/PT (occupational therapy/physical therapy). Continues to require mod/max (moderate/maximum) assist with ADLs (activities daily living)/personal cares. Receiving insulin scheduled and per sliding scale. BGLS (blood glucose levels) monitored QID (four times daily) BGLS within MD parameters. The nurses note dated 8/28/16 documents, Continues with daily wound care treatments to abdomen, right stump to RLE and left foot/heel. S/p left foot debridement 08/25, left foot with dressing, CDI. Continues on ABX [MEDICATION NAME] 875 mg without any noted adverse effects. Right stump with redness, area without increased warmth or pain. Continues to participate with OT/PT. Continues to require Mod/Max assist with ADLs/personal cares. Receiving insulin scheduled and per sliding scale BGLS monitored QID, BGLS within MD parameters. The eMar note dated 8/29/16 documents, Change dressing daily with [MEDICATION NAME] in the morning per resident not to be changed until MD sees it. Cleanse with normal saline, apply Santyl to wound bed of right stump on eschar. Peri wound apply A & D Avoid Santyl on healthy tissue. Cover with contact drsg. (dressing) (border) every day shift for ulcer completed 3rd shift. APNP-U progress note dated 8/31/16 under physical exam documents, Skin: right stump eschar measures 5.5 x 6.5 cm unstageable wound. Has small open area lateral to eschar measuring 1.8 x .5 cm with slough in wound bed and periwound [DIAGNOSES REDACTED] present. Right stump has rubor (redness of the skin) at the end of the entire stump when sitting and stump cool till above knee. Unable to palpate popliteal pulse. Has [MEDICAL CONDITION] of stump and upper thigh extending into abd. (abdomen). Left leg has coban dressing presently on but has 3+ [MEDICAL CONDITION] of foot. Foot again has rubor present at toes when sitting. Unable to visualize heel today. Last heel measurement was on 8/23/16 and was unstageable with left heel ulcer 2 x 1.5 cm with black eschar present in crater wound eschar area on heel and fluctuant, [DIAGNOSES REDACTED] present surrounding heel. Left foot cool to touch but faint pulse present today. The last nursing assessment of Resident #3's pressure injury on the right stump and left heel is dated 8/14/16. The nurses note dated 9/1/16 documents, Resident is being treated for [REDACTED]. Resident #3's medical record does not reflect when Resident #3 was transferred to the hospital. The last nurses notes are dated 9/1/16 and then the next date there is documentation is 9/13/16. Physician-HH operative report dated 9/2/16 documents under preoperative diagnosis/diagnoses, Infected necrotic ulcer right below knee amputation stump. Under procedure performed documents, Excisional debridement of skin and subcutaneous tissue as well as bone measuring 8 centimeters x 5 centimeters. The deepest portion has a 1 centimeter depth but most of the wound is superficial. Under indications for procedure documents, This is a [AGE] year old female who had a below knee amputation done almost 2 years ago. She has been in prosthetic. I saw her in the office a few weeks ago with a small wound measuring about 2 centimeters in size at the stump which at that time presumed to be related to some sort of a pressure maybe related to the prosthetic. I see her today in preoperative holding area. She has got much more redness and much larger necrotic area. It to me almost looks like it is more of a pressure ulcer from where her stump has been simply laying in bed without much movement. Any which way, this needs debridement and plan is for IV antibiotics after debridement as well. Did discuss specifically with the patient that given the progression of the size there may be even more vascular issue as well. I am unsure if this is going to heal and ultimately this may even require an above knee amputation. The hospital discharge summary for admitted [DATE] and discharge date of [DATE] documents under admitting [DIAGNOSES REDACTED]. 2. [MEDICAL CONDITION] stage 3. 3. Diabetes mellitus, uncontrolled. 4. Hypertension. Under discharge diagnosis/[DIAGNOSES REDACTED]. status [REDACTED]. 2. [MEDICAL CONDITION] stage 3. 3. Diabetes mellitus insulin dependent. 4. Hypertension. Under hospital course documents, The patient is a [AGE] year old female with multiple medical problems. She wishes to be not resuscitated status. She was evaluated by Physician-HH in his office and found to have an infected necrotic ulcer on her stump. She was admitted to the hospital and started on IV antibiotics. Prior to that, she also went to the operating room and had a debridement done. After that she had a wound VAC placed and was monitored in the hospital for about there days. There was no improvement with that. Actually it was getting worse despite antibiotic, wound VAc and the debridement. Therefore, the surgeon decided and discussed with the patient a right AKA. The patient was taken to the operating room on her hospital day #8 and postoperatively returned to the same room. Her surgery included a right above knee amputation. The skin/wound note dated 9/15/16 documents, Resident was assessed by writer with NP present. Resident had amputation of right AKA. Resident has 31 staples in place. No signs/symptoms of infection. Surrounding skin is not hot to touch. On 10/3/16 at 11:19 a.m., Surveyor # observed Resident #3 in bed on her right side with her left heel resting directly on the mattress. Resident #3's heel was not being floated according to her plan of care. On 10/3/16 at 12:01 p.m., Surveyor # observed Resident #3 in bed on her right side with her left heel resting directly on the mattress. Resident #3's heel was not being floated according to her plan of care. On 10/3/16 at 12:45 p.m., Surveyor # observed Resident #3 in bed on her right side with her left heel resting directly on the mattress. Resident #3's heel was not being floated according to her plan of care. On 10/3/16 at 2:42 p.m., Surveyor # observed Resident #3 asleep in bed on her right side with her left heel resting directly on the mattress. Resident #3's heel was not being floated according to her plan of care. On 10/3/16 at 3:40 p.m., Surveyor # observed Resident #3 asleep in bed on her right side with her left heel resting directly on the mattress. Resident #3's heel was not being floated according to her plan of care. On 10/4/16 at 7:31 a.m., Surveyor # observed Resident #3 in bed on her right side with the television on. Surveyor # observed Resident #3's left heel is resting directly on the mattress and is not being floated according to her plan of care. On 10/4/16 from 7:48 a.m. to 8:06 a.m., Surveyor # observed APNP-U and RN (Registered Nurse)-S assess, measure and complete the treatment for [REDACTED]. After RN-U completed the treatment, RN-U did not speak to Resident #3 about floating her left heel nor did she float Resident #3's left heel. On 10/4/16 at 11:29 a.m., Surveyor # observed Resident #3 asleep in bed on her right side. Surveyor # observed Resident #3's left heel is resting directly on the mattress and is not being floated according to Resident #3's plan of care. On 10/4/16 at 12:53 p.m., Surveyor # observed Resident #3 asleep in bed on her back. Surveyor # observed Resident #3's left heel is resting directly on the mattress and is not being floated according to Resident #4's plan of care. On 10/5/16 at 7:43 a.m., Surveyor # observed Resident #3 asleep in bed on her right side. Surveyor # observed there is a pillow under Resident #3's left foot, but Resident #3's left heel is resting directly on the pillow and is not being floated according to the care plan. On 10/5/16 at 1:29 p.m., Surveyor # met with Interim DON (Director of Nursing)-B to discuss Resident #3. Surveyor # informed Interim DON-B that Resident #3 was admitted on [DATE] with unstageable pressure injury but there isn't any nursing assessment until 4/18/16. Interim DON-B informed Surveyor # that she will have to look into this. Surveyor # stated in Resident #3's medical record there is documentation that Resident #3's

