Every finding on record at Lindengrove Waukesha

Based on record review, interviews, and facility policy review, the facility failed to ensure resident representatives and three of three residents (Resident (R) 1, R9, and R10) reviewed for transfer requirements out of a sample of 10 were provided with written notification of the facility's bed hold policy prior to transfer to the hospital. The facility also failed to submit documentation of the facility discharge notices to representatives of the Office of the State Long-Term Care Ombudsman. By not ensuring information regarding the bed hold process is explained to residents and/or representatives could create distress or confusion related to readmission to the facility due to the facility-initiated discharge.Findings include:1.Review of R1's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted [DATE] and the date of discharge to the hospital was [DATE].Review of R1's discharge return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R1's cognition was moderately impaired.Review of R1's Progress Notes dated [DATE] and located under the Prog Note tab of the EMR, revealed, Upon arrival resident was in the room laying on his right side, alert, and noted a cut/bruise and bleeding on the right side of his eyelid.Writer assessed the resident and sent resident to hospital for evaluation. Writer notified power of attorney (POA).Review of an eInteract Transfer Form dated [DATE] and located in R1's EMR under the Assmnts [Assessment] tab revealed Transfer/Discharge Details: Sent to: [name of hospital]. Reason(s) for Transfer: Other.Reason for transfer: Unplanned. Further review of the Transfer form revealed R1's representative was notified of the transfer by Registered Nurse (RN) 1 however, there was no documentation the bed hold process was explained, documentation given to the resident and/or representative of R1, and no documentation of notification to the Ombudsman of the discharge to the hospital.Review of R1's Progress Notes located under the Prog Note tab of the EMR, dated [DATE], revealed Writer contacted POA to know if he needed bed to be hold [sic]. Per POA No.During an interview on [DATE] at 11:36 AM, regarding the process for bed hold, the Social Services Director (SSD) stated, If a resident is their own responsible person, the nurses are supposed to explain the bed hold process to the resident and ask them if they want the bed hold. Then a carbon copy of the bed hold is sent with the resident and we keep the other. The SSD then stated, If they have a POA, the nurses are supposed to call the POA and go over what the bed hold is, the daily rate they would be responsible for, and the right to contact the Ombudsman regarding the decision or appeal. There is a section on the bottom of the bed hold document where the resident and/or representative would indicate they had been given the information, if they want a bed hold, or not, and the staff member who completed the form. When R1's EMR was reviewed with the SSD, she confirmed there was no documentation of a bed hold given to R1 or R1's representative.During an interview on [DATE] at 1:08 PM, and review of R1's EMR, the Assistant Director of Nursing (ADON) stated, [name of R1] went out to the hospital on [DATE] and did not return. When asked if there was documentation of a bed hold in R1's EMR, the ADON reviewed the EMR and stated, I don't see one was done.During an interview on [DATE] at 1:35 PM, and review of R1's EMR, the Director of Nursing (DON) confirmed R1 was sent to the hospital on [DATE], did not return to the facility. The DON further confirmed there was no documentation in the EMR of a bed hold.During an interview on [DATE] at 2:11 PM, and review of R1's EMR, RN1 confirmed she was the nurse who sent R1 to the hospital on [DATE]. Regarding the bed hold, RN1 stated she recalled speaking to R1's responsible party about it over the phone, and he said no. However, when reviewing R1's EMR, RN1 confirmed there was no specific documentation of the bed hold being completed and what the cost per day would be.During an interview on [DATE] at 2:49 PM, regarding the bed hold policy, the Administrator stated, My expectation is that the nurses should be having a conversation with the POAs if they want to hold the bed. We have a carbon copy form, and they should be filling it out with the cost per day, the Ombudsman information, the right to appeal, and if they want to hold the bed or not. The Administrator further stated, If a resident is their own responsible person, my expectation would be for us to explain the process and give them a copy. That should be the process here. Regarding R1, the Administrator stated, I don't see the bed hold was done.During a phone interview on [DATE] at 3:50 PM, regarding the facility discharge of R1 on [DATE], the Ombudsman stated, I wasn't notified by the facility. I didn't receive any documentation from the facility related to discharge.2. Review of the admission Record located under the Profile tab in the EMR revealed R9 was admitted to the facility on [DATE] and discharged to the hospital on [DATE].Review of the admission MDS with an ARD of [DATE] in the EMR under the MDS tab revealed R9 had a BIMS score of 15 out of 15 which indicated R9 had no cognitive impairment.Review of the discharge return anticipated MDS with an ARD of [DATE] and located in R9's EMR under the MDS tab revealed the type of discharge was Unplanned. The Discharge status was to an acute hospital. R9 did not return to the facility upon discharge to the hospital.Further review of R9's EMR revealed no documentation a bed hold was discussed with R9 or the representative regarding the discharge to the hospital on [DATE]. There was no documentation of the cost of services per day, or if R9 chose to have a bed hold. There was also no documentation in the EMR the Ombudsman was notified of the discharge to the hospital.During a phone interview on [DATE] at 8:48 AM, regarding the bed hold for R9, the SSD stated, She did not return from the hospital. When asked if R9 or the representative received a bed hold, the SSD stated, I don't see we did one for her.3. Review of the admission Record and located under the Profile tab in the EMR revealed R10 was admitted to the facility on [DATE] and discharged to the hospital on [DATE].Review of the discharge return anticipated MDS with an ARD of [DATE] and located in R10's EMR under the MDS tab revealed the type of discharge was Unplanned. The Discharge status was to the hospital for abnormal vital signs. R10 did not return to the facility upon discharge to the hospital.Further review of R10's EMR revealed no documentation a bed hold was discussed with R10 or the representative regarding the discharge to the hospital on [DATE]. There was no documentation of the cost of services per day or if R10 chose to have a bed hold. There was also no documentation in the EMR the Ombudsman was notified of the discharge to the hospital.During a phone interview on [DATE] at 8:48 AM, regarding the bed hold for R10, the SSD stated I'm not seeing one was completed. The nurse should have completed one with her representative.During a review of the Admission/Discharge to/from Report from [DATE] to [DATE], and interview with the SSD on [DATE] at 11:36 AM, the SSD stated, I fax over a monthly list of our discharges to the Ombudsman the first Monday of the month. I don't hang on to those though. I just fax them.During a phone interview on [DATE] at 3:50 PM, regarding the Admissions/Discharge to/from Report a representative of the Long-Term Care Ombudsman program stated, I haven't gotten the monthly discharges list from the facility since [DATE]. We told them they needed to maintain documentation they were sending them to us. We are not being made aware.During a second interview on [DATE] at 4:16 PM, regarding the facility-initiated discharge notifications to the Ombudsman, the SSD stated, I print out the Admissions/Discharge report which shows who went home, went to the hospital, expired, or went to an assisted living. I just send them a fax, then throw that away. I don't hang on to any documentation that I faxed.Review of the facility's policy titled, Individual Bed Hold reviewed [DATE] revealed Policy-The individual, guardian, and/or individual representative will be informed upon admission and/or hospital/therapeutic leave of their bed hold options at the facility. Procedure: Upon transfer to hospital and/or therapeutic leave 1. Individual will be informed and receive a copy of the bed hold procedure and letter. 2. Options will be given for a decision to be made regarding bed hold status. 3. If individual is unable to make preference known, designed will contact individual representative to determine preference. 4. Response will be documented. 5. Life Coach, or designee, will contact the individual representative on the next working day to ensure that the representative understands the bed hold and return to facility information.Review of the facility's policy titled, Individual Transfer and Discharge reviewed [DATE], revealed Procedure: . 3. The appropriate Ombudsman will be notified of all facility-initiated discharges, including hospitalizations.