Based on record review and interview, the facility did not not provide adequate supervision and assistive devices to prevent accidents for 2 of 7 residents (Resident #14 and Resident #9) reviewed for falls out of a sample of 16 residents. Resident #14 suffered a nasal fracture due to a fall in which interventions to prevent accidents and falls were not in place. Resident was observed walking in the corridor without staff assistance (no contact guard assist) with her 2 wheeled walker as per Resident's care plan. The facility did not have effective measures in place to prevent or limit falls and injury to Resident #9 while she was performing mini lunges during physical therapy. As a result of the fall, Resident #9 continued to reside at the facility past her anticipated discharge date and received two additional surgeries to her right knee. After her fall, Resident #9 has experienced depression and anger as a result of her continued residence at the facility. Findings include: 1. Surveyor # reviewed Resident #14's medical record. Resident #14 has [DIAGNOSES REDACTED]. Between June 15, 2016 and October 7, 2016 Resident #14 had 7 falls. Documentation in the progress notes indicate falls occurred on 6/15/16, 6/27/16, 7/10/16, 7/17/16, 8/14/16, 8/28/16, and 10/6/16. The facility's FALL AND FALL RISK, MANAGING policy, revised December of 2007, states, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Surveyor # requested to review Fall Reports for Resident #14's fall from June to present. Surveyor # reviewed all Occurrence Reports/Incident Investigation and Follow-Up Actions reports provided and reviewed Resident #14's progress notes in the clinical record beginning with the first fall in July 2016. a. Resident #14's progress notes on 7/10/16 document, Resident roommate yelled for help d/t (due to) resident fell . Found laying on the floor reported that she slipped in her room. Writer called for RN (registered nurse) to assess. (Daughter) called and informed about the fall. On call MD/triage nurse called and updated about fall. ADON (assistant director of nursing) was made aware. Will continue to monitor. On 10/6/16 at 9:12 a.m. Interim DON (Director of Nursing)-B, who was the ADON on July 10th, informed Surveyor # that she does not have an occurrence report for Resident #14's 7/10/16 fall. Interim DON-B stated that even though the progress note states she was notified of the fall, she was not notified. With no Occurrence Report completed for the 7/10/16 fall, there is no documentation of an evaluation addressing possible factors of the fall, or revision of Resident #14's plan of care to reduce the likelihood of another fall. b. On 7/17/16 the Incident Investigation detailed description of the resident's second fall: Resident stated she was coming back from bathroom and fell . The document continues to state, The facility has taken the following actions based on the facts and conclusion of the investigation: assessment completed, Neuro checks initiated, gripper socks, education to use walker and call light system. Surveyor # noted that interventions to remind to wear gripper socks, provide frequent reminds to use walker, and ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed, had been in place with an initiation date of 6/18/2015. The Incident Investigation lists new interventions of bed in lowest position. Call light within reach. Surveyor # noted that the care plan documents those interventions in place with an initiation date of 6/18/2015. c. On 8/14/16, Resident #14's progress note states, was called to room by CNA (certified nursing assistant). Resident was laying on her back on the floor. There was blood on her face, she appeared to bleeding on both sides of her face and on her forehead. There was also a large knot or hematoma on the right side of her head. Resident stated that she was trying to put her bra on and was not sure how she ended up on the floor. The RN was called in the room to assess her. Vital signs were: BP 169/107, T97.9, SpO2 93%, P100, RR30. Resident tried to get up, but I instructed her to remain still. I asked if she was in pain, and she said that was not sure, but said that she did not think so. The RN called the rescued squad . The Occurrence Report Conclusion for the 8/14/16 fall signed by RN Manager-P on 8/18/16 states, Resident was getting her bra on and fell to the floor. Resident was transferred to hospital and admitted under observations status. Resident had nasal fracture. POA had signed Fall Risk Notice signed prior to fall. The Incident Investigation for the fall documents New Interventions as continue with physical therapy, encourage resident to ask for assistance. Surveyor # noted that these interventions had been in place prior to Resident #14's fall on 8/14/16. Resident #14 was admitted to the hospital overnight and was noted to have a nasal bone fracture. The hospital course also notes that Resident #14 was noted to have severe bradycardia at night, with a heart rate in the low 30's. She had 2 sinus pauses, less than 3 seconds. Surveyor # reviewed Resident #14's care plan and noted that the intervention for dressing with an initiation date of 6/18/15 states, The resident requires limited assist from staff to dress. She does try to do it as self sufficient as able. Surveyor # noted that no increased supervision was care planned for dressing following Resident #14 falling while putting her bra on. d. Resident #14's progress notes document on 8/28/16 at 3 p.m. CNA responded to resident's BR (bathroom) call lite. Found resident sitting on her buttocks on the floor; front of toilet. States she stood, slipped, slide down the wall, & landed on her buttocks . The Occurrence Report for the 8/28/16 fall contains no conclusion. The Incident Investigation and Follow-Up Actions with a review date of 9/1/16 states, The facility has taken the following actions based on the facts and conclusion of the investigation f/u (follow-up) appt. (appointment with) cardiologist 8/29/16. Neuro checks initiated. RN assessment. Call daughter for suggestion of interventions. Resident #14's progress notes on 9/1/16 documents, On 8-26-16 received call from daughter, POA (power of attorney) regarding earlier call from unit manager. States she doesn't know any new interventions pertaining to her falls. States she knows she wouldn't be able to handle her @ (at) home, so that's why she is a resident here. Resident #14's cardiologist consult notes, Asymptomatic brady (bradycardia). -> 4 sec (second pause in AFib (atrial Fibrillation) while sleeping. Does NOT meet indications for pacing. e. On 10/6/16, Resident #14 fell . The Incident Investigation and Follow-Up Actions documents that Resident was trying to move the blue chair in her room closer to her bed. She tripped over her own feet and landed on her butt. The document continues to state, The facility has taken the following action based on the facts and conclusion of the investigation: Staff to ask resident if she needs anything when passing by her room/assist with rearrange furniture as requested. Surveyor # reviewed Resident #14's plan of care on 10/6/16 for the focused area that include, The resident is risk for falls . with a goal and a target date of 12/01/16 that states, The resident will not sustain serious injury through the review date. Surveyor # noted that no new interventions have been implemented or changed on the care plan since 6/18/2015. On 10/10/16 at 3:45 p.m., Surveyor # met with RN Manager-P. Surveyor # requested any additional information related to interventions put into place to prevent Resident #14 from falling. On 10/11/16 at 7:56 a.m., Surveyor # met with RN Manager-P. Surveyor # asked why Resident #14 has had no new fall interventions since 2015. RN Manager-P informed Surveyor # that the intervention for the fall on 8/14/16 (when Resident #14 fractured her nose) was that she was sent to the emergency room for evaluation. Surveyor # asked what was done to prevent Resident #14 from falling when she returned back to the facility. RN Manager-P informed Surveyor # that Resident #14 was having cardiac events and seen by cardiology. Surveyor # asked what was done following the results from the consult. RN Manager-P informed Surveyor # that she would look into it. On 10/11/16 at 10:26 a.m., RN Manager-P informed Surveyor # that the facility was now monitoring Resident #14 blood pressure and pulse every shift. Surveyor # asked if the facility had done an orthostatic blood pressure. RN Manager-P stated that she did not see one completed. On 10/11/16 at 12:49 p.m., Surveyor # asked RN Manager-P if she had any additional information regarding Resident #14's falls. No further information was provided. Resident #14's care plan with a goal of The resident will maintain current level of function in self cares through the review date with a target date of 12/01/16 includes an intervention of TRANSFER: requires CGAx1 (contact guard assist) x1 for ambulation, transfers. Resident #14's CNA Careplan Kardex dated 8/15/16 under the section AMBULATION/TRASNFER/REPOSITIONG states: Assist of 1 (with ) 2ww (two wheeled walker). Contact guard, Encourage to use walker and keep walker close. On 10/5/16 at 1:04 p.m., Surveyor # observed Resident #14 walking down the hallway without staff assistance with her 2 wheeled walker to the dining room. On 10/6/16 at 10:05 a.m., Surveyor # observed Resident #14 walking in the hallway without staff assistance and with her 2 wheeled walker. Surveyor # observed an unidentified staff member come over to talk with Resident #15, who was in front of Resident #14, about a wedding. The staff member stated, I thought you were pushing her to Resident #14, in regards to Resident #15 who was self-propelling herself in her wheelchair in front of Resident #14. Surveyor # observed Resident #14 walk to her room with no contact guard assist provided. On 10/10/16 at 3:45 p.m. Surveyor # met with RN Manager-P. RN-Manager-P confirmed that Resident #14 is to be contact guard assist with 1 staff for ambulation. 2. Surveyor # reviewed Resident #9's medical record from 10/3/16 to 10/11/16. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's Significant Change in Condition MDS (Minimum Data Set) dated 7/1/16 documents a BIMS (Brief Interview for Mental Status) of 15, indicating that Resident #9 is cognitively intact. Resident #9's social service noted dated 6/12/16 documents Resident #9's anticipated discharge date as 6/15/16. On 10/6/16 at approximately 8:00 a.m., Surveyor # reviewed Resident #9's physical therapy plan of care, therapy progress notes, and therapy statements. Resident #9's physical therapy plan of care is signed as completed by PT/Therapy Director-L on 5/27/16. Resident #9's physical therapy plan of care documents under the Goal section, The patient will increase right knee flexion and extension muscle to less than full ROM (range of motion) more than 50% against gravity to improve ambulation in environment. The goal completion date for the above goal is documented as 6/10/16. Resident #9's physical therapy progress note dated 6/7/16 and signed by PT/Therapy Director-L, documents under Current Level of Function Section, Strength: Knee; Right; The patient demonstrates right knee extension muscle straight of 3/5 fair (full ROM against gravity with no added resistance). Resident #9's physical therapy progress note dated 6/7/16 and signed by PT/Therapy Director-L, documents under the Impact on Burden of Care/ Daily Life section, Patient has progressed in bed mobility and transfers and is no longer dependent on upon caregivers for these tasks. Resident #9's physical therapy progress note dated 6/7/16 and signed by PT/Therapy Director-L, documents under the Remaining Functional Deficits/Underlying Impairments section, deficits in right knee ROM and strength, deficits in left knee strength. Resident #9's physical therapy progress note dated 6/7/16 and signed by PT/Therapy Director-L, documents under the Updates to Treatment Approach section, focus on negotiating stairs, has 20 stairs to negotiate at home. Resident #9's physical therapy progress note dated 6/13/16 and signed by PTA-M documents, Patient completed mini squats unsupported x 5 (five times) but discontinued due to reports of left knee pain. Pt (patient) able to complete 2 (mini) lunges on each LE (lower extremity) with aid of 2ww (wheeled walker) for stability with BUE (bilateral upper extremity) support due to patient reporting left knee pain, PTA heard popping sound, the patients (patient's) right knee buckled, and PTA assisted patient to floor laterally. Patient landed on right knee on incision site then down to right shoulder. Resident #9's nursing note dated 6/13/16 at 11:29 a.m. documents, Writer heard resident yell out while in therapy. Writer ran to the therapy room at 10:42 a.m. and found resident laying on the floor with the therapist by her side. Resident was moaning in pain and tears were in her eyes.Therapist stated resident stepped forward with RLE (right lower extremity), she heard a popping sound and residents knee buckled. Resident #9's Emergency Provider notes dated 6/13/16 documents, Resident #9 presented to the Emergency Department for evaluation of knee pain .Patient explains she was doing shallow lunges at physical therapy today (6/13/16) when her right knee buckled and she head a pop and crunch. Resident #9's Emergency Provided notes dated 6/13/16 documents under the Imaging section, Final Result: Avulsion fraction superior aspect of the patella. Impression: Avulsion fracture involving upper pole of the patella. Resident #9's Therapy Progress and Updated Plan of Care dated 6/14/16 and signed by PT/Therapy Director-L documents under the Analysis of Functional Outcome/Clinical Impression section, Patient was progressing well toward all ST (short term) and LT (long term) goals and was scheduled for DC (discharge) on 6/14/16. Patient fell on [DATE] and suffered a right quad tendon rupture and patellar fracture, returning to SNF (skilled nursing facility) with MD (physician) orders for right knee immobilizer at all times, and NWB (non weight bearing) RLE (right lower extremity). Surveyor # noted that a review of Resident #9's therapy progress notes does not document any instances prior to 6/13/16 where Resident #9 was directed to perform mini lunges during physical therapy. On 10/5/16 at 9:42 a.m., Surveyor # interviewed Resident #9 regarding her quality of life at the facility. During the interview, Resident #9 expressed concerns regarding her safety during physical therapy. Resident #9 informed Surveyor # that she had experienced a fall while performing physical therapy that had caused her to extend her stay at the facility. Resident #9 informed Surveyor # that two days before she was to be discharged home, she was performing lunges during physical therapy and fell , causing her to extend her stay at the facility. Resident #9 informed Surveyor # that she since the fall she has been depressed and still wonders why the PTA (Physical Therapy Assistant) had her perform lunges during therapy. On 10/5/16 at approximately 11:40 a.m., Surveyor # requested from DON (Director of Nursing)-G the fall investigation report for Resident #9's fall on 6/13/16. On 10/5/16 at approximately 12:00 p.m., DON-G provided Surveyor # with a copy of the facility's fall investigation report for Resident #9's fall on 6/13/16. The facility's fall investigation report dated 6/13/16 and titled, Occurrence Report, documents under the Notes Section-Nurse's Note of What Happened, Per PTA (physical therapy assistant)-M, resident was completing lunges with 2 assist for stability and resident stepped forward with RLE (right lower extremity) when therapist heard a pop and right knee buckled. Resident reported pain 7/10 after fall. The facility's fall investigation report documents under the Root Cause section the root cause of Resident #9's fall on 6/13/16 as, Other, medical issue. The facility's fall investigation report documents under the Conclusion section, Resident was working with therapy when a pop was heard and resident immediately fell to ground. Resident was diagnosed with [REDACTED]. On 10/5/16 at 2:10 p.m., Surveyor # interviewed PT (physical therapist)/Therapy Director-L regarding Resident #9's fall on 6/13/16. Surveyor # asked PT/Therapy Director-L who was working with Resident #9 on 6/13/16 when Resident #9 fell . PT/Therapy Director-L informed Surveyor # that PTA-M was performing a lunging activity with Resident #9 when Resident #9 fell on [DATE]. Surveyor # asked PT/Therapy Director-L why PTA-M was having Resident #9 perform lunges. PT/Therapy Director-L informed Surveyor # that lunges are considered a muscle strengthening activity. Surveyor # asked PT/Therapy Director-L if PTA-M's directions of having Resident #9 perform lunges was an appropriate therapy activity for Resident #9's post knee replacement rehabilitation. PT/Therapy Director-L informed Surveyor # that PTA-M's directions of having Resident #9 perform lunges were not an appropriate therapy activity for Resident #9's post knee replacement rehabilitation. PT/Therapy Director-L informed Surveyor # that in her opinion, performing lunges was not an appropriate exercise for Resident #9's to perform after her right knee replacement. Surveyor # asked PT/Therapy Director-L how exercises and therapy determinations are made so that they are appropriate for residents. PT/Therapy Director-L informed Surveyor # that exercise and therapy determinations are made by the supervising PT and that PTAs are supposed to consult with PTs to ensure that exercise and therapy recommendations are appropriate for residents. Surveyor # asked PT/Therapy Director-L if PTA-M had consulted with a PT prior