Based on observations, interviews, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 (R13, R2, R8, and R19) of 6 residents reviewed for falls. * R13 experienced 2 falls on 7/18/25 and was sent to the emergency room. R13 was diagnosed with blunt head trauma, forehead laceration requiring sutures, and traumatic intracranial hemorrhage (bleeding on the brain). When R13 returned to the facility, R13 fell an additional 8 times between 7/18/25 through 9/7/25. Two of these falls resulted in R13 hitting his head again and required steri-strips to close the wounds. The 10 falls that R13 experienced at the facility were not thoroughly investigated and did not determine a root cause for R13's falls. A resident-specific care plan intervention was not always put in place after a fall, and previous interventions were not always documented if they were in place at the time of the fall. R13's fall care plan interventions were observed to not be in place during the survey process. The facility's failure to provide adequate supervision to R13, failure to thoroughly investigate R13's falls to determine an accurate root cause, and failure to implement resident-centered care plan interventions to prevent future falls and ensure safety for R13 created a finding of immediate jeopardy that began on 7/18/25. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the finding of immediate jeopardy on 09/15/2025 at 1:49 PM. The immediate jeopardy was removed on 9/26/25. Deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following examples: *R2 has a history of falls. R2 experienced falls with no injury on 1/31/25, 2/2/25, 2/3/25, and 2/4/25 that were not thoroughly investigated to determine an accurate root cause, and a resident-centered care plan was not always initiated after each fall. On 5/16/25, R2 experienced a fall while unsupervised in the dining room and suffered a closed head injury. The fall on 5/16/25 was not thoroughly investigated to determine an accurate root cause. R2 had 2 additional falls with no injury on 7/1/25 and 7/15/25 that were not thoroughly investigated to determine an accurate root cause. *On 6/26/25, at 7:15 AM, R8 sustained an unwitnessed fall and was found by facility staff lying on the floor in R8's room. The facility did not complete a thorough fall investigation, determine a thorough root cause, place interventions on R8's care plan after R8's fall, and care plan interventions were observed to not be in place during the survey process. *R19's fall interventions were not observed to be in place. R19 experienced a fall on 8/12/25 that was not thoroughly investigated. Findings include: The facility staff policy with a last review date of 5/8/25, titled Falls, documents, in part: Prevention measures are put in place to reduce the occurrence of falls and risk of injury from falls. A licensed nurse will determine the individuals' risk for falls and individualized care needs. If the individual is at risk for falls, then create a falls care plan. Procedure of fall event and implementation of intervention: Licensed nurse completes electronic documentation of the Fall Incident Report. The care plan will be updated with an identified intervention. Registered Nurse reviews and completes the fall assessment and interventions. The Interdisciplinary Team (IDT) will review Fall incident report and utilize root cause analysis to make further recommendations. Director of Nursing (or designee) and Executive Director to review and sign Fall Incident Report. The undated facility protocol titled, Standard Falls Protocol documents in part: Problem: Individual is at risk for falling. Goal: Risk of injuries related to falling will be minimized. Nursing. Teach safety measures as needed (i.e. proper hand placement when transferring, keep assistance device close to self with mobility) . Keep bed in lowest position. Encourage use of proper, well-maintained footwear. Respond to call lights and assist as able. Provide clutter free environment. Reorient to environment. Call light within reach. Keep personal and frequent items within reach. Report safety concerns to nursing. Offer diversional activities. Involve individual and/or responsible party in care plan process. 1.) R13 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease with late onset, Dementia with agitation, Depression, Muscle weakness, and Unsteadiness on feet. R13's admission Minimum Data Set (MDS) assessment dated [DATE] documents that R13 is severely cognitively impaired. The MDS documents: R13 displays verbal behaviors directed towards others 4-6 days a week; R13 is dependent for toileting and hygiene; R13 requires partial/moderate assist for transfers; R13 is always incontinent of urine and frequently incontinent of bowel; R13 has a history of falls; R13 has had falls since admission, one fall with no injury and one fall with major injury; R13 takes an antipsychotic medication and an antidepressant medication. R13's Fall Care Area Assessment (CAA) dated 7/22/25 documents: [R13] has a history of falls prior to admission and has had three falls since admission . [R13] is at risk for fall related injury. Resident is receiving physician ordered antidepressant increasing his fall risk. No referrals at this time, will proceed to care plan with goal to have no fall related injuries. R13's Behavior CAA dated 7/22/25 documents: [R13] triggered behavior CAA for having episodes of yelling out/screaming. [R13] is in a new environment which can lead to increased behaviors and confusion. [R13] has a diagnosis of dementia and Alzheimer's which can lead to increased behaviors. [Plan of Care] in place for [R13] to have an improvement in behaviors. R13's Psychotropic drug use CAA dated 7/22/25 documents: CAA triggered for psychotropic drug due to [R13] receiving physician ordered anti-depressant and anti-psychotic medication to manage diagnosis of depression and antipsychotic . Resident is at risk for adverse reactions to these medications including falls . MD is updated with medication refusals. Resident has had three falls since admission. No referrals at this time. Will proceed to care plan with goal to have no drug related side effects. Surveyor reviewed R13's Comprehensive Care plan and noted R13 does not have an active care plan for R13's behaviors and does not have an active care plan for psychotropic drug use. R13's Fall care plan initiated on 7/15/25 documents in part: The resident is at risk for falls [related to] unsteady gait. Interventions include: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate footwear when ambulating, transferring or mobilizing in [wheelchair]. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. R13's Activities of daily living care plan initiated on 7/15/25 documents the following intervention: Transfer: the resident is able to [complete by] assist of 1, gait belt and with or without [wheeled walker].R13's Fall risk evaluation dated 7/15/25 documents a score of 13, indicating R13 is at high risk for falls.R13's MD orders with a start date of 7/15/25 documents:-Duloxetine (an antidepressant medication) 20 milligrams (mg) 2 times a day.-Seroquel (an antipsychotic medication) 25 mg 3 times a day.-Mirtazapine (an antidepressant medication) 7.5 mg at bedtime.Surveyor reviewed all R13's MD orders and noted that R13 is not on a blood thinning medication. R13's progress note dated 7/18/25 at 6:16 PM documents: [R13] was in [R13's] wheelchair at the nurse's station and attempted to stand up without help. [R13] fell down onto [R13's] buttocks and did not hit [R13's] head. [R13] denies pain, range of motion within normal limits. Vital signs stable. Will continue to monitor. R13's facility fall investigation dated 7/18/25 documents in part: Fall occurred at 4:30 PM. Was this incident witnessed: Yes. [R13] was wearing gripper socks at the time of the fall. Immediate action taken: . Resident brought closer to the desk to try and watch [R13]. No injuries observed at time of incident. MD, [Power of Attorney], [Director of Nursing] updated. Root cause: IDT team met. Resident restless and wants to walk. [R13] attempted to stand up without assistance Resident fell on [R13's] bottom. Fall was witnessed by nurse. Intervention: Resident will have tray table in front of [R13] at nurses' station with activity to keep busy. Surveyor reviewed R13's fall care plan and noted the intervention for R13's 7/18/25, 4:30 PM fall was not present on R13's fall care plan. Surveyor noted the facility did not document an accurate root cause as to why R13 was trying to get up. Surveyor noted the facility did not document when R13 was last toileted or checked. Surveyor noted that, aside from the nurse who documented on the fall, staff statements were not collected by facility staff. On 9/11/25 at 7:02 AM, Surveyor interviewed Registered Nurse (RN)-M, who witnessed and documented R13's fall on 7/18/25. RN-M stated R13 had been at the facility 3 days and RN-M noticed that R13 had a cognitive deficit, was confused and impulsive. Because of these reasons, RN-M decided to keep R13 in the common area by the nurse's station. RN-M stated RN-M was at the nurse's station and saw R13 starting to stand up. RN-M stated RN-M got to R13 as fast as RN-M could but R13 fell on R13's buttocks. On 9/10/25 at 11:52 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R13's fall on 7/18/25 at 4:30 PM. Surveyor asked what the real root cause was for this fall and if there was documentation of when R13 was last toileted. DON-B stated R13 was previously toileted before R13 was brought to the nurse's station. DON-B stated R13 was not incontinent at the time of the fall. DON-B stated R13's Power of Attorney (POA)-Q made staff aware that R13 had a history of getting restless and trying to stand without assistance. Surveyor noted the facility did not provide documentation on the last time R13 was toileted. Surveyor noted DON-B did not provide clarification on the root cause of this fall. R13's Progress note dated 7/18/25 at 8:14 PM documents in part: [R13] was seated in [R13's] wheelchair in the dining room. [R13] fell out of [R13's] chair and fell onto the floor, striking the left side of [R13's] face. There was a small hematoma noted and some bleeding on [R13's] face and on the floor. Staff placed a blanket under [R13's] head and this writer called 911 immediately. EMS arrived and transported [R13] to the hospital for further evaluation of head trauma. Director of nursing updated. Writer also called and updated resident's [POA], [POA-Q] stated that [POA-Q] would be going to the hospital to check on R13. Provider updated . This writer received a phone call from the [Emergency Room] with an update that they are performing a head CT at this time. R13's facility fall investigation dated 7/18/25 documents in part: Fall occurred at 6:30 PM. Was this incident witnessed: No. Root cause: Was in the dining room without supervision after dinner and tried to ambulate without assistance. Intervention: Resident will be brought back to the nurse's station after dinner with [R13's] tray table and activity until bedtime for supervision. Surveyor reviewed R13's fall care plan and noted an intervention with an initiation date of 7/21/25: Resident will be brought back to the nurse's station after dinner with [R13's] tray table and activity until bedtime for supervision. Surveyor noted the fall intervention was placed in R13's care plan 3 days after the fall on 7/18/25. Surveyor noted the fall investigation documents the fall was unwitnessed. Surveyor noted the facility did not document an accurate root cause as to why R13 was up and trying to ambulate in the dining room. Surveyor noted facility staff did not document when R13 was last toileted or checked. Surveyor noted the fall investigation did not include what R13 was wearing on R13's feet. Surveyor noted that, aside from the nurse who documented on the fall, staff statements were not collected by facility staff. On 9/11/25 at 7:02 AM, Surveyor interviewed Registered Nurse (RN)-M, who assessed R13 after the fall and documented R13's fall. RN-M stated R13 was in the dining room after dinner. RN-M stated R13 had some sort of activity in front of R13 at the table. RN-M stated RN-M went to take care of another resident. RN-M stated RN-M heard a holler and went to the dining room right away to see what happened. RN-M stated RN-M thinks a Certified Nursing Assistant (CNA) was in the dining room at the time that R13 fell. RN-M stated as soon as RN-M got to the Dining room, RN-M assessed R13 and called 911. RN-M stated it was obvious that R13 needed intervention at a higher level of care. RN-M stated R13 still had the same gripper socks on that R13 was wearing during the previous fall. RN-M stated R13 returned from the hospital the same evening. RN-M continued neurological checks per facility policy and monitored R13 more closely. R13's Hospital emergency room Visit note dated 7/18/25 documents, in part: . Computed tomography scan (CT) head and cervical spine were obtained. There was no cervical fracture but there was evidence of post traumatic intracranial bleed. I discussed the CT findings with [POA-Q]. Hospitalization was considered. [R13] has had a brain bleed in the past. [POA-Q] understands this could be fatal, but [POA-Q] indicates [R13] survived the last one. [POA-Q] agrees there is no indication for hospitalization as [R13] is not a candidate for intervention or any form of surgery. Comfort care can be provided to [R13] at subacute rehab facility.R13's Hospital After Visit Summary (AVS) dated 7/18/25 documents in part: . Reason for visit: Fall. Head injury. Diagnoses: Fall, Blunt head trauma, Forehead laceration, and Traumatic intracranial hemorrhage. CT scan neck shows no fracture. CT scan head shows bleeding on the left side of the brain. Laceration was repaired with sutures. R13 was discharged from the ER and returned to the facility on 7/18/25. On 9/10/25 at 11:52 AM, Surveyor interviewed DON-B about R13's fall on 7/18/25 at 6:30 PM. Surveyor asked if the facility has documentation of the last time R13 was toileted and what was on R13's feet at the time of the fall. DON-B stated DON-B talked to the nurse and the nurse told DON-B that R13 was toileted just before the fall. DON-B stated that through investigation DON-B found that R13 was wearing shoes. Surveyor asked what the real root cause of the fall was. DON-B stated R13 was brought to the dining room table early and did not have an activity in front of R13 and that is why it was added as the intervention. Surveyor noted discrepancies between what the RN-M recalls about the fall and what DON-B recalls. RN-M stated resident was in gripper socks. DON-B stated R13 was in shoes. RN-M stated that R13 had an activity in front of R13 but was not sure what it was. DON-B stated R13 did not have an activity. Surveyor noted DON-B stated the root cause was R13 being brought to the dining room early for dinner. Surveyor noted that the fall occurred at 6:30 PM after dinner was served. Surveyor noted there is no facility documentation to clarify the discrepancies. R13's progress note dated 7/26/25 at 5:18 PM documents: Fall in dining room at [4:20 PM]. Witnessed by staff, CNA unable to physically get to resident in time. Resident got up from [wheelchair] and attempted to step over [left] foot pedal, falling to ground. Did not bump [R13's] head. Small superficial abrasion to [left] knee . Unable to follow direction for [active range of motion]. [Passive range of motion] provided as allowed. Assisted to [wheelchair] with two and [gait belt]. Remains in supervised area. Foot pedals removed from [wheelchair]. R13's facility fall investigation dated 7/26/25 documents in part: Fall occurred at 4:20 PM. [R13] was in supervised area. Immediate action taken: Foot pedals removed from [wheelchair]. To resume supervised area and/or one on one as allowable by staff. Notes: Confused. No safety awareness. Requires one on one supervision. Root cause: Resident was trying to stand up and step over her wheelchair foot pedals. Intervention: IDT met and when resident is taken to the dining room, set resident up at the table with something in front of [R13] to keep [R13] busy. Surveyor reviewed R13 fall care plan and noted the following intervention initiated on 7/28/25: When resident is taken to the dining room, set resident up at the table with something in front of [R13] to keep [R13] busy. Surveyor noted the fall intervention was placed in R13's care plan 2 days after the fall. Surveyor noted there is not an intervention that lists what activities work with keeping R13's attention and no documented investigation into what would keep R13's attention. Surveyor noted facility staff did not document an accurate root cause as to why R13 was trying to get up and step over the foot pedal. Surveyor noted the facility did not document when R13 was last toileted or checked. Surveyor noted the fall investigation did not include what R13 was wearing on R13's feet. Surveyor noted that, aside from the nurse who documented on the fall, staff statements were not collected by facility staff, even though, according to facility documentation, this fall was witnessed by a facility CNA. Surveyor noted the intervention was vague and documented to put something in front of R13 to keep R13 busy. On 9/10/25 at 11:26 AM, Surveyor interviewed RN-N, who assessed and documented R13's fall on 7/26/25. Surveyor asked what happened when R13 fell on 7/26/25. RN-N stated not sure. RN-N stated RN-N could not remember anything. Surveyor asked what RN-N should do if a resident falls. RN-N stated follow facility protocol. Surveyor asked what facility protocol was. RN-N stated assess resident, notify appropriate parties, speak with staff to see what happened and document it all in the medical record. Surveyor asked when R13 was last toileted, what the root cause was for the fall, what R13 was wearing on R13's feet, and if R13 had an activity to work on prior to the fall. RN-N stated RN-N could not remember anything. On 9/10 25 at 11:52 AM, Surveyor interviewed DON-B about R13's fall on 7/26. Surveyor asked about previous interventions being in place. DON-B stated R13 had a puzzle in front of R13 while at the table before the fall. Surveyor asked for clarification if there was an activity or something in front of R13 before the fall, why was the intervention placed about setting the table up with something in front of R13 to keep R13 busy. DON-B stated DON-B gave R13 a book after the fall because R13 could have been bored with the puzzle. Surveyor asked what the real root cause of the fall was, when R13 was last toileted or checked and what was on R13's feet. DON-B indicated DON-B would look into it. On 9/15/25 at 8:37 AM, DON-B returned to Surveyor. DON-B stated for the fall that occurred on 7/26/25, R13 was taken to the dining room earlier and her drink and table setting was not set up. DON-B said that is what caused R13 to try and get up. R13's progress note dated 7/27/25 at 4:11 PM documents in part: [R13] was found on the floor in the common area, laying on [R13's] back in front of [R13's] wheelchair. [R13] unable to provide information as to what happened. [R13] was responsive to verbal and tactile stimuli, responded with opening eyes, nonverbal. Able to demonstrate [range of motion] per baseline. Palpated head and body, no noted areas of concern. [R13] denies pain or discomfort. [Doctor] in to visit and updated. R13's facility fall investigation dated 7/27/25 documents in part: Fall occurred at 3:30 PM. Was this incident witnessed? No. No injuries observed at time of incident. Notes: [R13] has dementia, is confused and forgetful and unable to follow directions. Root cause: It is believed resident was trying to get up and ambulate without assistance when in the common area. Intervention: Ensure resident has a tray table in front of her with an activity present whenever at the common area, to help with restlessness and keep resident's interests. On 9/15/25 at 8:37 AM, DON-B informed Surveyor that the intervention from the 7/26/25 fall was not entered onto the care plan at the time of this fall on 7/27/25. For that reason, the same intervention was placed for this fall on 7/28/25. Surveyor noted the fall intervention was placed in R13's care plan 1 day after the fall. Surveyor noted there is not an intervention that lists what activities work with keeping R13's attention and no documented investigation into what would keep R13's attention. Surveyor noted facility staff did not document if past interventions were in place at the time of the fall. Surveyor noted the facility did not document an accurate root cause as to why R13 was found on the floor. Surveyor noted the facility did not document when R13 was last toileted or checked. Surveyor noted the fall investigation did not include what R13 was wearing on R13's feet. Surveyor noted that, aside from the nurse who documented on the fall, staff statements were not collected by facility staff. On 9/10 25 at 11:52 AM, Surveyor interviewed DON-B about R13's fall on 7/27/25. DON-B stated this fall was the same common theme for most of R13's falls. Surveyor asked if there is documentation of when R13 was last toileted or checked. DON-B stated R13 was incontinent at the time of this fall. DON-B stated staff were just about to do rounds to check on resident. Surveyor asked when R13 was last seen. DON-B stated the CNAs pass water and do their afternoon rounds at 2:30, so R13 would have been seen then. Surveyor asked for documentation. DON-B indicated there is not documentation confirming that. Surveyor asked what R13 was wearing on R13's feet. DON-B stated DON-B did not have that information. Surveyor shared concern that there is no actual root cause. DON-B stated, right. R13's hospice nurse's note dated 7/29/25 documents, in part: . [R13] has not tried to leave [R13's] unit but has had multiple falls when trying to get up alone. Last fall was 2 days ago.Staff has made changes to patient environment with bed low to the ground, padding/pillows on floor next to bed, moving [R13] to the nurse's station during wake times for more visibility. Surveyor reviewed R13's comprehensive care plan and noted that the interventions listed in the above hospice note are not documented in the facility's fall care plan for R13.R13's hospice nurse's note dated 7/31/25 documents in part: Broda chair ordered .A Broda chair is a specialized wheelchair designed to provide superior comfort, stability and therapeutic support for individuals with mobility challenges. On 9/15/25 at 11:15 AM, DON-B informed Surveyor that R13's Broda chair was delivered to the facility and implemented on 8/1/25. On 9/11/25 at 1:24 PM, Surveyor interviewed Hospice Case Manager (HCM)-O. Surveyor asked why a Broda chair was ordered and delivered for R13. HCM-O stated the original reason that a Broda chair was ordered is because the facility was worried that R13 would continue to fall in a regular wheelchair. HCM-O stated the facility staff wanted a Broda chair to get R13's feet off the ground to prevent R13 from standing up without assistance. On 9/15 at 8:37 AM, DON-B informed Surveyor that on 8/1/25, the facility IDT team met. DON-B stated DON-B had talked to nursing staff and noted that R13's most active time is between 4 and 630 PM. A new intervention was added to R13's care plan on 8/1/25 and documents: Resident is the most active between [4 and 630 PM] and needs regular supervision at nurse's station and [to follow] the nurse while on the med cart when CNA needs to complete cares in a room. R13's progress note dated 8/4/25 documents: Writer walked into [R13's] room and noticed [R13] on the floor, [R13] didn't know how [R13] got down there, [R13] was assessed and placed into Broda chair. Vitals signs [within normal limits], no [complaints of] pain [or] injuries. Denies hitting head, neuro checks in place, [Assistant Director of Nursing], [POA-Q] and [Nurse Practitioner] all notified of fall. On 9/10 25 at 11:52 AM, DON-B informed Surveyor that the above progress note was a late entry for a fall that R13 had on 8/2/25. DON-B provided the fall investigation to Surveyor. R13's facility fall investigation dated 8/2/25 documents in part: Fall occurred at 11 AM. Was this incident witnessed. No. No injuries observed at time of incident. Root cause: [R13] was in [R13's] room in the morning and kept trying to get out of bed unassisted and was found on the floor. Intervention: Resident will be a morning wake up and after breakfast resident will be placed at the nurse's station with an activity. Surveyor reviewed R13's fall care plan and noted the following intervention initiated on 8/5/25: Resident will be a morning wake up and after breakfast resident will be placed at the nurse's station with an activity. Surveyor noted the fall intervention was placed in R13's care plan 3 days after the fall. Surveyor noted facility staff did not document if past interventions were in place at the time of the fall. Surveyor noted the facility did not document an accurate root cause as to why R13 was getting out of bed. Surveyor noted the facility did not document when R13 was last toileted or checked. Surveyor noted the fall investigation did not include what R13 was wearing on R13's feet. Surveyor noted there is no documentation as to if R13's call light was on or if R13's call light was within reach. Surveyor noted that, aside from the nurse who documented on the fall, staff statements were not collected by facility staff. Surveyor noted facility staff did not document that hospice was made aware of the fall on 8/2/25. On 9/11/25 at 1:24 PM, Surveyor interviewed HCM-O. HCM-O confirmed that hospice was not made aware that R13 fell on 8/2/25. On 9/10/25 at 11:22 AM, Surveyor attempted to reach the nurse who documented R13's fall on 8/2/25 by telephone. The nurse did not answer Surveyor's phone call. On 9/10 25 at 11:52 AM, Surveyor interviewed DON-B about R13's fall on 8/2/25. Surveyor asked what the phrase in the facility fall investigation, Kept trying to get out of bed meant. DON-B stated facility staff were trying to see if laying R13 down in between breakfast and lunch would help with R13's restlessness. DON-B stated it did not work. DON-B stated the intervention for this fall is effective and works well now. Surveyor asked when resident was last toileted or seen. DON-B stated 10 AM. Surveyor asked where that information is documented. DON-B stated it is standard for CNAs to do rounds at 10 AM. DON-B stated during that time, DON-B and other leadership do purposeful rounding with staff at that time and DON-B can see that CNAs are rounding. Surveyor asked why interventions are put in days later after a fall has happened. DON-B stated DON-B does not like to put interventions in right away. DON-B likes to make sure that the intervention makes sense and is effective before documenting it on the care plan. DON-B stated it is not effective to just put an intervention in the care plan right away. R13's MD orders with a start date of 8/7/25 documents: -Targeted Behavior: Hallucinations observed this shift. -Targeted Behavior: Yelling out observed this shift. Surveyor reviewed R13's Medication Administration Record and noted that R13 was receiving Seroquel as ordered since admission on [DATE] and Behavior Monitoring started 8/7/25. R13's progress note dated 8/9/25 at 8:30 PM documents: At about [8PM] writer was informed by one [of] the CNAs that [R13] was on the floor. Upon arrival, [R13] was laying on [R13's] buttock, alert, no bruise, bleeding noted, denied pain. Assessed pain, obtained vital signs and neuro check. Notified case manager [name of a hospice company], [provider], [POA-Q] [and] [NHA-A]. [R13] was assisted back to bed, bed on lower level, call light within reach and precaution mat placed on the floor. Continue check on R13. Surveyor noted that the wrong hospice company was notified of R13's fall on 8/9/25. On 9/11/25 at 1:24 PM, Surveyor interviewed HCM-O. HCM-O confirmed that R13's hospice was not made aware that R13 fell on 8/9/25. R13's facility fall investigation dated 8/9/25 documents, in part: Fall occurred at 8 PM. Was this incident witnessed. No . No injuries observed at time of incident. Root cause: Resident with Alzheimer's and also becomes restless. Fall prevention intervention: staff to round/check on resident every 2 hours, even [if] resident placed at nurse's station. Surveyor reviewed R13's fall care plan and noted the following intervention initiated on 8/11/25: Staff to round on resident every 2 hours, even if resident is stationed by the nurse's station. Surveyor noted the fall intervention was placed in R13's care plan 2 days after the fall. Surveyor noted facility staff did not document if past interventions were in place at the time of the fall. Surveyor noted the facility did not document an accurate root cause as to why R13 was found on the floor. Surveyor noted the facility did not document when R13 was last toileted or checked. Surveyor noted the fall investigation did not include what R13 was wearing on R13's feet. Surveyor noted there is no documentation as to if R13's call light was on at the time of R13's fall. Surveyor noted there is no documentation if R13 had an activity to keep R13's attention. Surveyor noted that, aside from the nurse who documented on the fall, staff statements were not collected by facility staff, even though a staff CNA found the resident and alerted the nurse to come to R13's room. On 9/10/2025 at 10:52 AM, Surveyor interviewed RN-P, who was the nurse who responded to R13's room after R13's fall on 8/9/25. RN-P stated that a CNA notified RN-P that R13 was on the floor. RN-P stated RN-P assessed R13, and completed the notifications to hospice, POA, and provider. Surveyor asked what RN-P thinks caused R13 to fall. RN-P stated RN-P was told by other staff members that R13 is a jumper. RN-P stated R13 was just restless and always wants to get up. RN-P stated R13 likes music and that has worked in the past to keep R13 calm. Surveyor asked when R13 was last seen or last toileted. RN-P stated that RN-P was not sure. RN-P stated that it could be that [R13] wanted to go to the bathroom, but RN-P was not 100% sure. RN-P stated R13 was not wearing shoes but thinks that R13 had socks on. Surveyor asked if the call light was on. RN-P stated that RN-P is not sure that R13 knows how to use it. RN-P stated that the call light was in reach though. On 9/10/25 at 11:52 AM, Surveyor interviewed DON-B about R13's fall on 8/9/25. DON-B stated DON-B believed that the interventions in place on R13's fall care plan were ef

Based on interview and record review, the facility did not ensure that all facility staff received required Quality Assessment and Performance Improvement (QAPI) program training for 1 of 5 sampled Certified Nursing Assistants (CNAs).This deficient practice has the potential to affect residents who reside at the facility on the wing where CNA-W is working and have the potential to receive care from CNA-W. Findings Include:On 09/25/24, at 11:00 AM, Surveyor reviewed CNA-W's completed trainings for the past year and noted there was no documentation that CNA-W received training on the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program. On 9/25/24, at 12:01 PM, Surveyor requested missing documentation from NHA (Nursing Home Administrator)-A for CNA-W's training of the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program. Surveyor was informed by NHA-A to call Learning Facilitator (LF)-X. NHA-A informed Surveyor that LF-X tracks and records the education for all the facility's staff.On 9/25/24, at 12:24 PM, Surveyor conducted a phone interviewed with LF-X about CNA-W's training of the facility's QAPI program. LF-X informed Surveyor that CNA-W had not yet completed the required training of the facility's QAPI program.On 09/25/25, at 12:45 PM, Nursing Home Administrator (NHA)-A confirmed the facility has not provided CNA-W with the mandatory QAPI training. NHA-A informed Surveyor the facility was working on providing QAPI training to CNA-W.No additional information was provided as to why the facility did not ensure that CNA-W received the required Quality Assessment and Performance Improvement program training.

Based on interview and record review the facility did not ensure 6 (R3, R4, R1, R8, R19, and R47) of 6 residents reviewed for hospitalizations received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (including mail and email) with the telephone number of the Office of the State Long-Term Care Ombudsman, were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the residents bed. *R3 was transferred to the hospital on 4/3/25 and 5/20/25. A transfer notice and bed hold rate was not provided in writing to R3 and/or R3's representative. *R4 was transferred to the hospital on 7/16/25 and 8/11/25. A transfer notice and bed hold rate was not provided in writing to R4 and/ or R4's representative. *R1 was transferred to the hospital on 3/15/25. A transfer notice and bed hold rate was not provided in writing to R1 and/ or R1's representative. *R8 was transferred to the hospital on 4/30/25 and 6/26/25. A transfer notice and bed hold rate was not provided in writing to R8 and/ or R8's representative. *R19 was transferred to the hospital on 5/9/25. A transfer notice and bed hold rate was not provided in writing to R19 and/ or R19's representative. *R47 was transferred to the hospital on 9/2/25. A transfer notice and bed hold rate was not provided in writing to R47 and/ or R47's representative. Findings include: The facility policy titled Individual Bed Hold dated 5/2/25 documents: Upon transfer to the hospital: individual will be informed and receive a copy of the bed hold procedure and letter. The facility policy titled Individual Transfer and discharge date d 5/2/25 documents: The individual and/or individual representative will receive a written notice including the resident's reason for transfer. The notice shall contain the name, address and telephone number of the board on aging and long-term care. On 09/10/2025 at 2:28 PM, Director of Nurses (DON)-B was interviewed and indicated there were no bed hold or transfer notices completed for R3, R4, R1, R8, R19 or R47's transfers to the hospital. 1.) R3 was admitted to the facility on [DATE]. On 9/9/25 R3's medical record was reviewed and indicated he has transferred to the hospital on 4/3/25 and 5/20/25. No bed hold or transfer notice could be located in R3's medical record. The above findings were shared with Nursing Home Administrator (NHA)-A and DON-B on 9/10/25 at 3:00PM. Additional information was requested as to why R3 did not receive bed hold and transfer notices for his 4/3/25 and 5/20/25 hospitalizations. None was provided. 2.) R4 was admitted to the facility on [DATE]. On 9/9/25 R4's medical record was reviewed and indicated he has transferred to the hospital on 7/16/25 and 8/11/25. No bed hold or transfer notice could be located in R4's medical record. The above findings were shared with Nursing Home Administrator (NHA)-A and DON-B on 9/10/25 at 3:00PM. Additional information was requested as to why R4 did not receive bed hold and transfer notices for his 7/16/25 and 8/11/25 hospitalizations. None was provided. 3.) R1 was admitted to the facility on [DATE], with diagnoses including bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression), dementia (a decline in cognitive abilities such as memory, thinking, reasoning, and judgment), and paraplegia (a condition characterized by the loss of movement and sensation in both legs). R1's Electronic Medical Record (EMR) documents R1 was transferred to the hospital on 3/15/25 for a change in condition. There is no documentation that R1 was provided a written copy of transfer notice or bed hold rate for R1's hospitalization on 3/15/25. DON-B was notified of these findings and additional information was provided. None was provided. 4.) R8 was admitted to the facility on [DATE], with diagnoses that include right femur fracture (a break in the right thighbone), difficulty walking, and weakness. R8's EMR documents R8 was transferred to the hospital on 4/30/25 and 6/26/25 for a change in condition. There is no documentation that R8 was provided a written copy of transfer notice or bed hold rate for R8's hospitalization on 4/30/25 and 6/26/25. On 9/9/25, at 1:42 PM, Surveyor interviewed Social Worker (SW)-C about bed hold notice and transfer notice when a resident is transferred to the hospital. SW-C stated she is under the impression nursing staff completes the bed hold and transfer forms. On 9/9/25, at 2:36 PM, at the daily exit meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, Surveyor requested bed hold notices and transfer notices for R1 dated 3/15/25 and R8 dated 4/30/24 and 6/26/25. NHA-A informed Surveyor they would review and let Surveyor know. On 9/10/25, at 9:00 AM, Consultant-H notified Surveyor the facility did not have bed hold notices and transfer notices for R1 and R8. Consultant-H indicated she was previously completing bed hold and transfer notices. Surveyor asked who at the facility is responsible for completing the bed hold and transfer notices. Consultant-H states she is unsure who completes the bed hold notices and transfer notices since she has not been onsite at the facility for two months. Consultant-H then stated she is not surprised the survey team has not received the requested bed hold and transfer notices. Surveyor notified Consultant-H of concerns with R1 not receiving the bed hold and transfer for 3/15/25 and R8 not receiving the bed hold and transfer notice for 4/30/25 and 6/26/25. On 9/10/25, at 3:16 PM, Surveyor notified Director of Nursing (DON)-B, Assistant Director of Nursing (ADON)-D, and Consultant-H of concerns that the facility did not provide R1 and R8 bed hold notices and transfers for R1 and R8. DON-B, ADON-D, and Consultant-H acknowledged these concerns. Surveyor requested additional information if available. None was provided. 5.) R19 was admitted to the facility on [DATE] . On 9/9/25 R19's medical record was reviewed and indicated he has transferred to the hospital on 5/9/25. No bed hold or transfer notice could be located in R19's medical record. The above findings were shared with Nursing Home Administrator (NHA)-A and DON-B on 9/10/25 at 3:00PM. Additional information was requested as to why R19 did not receive bed hold and transfer notice for the 5/9/25 hospitalization. None was provided. 6.) R47 admitted to the facility on [DATE] and has diagnoses that include Hepatic Encephalopathy, Metabolic Encephalopathy, infection and inflammatory reaction due to indwelling urethral catheter, severe protein-calorie malnutrition, alcohol dependence with alcohol-induced persisting dementia, retention of urine, second degree Atrioventricular Block (AV) and anemia. R47 was hospitalized on [DATE] for a change in condition. The hospital discharge summary documented diagnoses of acute cystitis without hematuria, second degree AV block, Mobitz type I, bradycardia, chronic cognitive impairment presumably due to heavy ETOH (alcohol). There is no evidence R47 was provided a written copy of transfer notice or bed hold rate for this hospitalization. On 9/9/25 at 1:35 PM, Surveyor asked Nursing Home Administrator (NHA)-A who is responsible for hospital transfer/discharge and bed hold notices. NHA-A reported the Social Worker (SW) is responsible. Surveyor asked for the above information regarding R47's hospitalization on 9/2/25. On 9/9/25 at 1:43 PM, SW-C advised Surveyor she does not have any of the requested information. SW-C reported she was under the impression the nurses did it, but there is confusion as to who was supposed to do it, and NHA-A is looking into it. No additional information was provided.

Based on interview and record review, the facility did not ensure that all facility staff received required compliance and ethics program training for 1 of 5 sampled Certified Nursing Assistants (CNAs).This deficient practice has the potential to affect residents who reside at the facility on the wing where CNA-W is working and have the potential to receive care from CNA-W. Findings Include:On 09/25/24, at 11:00 AM, Surveyor reviewed CNA-W's completed trainings for the past year and noted there was no documentation that CNA-W received training of the facility's compliance and ethics program.On 9/25/24, at 12:01 PM, Surveyor requested missing documentation from NHA (Nursing Home Administrator)-A for CNA-W's training of the facility's compliance and ethics program. Surveyor was informed by NHA-A to call Learning Facilitator (LF)-X. NHA-A informed Surveyor that LF-X tracks and records the education for all the facility's staff.On 9/25/24, at 12:24 PM, Surveyor conducted a phone interviewed with LF-X about CNA-W's training of the facility's compliance and ethics program. LF-X informed Surveyor that CNA-W had not yet completed the required training of the facility's compliance and ethics program.On 09/25/25, at 12:45 PM, Nursing Home Administrator (NHA)-A confirmed the facility has not provided CNA-W with the mandatory compliance and ethics program training. NHA-A informed Surveyor the facility was working on providing compliance and ethics program training to CNA-W. No additional information was provided as to why the facility did not ensure that CNA-W received the required compliance and ethics program training.

Based on interview and record review, the facility did not ensure that all facility staff received required effective communication program training for 1 of 5 sampled Certified Nursing Assistants (CNAs).This deficient practice has the potential to affect residents who reside at the facility on the wing where CNA-W is working and have the potential to receive care from CNA-W. Findings Include:On 09/25/24, at 11:00 AM, Surveyor reviewed CNA-W's completed trainings for the past year and noted there was no documentation that CNA-W received training on the facility's effective communication program which outlined and informed staff of the elements and goals of the facility's effective communication program. On 9/25/24, at 12:01 PM, Surveyor requested missing documentation from NHA (Nursing Home Administrator)-A for CNA-W's training of the facility's effective communication program which outlined and informed staff of the elements and goals of the facility's effective communication program. Surveyor was informed by NHA-A to call Learning Facilitator (LF)-X. NHA-A informed Surveyor that LF-X tracks and records the education for all the facility's staff.On 9/25/24, at 12:24 PM, Surveyor conducted a phone interviewed with LF-X about CNA-W's training of the facility's QAPI program. LF-X informed Surveyor that CNA-W had not yet completed the required training of the facility's effective communication program.On 09/25/25, at 12:45 PM, Nursing Home Administrator (NHA)-A confirmed the facility has not provided CNA-W with the mandatory QAPI training. NHA-A informed Surveyor the facility was working on providing effective communication training to CNA-W.No additional information was provided as to why the facility did not ensure that CNA-W received the required effective communication program training.

Based on the comprehensive assessment of a resident, the facility must ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 1 of 6 (R50) residents reviewed for pressure injuries.R50's pressure injury was not comprehensively assessed upon admission. The pressure injury was assessed by the wound physician 6 days later and documented as an unstageable DTI (Deep Tissue Injury) with moderate serosanguinous exudate. Findings include:The facility policy and procedure titled Pressure Injury Prevention and Managing Skin Integrity reviewed 5/8/25, documents (in part) . Prevention measures are put in place to reduce the occurrence of pressure injuries.a. Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds.b. Registered Nurse (RN) or designee will: Conduct weekly skin evaluation. Update the PCP (Primary Care Provider) with any decline in wound appearance, or as necessary. Update the care plan with any new interventions as applicable. Update individual representative as indicated. R50 admitted to the facility on [DATE] and has diagnoses that include acute and chronic respiratory failure with hypoxia, encephalopathy, fluid overload, Diabetes Mellitus type 1, kidney transplant status, hypertensive heart and chronic kidney disease, anxiety disorder, chronic Atrial Fibrillation, dysphagia, Hypothyroidism, Hyperlipidemia and Atherosclerotic Heart Disease.On 9/8/25 at 1:32 PM, during the initial interview, R50 reported she has a pressure injury on her heel that was present before she admitted to the facility. She reported she wears Prevalon boots whenever she is in bed and they are working hard to get it to heal, but I'm diabetic too, so that don't help. R50's Braden dated 8/21/25 documents a score of 16, indicating R50 is at risk for the development of pressure injuries.R50's care plan documents: The resident has actual DTI (Deep Tissue Injury) to the R (right) heel upon admission - initiated 8/21/25. Apply pressure relieving boots while in bed or chair. R50's Admit/Readmit Screener dated 8/21/25, Section C -Skin Integrity documents:Site: Right heel. Type: Pressure. Length/Width/Depth/Stage - No documentation. Surveyor noted that there was no evidence of a comprehensive assessment to include a description, measurements or staging of the pressure injury.R50's Medication Administration Record (MAR) documented: DTI R (right) lateral heel. Cover with Mepilex every Day shift for wound care - start 8/22/25, discontinued 8/27/25.Surveyor located no other documentation regarding the pressure injury except for a progress noted dated 8/23/25 at 8:27 PM, which documented: Resident has right heel scabbed area, area cleansed and rebandaged for protection.The facility Skin & Wound Evaluation dated 8/27/25 documents: Deep Tissue Injury (Persistent non-blanchable deep red, maroon or purple discoloration) right heel present on admission. Staged by wound care clinic. Exudate Moderate Serosanguinous. There were no measurements or wound bed description.The [NAME] Wound Physician Initial Wound Evaluation & Management Summary dated 8/27/25, documents: Focused Wound Exam - Unstageable DTI of the right heel. Wound Size (L x W x D): 1 x 0.6 x 0.1 cm (centimeters). MDS 3.0 stage: Unstageable DTI within and around wound. Exudate: Moderate serosanguinous.Dressing treatment plan: Primary dressing - Leptospermum honey apply three times per week and as needed. Secondary dressing - Foam with border apply three times per week and as needed if saturated, soiled, or dislodged.R50's August TAR documented: DTI Right lateral heel - Cleanse with wound cleanser, Dry. Apply border foam dressing in the morning every Mon, Wed, Fri for wound care - start date 8/29/25. Surveyor noted this was not the treatment ordered by the wound physician on 8/27/25. Although treatment was not implemented as ordered, the wound did not decline.The [NAME] Wound Physician Wound Evaluation & Management Summary dated 9/3/25 documents: Focused Wound Exam - Unstageable DTI of the right heel. Wound Size 0.9 x 0.4 x 0.1 cm. MDS 3.0 stage: Unstageable DTI within and around wound. Exudate: Moderate serosanguinous. Wound progress: Improved evidenced by decreased surface area.Surveyor noted R50's September TAR documented treatment implemented as ordered. On 9/10/25 at 10:59 AM, Surveyor was unable to observe wound care as scheduled because R50 was sent out and admitted to the hospital the prior evening. On 9/10/25 at 1:01 PM, Surveyor asked Director of Nursing (DON)-B what the expectation for a resident that admits with or if staff identifies a pressure injury. DON-B reported the nurse should document on the admit/readmit screener, call for a treatment order and the wound care nurse (WCN) would assess it the next day. Surveyor advised DON-B the admission assessment documents only pressure right heel, there is not a comprehensive assessment to include a description of the wound or measurements. There is no evidence the pressure injury was assessed by the WCN the next day (Friday). There is no evidence of a comprehensive assessment until a week later, on 8/27/25 when R50 was seen by the wound physician, who then documents the pressure injury as an unstageable DTI of the right heel - unstageable DTI within and around wound with moderate serosanguinous exudate. Surveyor advised the physician ordered treatment on 8/27/25 of Leptospermum honey did not get implemented until after she was seen by [NAME] on 9/3/25. DON-B reported it was 6 days later, not a week - when R50 was seen by the wound physician, stating I believe we have a week to do the assessment. Surveyor advised DON-B that I was not sure what she meant by we have a week to do the assessment. DON-B stated, Upon admission we do the skin check and document any areas and then add the resident to weekly wound rounds. Surveyor advised DON-B a wound can change within a week and there is no evidence the facility completed a comprehensive assessment of the wound upon admission (to include a description of the wound and measurements) until she was seen by the wound physician, when he then documents the pressure injury as unstageable.On 9/10/25 2:36 PM, DON-B provided Surveyor the hospital After Visit Summary (AVS) to show R50's pressure injury was present prior to admission (PTA). Surveyor advised DON-B there is no dispute R50 admitted with a pressure injury. The concern is the facility did not comprehensively assess the pressure injury to include a description/characteristic of the wound, measurements or staging of the pressure injury upon admission. R50's pressure injury wasn't comprehensively assessed until she was seen by the wound physician 6 days later, when it was documented as unstageable DTI within and around the wound with moderate serosanguinous exudate.Surveyor reviewed the hospital AVS most recent documentation on 8/19/25 which documented: DTPI (Deep Tissue Pressure Injury). Dressing clean, dry, intact, reinforced. Wound exudate: None. Wound bed/tissue type: Maroon, purple, red, boggy. Wound edge poorly defined. Last measurements on 8/19/25 - 2 x 1.3 x 0 cm. Based on these measurements, there is no evidence the wound was open or had drainage on that date. On 9/11/25 at 9:38 AM, Consultant-H was advised of the above concerns and reported she understood the concern. On 9/11/25 at 1:52 PM, Surveyor spoke with Medical Doctor (MD)-L and asked if he can explain the documentation of R50's wound on 8/27/25. MD-L stated, It's just like it sounds, there is a DTI component to it, within, surrounded by an open wound. Normally for a DTI, I would order skin prep or betadine, but it was open around the edges, so I ordered the honey to promote healing. If it gets entered as DTI, the system shuts down and will not allow me to type in the characteristics because a DTI is not open, but hers was open with the DTI component within the wound. R50 readmitted to the facility on [DATE].Facility progress notes entered by Licensed Practical Nurse (LPN)-J document:9/12/25 at 3:41 PM, Skin assessment completed, buttocks has o/a (open area) stage 1 on buttocks, zinc applied, her left heel is scabbed. No drainage noted.9/13/25 at 9:18 PM, her bilateral buttock and coccyx area is excoriated, areas measured this shift and noted, no drainage. She denies pain or discomfort, zinc applied TID (three times daily) and as needed after changing.9/14/25 at 6:02 PM, her buttocks is excoriated, zinc applied TID and after changing. Will continue to monitor, bandage placed on left heel for protection. Denies pain or discomfort.R50's Admit/Readmit Screener dated 9/12/25 documents: Site - Left buttock. Type -other (specify) - red, OA, skin shear. Left heel pressure. Comments: Random bruising from hospital pokes, g-tube site draining serosanguinous fluids, red and inflamed. Surveyor was unable to locate any measurements of the excoriated shear areas on her buttocks or the scabbed area on her heel.On 9/15/25 at 9:10 AM, Surveyor asked Registered Nurse (RN)-I to observe R50's skin and treatments. RN-I informed Surveyor R50 doesn't really have any treatments, she only has some excoriated areas on her buttocks and gets zinc applied with cares. Surveyor observation of R50's skin: Left heel skin intact, no redness or skin breakdown. Right heel small, dried pale patchy scabbed area on lateral heel, no redness. Buttocks - several dry excoriated areas on coccyx that do not appear to be open. 2 small open excoriated areas on left buttock. Surveyor observed evidence of white zinc oxide cream covering buttocks, resident had not been washed up yet.On 9/15/25 during the exit meeting, the facility was advised of the above concerns. No additional information was provided at that time.On 9/15/25, while Surveyor was exiting the facility, Consultant-G asked to speak with Surveyor. Consultant-G asked for clarification of why the pressure injury concern would be a harm level citation, because R50 admitted with the pressure injury, it improved and is now healed. Surveyor explained the facility admission assessment only documented pressure there was no description of the pressure injury, measurements or staging. A comprehensive assessment was not completed until she was seen by the wound physician 6 days later, where the pressure injury was then documented as unstageable and open with exudate. Consultant-G reported the facility had additional information that the pressure injury was present in the hospital and did not decline while in the facility. Surveyor advised Consultant-G that I would be happy to review any additional information and provided card with email information.On 9/16/25, Surveyor received additional information via email from Consultant-G.The facility typed review and timeline on resident heel wound:- Heel wound measured in hospital on 8/19/25 shows 2 x 1.3 x 0 cm. Treatment during inpatient stay - foam with borders. Heel assessment notes 8/18/18 indicate necrotic tissue with eschar wound bed.- admission assessment completed by staff nurse - skin assessed, and pressure noted to right heel; as no order was on hospital DC summary, treatment obtained and entered 8/21. (Surveyor concern: Facility reports admission assessment completed; however, the assessment only listed pressure - there was no description, measurements or staging).- Wound was being viewed daily as evidenced by treatment order completion records. (Surveyor noted there was no documentation of what the wound looked like).- [NAME] wound MD (physician) evaluation on 8/27, wound decreased in size from hospital measurements on 8/19, no sign of infection. (Surveyor noted measurements did improve, except for the depth. Hospital measurements documented 0 mm - indicating the wound was not open. [NAME] documented 0.1 cm indicating an open wound).- [NAME] wound MD evaluation on 9/3 documents continued improvement and decrease in size of wound. (Surveyor does not dispute. Pressure injury did improve and was all but healed at the end of survey.)No additional information was provided.