to having Resident #9 perform lunges on 6/13/16. PT/Therapy Director-L informed Surveyor # that PT/Therapy Director-L was the supervising PT for PTA-M on 6/13/16. PT/Therapy Director-L informed Surveyor # that PTA-M did not consult with her (PT/Therapy Director-L) prior to having Resident #9 perform lunges. PT/Therapy Director-L informed Surveyor # that she (PT/Therapy Director-L) was not aware that PTA-M was having Resident #9 perform lunges until after Resident #9 fell on [DATE]. Surveyor # asked PT/Therapy Director-L if performing lunges was in Resident #9's therapy plan of care. PT/Therapy Director-L informed Surveyor # that no specific exercises are described in Resident #9's therapy plan of care and that exercises and therapy difficulty is increased as a resident progresses through their rehabilitation plan. PT/Therapy Director-L informed Surveyor # that performing lunges would be considered a progression in Resident #9's therapy plan of care. Surveyor # asked PT/Therapy Director-L if PTAs are supposed to consult with PTs when starting new exercises or progressing a residents plan of care. PT/Therapy Director-L informed Surveyor # that PTAs are supposed to be in constant communication with PTs and must consult a PT before progressing to a new exercise or if a change in a resident's therapy plan of care occurs. Surveyor # asked PT/Therapy Director-L if PTA-M consulted with her (PT/Therapy Director-L) before progressing Resident #9's therapy plan of care by having Resident #9 perform lunges. PT/Therapy Director-L informed Surveyor # that PTA-M did not consult with her (PT/Therapy Director-L) prior to having Resident #9 perform lunges. Surveyor # asked PT/Therapy Director-L if Resident #9 was assisted by additional staff besides PTA-M when performing lunges as described in the facility's fall investigation report dated 6/13/16. PT/Therapy Director-L informed Surveyor # that there were no additional staff besides PTA-M assisting Resident #9 perform lunges on 6/13/16. PT/Therapy Director-L informed Surveyor # that the facility's fall investigation report for Resident #9 was not accurate when describing Resident's assistance level when performing lunges on 6/13/16. Surveyor # asked PT/Therapy Director-L if she would have approved PTA-M's directions to have Resident #9 perform lunges on 6/13/16. PT/Therapy Director-L informed Surveyor # that had PTA-M consulted with her and made her (PT/Therapy Director-L) aware that PTA-M was to have Resident #9 perform lunges, she would have been hesitant and not approved PTA-M to have Resident #9 perform lunges. Surveyor # asked PT/Therapy Director-L if PTA-M had been disciplined as a result of not consulting with PT/Therapy Director-L before directing Resident #9's to perform lunging exercises. PT/Therapy Director-L informed Surveyor # that PTA-M was suspended after Resident #9's fall and was found not to be at fault by Rehab Care, the facility's contracted therapy company, during Resident #9's fall investigation. PT/Therapy Director-L informed Surveyor # that once PTA-M returned from suspension, she received additional instructions in the appropriate progression of rehabilitation activities and was provided with a copy of the total knee replacement protocol. PT/Therapy Director-L informed Surveyor # that in addition to additional instruction, PTA-M was required to discuss daily plans of care with the supervising PT for 30 days to ensure the quality and appropriateness of care provided to residents. On 10/5/16 at 4:00 p.m., Surveyor # interviewed PTA-M regarding Resident #9's fall on 6/13/16. Surveyor # asked PTA-M why she had Resident #9 perform lunges on 6/13/16. PTA-M informed Surveyor # that she had Resident #9 perform modified mini lunges with bilateral upper body support to strengthen the muscles in Resident's right leg. Surveyor # asked PTA-M if she had directed Resident #9 to perform mini lunges prior to Resident #9's fall on 6/13/16. PTA-M informed Surveyor # that she had never directed Resident #9 to perform mini lunges prior to Resident #9's fall on 6/13/16. Surveyor # asked PTA-M if she consulted or informed PT/Therapy Director-L that she (PTA-M) was going to have Resident #9 perform mini lunges. PTA-M informed Surveyor # that she did not consult or inform PT/Therapy Director-L prior to having Resident #9 perform mini lunges. PTA-M informed Surveyor # that she did not have to consult with PT/Therapy Director-L for every single exercise she directed Resident #9 to perform as long as the exercises were appropriate. Surveyor # asked PTA-M how she knew what exercises and therapy recommendations were appropriate for residents. PTA-M informed Surveyor # that if she had any doubts on whether an exercise or therapy recommendation was appropriate for a resident, she would consult with PT/Therapy Director-L. Additionally, PTA-M informed Surveyor # that she did not have to consult with a PT for every therapy or exercise she directed Resident #9 to perform as long as she followed Resident #9's therapy plan of care. Surveyor # asked PTA-M if she would consult with a PT if there were any changes to Resident #9's therapy plan of care. PTA-M again informed Surveyor # that she did not have to consult with a PT for every therapy or exercise as long as she (PTA-M) followed Resident #9's therapy plan of care. Surveyor # asked PTA-M if Resident #9 was assisted by additional staff besides PTA-M when performing lunges as described in the facility's fall investigation report dated 6/13/16. PTA-M informed Surveyor # that there were no additional staff besides her (PTA-M) assisting Resident #9 perform lunges on 6/13/16. PTA-M informed Surveyor # that the facility's fall investigation report for Resident #9 was not accurate when describing Resident's assistance level when performing lunges on 6/13/16. Surveyor # asked PTA-M if she would need to consult with PT/Therapy Director-L before progressing a resident to a new exercise. PTA-M informed Surveyor # that she did not have to consult with PT/Therapy Director-L before progressing a resident to a new exercise as long as it was appropriate. Surveyor # asked PTA-M how she would know if exercises or therapy recommendations were appropriate for residents. PTA-M informed Surveyor # that exercises and therapy recommendations were based on a specific resident and that exercises and therapy recommendations were discussed with a PT to ensure that they were appropriate for residents. Surveyor # asked PTA-M if she consulted or informed PT/Therapy Director-L that she (PTA-M) was progressing Resident #9's therapy plan of care by having Resident #9 perform mini lunges. PTA-M informed Surveyor # that she did not consult or inform PT/Therapy Director-L that she (PTA-M) was progressing Resident #9's therapy plan of care by having Resident #9 perform mini lunges. PTA-M again informed Surveyor # that she did not have to consult with a PT for every therapy recommendation or exercise as long as she (PTA-M) followed Resident #9's therapy plan of care. On 10/6/16 at approximately 8:00 a.m., Surveyor # reviewed PTA-M's written statement dated 6/13/16, regarding Resident #9's fall on 6/13/16. PTA-M's written statement documents, Pt (patient) was completing lunges (mini) with aid of 2ww (wheeled walker) for stability. Pt stepped forward with RLE (right lower extremity) when PTA heard a popping sound and pts (patient's) knee buckled. Pt unable to maintain upright standing and required assist down to the ground. Pt landed on right knee, then down to right shoulder. Pt reported pain 7/10 prior to there (therapeutic) ex (exercise) and 10/10 after fall. On 10/6/16 at approximately 8:00 a.m., Surveyor # reviewed PTA-M's significant event log in regards to Resident #9's fall on 6/13/16. PTA-M's significant event log documents at the top of the log, Use this form (or something similar) to record performance that either exceeds or falls below your expectations. Indicate the date of occurrence .and indicate the date you discussed it with the employee. PTA-M's significant event log dated as discussed on 6/13/16 documents under the Significant Event section, Patient (Resident #9) fell while being treated by PTA-M- performing lunges and right knee buckled. Pt (patient) fell on right knee and cried out. Sent to ER (emergency room ). Suffered patellar fx (fracture) and quad tendon rupture. Clinician (PTA-M) was placed on temporary suspension until Rehab Care (facility's contracted therapy service) completes risk management. PTA-M's significant event log dated as discussed on 6/23/16 documents under the Significant Event section, Clinician (PTA-M) allowed to return to work this date following risk management investigation. Clinician given copy of TKR (total knee replacement) protocol and provided with instruction in appropriate progression of rehab (rehabilitation) activities. Clinician will need to discuss daily POC (plan of care) with supervising PT each day for 30 days to ensure quality and appropriateness of care. PTA-M's significant event log dated as discussed on 8/3/16 documents under the Significant Event section, At this time, clinician (PTA-M) demonstrates appropriate clinical judgement with POCs (plans of care) .Clinician no longer needs to meet with PT weekly, but is encouraged to continue with daily checks and supervising PT re (regarding): POC (plans of care). On 10/6/16 at 8:35 a.m., Surveyor # interviewed PT/Therapy Director-L regarding Resident #9's fall on 6/13/16. Surveyor # asked PT/Therapy Director-L if she had provided education to all therapy staff regarding communication with supervising PTs (physical therapists) and OTs (occupational therapists) to ensure that therapy exercises and recommendations were appropriate for residents. PT/Therapy Director-L informed Surveyor # that she had an informal discussion with therapy staff regarding communication with supervising PTs and OTs to ensure that therapy exercises and recommendations were appropriate for residents. PT/Therapy Director-L informed Surveyor # that there was no formal education provided to staff besides the informal discussion described above. Surveyor # asked PT/Therapy Director-L if PTAs in the therapy department do not communicate or consult with PTs prior to starting new therapy exercises or progressing a resident's therapy plan of care. PT/Therapy Director-L informed Surveyor # that PTAs in the therapy department are constantly communicating and consulting with PTs prior to starting new therapy exercises and progressing a resident's therapy plan of care. PT/Therapy Director-L informed Surveyor # that PTAs would communicate with PTs prior to progressing or having a resident start a new exercise such as lunges. On 10/6/16 at 8:37 a.m., PT/Therapy Director-L provided Surveyor # with a copy of Rehab Care (the facility's contracted therapy provider)'s policy and procedure with a release date of 4/8/16 and titled, Physical Therapist Assistant Standards of Ethical Conduct. Surveyor # reviewed with PT/Therapy Director-L the policy and procedure with a subcategory titled, Accepted Standards of Medical Practice. The policy and procedure documents under the Standards section, Principle #3: Physical therapist assistants shall make sound decision in collaboration with the physical therapist and within the boundaries established by laws and regulations. Under Principle #3, it is documented 3E. Physical therapist assistants shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient/client status requires modifications to the established plan of care. On 10/6/16 at 8:57 a.m., Surveyor # interviewed PTA-N in regards to Resident #9's therapy plan of care. Surveyor # specifically interviewed PTA-N because Resident #9's therapy progress notes dated 6/12/16 document that PTA-N worked with Resident #9 during a therapy session. Surveyor # asked PTA-N if she had ever directed Resident #9 to perform mini lunges. PTA-N informed Surveyor # that she had never directed Resident #9 to perform mini lunges as she did not feel comfortable having Resident #9 perform lunges. PTA-N informed Surveyor # that directing Resident #9 to perform lunges was a standing activity that was more difficult and would have caused her to consult with PT/Therapy Director-L before having Resident #9 perform lunges. Surveyor # asked PTA-N if she usually consulted PT's before starting a new therapy exercise with a resident. PTA-N informed Surveyor # that before trailing any new exercise, she (PTA-N) would always consult with a PT, although this consult would not necessarily be done in formal manner. PTA-N informed Surveyor # that she would never start a new therapy exercise with a resident without consulting with PT/Therapy Director-L. PTA-N informed Surveyor # that although the consult would not be done in a formal manner, that she would be i

Based on observations, interviews and record review, the facility did not ensure resident safety while being transported in a wheelchair for 1 of 1 resident reviewed with a fall. * Resident #3 fell backwards in the facility transportation van after she was not properly strapped in and suffered a laceration to the back of her head requiring sutures. Findings include: Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #3's Initial Minimum Data Set (MDS) with a reference date of 4/12/16 indicated Resident #3 had a Brief Interview for Mental Status score of 15 (no cognitive deficit). On 4/25/16 at 9:45 a.m. Surveyor # interviewed Resident #3 who stated that approximately 2 weeks ago she was in the facility van being transported by Driver-D (who is employed by the facility) and Driver-D accelerated through an intersection and her wheelchair tipped back onto the van floor. Resident #3 stated she went to the hospital and received 6-8 stitches to the back of her head. On 4/25/16 at 1:55 p.m. Surveyor # interviewed Driver-D who stated on 4/14/16 he was transporting Resident #3 and came to a complete stop at an intersection. Driver-D stated when he started to accelerate slightly uphill Resident #3's wheelchair tipped backwards and Resident #3 fell on the floor. Driver-D stated that he took the van to the company that equipped it on 4/18/16 and was told that the wheelchairs back wheels were not supposed to be strapped but instead the frame of the wheelchair should be strapped. Driver-D stated he strapped Resident #3's back wheelchair wheels to the van and not the frame. Driver-D also stated that the company that equipped the van told him there should be 2 harnesses for the front of the wheelchair and 2 in the back and there was only one in the front and one in the back when Resident #3 fell . Driver-D stated that he has done about a hundred transports the same way. Surveyor # then asked Driver-D about the training he had received regarding the securing of wheelchairs to the facility van. Driver-D stated his first transport he received no training and was just handed the keys and told to do it. Driver-D then stated that he received training with several other people and it was hard to see what was going on but he felt confident enough to do it safely. Driver-D stated Activity Personnel-E did the training and used to do transport for the facility. Driver-D stated he was never trained the correct way to strap the wheelchairs in the van. Driver-D stated no residents were transported in the van after the problem was identified. On 4/25/16 Surveyor # reviewed the facility investigation, written by Administrator-A regarding Resident #3's fall on 4/14/16 which read: On return trip to the facility, the wheelchair Resident #3 was being transported in tipped over backwards. Driver-D immediately pulled the van into a gas station parking lot and called 911. Resident #3 returned to the facility after receiving 6-8 stitches to the back area of her head. On the day of the incident Driver-D did follow the steps the facility believed to be the correct ones to fully secure the wheelchair in the van. Since delivery (of the van) in November of 2015 there was been an average of approximately 100 transports per month with no incident. When an attempt to recreate the incident resulted in the possibility that there may be a circumstance that a wheelchair could be tipped backwards, the van was taken to the company that equipped it. That was when it was determined that the issue was where the S hook on the harness strap of the 4-point system was being attached to a wheelchair incorrectly to the wheels and not correctly to the frame. In addition there was one harness strap incorrectly placed to be positioned behind where a wheelchair would be rather than in front of where it would be. Being correctly place in front of where a wheelchair would be also adds to the security of the placement of a wheelchair. On 4/25/16 Surveyor # reviewed Resident #3's emergency room report dated 4/14/16 which read Trauma head laceration after fall. Sutured wound care. Suture removal in 10 days. The above findings were shared with Director of Nurses-B and Director of Clinical Services-C on 4/25/16 at 3:00 p.m. Information related to any training that was provided for van drivers following the incident, including training attendance records was requested. None was provided.