Based on observation, interview and record review the facility did not ensure its medication error rate is not 5 percent or greater. The medication error rate was 11.54%.Findings include:The facility policy titled Medication Administration General Guidelines dated May 2018 documents (in part):Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.7). Tablet crushing/capsule opening: Crushing tablets may require a physician's order, per facility policy. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines:c. Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. For example:1. Long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought.On 9/10/25 at 7:45 AM, Surveyor observed Nurse Extern-K prepare R24's medications. The following medications were prepared and placed in a plastic medication cup:Divalproex capsule 125 mg (milligrams) DR (Delayed Release) 2 capsules, Multivitamin with minerals 1 tablet, Miralax Polyethylene Glycol 17 grams, Finasteride 5 mg 1 tablet, Metoprolol Tartrate 25 mg 1 tablet, Trazodone 50 mg 1/2 tablet, Pregabalin 50 mg 1 capsule.Nurse Extern-K stated aloud, I don't have this med (medication) so I can't give it. Surveyor asked which medication she was referring to. Nurse Extern-K stated, Apixaban 5 mg. I'll have to let pharmacy know. Surveyor verified the number of tablets. Nurse Extern-K removed the Divalproex and Pregabalin capsules, placed them in a separate medication cup, then crushed the remaining tablets and added them to applesauce. Nurse Extern-K opened the Pregabalin capsule and Divalproex Delayed Release capsules and emptied the contents of the capsules into the applesauce containing the crushed medications. The medications were administered to R24 followed by water. On 9/10/25 at 9:20 AM Surveyor reconciled R24's medications. R24's Medication Administration Record (MAR) documented an order for Apixaban Oral Tablet 5 mg give 1 tablet by mouth two times a day related to mixed hyperlipidemia. Times: Morning and HS (hour of sleep) 7 PM. Surveyor noted Nurse Extern-K signed/entered 5 (hold/see progress notes) for the AM dose on 9/9/25 and today (9/10/25).After reconciling R24's medications, Surveyor asked Nurse Extern-K if she gave R24's Apixaban this morning. Nurse Extern-K stated, No, it wasn't available, I still have to call pharmacy to let them know we don't have it. Surveyor advised the MAR documents she entered 5 for the 9/9/25 AM dose of Apixaban as well. Nurse Extern-K stated, Yes, I didn't have it yesterday either. Surveyor advised Nurse Extern-K that PM shift documents the medication signed out as administered the past 2 days and asked if they have a separate card for Apixaban. Nurse Extern-K stated, Yes, there are cards for AM and PM shift.Surveyor asked Nurse Extern-K if the facility has a medication contingency supply, Nurse Extern-K replied Yes. Surveyor asked if Apixaban is available in contingency. Nurse Extern-K replied, Sometimes it is, sometimes it isn't. Surveyor asked if she checked contingency to see if Apixaban is available to be given this morning. Nurse Extern-K stated, No, I was just going to call pharmacy.On 9/10/25 at 9:25 AM, while Surveyor was still on the unit, Nurse Extern-K informed Surveyor that Apixaban is available in contingency, and asked Do you want me to give it? Surveyor advised Nurse Extern-K to do what she would normally do; as Surveyor was not telling her what to do. Surveyor reviewed the list of medications available in the Omnicell contingency supply. Surveyor verified Apixaban 2.5 mg tablet is available in the facility contingency.On 9/10/25 at 11:34 AM, Surveyor verified R24's MAR still documented Apixaban entered as 5 indicating the medication was not given. There was no documentation in progress notes regarding holding of the medication or Physician notification.On 9/11/25 at 8:57 AM, Surveyor verified R24's MAR still documented Apixaban entered as 5 indicating the AM dose was not given on 9/10/25. There was no documentation in progress notes regarding holding of the medication or Physician notification.On 9/10/25 a 8:00AM Surveyor observed Licensed Practical Nurse (LPN)-J prepare R47's medications. The following medications were prepared and placed in plastic medication cups:Ferrous Sulfate EC (Enteric Coated) 325 mg 1 tablet, Folic Acid 1 mg 1 tablet, Lactulose 10g (grams)/15 ml (milliliters) 15 ml, Magnesium Oxide 400 mg 1 tablet, Multivitamin with minerals 1 tablet, Pantoprazole 40 mg 1 tablet, Vitamin B1 100 mg 2 tablets, Vitamin D3 50 mcg (micrograms) 1 tablet.Surveyor verified the number of tablets. LPN-J then crushed all the tablets together, mixed them with vanilla pudding and the resident swallowed the medications followed by water.Surveyor reconciled R47s medications. R47's MAR documented an order for Ferrous Sulfate Oral Tablet Delayed Release 325 MG Give 1 tablet by mouth in the morning for supplement with breakfast. On 9/10/25 at 1:01 PM, Director of Nursing (DON)-B was advised of concerns that Delayed Release medication was opened/administered and Enteric Coated medication was crushed/administered. In addition, Apixaban was not administered, even though the medication was available in contingency. No additional information was provided.

Based on interviews and record review, the facility did not complete neurological checks in accordance with facility protocol and standards of practice for 2 (R2 and R13) of 4 residents reviewed for unwitnessed falls.*R2 sustained unwitnessed falls on 1/31/25, 2/2/25, 2/3/25, 5/16/25 and 7/1/25. Facility staff did not document neurological checks as completed per the facility protocol and standards of practice.*R13 sustained unwitnessed falls on 9/2/25 and 9/7/25. Facility staff did not document that neurological checks were completed per the facility protocol and standards of practice.Findings include:On 9/15/25 at 8:59 AM, Consultant-G informed Surveyor that the facility does not have a neurological check policy.The American Association of Post-Acute Care Nursing document dated August of 2021 and titled, Post Fall Assessments documents, in part: . An assessment of neurological status, often called a neuro check, should be done when a resident hits his or her head or if it is unknown if they hit their head (unwitnessed fall). A subdural hematoma may not show symptoms until several days after the fall.The undated facility document titled, Neurological Flow Sheet documents, in part: Vital signs and Neuro Checks: At the time of event. [Every] 30 [minutes] x 2. [Every] 1-hour x 4. [Every] shift x 3. Progress along this time schedule only if signs are stable.1.) R2 was admitted to the facility on [DATE] with diagnoses that include Dementia with other behavioral disturbance, Generalized anxiety disorder, and Depression.R2's Significant change Minimum Data Set (MDS) assessment dated [DATE] documents, R2 is severely cognitively impaired. R2 uses a wheelchair for mobility. R2 is dependent for toileting. R2 is dependent for bed mobility and transfers. R2 had recent surgery requiring care.R2's Fall Risk Evaluation dated 1/17/25 documents a score of 13, indicating R2 is at high risk for falls.R2's progress note dated 1/31/2025 at 3:37 AM, documents, in part: [Certified Nursing Assistant (CNA)] notified writer that [R2] was on the floor. writer entered the room, and [R2] was laying alongside [R2's] bed on [R2's] stomach. vitals were taken and were [within normal limits]. Assessment was complete, [R2] complained of all over pain, no new bruises noted. [POA] notified. [R2] was sent out via stretcher with. ambulance.Surveyor reviewed the facility fall investigation for R2's fall on 1/31/25. Surveyor noted R2's fall was unwitnessed. Surveyor reviewed R2's paper documentation and electronic medical record for documentation of completed neurological (neuro) checks after R2's fall. Surveyor did not locate completed neuro checks.On 9/11/25 at 9:12 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-R, who was the nurse who first assessed R2 and documented the fall on 1/31/25. Surveyor asked if neurological checks were completed. LPN-R stated not sure. R2's progress note dated 2/2/2025 at 11:11 AM, documents in part: Writer/nurse was notified that [R2] had a unwitnessed fall at [755 AM], nurse/writer went into resident room right away and observed [R2] lying face down on [R2] bedroom floor with [R2] head under [R2] bed with the right leg bent. Writer/nurse called 911 at [8:01 AM] to send [R2] to [Hospital] for further observation. While [R2] was being treated at hospital, nurse/writer spoke with the doctor caring for [R2] and they notified nurse that [R2] sustained no injuries and . will be returning back to facility today with no new orders.Surveyor reviewed the facility fall investigation for R2's fall on 2/2/25. Surveyor noted R2's fall was unwitnessed. Surveyor reviewed R2's paper documentation and electronic medical record for documentation of completed neuro checks after R2's fall. Surveyor did not locate completed neuro checks.On 9/11/25 at 9:28 AM, Surveyor attempted to reach the nurse who cared for and documented R2's fall on 2/2/25 over the telephone. The nurse did not answer Surveyors attempts for interview.R2's progress note dated 2/3/25 at 11:26 AM documents, in part: [R2] was found down with [R2's] legs on the floor, chest and head against the bed . EMS (emergency medical services) called. [R2] to hospital at [7:25 AM] for evaluation. POA. Manager notified. [Nurse Practitioner] notified. [R2] returned at [11:15 AM] via EMS. Vitals assessed upon return. [R2] resting comfortably in bed.Surveyor reviewed the facility fall investigation for R2's fall on 2/3/25. Surveyor noted R2's fall was unwitnessed. Surveyor reviewed R2's paper documentation and electronic medical record for documentation of completed neuro checks after R2's fall. Surveyor did not locate completed neuro checksSurveyor attempted to reach the nurse who assessed and documented R2's fall but was unable to interview the nurse.R2's progress note dated 5/16/25 at 9:06 PM documents, in part: [R2] found on floor of dining room. [R2] alert and talking to staff. Able to tell staff that [R2] was reaching for something and got caught. Mentation is at baseline. [R2] does report hitting [R2's] head when [R2] fell. [R2] complaining of pain in [R2's] head. [R2] does have a lump developing in the back of [R2's] head. Called an ambulance and sent [R2] to [hospital] for further evaluation. Notified family and all other pertinent parties per protocol.Surveyor attempted to reach the nurse who assessed and documented R2's fall on 5/16/25 but was unable to interview the nurse.R2's Hospital After Visit Summary dated 5/16/25 documents, in part: . Reason for visit-Ground level fall. Diagnoses-Fall from wheelchair. Closed head injury. [R2] presents to the emergency department for evaluation after fall from wheelchair. [R2] does have a small posterior scalp. [R2] remained stable and will plan for discharge back to facility.Surveyor reviewed the facility fall investigation for R2's fall on 5/16/25. Surveyor noted R2's fall was unwitnessed and R2 was diagnosed with a closed head injury. Surveyor reviewed R2's paper documentation and electronic medical record for documentation of completed neuro checks after R2's fall. Surveyor did not locate completed neuro checks.Surveyor was provided a fall investigation for a fall that R2 had on 7/1/25. Surveyor reviewed R2's progress notes and noted facility staff caring for R2 on 7/1/25 did not document a progress note about the fall.R2's facility fall investigation dated 7/1/25 documents, in part: Time occurred 3:10 PM. Alerted by staff, found resident sitting on floor in bathroom (nearest nursing station). Resident sitting on floor in front of toilet and holding self-upright. [R2] alerted staff by calling out for help. Denies head bump and/or injury. Resident description: Unable to articulate events.Surveyor noted R2's fall was unwitnessed. Surveyor reviewed R2's paper documentation and electronic medical record for documentation of completed neuro checks after R2's fall. Surveyor did not locate completed neuro checksOn 9/10/25 at 10:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-J. Surveyor asked when neuro checks should be completed. LPN-J stated that they are completed after every fall where a resident hits their head or if the fall is unwitnessed. LPN-J stated that LPN-J typically completes them after every fall.On 9/11/25 at 7:02 AM, Surveyor interviewed Registered Nurse (RN)-M. Surveyor asked when neuro checks are completed. RN-M stated that RN-M follows the policy and does them for an unwitnessed fall and a fall that the resident hit their head.On 9/9/25 at 2:37 PM, Director of Nursing (DON)-B informed Surveyor that neuro checks are completed after an unwitnessed fall and after a fall with head injury. DON-B stated that the neuro checks are completed on a paper form. Once all neuro checks are completed, they are scanned into the electronic medical record.On 9/11/25 at 9:28 AM, Surveyor interviewed DON-B. Surveyor reviewed R2's falls. Surveyor asked if neuro check should have been done for R2 after the falls on 1/31, 2/2, 2/3, 5/16 and 7/1/25. DON-B indicated yes. Surveyor shared the concern that the facility did not provide documentation of completed neuro checks for the 5 falls. DON-B indicated that DON-B understood.On 9/11/25 at 9:58 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern that R2 sustained multiple unwitnessed falls and neuro checks were not completed per facility protocol. NHA-A stated ok.2.) R13 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease with late onset, Dementia with agitation, Depression, Muscle weakness, and Unsteadiness on feet.R13's admission Minimum Data Set (MDS) assessment dated [DATE] documents: R13 is severely cognitively impaired. R13 has a history of falls. R13 has had falls since admission, one fall with no injury and one fall with major injury.R13's Fall Care Area Assessment (CAA) dated 7/22/25 documents, in part: . [R13] has a history of falls prior to admission and has had three falls since admission. [R13] is at risk for fall related injury.R13's Fall risk evaluation dated 7/15/25 documents a score of 13, indicating R13 is at high risk for falls.R13's progress note dated 9/2/25 at 12:32 PM documents: [R13] found on the floor sitting in front of a chair with [R13's] feet in front of [R13] directly next to [R13's] Broda chair. Vitals stable. No new injuries. Safely transferred [R13] into Broda chair. Neuro checks negative. Denies any pain. Alert and baseline behavior noted. Presently up eating lunch with [POA-Q].Surveyor noted R13's progress note documents neuro checks negative. Surveyor asked DON-B for R13's fall investigation and neuro check documentation for R13's fall on 9/2/25. Surveyor was provided documentation of a fall investigation for this fall.Surveyor reviewed the facility fall investigation for R13's fall on 9/2/25. Surveyor noted R13's fall was unwitnessed. Surveyor reviewed R13's paper documentation and electronic medical record for documentation of completed neuro checks after R13's fall. Surveyor did not locate completed neuro checks.On 9/10/25 at 11:24 AM, Surveyor attempted to reach by telephone, the nurse who documented R13's fall on 9/2/25. The nurse did not answer Surveyor's phone call.R13's progress note dated 9/7/25 at 3:42 PM documents: [R13] had a fall, writer was called after taking a break for a couple minutes that [R13] was on the floor screaming. Writer came and seen that [R13] was on the floor with blood coming from [R13's] head. Writer then called hospice and made them aware of the situation and writer was told to send [R13] out. R13's Hospital Emergency Department Provider Note dated 9/7/25 documents, in part: . [R13] presents to the emergency department with a head injury. The patient had an unwitnessed fall resulting in a bleeding hematoma on the left forehead. There are multiple abrasions oozing with the hematoma, but there is no lacerations that need suture repair. The wound was cleaned, and I used 2 Steri-strips to tack avulsions skin back in place. [POA-Q] . [stated] that [POA-Q] would not like any imaging performed. [POA-Q] declined any imaging for the patient. Surveyor noted R13's fall was unwitnessed and in R13's emergency department documentation, R13 had a head injury. Surveyor asked DON-B for the fall investigation and neuro checks for R13's fall on 9/7/25. Surveyor was not given a fall investigation or neuro check documentation regarding R13's fall on 9/7/25.On 9/10/25 at 11:09 AM, Surveyor interviewed Nurse extern (NE)-K, who was the nurse who assessed and documented R13's fall on 9/7/25. NE-K indicated that R13's head was bleeding quite a bit so after alerting all the necessary people, R13 was sent to the hospital. NE-K stated that R13 returned to the facility the same day around 7 PM. Surveyor asked when neuro checks should be completed. NE-K stated they should be completed with unwitnessed falls. Surveyor asked if they were completed after R13's fall on 9/7. NE-K could not remember.On 9/10/25 at 10:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-J. Surveyor asked when neuro checks should be completed. LPN-J stated that they are completed after every fall where a resident hits their head or if the fall is unwitnessed. LPN-J stated that LPN-J typically completes them after every fall.On 9/11/25 at 7:02 AM, Surveyor interviewed Registered Nurse (RN)-M. Surveyor asked when neuro checks are completed. RN-M stated that RN-M follows the policy and does them for an unwitnessed fall and a fall that the resident hit their head.On 9/9/25 at 2:37 PM, Director of Nursing (DON)-B informed Surveyor that neuro checks are completed after an unwitnessed fall and after a fall with head injury. DON-B stated that the neuro checks are completed on a paper form. Once all neuro checks are completed, they are scanned into the electronic medical record.On 9/11/2025 9:53 AM Surveyor interviewed DON-B. Surveyor shared the concern that neuro checks were not completed when R13 sustained an unwitnessed fall on 9/2/25 and 9/7/25. DON-B stated that's fair. DON-B then stated that R13 was sent to the hospital after the fall on 9/7 and DON-B believed that is why there is not documentation of neuro checks being completed. DON-B stated that DON-B would look into that and get back to Surveyor.Surveyor reviewed R13's electronic medical record and noted R13 returned to the facility the same day on 9/7/25.On 9/11/25 at 9:58 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern that R13 sustained 2 unwitnessed falls and neuro checks were not completed per facility protocol. NHA-A stated ok.No additional information was provided.

Based on observation and staff interview the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (R2 and R13) of 15 residents reviewed R2 and R13 did not have comprehensive behavior care plans based on their comprehensive assessments for behavior management including targeted behaviors and non-pharmalogical approaches for behavior management. Findings include: 1.) R2 was admitted to the facility on [DATE] with diagnoses that included Anxiety and Dementia with Behavioral Disturbance. R2's quarterly Minimum Data Set (MDS) dated [DATE] documented R2 exhibited rejection of care 1-3 days over the last week of the reference period. On 9/10/25, R2's current physicians orders were reviewed and documented: Seroquel 25 milligrams (mg) twice a day with a start date of 2/6/25 for dementia with behavioral disturbance. Seroquel is an anti-psychotic medication. On 9/10/25 R2's care plan was reviewed and included monitoring for side effects of psychotropic medication but does not include any non-pharmalogical approaches for R2's behaviors of pacing and, violence and aggression toward staff and others. In addition, R2's care plan does not address the rejection of care documented on her 7/21/25 Quarterly MDS. On 9/10/25 at 1:30 PM Director of Nurses (DON)-B was interviewed and indicated R2's care plan should include non-pharmalogical interventions and all the behaviors she is exhibiting should be addressed. On 9/10/25, the above findings were shared with Nursing Home Administrator (NHA)-A and Director of Nurses-B. Additional information was requested if available as to why R2 did not have her pharmacy recommendations addressed. None was provided. 2.) R13 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease with late onset, Dementia with agitation, and Depression. R13's admission Minimum Data Set (MDS) assessment dated [DATE] documents R13 is severely cognitively impaired. R13 displays verbal behaviors directed towards others 4-6 days a week. R13 takes an antipsychotic medication. R13's Behavior Care Area Assessment (CAA) dated 7/22/25 documents, in part: . [R13] triggered behavior CAA for having episodes of yelling out/screaming. [R13] is in a new environment which can lead to increased behaviors and confusion. [R13] has a diagnosis of dementia and Alzheimer's which can lead to increased behaviors. [Plan of Care] in place for [R13] to have an improvement in behaviors. R13's Psychotropic drug use CAA dated 7/22/25 documents: CAA triggered for psychotropic drug due to [R13] receiving physician ordered anti-depressant and anti-psychotic medication to manage diagnosis of depression and antipsychotic . Resident is at risk for adverse reactions to these medications including falls . MD is updated with medication refusals. Resident has had three falls since admission. No referrals at this time. Will proceed to care plan with goal to have no drug related side effects. R13's MD order with a start date of 7/15/25 documents: Seroquel (an antipsychotic medication) 25 mg 3 times a day. Surveyor reviewed R13's Comprehensive Care plan and noted R13 does not have an active care plan for R13's behaviors and does not have an active care plan for psychotropic drug use despite R13's CAAs documenting that R13 has plan of care. On 9/15/25 at 7:36 AM, Surveyor interviewed Registered Nurse (RN)-U Surveyor asked if a resident who is on an antipsychotic medication should have a care plan. RN-U stated yes. They would have an antipsychotic care plan. The care plan would include things that help specific resident's behaviors, and it would have side effect monitoring. On 9/15/25 at 8:37 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if a resident on an antipsychotic medication should have a care plan. Surveyor informed DON-B that R13 has been on Seroquel from the start of R13's admission and does not have a psychotropic and/or behavior care plan. DON-B stated that the MDS nurse is typically the one who puts the care plan in. DON-B stated that DON-B would look into that. On 9/15/25 at 2:56 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concern that R13 was taking an antipsychotic medication since admission and R13 does not have a psychotropic drug use care plan in place to address non-pharmalogical interventions and any behaviors that R13 is exhibiting. No additional information was provided.

Based on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action was taken to address them, for 3 (R1, R2, R43) of 5 residents reviewed. *R1 had pharmacist reviews dated 7/3/25, 8/7/25, and 9/3/25 with recommendations for a tardive dyskinesia assessment to be completed as R1 is on antipsychotic medication. The pharmacy recommendations were not followed up on. *R2's pharmacy reviews for 6/25, 7/25, 8/25, and 9/25 indicated that a screening for tardive dyskinesia assessment was needed to be completed due to Seroquel administration. The pharmacy recommendations were not followed up on. *The Pharmacist monthly review for R43 recommended the facility conduct an AIMS Assessment. The facility did not act upon this recommendation although R43 continued to take Antipsychotic medication. On 8/7/25, the Pharmacy Review again questioned why the AIMS assessment had not been completed for R43. Findings include: The facility's policy titled Consultant Pharmacist Reports, dated 05/2018, documents the following: Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. If there is potential for serious harm and the attending physician or prescriber does not concur, or refuses to document an explanation for disagreeing, the director of nursing and the consultant pharmacist will contact the medical director. The director of nursing or designated licensed nurse address and document recommendations that do not require a physician intervention, for example monitor blood pressure. 1.) R1 was admitted to the facility on [DATE], with diagnoses including bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression), dementia (a decline in cognitive abilities such as memory, thinking, reasoning, and judgment), and paraplegia (a condition characterized by the loss of movement and sensation in both legs). On 9/9/25, Surveyor reviewed R1's Pharmacist's Medication Regimen Reviews dated 7/3/25, 8/7/25, and 9/3/25, which documents recommendations for tardive dyskinesia AIMS (Abnormal Involuntary Movement Scale) assessments to be completed for R1. R1's Electronic Medical Record (EMR) including current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR), documents that R1 is prescribed Aripiprazole 15 mg by mouth in the evening for bipolar disorder and Lamotrigine 200 mg by mouth one time a day for bipolar disorder. R1's EMR documents an AIMS completed on 10/5/24 and 4/10/24. Surveyor notes R1's EMR documents monthly pharmacy reviews dated 7/3/25, 8/7/25, and 9/3/25, with recommendations to complete an AIMS. On 9/9/25, Surveyor requested all AIMS assessments for R1, and documentation of follow up from R1's Pharmacist's Medication Regimen Reviews dated 7/3/25, 8/7/25, and 9/3/25, from the facility. On 9/10/25, at 10:41 AM, Surveyor interviewed Director of Nursing (DON)-B who indicates the facility meets with the pharmacist monthly to review monthly pharmacy recommendations. Surveyor asked DON-B about R1's pharmacy recommendations dated 7/3/25, 8/7/25, and 9/3/25, which recommend the facility complete an AIMS for R1. DON-B stated R1 did not have an AIMS completed as recommended by the pharmacist on 7/3/25, 8/7/25, and 9/3/25. DON-B then stated we need to improve our Pharmacist Medication Regimen Review process and takes full responsibility for not following up on recommendations from 7/3/25, 8/7/25, and 9/3/25. DON-B stated it's an important process and she will be making changes. Surveyor notified DON-B of concerns with R1 not having an AIMS completed as recommended by the pharmacist on 7/3/25, 8/7/25, and 9/3/25, and per facility policy. DON-B acknowledged these concerns. No additional information was provided. 2.) R2 was admitted to the facility on [DATE] with diagnoses that included Anxiety and Dementia with Behavioral Disturbance. On 9/10/25, R2's current physicians orders were reviewed and read: Seroquel 25 milligrams (mg) twice a day with a start date of 2/6/25 for dementia with behavioral disturbance. Seroquel is an anti-psychotic medication. On 9/10/25 R2's pharmacy reviews were reviewed and documented under recommendations for 6/5/25, 7/3/25, 8/7/25, and 9/4/25 was for the facility to complete an Abnormal Involuntary Movement Scale (AIMS) for R2. On 9/20/25 R2's medical record was reviewed, and no AIMS assessment was found. On 9/10/25 at 1:30 PM Director of Nurses (DON)-B was interviewed and indicated that R2 did not have her pharmacy recommendations for AIMS completed and it should have been. The above findings were shared with Nursing Home Administrator (NHA)-A and Director of Nurses-B on 9/10/25 .Additional information was requested if available as to why R2 did not have her pharmacy recommendations addressed. None was provided. 3.) R43 was admitted to the facility on [DATE] with diagnosis that included dementia and major depressive disorder. R43's quarterly MDS ( Minimum Data Set), dated 8/21/25, documents that R43 receives antipsychotic medications on a routine basis. The surveyor conducted a review of R43's medications and noted a physician order for Quetiapine Fumarate ( Seroquel) tablet 25 mg, give 0.5 tablet by mouth at bedtime related to Dementia with mood disturbance. On 7/3/25, the consulting pharmacist made a recommendation that R43 needed to have a AIMS ( Abnormal Involuntary Movement Scale) completed. The consulting pharmacist again recommended the AIMS be completed on 8/7/25. R42's monthly pharmacy review recommended the facility conduct a AIMS Assessment. The facility did not act upon this recommendation although R43 continued to take an antipsychotic medication. On 8/7/25, the pharmacy review again questioned why the AIMS assessment had not been completed for R43. Surveyor conducted further review of R43's medical record and noted that the facility had only completed an AIMS assessment on 8/22/24. No further assessments had been completed, per policy, until 8/7/25 after the second recommendation from the pharmacist. On 9/11/25 at 1:10 PM, Surveyor interviewed DON (Director of Nursing)- B regarding R43 not having an AIMS assessment completed per policy. DON- B stated that an assessment was completed as a result of the pharmacist recommendation on 8/7/25. No additional information was provided as to why R43 did not have an AIMS assessment per the pharmacist recommendations on 7/3/25 and not until 8/7/25.

Based on interview and record review, the facility did not ensure that 2 (R8 and R30) of 2 residents with allegations of abuse was reported to the State Survey Agency within the required reporting timeframe. *On 7/3/25, R8's Activated Power of Attorney (APOA) notified Director of Nursing (DON)-B that R8's wallet was missing. The facility started an investigated on 7/3/25 and submitted an initial report to the State Agency on 7/3/25, at 3:57 PM. The facility did not submit a 5-day report to the State Agency as required. *R30 informed Surveyor that a facility staff member, Certified Nursing Assistant (CNA)-F, yelled at R30 and made R30 scared. R30 had informed Certified Nursing Assistant (CNA)-E of the interaction between R30 and CNA-F. R30 stated that CNA-E informed R30 that CNA-E would file a complaint. CNA-E did not file a complaint and did not inform Assistant Director of Nursing (ADON)-D, Director of Nursing (DON)-B or Nursing Home Administrator (NHA)-A of R30's concern. On 9/8/25, Surveyor informed NHA-A that R30 reported to Surveyor that a facility staff member yelled at R30 and made R30 scared. NHA-A did not report this to the State Agency as an allegation of potential abuse. Findings include: The facility's policy titled “Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program”, dated 8/28/17, last reviewed 11/8/23, documents: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by a resident, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Abuse Policy Requirements: Immediately upon receiving a report on alleged abuse, the Executive Director, and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable residents are of utmost priority. Safety, security and support of the resident, their roommate, if applicable and other residents with and potential to be affected will be provided. Reporting and Response: It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against the resident in the facility. External Reporting: Each covered resident shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any resident who is a resident of or is receiving care from, the facility, and each covered resident shall report immediately, but not more than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Initial reporting of allegations: If an incident or allegation is considered reportable the Executive Director or designee will make an initial (Immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five (5) working days. When making a report, Misconduct Incident Reporting (MIR) system will be used. Report the results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with State law, including immediate or 24 hour reporting to the State Survey Agency, law enforcement and the follow up report to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff will fully cooperate with the local law enforcement designee. 1.) R8 is a [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses that include dementia, anxiety, osteoporosis, macular degeneration, glaucoma, history of falls, weakness, difficulty walking, and Peripheral Vascular Disease (PVD). R8's Significant Change Minimum Data Set (MDS) completed 7/8/25 documents that R8 has a history of one fall with a fracture in the last month. R8 requires substantial/maximal assistance with showering, chair to bed transfers, and rolling left to right. R8 is dependent for toileting hygiene, and shower transfers. R8 was documented as having a Brief Interview for Mental Status (BIMS) score of 3, indicating that R8 is severe cognitively impaired. On 9/9/25, Surveyor reviewed the facility self-report for allegations of misappropriation for R8, which documents the following: Initial report submitted to the State Agency on 7/3/25, at 3:57 PM. On 7/3/25, R8's APOA reported to DON-B, R8's wallet was missing out of R8's purse. Social Worker (SW)-C immediately performed the facility investigation on 7/3/25. SW-C interviewed R8 who agreed to have SW-C search R8's room and laundry. SW-C was unable to locate R8's wallet after searching R8's room and laundry. Facility staff contacted local law enforcement on 7/3/25. Self-report Summary was signed and dated 7/8/25, by Nursing Home Administrator (NHA)-A. SW-C performed interviews and statements with R8, R8's APOA, 22 residents, and 5 staff members. Surveyor noted there is was 5-day report submitted to the State Agency as required. On 9/10/25, at 1:19 PM, Surveyor interviewed SW-C who indicated that she was notified on 7/3/25, by DON-B of allegations of misappropriation with R8's missing wallet. SW-C stated she started an investigation immediately on 7/3/25. SW-C states she contacted local law enforcement, and a case number was provided. SW-C states NHA-A submits self-reports to the State Agency. On 9/11/25, at 8:41 AM, Surveyor interviewed NHA-A who indicated he is responsible for submitting facility self-reports to the State Agency. NHA-A states he was notified of allegations of misappropriation with R8's wallet missing on 7/3/25. NHA-A states SW-C started an investigation immediately on 7/3/25. NHA-A states he submitted the initial self-report of the allegations of misappropriation of R8's wallet going missing on 7/3/25. Surveyor asked NHA-A for documentation of the 5-day self-report being submitted to the State Agency. NHA-A stated he did not submit the 5-day self-report as required. Surveyor asked why the 5-day self-report wasn't submitted to the State Agency. NHA-A replied he was submitting facility self-reports by email to the State Agency for a while but had recently switched email accounts and is now unable to locate an email confirming the 5-day report was submitted to the State Agency for the allegations of misappropriation of R8's missing wallet. NHA-A then stated his emails delete after 30 days. Surveyor notified NHA-A of concerns with the 5-day self-report not being submitted to the State Agency as required and requested additional information if available. NHA-A acknowledged these concerns. No additional information was provided. 2.) R30 was admitted to the facility on [DATE]. R30's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R30 is cognitively intact. On 9/8/25 at 10:44 AM, R30 informed Surveyor that about 4 to 6 weeks ago, R30 put R30's call light on. R30 stated that R30 has an electric wheelchair and wanted to know if it was plugged in or not so that R30 could use it later in the day. R30 stated that a CNA-F came in to answer the call light and started yelling at R30. R30 indicated that the CNA-F screamed that CNA-F did not have time for questions like that. R30 stated that CNA-F scared R30. R30 stated that R30 and R30's family member informed CNA-E that same day of the interaction. R30 stated that CNA-E told R30 that CNA-E would file a complaint. R30 stated that CNA-F returned to R30's room and confronted R30 and CNA-F asked R30 if R30 had put a complaint in about CNA-F. R30 stated that R30 was scared but told CNA-F that R30 did complain about CNA-F and how CNA-F screamed at R30. R30 stated that no one else from the facility talked to R30 about the interaction. R30 stated that after CNA-F screamed and scared R30, R30 never saw CNA-F again. Surveyor reviewed the facility reported incident files for the last 3 months and a report about this interaction between R30 and CNA-F and none was located. Surveyor reviewed the facility grievance log for the last 3 months and no grievance for this interaction between R30 and CNA-F and none was located. On 9/8/25 at 2:43 PM, Surveyor interviewed CNA-E. Surveyor asked if CNA-E recalled a time that R30 reported to CNA-E an incident of R30 being yelled at and scared of a facility employee. CNA-E stated that over a month ago, R30 and R30's family member informed CNA-E that a different staff member yelled at R30 and that R30 and did not like the way R30 was talked to. CNA-E stated that at the time R30 could not remember the name of the CNA who yelled at R30. Surveyor asked if CNA-E reported the incident to anyone. CNA-E stated No. CNA-E stated that CNA-E told R30 to tell the nurse and told R30 that CNA-E could not do anything if R30 did not know the name of who it was that yelled at R30. Surveyor asked what CNA-E should do if a resident reports a different staff member yelling and making them scared. CNA-E stated that if there was a situation of abuse, CNA-E would take that seriously. CNA-E would first go to the coworker to see what happened and then go the nurse. CNA-E indicated that sometimes staff can be cranky in the morning and can short with other staff and residents. CNA-E stated that R30's interaction was not an abuse situation and CNA-E would have done something if CNA-E believed that it was abusive. On 9/8/25 at 2:56 PM, Surveyor informed Nursing Home Administrator (NHA)-A that R30 reported to Surveyor that about 4 to 6 weeks ago, a CNA yelled at R30 and made R30 scared. R30 reported this to CNA-E who told R30 that CNA-E would file a complaint. CNA-E did not file a complaint or grievance. R30 told Surveyor that the CNA who yelled at R30 returned to R30's room and confronted R30. R30 stated again that during that interaction R30 was scared. Surveyor asked NHA-A what NHA-A would expect staff to do if they were told by a resident that they were yelled or scared of a different facility staff. NHA-A stated that they should let the nurse, supervisor and NHA-A know and NHA-A would take it from there. NHA-A stated that the facility will go speak to R30 and follow up with CNA-E about the incident. On 9/9/25 at 11:01 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-D. Surveyor asked if ADON-D had been informed weeks ago that R30 reported that a staff member yelled at R30. ADON-D stated that ADON-D had not heard anything about that. Surveyor asked what a staff member should do if a resident reports to a staff that a different staff member yelled at them. ADON-D stated that staff should come to one of us (management). From there, they would submit a grievance and discuss the incident with management team to see if anything further should be done. On 9/9/25 at 1:18 PM, Surveyor interviewed Social Worker (SW)-C. SW-C stated that SW-C spoke to R30 yesterday. SW-C stated that the CNA who yelled at R30 is no longer working for the facility. SW-C stated that SW-C did fill out a grievance for R30 regarding the incident from weeks ago. SW-C stated that NHA-A spoke to CNA-E about the incident. SW-C provided R30's grievance to Surveyor. R30's grievance dated 9/8/25 documents, in part: … Resident expressed concern to Surveyor regarding a verbal interaction she had with a CNA 4-6 weeks ago… Facility spoke with resident and CNA resident reported concerns to at time of incident… CNA Resident had interaction with no longer works at the facility speaking with resident. [R30] has had no further concerns regarding verbal interactions with staff. CNA that received concern educated on grievance process… On 9/9/25 at 1:22 PM, Surveyor spoke to NHA-A. NHA-A stated that facility staff spoke to R30 yesterday. NHA-A stated that everything is good, and this was one isolated incident. NHA-A stated that CNA-E knew who R30 was talking about (CNA-F). NHA-A stated that CNA-F no longer works for the facility. NHA-A stated that the situation should have been brought to the nurse's attention, and a staff should have followed the grievance process. NHA-A indicated that a grievance had now been filed. Surveyor reviewed CNA-F's employee file and noted CNA-F's last day of employment at the facility was 8/5/25. On 9/9/25 at 2:37 PM, Surveyor shared concern with NHA-A that Surveyor was told by R30 that a facility staff member screamed at R30 and scared R30. Surveyor shared this with NHA-A on 9/8/25 at 2:56 PM and this was not reported to the State Agency as an allegation of abuse. NHA-A stated that R30 did not report this to facility staff when they went to go speak to R30 yesterday. Surveyor informed NHA-A that R30 made the allegation of abuse to Surveyor and after Surveyor informed NHA-A, the allegation should have been reported to the State Agency. No additional information was provided.

Based on record review, staff and family interviews, the facility did not inform the resident or the resident's guardian of a psychoactive medication that required informed consent for administration for 1(R43) of 5 sampled residents reviewed for unnecessary medications.R43 received the antipsychotic medication Seroquel and the antidepressant medication Zoloft without receiving consent from R43's guardian.Findings include:R43 was admitted to the facility on [DATE] with diagnosis that included Dementia and Major Depressive Disorder.R43 has an activated Power of Attorney/Guardian.R43's quarterly MDS, dated [DATE], documents that R43 received antipsychotic and antidepressant medications daily during the assessment reference period.A review of the current physician orders for R43 document the following:Quetiapine Fumarate (Seroquel) 25 MG (milligram), give 0.5 tablet by mouth at bedtime. This order was active starting 6/5/25.Sertraline 50 MG, give by mouth in the morning related to Major Depressive Disorder. The order was active starting 5/30/25.A review of R43's medical record showed that signed consent was given by the Guardian on 7/16/25 for the Quetiapine 50-100 mg (anticipated dosage range) and Sertraline 50- 100 mg (anticipated dosage range) and after R43 was already administered the medications. On 9/11/25 at 11:33 AM, Surveyor interviewed DON (Director of Nursing)- B regarding the need for consent prior to the administration of psychoactive medication. DON- B stated that yes, consent is needed from either the resident or their Guardian before the resident is administered the medication. DON- B stated she does not know why the facility did not obtain consent on 5/30/25 for the Sertraline or on 6/5/25 for the Quetiapine for R43 prior to both medications being administered to R43. No additional information was provided as to why the facility did not obtain consent from R43's guardian prior to administering the above psychoactive medications.