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free from accidents as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed with assistive devices for eating. On 4/20/15, Resident #7 received 4 second degree burns to her legs when adequate supervision and assistive devices were not provided when she spilt a cup of hot coffee on herself. On 4/20/15, Resident #7 was not provided with a covered cup with handles as per care plan kardex dated 2/10/15, and/or an assistive (sippy) cup per Assistant Director of Nursing (ADON) and/or a spill proof cup with lid per Occupational Therapist's recommendation on 7/28/14. The Occupational Therapists recommendation on 7/28/14 was a result of a previous incident on 7/25/14 in which Resident #7 spilled coffee on her lap resulting in a red area from the groin down. The cause of the 4/20/15 accident was not thoroughly investigated after the event. Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/29/15 Surveyor # reviewed Resident #7's current care plan dated 9/23/13 titled, Potential for Injury related to Cerebral Vascular Accident with [DIAGNOSES REDACTED]. Under interventions, the care plan read: refer to kardex for further instructions. The kardex dated 2/10/15 read: use covered cup with handles ½ full. On 7/22/15, Surveyor # reviewed Resident #7's incident report dated 4/20/15 at 8:40 a.m. which read: On 4/20/15, Resident #7 spilt hot coffee in lap this a.m. Has reddened area on upper right and left inner thighs with 2 blisters to left upper thigh and 2 small blisters to right inner thighs. Causes or contributing factors to the incident: paper cup used instead of regular cup. Similar incidents: has happened at least one time before. Possible cause: Resident #7 needs to use sippy cup but was using disposable cups related to gastrointestinal illness. Needs sippy cup at all meals. On 7/29/15, Surveyor # reviewed a previous spill with a burn incident report regarding Resident #7, dated 7/25/14 at 7:15 a.m. which read: Resident #7 was in the dining room stirring coffee and cup tipped spilling coffee on her lap. Red area from groin down inner leg on right side. Intervention: assess Resident #7 for need of adaptive equipment due to Parkinson's disease. On 7/22/15, Surveyor # reviewed Resident #7's physician orders [REDACTED]. The order was discontinued on 6/11/15 and indicated as healed. On 7/29/15, Surveyor # reviewed Resident #7's physician note dated 4/20/15 which read: spilled hot coffee onto lap today. Reddened area to right upper inner thigh was noted to blister earlier but none now. Left thigh inner aspect large blister intact and one large blister that has broken. Local [DIAGNOSES REDACTED] (redness). Resident denies pain raw but was previously painful. Second degree burn left thigh. First to second degree burn right thigh. On 7/29/15 at 9:40 a.m., Surveyor # interviewed Assistant Director of Nurses (ADON)-G who stated on 4/20/15 there was a gastrointestinal outbreak in the facility and the kitchen sent all Styrofoam cups. ADON-G stated Resident#7 was supposed to have a sippy cup. ADON-G stated she completed the investigation but did not know who served Resident #7 the hot coffee in the Styrofoam cup. ADON- G stated no formal training was done after Resident #7 spilled the coffee on herself but more sippy cups were ordered. On 7/29/15 at 1:45 p.m., Surveyor # interviewed Registered Nurse (RN)-I who stated she was called out in the lounge when Resident #7 spilt the hot coffee on herself. RN-I stated she did not know who served Resident #7 the coffee. RN- I stated she immediately had Resident #7 put in bed and ice applied to the burn areas and 4 blisters developed on the right and left thighs. RN-I stated she called Resident #7's doctor and family. The doctor ordered silvadene cream which RN-I indicated she applied. RN-I indicated Resident #7 should have a sippy cup. On 7/29/15 at 2:30 p.m., Surveyor # interviewed Occupational Therapist-H who evaluated Resident #7 on 7/28/14 and made a recommendation for Resident #7 to have a spill proof cup with a lid for hot liquids to keep her out of immediate danger due to her lack of strength and limited range of motion This recommendation was observed to be recorded on a change of diet form dated 7/28/14. Occupational Therapist-H stated on 8/22/14 after a complete evaluation and assessment the recommendation for Resident #7 was a cup ½ full with cover and handles for warm liquids. This recommendation was observed to be documented on rehabilitation recommendation to caregivers dated 8/22/14. On 7/30/15 at 8:30 a.m., Surveyor # interviewed the Director of Nurses-B who stated they found out today who served the coffee to Resident #7 in the Styrofoam cup on 4/20/15 and provided Surveyor # with an interview from Certified Nursing Assistant (CNA) -J dated 7/30/15. On 7/30/15 at 9:35 a.m. Surveyor # interviewed CNA-J who stated the facility was in quarantine because of a gastrointestinal outbreak on 4/20/15. CNA-J stated Resident #7 was supposed to use a sippy cup but none were sent due to the outbreak. CNA-J stated she poured a cup of coffee for Resident #7 in a Styrofoam cup and placed it on her table in a place she thought was out of her reach. CNA-J then stated she turned to get a breakfast tray and Resident#7 had split the coffee on herself. The above findings were shared with the Administrator and Director of Nurses on 7/29/15 at 3:00 p.m. at the daily exit meeting. Additional information was shared on 7/30/15 in regards to an investigation completed on 7/30/15 into the events leading to Resident #7's burn and is included in the above findings.

Based on record review and staff interviews, the facility did not provide a therapeutic diet that takes into account the resident's condition for 1 (Resident #1) of 3 residents that are assessed to require a pureed diet. On [DATE] Resident #1 was assessed by the Speech Therapist. The Resident was identified as having swallowing abnormalities and an order for [REDACTED].#1's plan of care indicates the Resident requires assistance with meals and eats in the Lounge Dining Room. On [DATE], during the dinner meal, the Resident was brought to the Main dining room by an Occupational Therapist. The Resident's plate was dished up with a regular texture diet by the cook, and the plate was served by the Dietary Aide. The meal consisted of a hotdog and American fried potatoes. Neither the cook nor the dietary aide looked at the meal ticket to identify the Resident's meal texture order. The Resident ate the regular textured food, choked on the food, required the [MEDICATION NAME] maneuver, became unresponsive, was intubated by paramedics and had a cardiorespiratory arrest. The resident was admitted to the hospital. The Neurology Consult, dated [DATE], indicates the Resident has [MEDICAL CONDITIONS] and that prognosis for recovery/survival is poor. The facility's failure to ensure that the correct diet texture was provided for Resident #1 created a situation of immediate jeopardy that started on [DATE]. On [DATE] at 12:00 p.m., the Surveyor notified the Administrator of the determination of immediate jeopardy at a scope and severity of a J (immediate jeopardy/isolated). The facility removed the immediate jeopardy on [DATE] when they implemented an Action Plan to ensure correct diet texture food delivery to residents. After that date, the deficient practice continued at a scope and severity of an E (potential for harm that is not immediate jeopardy/pattern) until the facility fully implemented its action plan and provided education of all staff regarding new dining service policies and procedures to ensure that the 19 residents requiring physical assistance or extensive cueing for meal intake are supervised and/or assisted by qualified staff according to care plan. Findings include: On [DATE] Surveyor # reviewed the facility's Diet Textures policy and procedure (undated). The policy indicated a Regular diet texture has no foods restricted because of texture. The policy indicates a Pureed diet is for residents who are edentulous, having chewing and/or swallowing problems that are not eliminated by the mechanical soft diet. All foods are of a pureed consistency. On [DATE] Surveyor # reviewed the Dining Services: Resident Meals policy and procedure (undated). The policy indicates, under Person Centered Dining, Residents requiring assistance are served in the East and West Alcoves (Lounge dining areas) because it is safer for residents. On [DATE] the Surveyor conducted a medical record review of Resident #1. The Hospital transfer Summary, dated [DATE] (prior to admission to the facility) indicates Resident #1 was transferred from the hospital to the facility for sub-acute rehab. The summary indicates the Resident's discharge/transfer [DIAGNOSES REDACTED]. The summary indicates a video swallow was completed which indicated the Resident is still extremely unsafe for thin liquids, and therefore a honey thick liquids consistency is being utilized. The summary indicates the Resident has a good cough reflex. The record review indicates the Resident is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Community Partnership SNF/ Hospital Hand-Off Guideline (undated), used as the admission diet order, indicates the Resident's physician order [REDACTED]. The Advanced Directives, dated [DATE], indicates the Resident has an activated Power of Attorney and has indicated yes to