Based on observations, interviews and record review, the facility failed to ensure hospice collaboration and communication was established to ensure continuity of care between hospice provider and the facility for 1 (R13) of 2 residents reviewed for hospice services. *R13 started receiving hospice care and treatment on 7/29/25. R13's hospice plan of care initiated on 7/29/25, included Lorazepam (an anti-anxiety medication) and Hydromorphone (a narcotic pain medication) to be ordered and implemented by facility staff. Facility staff did not enter the physician order for Lorazepam until 9/6/25 and Hydromorphone until 9/15/25. R13 sustained falls on 8/2/25, 8/9/25, 8/18/25 and 9/2/25. Facility staff did not inform hospice staff of these falls on the day the falls happened. According to hospice and facility staff, R13 is to have a hospice binder at the nurse's station to aid in communication between the facility and the hospice provider. R13 was observed to not have a hospice binder.Findings include:The facility hospice contract dated 6/1/2028 titled, Hospice-Nursing facility Services Agreement documents, in part: Coordination of care: General: Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. Design of hospice plan of care: Hospice retains primary responsibility for determining each Hospice Patient's appropriate Hospice Plan of Care. Facility shall ensure that Facility's care plan for each Hospice Patient reflects both the most recent Hospice Plan of Care. Modifications to Hospice Plan of Care: Facility will not make any modifications to the Hospice Plan of Care without first consulting with Hospice. Hospice retains the sole authority for determining the appropriate course of hospice care provided. Notification of Change in Condition: Facility shall immediately inform Hospice of any change in the condition of a hospice patient.R13 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease with late onset, Dementia with agitation, Depression, Muscle weakness, and Unsteadiness on feet.R13's admission Minimum Data Set (MDS) assessment dated [DATE] documents R13 is severely cognitively impaired. R13 displays verbal behaviors directed towards others 4-6 days a week. R13 is dependent for toileting and hygiene. R13 has a history of falls. R13 has had falls since admission, one fall with no injury and one fall with major injury.R13's physician order entered on 7/28/29 documents: Hospice [evaluation] and treat.R13 started receiving hospice services on 7/29/25. The admitting diagnosis for hospice services is Alzheimer's disease with late onset.R13's hospice care plan initiated 7/31/25 documents the following pertinent interventions: Assess resident coping strategies and respect resident wishes. Keep the environment quiet and calm. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Work with nursing staff to provide maximum comfort for the resident.HOSPICE MEDICATIONSR13's Hospice plan of care effective on 7/29/25 included the following hospice medication orders, in part:-Hydromorphone (narcotic pain medication) 2 mg every hour as needed for moderate pain or shortness of breath. Take 4 mg every hour as needed for severe pain or shortness of breath.-Lorazepam (antianxiety medication) 1 mg by mouth every hour as needed for moderate anxiety. Take 2 mg by mouth every hour as needed for severe anxiety.Surveyor reviewed R13's physician medication orders and noted Hydromorphone and Lorazepam were not entered as active orders when R13 was started on hospice on 7/29/25. R13's hospice nurse's visit note dated 8/30/25 documents: . [Facility nurse] said they know to give Lorazepam if staff not able to calm [R13] down with distraction or laying [R13] down in bed. [Facility nurse] states [R13] usually calms down when lay [R13] down in bed.Surveyor noted that the hospice nurse and facility nurse talked about using Lorazepam as needed.Surveyor noted that despite hospice ordering Lorazepam on 7/29/25, as of 8/30/25, the facility had still not entered the order into R13's medical record and facility staff are not utilizing the anti-anxiety medication.R13's hospice nurse's visit note dated 9/5/25 documents, in part: . Per facility nurse, no lorazepam required this shift so far, states [R13] has been pretty sleepy.Surveyor noted that the hospice nurse and facility nurse talked about using Lorazepam. Surveyor noted that despite hospice ordering Lorazepam on 7/29/25, as of 9/5/25, the facility had still not entered the order into R13's medical record and facility staff are not utilizing the anti-anxiety medication.R13's physician order dated 9/6/25 documents: Lorazepam 1 mg every 1 hour as needed for Anxiety related to Dementia. May give 1-2 tabs every hour as needed. Surveyor reviewed R13's Medication Administration Record and noted that staff started using Lorazepam on 9/6/25 at 5:37 PM and again at 6:39 PM after the order was entered.R13's hospice nurses visit note dated 9/7/25 documents, in part: .Reminded [RN] of the [as needed] meds for agitation, Lorazepam and how and when to give. Reminded can give every hour if needed. [Nurse] verbalized [nurse] knows this.On 9/11/25 at 1:24 AM, Surveyor interviewed HCM-O. Surveyor reviewed R13's case with HCM-O. Surveyor noted that R13 had multiple falls. Surveyor asked what HCM-O thinks is the cause of R13's falls. HCM-O stated that R13 needs to be closely monitored. HCM-O stated that facility staff have not utilized the list of hospice medications like Lorazepam effectively. On 9/15/25 at 11:15 AM, Surveyor interviewed Director of Nursing (DON)-B about R13's hospice medications. Surveyor asked why Lorazepam was not put in place until 9/6/25 and Hydromorphone was not put into place until today, 9/15/25, when it was ordered by hospice on 7/29/25. DON-B stated that facility staff was concerned that Lorazepam was going to increase R13's fall risk and could be considered a chemical restraint. DON-B stated that facility was working to use other non-pharmacological interventions before implementing the medication and that is why facility staff decided not to put the hospice medication orders in.On 9/15/25 at 11:24, DON-B returned to Surveyor and stated that ordering Lorazepam and Hydromorphone on 7/29/25 was missed and that facility staff should have caught that the medications were not ordered. DON-B stated that DON-B would change it today. R13's physician order with a start date of 9/15/25 documents: Hydromorphone 2 mg by mouth every 1 hour as needed for moderate pain/shortness of breath AND give 4 mg by mouth every 1 hour as needed for severe pain/shortness of breath.Surveyor noted that R13's Hydromorphone order was placed after only Surveyor brought it to the facility's attention.FALLSR13's hospice nurse's note dated 7/29/25 documents, in part: . [R13] has not tried to leave [R13's] unit but has had multiple falls when trying to get up alone. Last fall was 2 days ago.Staff has made changes to patient environment with bed low to the ground, padding/pillows on floor next to bed, moving [R13] to the nurse's station during wake times for more visibility.Surveyor reviewed R13's facility's comprehensive care plan and noted that the interventions listed in this hospice note are not documented in the facility's care plan for R13.R13's progress note dated 8/4/25 documents: Writer walked into [R13's] room and noticed [R13] on the floor, [R13] didn't know how [R13] got down there, [R13] was assessed and placed into Broda chair. Vitals signs [within normal limits], no [complaints of] pain [or] injuries. Denies hitting head, neuro checks in place, [Assistant Director of Nursing], [POA-Q] and [Nurse Practitioner] all notified of fall.On 9/10 25 at 11:52 AM, DON-B informed Surveyor that the above progress note was a late entry for a fall that R13 had on 8/2/25. DON-B provided the fall investigation to Surveyor.Surveyor reviewed R13's facility fall investigation and noted facility staff did not document that R13's hospice was made aware of the fall on 8/2/25.On 9/11/25 at 1:24 PM, Surveyor interviewed Hospice Case Manager (HCM)-O. Surveyor asked if facility staff should contact the hospice team with any falls. HCM-O stated yes. HCM-O confirmed that hospice was not made aware that R13 fell on 8/2/25.R13's progress note dated 8/9/25 at 8:30 PM documents: At about [8PM] writer was informed by one [of] the CNAs that [R13] was on the floor. Upon arrival, [R13] was laying on [R13's] buttock, alert, no bruise, bleeding noted, denied pain. Assessed pain, obtained vital signs and neuro check. Notified case manager [name of hospice company], [provider], [POA-Q] [and] [NHA-A]. [R13] was assisted back to bed, bed on lower level, call light within reach and precaution mat placed on the floor. Continue check on R13.Surveyor noted that the wrong hospice company was notified of R13's fall on 8/9/25.On 9/11/25 at 1:24 PM, Surveyor interviewed HCM-O. HCM-O confirmed that hospice was not made aware that R13 fell on 8/9/25.R13's progress note dated 8/19/25 at 10:03 PM documents, in part: [R13] was sitting up at the nursing station and slid out of [R13's] Broda chair, when writer look up and notice[d] [R13] was sliding out, [R13] was placed into [R13's] Broda chair, no injuries were noted, [Provider], [DON-B] aware of fall, writer left message with. [POA-Q].On 9/10 25 at 11:52 AM, DON-B informed Surveyor that the above progress note was a late entry for a fall that R13 had on 8/18/25. DON-B provided the fall investigation to Surveyor.Surveyor noted facility staff did not document that hospice was made aware of the fall on 8/18/25. On 9/11/25 at 1:24 PM, Surveyor interviewed HCM-O. HCM-O confirmed that hospice was not made aware that R13 fell on 8/18/25.R13's progress note dated 9/2/25 at 12:32 PM documents: [R13] found on the floor sitting in front of a chair with [R13's] feet in front of [R13] directly next to [R13's] Broda chair. Vitals stable. No new injuries. Safely transferred [R13] into Broda chair. Neuro checks negative. Denies any pain. Alert and baseline behavior noted. Presently up eating lunch with [POA-Q].Surveyor noted facility staff did not document that hospice was made aware of the fall on 9/2/25. On 9/11/25 at 1:24 PM, Surveyor interviewed HCM-O. HCM-O confirmed that hospice was not made aware that R13 fell on 9/2/25.On 9/11/25 at 1:24 AM, Surveyor interviewed HCM-O. Surveyor asked how the communication is between the facility and hospice. HCM-O stated that it is good, but that hospice was not notified of all the falls R13 has had at the facility. HCM-O stated that HCM-O only found out about the falls on 8/2, 8/9, 8/18, and 9/2 through POA-Q, who told HCM-O that POA-Q was worried about all of R13's falls. HCM-O stated that HCM-O then had a conversation with DON-B to let DON-B know that staff need to call hospice with every fall.HOSPICE BINDERR13's hospice nurse visit note dated 8/30/25 documents, in part: . No hospice binder to leave note in on 2nd floor or 1st floor nurses' station. Hospice binder at 2nd floor nurses' station however has sticker on side over that states CNAs and Nurses (appears facility has used binder for their paperwork).Surveyor noted hospice nurse could not locate R13's hospice binder on 8/30/25.On 9/11/25 at 9:24 AM, Surveyor interviewed HCM-O. Surveyor asked how facility staff and hospice staff communicate with each other. HCM-O stated that HCM-O will speak to staff whenever HCM-O comes to visit R13. HCM-O stated that the facility also has a hospice binder for R13. HCM-O state that the binder is a way that staff from both teams can communicate back and forth. HCM-O stated that HCM-O received a call on 9/8/25 from a hospice music therapist who asked where the hospice binders are located because the music therapist could not locate it. HCM-O stated that the hospice music therapist did not locate the binder. HCM-O stated that HCM-O had used the binder the previous week but stated that the binder seems to go missing at times.On 9/10/25 at 7:47 AM, Surveyor interviewed Medication Technician (MT)-V. Surveyor asked how communication between facility staff and hospice works. MT-V stated that each resident has a hospice binder at the nurses' station.On 9/10/25 at 7:52 AM, Surveyor observed R13's nurse's station located on the 2nd floor of the facility. Surveyor could not locate R13's hospice binder.On 9/15/25 at 7:47 AM, Surveyor observed R13's nurse's station located on the 2nd floor of the facility. Surveyor could not locate R13's hospice binder.On 9/15/25 at 8:37 AM, Surveyor interviewed DON-B. Surveyor asked how communication with hospice services is. DON-B stated that communication is varied. DON-B stated that every time the hospice nurse visits, the hospice nurse is to fax the visit note from that day to the Assistant Director of Nursing (ADON) who leads communication from the facility's standpoint. DON-B stated that the notes are not always faxed and the ADON or DON-B will have to reach out to hospice to get the notes. The notes are then scanned into the facility's electronic medical record. Surveyor asked if residents are supposed to have a hospice binder at the nurse's station. DON-B stated that DON-B asks that hospice set up a binder for each resident on hospice. Surveyor informed DON-B that Surveyor was unable to locate R13's hospice binder. DON-B stated that DON-B reached out to hospice last Friday about the hospice binder. DON-B indicated that DON-B now thought R13's binder was at the nurse's station on the 2nd floor. DON-B stated that DON-B will have to look into that. Surveyor asked if DON-B finds R13's hospice binder, if Surveyor could have a copy of what is in the binder. DON-B stated yes.DON-B did not return to Surveyor with R13's hospice binder or copies of what is in the binder.On 9/15/25 at 2:56 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concerns that hospice ordered Lorazepam and Hydromorphone on 7/29/25 and facility staff did not enter active MD orders for the Lorazepam until 9/7/25 and Hydromorphone until 9/15/25. R13 had multiple falls that the hospice team was not made aware of. R13's hospice binder with communication between hospice staff and facility staff was not provided to Surveyor and hospice binder was not observed at R13's 2nd floor nurse's station.No additional information was provided.

Based on record review, interview, and facility policy review, the facility failed to accurately transcribe medication orders to ensure correct administration of prednisone (oral steroid) and failed to notify the provider of elevated blood glucose levels for one of three residents (Resident (R) 2) reviewed for blood sugars out of 10 sampled residents. This failure had the potential to result in withdrawal symptoms from not tapering the prednisone and in adverse health effects from not managing elevated blood glucose levels. Findings include: Review of the facility's policy titled, Medication Administration-General Guidelines, revised 12/19, revealed Medications are administered as prescribed . Review of the facility's undated policy titled, Standard Diabetes Mellitus Protocol revealed . 2) blood sugars to be within parameters as determined by the physician orders 3) exhibit no hypo/hyperglycemic episodes . update physician and responsible party as needed . Review of R2's Admission Record located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] following a hospital stay. R2 had diagnoses including diabetes mellitus, spinal stenosis, and sciatica. Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/25/24 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R2 was cognitively intact. Review of R2's Care Plan located in the EMR under the Care Plan tab, documented The resident has acute/chronic pain, initiated on 09/26/24 with an intervention, Administer medication per MD [medical doctor] orders. Review of R2's hospital Discharge Summary, dated 10/03/24 and located in the Documents tab of the EMR, revealed R2 had low back pain, sciatic pain, and spinal stenosis. It included an order to start prednisone 20 milligrams (mg) two tablets for three days, then 1.5 tablets for three days, then one tablet for three days, then 0.5 tablets for three days. During an interview on 05/28/25 at 10:43 AM, R2 stated she went out to the hospital and returned on a prednisone taper. There were days they wouldn't give it to me and days they gave me the incorrect number of tablets. Review of R2's Orders tab of the EMR, revealed orders for prednisone, reflected in the Medication Administration Record (MAR) dated 10/24 as: -20 mg, give two tablets for three days from 10/04/24 to 10/06/24, documented as administered. -20 mg, give two tablets for three days, with a start date and discontinued date of 10/07/24, documented as administered on 10/07/24. -20 mg, give two tablets from 10/10/24 to 10/12/24, documented as administered on 10/10/24 and as refused on 10/11/24 and 10/12/24. -20 mg, give 1.5 tablets from 10/13/24 to 10/15/24, documented as administered on 10/13/24 and as refused on 10/14/24 and 10/15/24. -20 mg, give one tablet from 10/16/24 to 10/18/24, documented as refused. -20 mg, give 0.5 tablets on 10/19/24 and 10/20/24, documented as refused. During an interview on 05/29/25 at 2:45 PM, the Director of Nursing (DON) reported orders for new admissions were put into the EMR based on the hospital discharge summary by an off-site informatics department. The orders went into a queue for two onsite nurses to verify. During an interview on 05/29/25 at 2:50 PM, the DON reported R2's prednisone orders on the MAR did not reflect what was ordered by the hospital. 2. Review of R2's Care Plan located in the EMR under the Care Plan tab, documented The resident has diabetes mellitus, initiated on 09/18/24 with an intervention, blood sugar monitoring as ordered by doctor. Review of R2's Orders tab of the EMR revealed an order, dated 10/03/24, for blood glucose tests four times daily, without parameters as to when to notify the provider. Lispro insulin was ordered from 10/03/24 to 10/07/24 in the afternoon and from 10/03/24 to 10/06/24 in the evening with no parameters provided as to when to notify the provider. Starting on 10/07/24 in the evening the sliding scale lispro insulin orders were clarified and also updated to include if blood sugar > 400 call provider. Review of R2's October 2024 MAR located under the Orders tab of the EMR, revealed two recorded blood glucose levels over 400. There were readings of 444 on 10/06/24 at 7:00 PM and 418 on 10/07/24 at 3:00 PM. Review of the Prog Notes tab of the EMR revealed a Nurse's Note, dated 10/06/24 at 7:38 PM: Resident is being monitored for hyperglycemia [high blood glucose]. No issues noted this shift. Resident has denied any s/s [signs/symptoms] related to hyperglycemia . There was no documentation of elevated blood glucose levels reported to the provider on 10/06/24 or 10/07/24. During an interview on 05/28/25 at 10:43 AM, R2 stated there were two nights she went to bed with a blood glucose over 400 for which staff did nothing. R2 received no additional insulin or a recheck of her blood glucose. During an interview on 05/28/25 at 11:32 AM, Registered Nurse (RN) 2 stated nurses were to notify the physician of elevated blood glucose levels based on the parameters in their orders. If there were no parameters, RN2 called the provider to obtain them. During an interview on 05/29/25 at 10:45 AM, Medication Administration Assistant (CMA) 1, who recorded the blood glucose level of 444 on 10/06/24, stated she could not recall that specific reading, but she would have reported a reading that high to the nurse immediately. During an interview on 05/29/25 at 11:40 AM, the Assistant Director of Nursing (ADON) reported that the facility reviewed new admissions with the nurse practitioner who determined orders specific to the resident on when to notify a provider of a blood glucose reading. During an interview on 05/29/25 at 3:00 PM, RN1 stated she went off the parameters in the order as to when to notify a provider of an elevated blood glucose reading. RN1 stated if there were no parameters, she notified the provider if a blood glucose reading was greater than 400. RN1 was unable to recall R2's reading of 418 on 10/07/24 but felt she would have notified the provider and documented the notification to the provider. During an interview on 05/29/25 at 4:05 PM, the DON reported she expected the provider to be notified of blood glucose readings greater than 400, or per the ordered parameters if they were different. The DON stated nurses were expected to document the notification to the provider and the provider's response in the EMR. The DON was unable to find evidence that the provider had been notified of the elevated blood glucose levels on 10/06/24 and 10/07/24.

Based on observation, interview, record review, and facility policy review, the facility failed to obtain wound treatment orders timely when a pressure injury was identified for two of three residents (Resident (R) 4 and R1) reviewed for pressure injury out of 10 sample residents. This had the potential for residents' pressure injuries to decline. Findings include: Review of the facility's policy titled, Pressure Injury Prevention and Managing Skin Integrity, dated 02/08/17, revealed: The care and intervention for any skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary team [IDT] regarding the presence of breakdown and the intervention plan . Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds. Registered Nurse [RN] or designee will: i. conduct weekly skin evaluation, ii. Update the [primary care provider] with any decline in wound appearance, or as necessary, iii. Update the care plan with any new interventions as applicable . 1. Review of R4's Admission Record located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] and had diagnoses including encounter for surgical aftercare following surgery on the digestive system and muscle weakness. Review of R4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/25 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The assessment revealed R4 was at risk for the development of pressure injuries but had none. Review of R4's eINTERACT Change in Condition Evaluation, dated 03/30/25 and located in the Assessments tab of the EMR, revealed R4 had a new mixed stage 1-2 pressure injury to her right gluteal fold. Located during cares. Cleansed with wound cleanser MD [medical doctor] notified through [facility's messaging system]. Orders received. Review of R4's Orders tab of the EMR, revealed no treatment orders for a pressure injury during her stay. No new orders were placed on 03/30/25, and R4 discharged on [DATE] to the hospital without orders for wound care. Review of R4's Care Plan located in the Care Plan tab of the EMR revealed R4 admitted with redness to her groin, initiated 03/18/25 with a goal of maintaining or developing clean and intact skin. The Care Plan did not address the pressure injury until 04/09/25 when it was added to the dietary focus. During an interview on 05/28/25 at 11:32 AM, Registered Nurse (RN) 2 stated if a resident was observed to have a new wound, the nurse gathered data and documented the information on a skin assessment. RN2 stated then the nurse obtained orders from the provider based on the observation and assessment. We have to document in the system what the wound is, make notifications to the provider, ensure we have orders, and get the resident on the weekly wound rounds list. During an interview on 05/28/25 at 11:40 AM, Assistant Director of Nursing (ADON) reviewed R4's documentation and reported she was unable to find any treatment orders for the pressure injury. During an interview on 05/29/25 at 1:40 PM, the Director of Nursing (DON) reported that when a resident developed a new pressure injury, it was expected that nursing would document it in risk management, which the DON checked daily. The DON stated R4's pressure injury was not put into risk management, and the order the nurse received was never documented. During an interview on 05/29/25 at 2:45 PM, the ADON reported she was doing off-site training when R4 was observed with the new pressure injury, so no one reported it to her. ADON stated the nurse who identified the pressure injury put the treatment on the 24-hour board (the system the facility used for residents who need additional monitoring) but did not put an order in the EMR for staff to refer to and sign off when completed. The ADON stated the order received was for mepilex (a wound dressing). 2. Review of R1's Admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes and vascular dementia. Review of R1's quarterly MDS with an ARD of 03/04/25 and located in the EMR under the MDS tab, revealed a BIMS score of six out of 15, indicating severely impaired cognition. R1 had a stage three pressure injury with pressure injury care. Review of R1's Care Plan located in the Care Plan tab of the EMR, revealed The resident has a stage 3 pressure injury to coccyx, initiated on 03/11/25, after Resident admitted with a wound to his coccyx, initiated on 08/26/24 was resolved. Review of R1's Nurse's Note, dated 08/26/24 and located in the Prog Note tab of the EMR, revealed R1 admitted with a surgical incision and coccyx wound with mepilex and wound vac. Review of R1's Nurse's Note, dated 08/28/24 and located in the Prog Note tab of the EMR, revealed R1's wound vac was removed and had been on his surgical wound on his leg and not on his coccyx. Review of R1's Skin Only Evaluation, dated 08/28/24 and located in the Assessments tab of the EMR, revealed R1 had a stage three pressure injury on his coccyx measuring three centimeters (cm) in length by 1.8 cm in width by 1.2 cm deep. Review of R1's Medication Administration Records (MARs) and Treatment Administration Records (TARs), dated 08/24 and 09/24 and located in the Orders tab of the EMR, revealed no treatment order for the stage three coccyx pressure injury until 09/09/24, two weeks after R1 was admitted to the facility. On 09/09/24, the order was for skin prep around the wound and a foam adhesive bordered gauze every other day to the coccyx. On 08/26/24, R1 had an order on admission for moisture barrier cream apply to topically topically [sic] every 24 hours as needed for ***nurse to enter diagnosis*** which was not signed off as administered. Review of an Initial Wound Evaluation & Management Summary report by the facility's wound provider, Physician1, dated 09/18/24, and located in the Documents tab of the EMR, revealed the wound provider identified R1's coccyx wound as a stage three pressure injury measuring 0.7 x 1.2 x 0.2 cm. During an interview on 05/28/25 at 8:47 AM, the ADON reported she was the facility's wound nurse and had been for about five to six months. The ADON stated prior to her being in the role of wound nurse, there had not been a wound nurse or system. The ADON stated had tried to assist with the initial assessment of resident's wounds when they were admitted . The ADON stated if the hospital ordered a wound treatment; the facility typically used that order. ADON stated if the hospital provided no orders, or there were concerns with the orders provided, the facility obtained orders from Physician1 or the resident's provider. The ADON confirmed R9 had no treatment orders for his coccyx wound from 08/26/25 until 09/09/25. During a concurrent observation and interview on 05/28/25 at 11:08 AM, Physician1 assessed R1's coccyx wound, and the ADON administered the treatment. Physician1 reported the coccyx wound had been getting better. During an interview on 05/29/25 at 1:40 PM, the DON reported she expected the floor nurse to do a Skin Only assessment or Admission Evaluation when a resident was admitted . Nursing management reviewed those reports the next business day. The DON stated if a resident was admitted to the facility on a Friday or after hours, the floor nurse was expected to reach out to the provider for a treatment order.

Based on observation, interview, record review, and facility policy review, the facility failed to have medications available to administer as ordered for two of four residents (Resident (R) 9 and R2) reviewed for medication availability out of 10 sample residents. This had the potential to result in adverse health outcomes. Findings include: Review of the facility's policy titled, Medication Administration - General Guidelines, revised 12/19, revealed: If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), .If electronic MAR [Medication Administration Record] is used, documentation of the unadministered dose is done as instructed by the procedures for use of the eMAR [electronic MAR] system . If [XX consecutive doses] of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response. 1. Review of R9's Admission Record located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. R9 had diagnoses including chronic respiratory failure with hypoxia (low oxygen levels). Review of R9's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/25 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Review of R9's Orders tab of the EMR, revealed an order for Breztri aerosphere inhaler two puffs twice daily for respiratory treatment, dated 05/14/25. Review of R9's MAR dated 05/25 and located under the Orders tab of the EMR, revealed the Breztri was documented with the code 9, which referred the reviewer to other/see progress notes for the evening doses on 05/21/25, 05/22/25, and 05/24/25. Fourteen of 28 doses from 05/14/25 to 5/28/25 were coded as 16 which indicated med unavailable - pharmacy contacted. Review of R9's eMar- Medication Administration Notes, located under the Prog Notes tab of the EMR, revealed the Breztri inhaler was on order on 05/21/25, 05/22/25, and 05/24/25. During an observation on 05/28/25 at 8:30 AM, Registered Nurse (RN) 3 administered R9's morning medications. The Breztri inhaler was unavailable, and RN3 documented a Progress Note stating, Pharmacy was notified however no inhaler has been received. During an interview on 05/28/25 at 8:40 AM, RN3 stated, I called pharmacy last week. It's a high-cost medication and so needs approval from management. When asked how management approved medications, RN3 stated the pharmacy faxed over a request, which the management needed to sign and return. During an interview on 05/29/25 at 11:40 AM, the Assistant Director of Nursing (ADON) stated the Director of Nursing (DON) was responsible for authorizing high-cost medications. The ADON stated if she was aware that medications were high cost, she spoke to the nurse practitioner who then spoke to the resident about changing high-cost medications to an alternative medication. ADON reported she was unaware R8's Breztri was unavailable because of the pharmacy needing authorization to send it. During an interview on 05/29/25 at 12:06 PM, Pharmacist1 reported the pharmacy had not sent R8's Breztri inhaler due to waiting on facility authorization due to the cost. The Pharmacist1 stated the pharmacy faxed requests for authorization on 05/14/25 and 05/22/25. During an interview on 05/29/25 at 1:40 PM, the DON reported she communicated with the resident about high-cost medications when the pharmacy sent faxes for authorization. The DON stated she was not notified that R8's Breztri needed authorization. During an interview on 05/29/25 at 2:50 PM, the DON stated she expected if medication was unavailable to administer, staff to check the contingency supply. The DON stated if the medication was not in contingency, staff were expected to call pharmacy and notify nursing management of the reason the medication was not available so they could follow up. 2. Review of R2's Admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. R2 had diagnoses including chronic obstructive pulmonary disease (COPD) and asthma. Review of R2's admission MDS with an ARD of 09/25/24 and located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, indicating intact cognition. Review of R2's Orders tab of the EMR, revealed an order for fluticasone-salmeterol (Advair) inhaler twice daily on 09/18/24 and renewed on 10/03/24. Review of R2's MARs, dated 09/24 and 10/25 and located under the Orders tab of the EMR, revealed the Advair inhaler was documented with the code 9, which referred the reviewer to other/see progress notes for the evening doses on 09/18/24 and 09/23/24 and for the day dose on 09/22/24. The 09/21/24 and 10/08/24 morning doses were coded as 16 which indicated med unavailable - pharmacy contacted. There was no documentation to indicate the Advair was administered for the morning doses on 09/23/24 and 10/04/24 or the evening dose on 09/24/24. Review of R2's eMar - Medication Administration Notes, located under the Prog Notes tab of the EMR, revealed the Advair inhaler was Not available, waiting pharmacy on 09/18/24, not available, waiting pharmacy on 09/22/24, and on order on 09/23/24. During an interview on 05/28/25 at 10:43 AM, R2 reported she did not receive her Advair discus twice daily as scheduled consistently through her stay. During an interview on 05/29/25 at 12:06 PM, Pharmacist1 reported R2's Advair inhaler was sent to the facility on [DATE] and again on 10/03/24. Pharmacist1 stated each inhaler provided 60 inhalations, good for 30 days, and so should have been available for all her scheduled doses. During an interview on 05/29/25 at 1:40 PM, the DON verified the documentation revealed that R2 had not received doses of the Advair inhaler.