Resuscitation (CPR). The Resident Admission Assessment, dated [DATE], indicates the Resident is alert to others but no real orientation to place and time, has no speech, has no teeth, and has chewing/swallowing difficulty. The Speech Therapy Plan of Care, with onset date of [DATE], indicates a treatment [DIAGNOSES REDACTED]. The plan of care indicates the Resident was referred for a speech therapy evaluation-following hospitalization due to changes in speech, language, cognition, and swallowing. The plan of care indicates skilled speech language therapy is required for dysphagia treatment to increase swallows function and toleration of least restrictive diet for optimal nutrition and hydration to improve the Resident's quality of life. The plan of care includes precautions for the Resident including thickening liquids to honey consistency and that a pureed diet is recommended. The Dietary Order Slip, dated [DATE], indicates ordered diet as a pureed diet with honey thick liquids. The Resident: Certified Nursing Assistant (CNA) Care Plan Kardex, dated [DATE], indicates the Resident receives a pureed diet with honey thick liquids. The Kardex indicates the Resident receives eating assistance of 1 and eats in the Lounge area dining room. The Plan of Care, dated [DATE], indicates the Resident has a texture modified diet: Pureed with honey thick liquids. The plan of care includes the intervention to provide dining assistance based on the Resident's ability to dine independently. The dinner dietary card, (a copy of the actual diet card used on the date of the incident, [DATE]), indicates the Resident receives a Puree with honey thick liquids. The dietary card indicates the resident selected the choice of meal as assorted crackers, hotdog on a bun, American Fried Potatoes and pear slices. The nursing notes, dated [DATE] at 9:45 p.m., indicates that Registered Nurse-G was coming into the dining room are at approximately 4:35 p.m., that RN-F had indicated she had completed [MEDICATION NAME] Maneuver on Resident #1 and removed pieces of potato, which were visibly seen on the Resident's pants, and one piece of hotdog. The note indicates the Resident was alert and responsive after the [MEDICATION NAME] Maneuver and that the Resident indicated he was alright. The note indicates that RN-G was bringing the Resident to the lounge area to monitor when the Resident's face turned gray/blue around the lips and the Resident was gasping for air. The note indicates the RN directed the CNA to get the portable oxygen and additional help. The note indicates the Resident became unresponsive and RN-G checked the Resident's airway and no food was seen. The note indicates the 911 Emergency Medical System (EMS) was activated. The note indicates the Resident was taken to his room and another piece of hotdog was expelled. The note indicates oxygen was applied, the airway was reassessed, the Resident's pulse was present and the Resident continued to be unresponsive. The note indicates that at 4:45, two additional RNs arrived to help, that the Resident was not breathing, no pulse was present and Cardiopulmonary Resuscitation (CPR) was initiated. The note indicates the Ambulance Service Emergency Medical Transport (EMTs) arrived in the room at 4:47 and continued CPR (the ambulance service was at the facility transporting a different resident at the time) until approximately 4:50, when 911 EMTs arrived on the scene, continued CPR, intubated the Resident and transported the Resident to the hospital. The Emergency Department Chart, dated [DATE], indicates the Resident presented to the Emergency Department (ED), with CPR in process, for evaluation of a Code Blue (no respirations, no pulse). The report indicates the Resident was intubated by paramedics after a choking episode and becoming unresponsive. The report indicated the Resident regained a pulse after being administered [MEDICATION NAME]. The report indicates that the Primary [DIAGNOSES REDACTED]. The hospital History and Physical report, dated [DATE], indicates the Resident's chief complaint is cardiorespiratory arrest after choking on food. The impression in the report indicates the Resident was intubated in route to the hospital per EMS. The Resident was pulseless upon arrival to the ED. The Resident was successfully resuscitated with one dose of [MEDICATION NAME]. The report indicates the Resident was admitted to the intensive care. The Neurology Consult, dated [DATE], indicates the Resident's Chief Complaint as coma. The consult indicates the Resident is not responsive, does not alert to strong tactile stimuli, and does not interact. The consult indicates the impression that the Resident has [MEDICAL CONDITIONS] and that prognosis for recovery/survival is poor. Surveyor # reviewed the Witness Statement, dated [DATE], obtained from Occupational Therapist (OT) - I who assisted the Resident to the main dining room and with completing his meal ticket for dinner, on [DATE]. The Witness Statement indicates that the OT assisted the Resident to the main dining room (verses the Lounge dining room), without inquiring from nursing staff which dining room the Resident should be seated in. The OT assisted the Resident with the completion of the meal ticket and she did not ask the Resident what his diet was, she just marked his choices with a check mark on the meal ticket. The Statement indicates the OT left the completed meal ticket on the table in front of the Resident. Surveyor # reviewed the Witness Statement obtained from the Cook-D, dated [DATE]. The statement indicates the dinner meal consisted of spinach quiche, American Fries, sliced carrots and an alternate meal of a hotdog on a bun. The statement indicates Resident #1's meal ticket was bought to Cook-D and he served up the meal. The statement indicates the Cook did not know the Resident's diet and ended up finding out it was pureed. The statement indicates the Cook stated he never served a pureed diet in the dining room that he could recall. Cook-D was terminated and was not available to be interviewed by the Surveyor. Surveyor # reviewed the Witness Statement obtained from the Dietary Aide-E, dated [DATE]. The statement indicates the Dietary Aide gave Cook-D the Resident's meal ticket and Cook-D served up gave Resident #1's plate with the hot dog and American Fries. The statement indicates the Dietary Aide-E did not know the Resident and did not look at the part of the meal ticket that indicated the required diet texture for the Resident. The statement indicates the Dietary Aide served the Resident his plate and that he admitted he did not check the diet and diet texture prior to serving the meal. Dietary Aide-E was terminated and was not available to be interviewed by the Surveyor. On [DATE] at 11:45 a.m. Surveyor # spoke with Speech Therapist (S.T.)-H who competed Resident #1's initial Speech Therapy plan of care. S.T.-H indicated that the Resident had cognitive, communication and swallowing deficits identified that were addressed in the Resident's treatment plan. The S.T. indicated that based on the initial evaluation of the Resident, the Resident had no oral control to tolerate solid textures at the current time. The S.T indicated the recommended diet for the Resident was pureed texture with honey thick liquids. The S.T. indicated that the Resident could feed himself, however he required some assistance with meals including verbal prompting and cueing. On [DATE] at 1:10 p.m., Surveyor # spoke with O.T.-I who assisted the Resident to the main dining room and with completing his meal ticket for dinner, on [DATE]. O.T.-I indicated she was working with the Resident on wheelchair mobility prior to dinner on [DATE], and assisted the Resident into the Main dining room. OT indicated she assisted the Resident to the main dining room (verses the Lounge dining room), without inquiring from nursing staff which dining room the Resident should be seated in. OT-I indicated she assisted the Resident with the completion of the meal ticket, marked his choices with a check mark on the meal ticket, and left the completed meal ticket on the table in front of the Resident. On [DATE] at 10:45 a.m., Surveyor # spoke with Registered Nurse (RN)-F who walked into the main dining room on [DATE] and was asked to assess the Resident because the Resident was spitting his food out. RN-F indicated the Resident was observed to be having some breathing difficulties, had pieces of potatoes on and around his plate and on his lap. RN-F indicated she also observed ¼ of a remaining hot dog and bun on the Resident's plate. RN-F indicated she could not recall if there were any beverages served to the Resident. RN-F indicates she was not familiar with the Resident's baseline and she removed the resident from the dining room to take him to the nurse's station so his unit nurse could assess him. RN-F indicated that the Resident slumped over in the hallway, just outside of the dining room. RN-F indicated the [MEDICATION NAME] Maneuver was completed and a whole chunk of hot dog was expelled. RN-F indicated the Resident was coughing and she proceeded to take the Resident to the nurse's station, when the Resident slumped over again. RN-F indicated she again performed the [MEDICATION NAME] Maneuver and another piece of hotdog was expelled. RN-F indicated the Resident was initially alert and responsive after the [MEDICATION NAME] Maneuver was done, but then again became unresponsive. RN-F indicated the 911 emergency response system was activated. On [DATE] at 2:00 p.m., Surveyor # spoke with Registered Nurse (RN)-G who was assigned to care for Resident #1 on [DATE]. RN-G indicates she went into the main dining room after hearing over the intercom that a nurse was needed in the dining room. RN-G indicated that when she was going to the dining room she noted RN-F in the hallway with Resident #1 and that RN-F had already performed the [MEDICATION NAME] Maneuver on the Resident. RN-G indicated that at that time, the Resident was alert and responsive. RN-G indicated she proceeded to the main dining room to find out who served the Resident his dinner and what diet texture was provided. RN-G indicated that Cook-D informed her that he had served up the Resident's meal without looking at the Resident meal ticket for the required food texture. RN-G indicated Cook-D informed her that he was not aware that the Resident received a pureed diet. RN-G indicated she could not recall if she inquired if the resident was served honey thick liquids. RN-G indicated the facility utilizes the Main dining room for residents who eat independently and the facility uses the Lounge dining rooms for residents who require supervision and/or assistance with meals. RN-G indicated that in the Main dining room the meals are served/delivered to the residents by either a dietary aide or a CNA, but in the Lounge dining rooms only CNAs serve/deliver meals to the residents. RN-G indicated Resident #1 required supervision with meals and should have been eating in the Lounge dining area and not the Main dining room. RN-G indicated that on [DATE], O.T.-I brought Resident #1 to the main dining room without inquiring from nursing staff which dining room the Resident should go to. On [DATE] at 8:35 a.m., Surveyor # spoke with Cook-J who indicated food is served to the residents in either the main dining room or in lounge dining rooms located on the resident living units. Cook-J indicated in the main dining room meal tickets are presented to the cook who should look at both the diet on the ticket and the required food texture. Cook-J indicated the cook then serves up the meal onto the plate and gives it to either a CNA or a dietary aide to verify the accuracy of the meal and provide it to the resident. Cook-J indicated that in the lounge dining rooms, located on resident living units, dietary aides are not involved in the delivery of food to the residents. In the lounge dining rooms, meal tickets are presented to the cook who should look at both the diet on the ticket and the required food texture. Cook-J indicated that after verifying the correct diet, the cook then serves up the food and gives it to the CNA, who also verifies the accuracy of the meal and provides it to the resident. On [DATE] at 10:45 a.m., Surveyor # spoke with Nurse Manager RN-K who indicated Residents who require assistance, encouragement or supervision with meals should eat in the lounge area dining rooms. Nurse Manager RN-K indicated that the lounge area dining rooms are more accessible to nursing staff and that only CNA staff serve the food. Nurse Manger-K indicated that the dining room location/decision is made by nursing staff and communicated on the Resident Careplan Kardex. Nurse Manager-K indicated Resident #1's Careplan Card directed that the Resident should eat in the lounge area dining room, and that on [DATE] the resident should not have been served dinner in the main dining room. On [DATE] at 10:30 a.m., Surveyor # spoke with the Director of Nursing (DON) who indicated she assisted with the investigation and obtaining witness statements regarding the choking incident with Resident #1. The DON indicated that during staff interviews, both Cook-D and Dietary Worker-E indicated that on [DATE] at the dinner meal, they served up and delivered Resident #1 his meal without checking the meal ticket for the resident's required food texture. The DON indicated that during the staff interviews, both Cook-D and Dietary Worker-E indicated the Resident was served a general texture diet of a hotdog on a bun and American fried potatoes. On [DATE] at 10:45 a.m., Surveyor # spoke with Regional Nurse RN-B and reviewed the facility's Action Plan, dated [DATE]. The interview and the review of the Action Plan revealed the following: Cook-D and Dietary Aide-E are responsible for checking a resident's menu choices, diet type and diet texture before serving food to residents. Both dietary employees (Cook- D and Dietary Aide-E) had received in-service training prior to the incident, and were informed to check both sides of the meal ticket for diet type and texture before serving the food to the residents. The lack of effective measures to ensure Resident #1 consistently received the correct pureed texture diet, based on the Resident's assessed needs, created a situation of immediate jeopardy, removed on [DATE]. The immediate jeopardy was removed on [DATE] when the facility developed and implemented an Action Plan that included: Employees that served the diet were suspended pending further investigation. All residents receiving mechanically altered diet textures were verified against the dietary tray tickets to ensure accuracy of diet orders/textures; this was competed on [DATE]. Designated staff will verify resident trays prior to being served to residents to ensure proper texture of foods/fluids. This process began on [DATE] with the breakfast meal. Dietary, licensed nursing, CNA, therapy department education initiated [DATE] to include texture differences, verification of trays prior to service to ensure proper texture of foods/fluids, risks and signs/symptoms of aspiration/choking, and reporting of variance in diet texture to nursing and dietary departments. Education to be completed for staff involved in dining service prior to employee resuming participation in dining service. Education to be completed [DATE]. Compliance of the Action Plan will be ensured by Quality Assurance audits daily at each meal for 7 days, then daily at varied meals 3 times per week, then 5 times weekly at varied meals, the 3 times weekly at varied meals for 4 weeks. Results of audits will be reviewed by the Administrator and the DON during morning department head meetings and brought through quality assurance committee monthly for 3 months for review and further recommendations.

Based on observation, record review and staff interview the facility did not provide comprehensive pain management to 1 of 11 sampled residents. (Resident #33). Resident #33 physician orders [REDACTED]. 72 hour [MEDICATION NAME] daily change every three days 9:00 am. Pain Scale: 0-10-10 for "Chronic Pain Destroy [MEDICATION NAME] with 2 (1 nurse/1 nurse or CNA)." Effective date 10/07/10. On 12/06/10, Resident #33's [MEDICATION NAME] was not changed. Findings Include: 1. Surveyor # reviewed the medical record of Resident #33 on 12/09/10. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicates Resident #33's cognition is modified independent-some difficulty in new situations only. Resident #33 requires extensive assistance with bed mobility, toilet use, personal hygiene, and bathing. Resident #33 also requires limited assistance with transfers and dressing and does not ambulate. The (MDS) also indicates Resident #33 has moderate pain daily, back pain, and joint pain. The quarterly Minimum Data Set ((MDS) dated [DATE] indicates Resident #33 has moderate pain daily. The pain assessment dated [DATE] indicates neuropathic pain schedule [MEDICATION NAME] and prn medications Tylenol/[MEDICATION NAME]. Left shoulder and side pain. Verbal severity: 0 worst it gets is 6 best is 0. The pain is daily. Resident #33 can express verbally that there is pain and rate pain. What causes pain prolong sitting: Alleviate pain [MEDICATION NAME] and [MEDICATION NAME]. The physician order [REDACTED]./hr patch 72 hour [MEDICATION NAME] daily change every three days 9:00 a.m. Pain Scale: 0-10-10 For Chronic pain. On 12/07/10 at 11:25 p.m., the nursing notes indicates Resident#33 had pain in legs and it was rated at 7. This was the first time Resident #33 rated the pain level at 7. Resident #33 was given ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] 5 mg-500 mg. Prn (as needed) which was for pain scale of 8-10 and [MEDICATION NAME]-[MEDICATION NAME] 5 mg.-325 mg. tablet was held. This for pain scale of 6-7. On 12/09/10, Surveyor # reviewed the facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Controlled Drug Use Record did not indicate the [MEDICATION NAME] 12 was signed out. On 12/09/10 at 9:00 a.m., Surveyor # observed the [MEDICATION NAME] 12 mcg. patch on Resident #33 left shoulder with (Licensed Practical Nurse) LPN-C. LPN-C verified the date on the [MEDICATION NAME] 12 mcg. patch was 12/03/10. LPN-C indicated the patch should have been changed 12/06/10. LPN-C placed a new [MEDICATION NAME] 12 mcg. patch on Resident #33 right shoulder and dated it 12/09/10. On 12/09/10 at 10:00 a.m., Surveyor # spoke with Registered Nurse (RN)-D who worked the unit on 12/06/10 when the [MEDICATION NAME] 12 mcg was suppose to be changed. RN-D indicated the [MEDICATION NAME] 12 mcg was not changed on 12/06/10. RN-D indicated it was missed. On 12/09/10 at 1:15 p.m., the above information was shared with the Administrator and the Director of Nursing. No further information was provided.