Based on observation, interview, and record review the facility did not ensure residents with a pressure injury or at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R8) of 3 residents reviewed for pressure injuries. R8 admitted to the facility with pressure injuries (PIs) on her left heel and right lateral foot which later resolved. R8 was assessed as high risk for PIs. Despite being at high risk, R8's physician's order for an air mattress was not implemented, a care plan for actual skin impairment was not initiated timely, and her weekly skin assessments were not completed weekly as per facility policy. R8 developed pressure injuries to her right lower extremity that deteriorated to a stage 3 and a stage 4 with necrosis and muscle/fascia visible in addition to developing two stage 2 PIs to her buttocks. R8's care plan was never revised with interventions to promote healing. Surveyors had observations of orders including repositioning and heel offloading not being implemented as well as observations of R8 removing her dressings and scratching the open areas with dirty fingernails. The facility's failure to provide care to prevent the development of pressure injuries and promote the healing of R8's pressure injuries, the failure to assess and update resident's pressure injury care plan, monitor R8's dressings, and provide repositioning created a finding of immediate jeopardy (IJ) that began on 1/31/2024. Surveyor notified Nursing Home Administrator (NHA)-A, Interim Director of Nursing (Interim DON)-C and assistant DON (ADON)-D of the immediate jeopardy on 5/30/2024 at 11:41 AM. The immediate jeopardy was removed on 6/3/24. The deficient practice continues as a scope and severity of a D (potential for harm/isolated) as the facility continues to implement their action plan. Findings include: The facility policy titled, Pressure Injury Prevention and Managing Skin Integrity, reviewed on 8/10/2023, documents: I. Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries. II. Procedure: 1. Risk Assessment. a. Upon admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. c. Based on the individuals Braden Scale Score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record. 2. Identify Interventions and Care Plan, a. Identify Interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown . 3. Identification of risk factors present or acquired that compromise skin integrity will be considered. b. Care Plan. i. In developing a plan of care, the following will be considered: 1. Individual pressure injury history, 2. Cognitive changes or impairment of the individual. 3. Current state of skin integrity and personal hygiene practices of the individual that impact skin health . 5. Risk for pressure ulcer development (Braden Scale). 3. Skin Checks; a. Skin check will be done upon admission, readmission, or as clinically indicated. b. While providing routine care, a licensed nurse is to monitor the skin condition of each individual weekly and document the Skin Check in the medical record. 4. Weekly Wound Rounds, . b. Registered Nurse (RN) or designee will: i. Conduct weekly skin evaluation . iii. Update the Care Plan with any new interventions as applicable . R8 was admitted to the facility on [DATE] and has diagnoses that include (idiopathic) normal pressure hydrocephalus, delusional disorder, chronic kidney disease stage 3, neoplasm of unspecified behavior of brain, major depressive disorder, and dementia with other behavioral disturbance. R8's quarterly minimum data set (MDS) dated [DATE] indicates R8 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4; requires maximal assistance with 1 staff member for repositioning and is dependent on 1 staff member for personal hygiene. R8 requires a Hoyer lift with 2 staff members for transferring and is incontinent of bowel and bladder and wears an adult brief. On 8/15/23, the facility assessed R8 to be high risk for the development of pressure injuries with a Braden score of 11. Surveyor notes R8 was admitted to the facility with pressure injuries to the left heel and right lateral foot, both resolved on 11/29/2023. R8 had a significant change MDS completed on 4/26/2024 and the facility assessed R8 to be dependent on staff with repositioning as well as all activities of daily living (ADLs) with assistance of 1 staff member. R8 has an activated POA (Power of Attorney.) Surveyor reviewed R8's physician orders and noted an air mattress was ordered on 9/14/2023 and was never implemented. Surveyor observed R8's current mattress is a foam mattress. Surveyor reviewed the Manufacturer's Owner's Manual and noted a description for the memory foam flip mattress, and it was designed to provide different levels of comfort on the two opposing sides of the mattress. The memory foam side of the mattress features a soft viscoelastic foam top layer with three support layers underneath. The traditional foam side of the mattress has a firmer feel while still providing comfort and pressure redistribution. A super-soft heel section is featured on both sides of the mattress . On 5/29/2024 at 3:46 PM, Surveyor interviewed Interim Director of Nursing (DON)-C who stated they are not sure why R8's air mattress was never implemented when ordered on 9/14/2023. Interim DON-C stated there may be a story there but would have to look into it. Surveyor never received further information regarding why R8's air mattress was never implemented. R8's care plan for actual skin impairment was not initiated until 9/27/2023 (6 weeks after admission with pressure injuries) and included the following interventions: - 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 s/sx of infection, maceration, etc . - Nursing collaborate with [Name of Wound Care company] wound care consultants on changes to or worsening of the wound. R8's current Certified Nursing Assistant (CNA) Kardex has the following interventions as of 5/29/2024: - Check positioning in chair and when alone in room, tilt chair back with feet elevated for safety and proper lower extremity position. Surveyor reviewed R8's [Wound Care Company] wound care assessments and noted on 1/31/2024 R8 was assessed to have two unstageable deep tissue injuries (DTIs): - Right lateral foot measuring 0.5 cm (centimeters) x 1.0 cm (length x width x depth) - Right ankle measuring 0.5 cm x 0.5 cm New orders included: - Skin prep ordered - Offload wound, reposition, pressure off loading boots Surveyor noted R8's care plan and CNA Kardex were not revised with the new interventions for offloading, pressure off loading boots, or repositioning. On 3/6/2024, the facility's assessment of R8's right ankle wound is documented as an unstageable PI with necrosis, 1 x 1 x 0.2, 20% necrotic (dead,) 80% granulation tissue. On 3/13/2024, the facility's assessment of R8's right lateral foot wound is noted to be a stage 3 PI measuring 0.2 x 0.2 x 0.2, 100% granulation tissue. Wound Medical Doctor (Wound MD)-P also indicated a possible concern for bone infection in right ankle due to it not healing and an x-ray was ordered. The x-ray was found to be negative for a bone infection. On 3/20/2024, the facility's assessment of R8's right ankle wound is documented as a Stage 4 measuring, 1 x 1 x 0.4, 20% necrotic, 80% granulation, muscle/fascia visible. On 3/29/2024, Wound MD-P ordered an ace wrap be applied around the right foot to keep the bandages in place. Surveyor noted the new order was not added to R8's care plan or added to R8's MAR (Medication Administration Record)/TAR (Treatment Administration Record). Surveyor did not observe an ace wrap around R8's right foot during the survey. On 5/14/2024, the facility's assessment of R8's right lateral foot wound documents a deterioration from a stage 3 to stage 4, measuring 2 x 2 x 0.3, 100% granulation tissue. On 5/21/2024, R8's wound measurements are documented as: -Right lateral foot, stage 4, 2.0 x 1.8 x 0.2, 90% granulation tissue, 10% muscle -Right ankle, stage 4, 2.0 x 2 x 0.3, 100% granulation tissue On 5/21/2024, Wound MD-P's assessment notes state it was stressed to R8's POA and facility nursing staff the need to ensure the patient offloads site as [R8] favors laying on the right side which is a concern for ongoing source of pressure. Wound MD-P's assessment notes discussed that [R8] has palpable pulse and with improvement seen since last week's assessment, R8 should have the ability to heal, but that will not occur unless R8 continues to have pressure relief to the wound site. Re-reviewed wound orders with nursing to complete as ordered and additionally discussed ways to ensure improved offloading and prevent [R8] from continuing to favor the right side and leading to worsening of [R8's] right foot wound. Discussed with R8's POA additional treatment or adjustment to the GOC (goal of care) for hospice versus aggressive therapies should wound worsen such as amputation. R8's POA wishes to continue with aggressive wound care given seeming improvement possible with offloading measures discussed. Surveyor noted there were no changes to R8's care plan or the CNA Kardex to include interventions discussed in Wound MD-P's progress notes. Surveyor also noted that the above information was not noted in the progress notes for nursing to see and that the need to make sure R8 is offloading R8's right ankle and pressure injury was not indicated. Surveyor noted the following concerns: - R8's care plan and CNA Kardex were never revised to include new interventions recommended by Wound MD-P for off-loading, repositioning, and pillow boots. - Multiple notes from Wound MD-P stating patient noncompliance with offloading and repositioning, and behaviors, and this was never addressed in care plan. - Quarterly MDS completed on 11/22/2023 and current MDS done 4/26/2023 do not document R8 refuses cares or is non compliant. Surveyor noted R8's current wound measurements as of 5/28/2024 are: - Right lateral foot, Stage 4, 2.2 x 1.5 x 0.2, 100% granulation tissue - Right ankle, Stage 4, 2 x 1.5 x 0.2 100% granulation tissue Buttock Pressure Injury On 2/7/2024 at 22:46 (10:46 PM) in progress notes, nursing documented, skin only evaluation indicating R8 has an open area on the buttock. Seen by Wound Doctor. Treatment in TAR. No other concerns. Surveyor noted there was no comprehensive assessment of the buttock pressure injury including measurements, description, or location of the open area on R8's buttock. Surveyor also noted there is no documentation by Wound MD-P regarding the open area on buttock from 2/7/2024. Surveyor reviewed R8's February 2024 MAR/TAR and noted a new treatment was not initiated on 2/7/2024 for the newly identified pressure injury. R8 had the following orders in place from 8/15/23 which documented: -[NAME] Buttocks External Ointment (Diaper Rash Products)-Apply to buttocks topically two times a day for skin protection (Start date: 8/15/2023). -Duoderm to right buttock, change every 3 days and PRN (as needed) (Start date: 9/17/2023.) Surveyor noted staff initialed the treatment as being completed 6 out of the 9 scheduled days in February. Surveyor also did not see any progress notes or assessments to indicate why R8's treatment to right buttock was changed from [NAME] Buttock Ointment to a Duoderm dressing three times a day on 9/17/23. Surveyor noted that there are no further assessments or progress notes regarding R8's open area on the buttocks which was noted on 2/7/2024. On 4/9/2024, Wound MD-P submitted a supplemental progress note which indicated R8 has buttock wounds which appear to be pressure related (stage 2) given patient frequently spends long periods of the day in [R8's] recliner. Will use Zinc TID (three times a day) for treatment in addition to upgrading patient cushion and mattress, reposition per protocol. Measurements were provided to Wound MD-P by facility staff: - Right buttock wound 2.1 x 0.49 x 0.1 - Left buttock wound 2.1 x 0.49 x 0.1 (per telephone from facility-did not assess) - Zinc ordered for 3x (times)/day in addition to upgrade patient cushion and mattress, reposition. Surveyor noted R8's mattress was not upgraded on 4/9/2024 as ordered by Wound MD-P. On 4/16/2024, Wound MD assesses R8's buttocks wounds: - Right buttock wound, stage 2, 2.5 x 3.0 x 0.1, open area with exposed dermis - Left buttock wound, stage 2, 5.0 x 1.0 x 0.2, open area with exposed dermis - TX (treatment) changed to leptospermum honey once daily and cover with bordered gauze. R8's current measurements right and left buttocks wounds as of 5/28/2024 are: - Right buttock wound, stage 2, 0.5 x 0.5 x 0.1. - Left buttock wound, stage 2, 3 x 3 x 0.1. On 5/28/2024 at 8:27 AM, Surveyor observed R8 lying on her right side in bed sleeping. Surveyor noted there was not an air mattress on R8's bed and there were 2 blue pillow boots in R8's wheelchair. Surveyor was unable to visualize R8's legs at this time. On 5/28/2024 at 11:03 AM, Surveyor observed R8 lying in bed on her back slightly leaning on R8's right side and R8's legs were turned to the right and R8's right foot/ankle were against the mattress. Surveyor observed two bandages on the sheets next to R8 that were dated 5/28/2024 with [initials] on the bandage. R8 was observed scratching R8's lower extremity. Surveyor asked R8 if Surveyor could look at R8's hands. Surveyor noted R8's fingernails on her right and left hands to be long and dirty. Surveyor also observed R8 throwing a blue type dressing on her bedroom floor where another blue dressing was already lying. Surveyor did not observe R8's feet offloaded, and 2 blue pillow boots were still located on R8's wheelchair. On 5/28/2024 at 11:29 AM, Surveyor observed R8 lying in bed scratching at her lower right leg. 2 bandages were still located on R8 bed, and 2 blue pillow boots were located on R8's wheelchair. Surveyor noted R8's right lower leg was exposed and asked R8 if Surveyor could look at R8's right foot. Surveyor noted an open area on the right lateral side by R8's pinky toe and R8's ankle had open areas that did not have dressing on them and R8 was scratching around the open areas. On 5/28/2024 at 12:36 PM, Surveyor observed CNA-M going into R8's bedroom. CNA-M stated CNA-M was getting R8 up for the day. Surveyor asked CNA-M what interventions R8 has in place for R8's wounds. CNA-M stated R8 gets repositioning at least every two hours and treatments to R8's wounds. Surveyor asked CNA-M if R8 has been getting repositioned. CNA-M stated R8 has been getting repositioned because R8 is unable to do it without help. Surveyor asked CNA-M if R8 is supposed to have dressings on R8's right foot pressure injuries. CNA-M stated CNA-M noticed they were off earlier and told the Nurse. Surveyor asked CNA-M how long ago that was, and CNA-M replied at least a couple hours ago. Surveyor asked CNA-M if R8 had any pressure injuries on R8's buttocks. CNA-M stated that R8 has some areas and gets a barrier cream applied. CNA-M provided cares on R8 and applied a barrier cream to R8's buttocks. On 5/28/2024 at 12:58 PM, Licensed Practical Nurse (LPN)-N entered R8's bedroom. LPN-N stated LPN-N redressed R8's dressings earlier and was not aware they had come off again. LPN-N redressed R8's right foot dressings to R8's right lateral and right ankle pressure injuries and wrapped R8's foot with a Coban dressing so the dressings stay on. LPN-N then cleaned and applied the ordered treatments to R8's right and left buttock pressure injuries. Surveyor asked LPN-N what interventions are in place for R8's wound management. LPN-N stated R8 should be repositioned, receives treatments to the areas, and should have pillow boots on but R8 rubs her legs, and they fall off all the time. On 5/29/2024 at 8:02 AM, Surveyor observed R8 lying slightly on R8's right side, her knees were propped on a pillow and her right ankle was directly against the mattress. R8 did not have pillow boots on and had a Coban wrap around the right foot. Surveyor noted R8's blue pillow boots were sitting on R8's wheelchair. On 5/29/2024 at 11:04 AM, Surveyor observed CNA-M and CNA-O putting R8 into R8's wheelchair. Surveyor asked CNA-M and CNA-O how the pressure injuries developed on R8's right foot and buttocks. CNA-M and CNA-O both stated they were most likely due to pressure. CNA-M stated R8 favors her right side and tends to want to lay on that side. Surveyor asked if CNA-M and CNA-O were ever instructed to keep R8 off her right side or put interventions in place for offloading R8's right foot so there is no pressure in that area. CNA-M stated the pillow boots are put on to keep pressure off. Surveyor shared with CNA-M and CNA-O that Surveyor had observations that the pillow boots were not in place and sitting in R8's wheelchair. CNA-M stated the staff tries to keep the pillow boots on when able. CNA-M and CNA-O stated they were not sure what else to do. On 5/29/2024 at 3:46 PM, Surveyor interviewed Interim Director of Nursing (DON)-C who stated they are not sure why R8's air mattress was never implemented when ordered on 9/14/2023. Interim DON-C stated there may be a story there but would have to look into it. Surveyor never received further information regarding why R8's air mattress was never implemented. During the interview, Surveyor shared concerns with Interim DON-C. Interim DON-C stated they are wound care certified and has been in the Interim DON position for almost 3 weeks. Interim DON-C stated the facility is aware some things were not being completed as the staff should such as care plan and CNA Kardex's. Surveyor shared concerns with Interim DON-C that R8's impaired skin integrity care plan was never revised after R8 developed the pressure injuries in the right lateral foot and right ankle, and it was not revised again after R8 developed two stage 2 pressure injuries on R8's buttocks. Surveyor also shared concern R8's CNA Kardex does not identify the recommendations to offload and keep R8 off her right side for wound care. Interim DON-C agreed with Surveyor R8's care plan and CNA Kardex were lacking and needed to be revised and the facility is aware there is a problem and they are working on it. Surveyor shared observations made of R8 not having her right foot offloaded, not having a dressing in place for several hours, her weekly skin assessments were not completed, and there were observations of R8 not wearing pillow boots. Interim DON-C stated it would be looked into. Interim DON-C stated Interim DON-C did wound rounds with Wound MD-P the last several weeks and is worried R8's right foot wound will not heal because the bone is exposed for whatever reason and afraid that it will get infected. Interim DON-C stated R8's family is thinking of hospice services for R8. On 5/30/2024 at 10:01 AM, Surveyor interviewed Wound MD-P who stated the primary issue with R8's wounds are not offloading them. Wound MD-P stated staff have been educated and reeducated to keep R8 off that right side, possibly using wedges to prevent rolling onto right side. Wound MD-P stated when they come to facility weekly (primarily on Tuesdays) R8 is usually lying on the right side and the pillow boots are not applied. Wound MD-P stated the wound will get better and then decline, it is like a roller coaster. Wound MD-P stated every week while I'm in the facility the staff is re-educated to make sure R8's right side is offloaded. Surveyor asked Wound MD-P if R8's pressure injury has a chance of healing. Wound MD-P stated R8's wound would heal if R8's right side stayed offloaded due to R8 having good pulses, no arterial issues, and the bone and wound tissue appear healthy, but facility staff have to keep R8 offloaded. Wound MD-P stated maintenance staff were also instructed if they observe R8 on R8's right side, they are to get someone to get R8 off that side. Surveyor asked Wound MD-P if R8 should have an air mattress in place. Wound MD-P stated R8 would benefit from an air mattress but it is not required to heal R8's right lateral foot and right ankle pressure injuries. Wound MD-P stated the facility needs to ensure R8's pillow boots remain in place and R8 stays off her right side. Wound MD-P stated if the pressure injuries on R8's buttocks worsen then she will require an air mattress for wound healing. Surveyor asked Wound MD-P to clarify notes written about R8's noncompliance with wound care. Wound MD-P stated R8 does not refuse treatment or interventions but R8 has severe dementia and has to be talked through and assure pain medication is given before treatments so R8 is comfortable with what is happening. Wound MD-P also stated the noncompliance is with R8 always going to that right side and not being offloaded. On 5/30/2024 at 11:41 AM, Nursing Home Administrator (NHA)-A, DON-B, and Assistant Director of Nursing (ADON)-D were informed of the facility's failure to implement changes/revisions to R8's care plan/CNA Kardex, complete skin assessments on R8, and current observations of interventions not in place for R8 to promote wound healing and prevent worsening. The immediate jeopardy was removed on 6/3/24 when the facility completed the following: *All nurses and CNAs have been educated on the facility's skin prevention policy. *All nurses and CNAs have been educated on the notification process of skin changes. Detailing that changes be communicated to resident provider and clinical leadership who then coordinates with wound NP, dietician, and provider as needed. *Facility skin sweep completed on 5/31/24. *Facility residents care plans reviewed for at risk skin and updated as needed. *Facility residents with skin alterations have had a review of their care plan, RN comprehensive skin evaluations, interventions, and treatment plans in place. *Daily the DON or designee will review progress notes, risk assessments and 24-hour boards for any resident alteration of skin integrity. *Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to provide the education. *Staff education will occur prior to the next shift and new agency staff will be educated upon their first shift. *Pressure Injury Prevention and Managing Skin Integrity policy reviewed and reviewed with Medical Director. *Interdisciplinary Team to have weekly wound meetings to review status to include: pressure injury Policy and Procedure compliance. All findings will be reported to QAPI committee. *DON or designee will audit 5 medical records to ensure the skin policy and procedure are being followed weekly x 4 weeks then monthly times 3 months. Findings will be reported to the QAPI committee. *Root cause analysis completed on 5/13/24.

Based on observation, interview and record review the facility did not follow proper sanitation and food handling practices in accordance with professional standards for food service safety in the kitchen and 1 of 2 serving areas with the potential to affect 44 residents. * Garbage cans in the kitchen were observed to be very soiled and a lid was not on a garbage can next to a food preparation area. * Multiple items in the kitchen were found to be undated and several were uncovered. * The handwashing sink in the kitchen was very dirty. * The serving area on the second floor was found to have a mop and bucket with dirty water next to a cart for food trays. * Several food storage bins were observed to have the scoop stored inside the bin in direct contact with the product. Findings Include: On 5/28/24 at 8:48 AM the following was observed in the kitchen: * In a refrigerator in the food preparation area was a chef salad and 3 packs of partially used cold cuts without a date. * In the walk in Refrigerator was a large container of partially used fruit salad with no date, a pan of red and blue jello with no cover or date, and 3 pieces of cake not labeled or dated. * In the bulk food bins of flour, sugar, oatmeal and bread crumbs the scoop was observed to be stored in the product even though there was a holder for the scoop on the bin. * A garbage can by the meat slicer was observed not to have a lid. 2 garbage cans were observed to be very soiled. * The handwashing sink was observed to be very dirty. Dietary Manager (DM)-T was interviewed immediately after the observation and indicated he was going to throw out the uncovered and undated food. DM-T indicated the scoops should be stored in the holder of the food bins and not in the product. On 5/29/24 at 10:30 AM the following was observed in the kitchen: * Scoops were observed in the food bins for oatmeal and food thickener. On 5/29/24 at 12:15 PM the following was observed in the second floor food serving area: * A mop bucket with dirty water and a mop in it by the refrigerator and food service cart. * The sink was observed to be very dirty. On 5/30/24 the facility policy titled Dining Cleaning (no date) was reviewed and documented: Waste receptacles should be cleaned and disinfected weekly. On 5/30/24 the facility policy titled Dining Storage (no date) was reviewed and documented: Scoops must be provided for bulk foods. Scoops are not to be stored in food. Food should be dated as it is placed on the shelves. The above findings were shared with Administrator-A and Director of Nursing-B on 5/30/24 at 3:00 PM.

Based on observation and interview, the facility did not ensure that residents have reasonable access to the use of telephone, in a place where calls can be made without being overheard. The facility provided telephones in resident's rooms on the first floor while resident's living on the second floor of the facility did not have reasonable access to the use of telephone. This deficient practice has the potential to affect 28 of 28 residents residing on the second floor of the facility who could request the use of telephone. Findings include: During Resident Council held on 5/29/24 at 2:00 PM, R14 stated, I am upset that there are not phones in the rooms on the second floor. R14 stated that they were told by the facility that the budget would be reviewed in July and a plan for phones would be addressed at that time. R14 stated that there was a phone at the end of the hallway on the second floor that residents could use but that it did not provide privacy. On 5/30/24 at 10:22 AM, Surveyor interviewed NHA (Nursing Home Administrator)-A regarding the phone system at the facility. Surveyor asked NHA why only the first-floor residents were provided with access to telephone in their room and not residents residing on the second floor of the facility. NHA-A informed Surveyor that the facility previously disconnected all the telephone systems on the second floor of the facility because the facility thought that they would not have any resident's residing on the second floor. NHA-A informed Surveyor that residents residing on the first floor had access to a personal telephone in each of their rooms. NHA-A informed Surveyor that since the phone system was taken out, the facility has had resident's residing on the second floor. NHA-A informed Surveyor that the facility has cordless telephones on the unit for residents to use and that residents residing on the second floor can also use their personal telephones. NHA-A informed the Surveyor that the facility is working on getting additional telephone access for resident's residing on the second floor. On 5/30/24 at 10:30 AM, Surveyor completed a walk-through of the second-floor units. Surveyor observed only two cordless telephones for all 28 residents residing on the second floor of the facility. Surveyor observed one cordless telephone to be inoperable and it would not turn on. On 5/30/24 at 10:31 AM, Surveyor interviewed RN (Registered Nurse)-L, who was working on the second floor of the facility, regarding the telephone access for residents residing on the second floor. Surveyor asked RN-L how many cordless telephones were available to residents residing on the second floor. RN-L informed Surveyor that there were two cordless telephones on the second floor but that one was not working as it was not charged. RN-L informed Surveyor that she did not know how the cordless telephones work and that she usually receives a call from family requesting to speak to residents via the facility telephone landline located inside the nurse's station. Surveyor asked how residents would be able to speak in private if they are only receiving calls via the telephone landline inside the nurse's station. RN-L informed Surveyor that if a resident wishes to speak in private, she has the resident's family call her personal cellular phone which she leaves with the resident in the resident's room. Surveyor asked RN-L if the facility needed additional cordless telephones for residents residing on the second floor to use. RN-L informed Surveyor that additional cordless telephones would be helpful as she should not have to use her personal cellular phone for resident's calls. On 5/30/24 at 3:02 PM, Surveyor notified NHA-A and DON (Director of Nursing)-B of the above information. No additional information was provided as to why the facility did not ensure that residents have reasonable access to the use of telephone, in a place where calls can be made without being overheard.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure that a resident who was admitted without a pressure injury was properly assessed and monitored to prevent the development of a pressure injury for one resident (Resident (R) 5) out of three residents reviewed for pressure injuries. This resulted in the development of a facility acquired, stage 3 pressure injury. Findings include: Review of the facility's policy titled, Pressure Injury-Prevention and Managing Skin Integrity dated 08/10/2023 indicated, 3. Skin Checks: a. Skin checks will be done upon admission, readmission or as clinically indicated. b. While providing routine care, a licensed nurse is to monitor the skin condition of each individual weekly and document the Skin Check in the medical record. Review of the R5's Admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, diabetes mellitus, chronic kidney disease, and transient ischemic attack (stroke). Review of R5's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/23/24 revealed the resident was assessed with a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating the resident was severely cognitively impaired. She was identified as being at risk for developing pressure injuries, however, did not have any pressure injuries on admission. Review of the Braden Scale for Predicting Pressure Ulcer Risk located under the Miscellaneous tab, completed on 01/16/24, the day of admission, revealed R5 scored 20 which indicated no risk of developing a pressure injury. Review of R5's care plans indicate despite risk for pressure injuries, there were no interventions to prevent the development of a pressure injury. Review of the Initial Wound Evaluation and Management Summary dated 01/31/24 completed by the wound care specialist physician revealed R5 was evaluated and treated for a Stage 3 pressure injury to her right buttock measuring 0.5 centimeters (cm) x 0.5 cm x 0.2 cm in depth with 100% granulation tissue. Review of the skin evaluation on this date indicates the wound is greater that 7 days in duration. Additional information from the wound physician was not available after the initial evaluation. The resident was transferred to the hospital for another reason and did not return to the facility. Review of the facility skin check/bath sheets indicate staff were either not completing this review to monitor R5's skin. Review of the Progress Notes located in the Progress Notes tab in the EMR, did not reveal any indication or identification the resident had any pressure injuries or skin condition in the physician or nurse practitioner notes from admission through the last entry of 01/31/24. Review of R5's EMR revealed no evidence of any supporting documentation of when the wound was initially identified or a description of the wound once identified. The facility was unable to provide any additional information from the medical record or from staff working the two weeks the resident was in the facility regarding the development of the resident's pressure injury. There were no skin assessments from the time of admission until the Initial Wound Evaluation and Management Summary dated 01/31/24. During an interview with Licensed Practical Nurse (LPN) 2 on 03/26/24 at 3:30 PM revealed she worked on the night shift and was not aware R5 had a pressure injury. She never received a report of the resident having any skin concerns. During an interview with the Assistant Director of Nursing (ADON) on 03/26/24 at 3:30 PM revealed she was not aware of the pressure injury and would review the medical record for additional information. During an interview with the Administrator on 03/27/24 at 1:30 PM, confirmed there was no additional information available prior to when the wound was first identified.

Based on interview and record review, the facility did not follow the menu and ensure that 13 of 13 residents who required a mechanically soft diet (R6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20) received a mechanically altered diet in accordance with established national guidelines. R6 choked on the broccoli that he received, and he later expired in the emergency room . The failure to follow the menu and ensure the resident received a mechanically altered diet, created a finding of Immediate Jeopardy that began on [DATE]. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on [DATE] at 3:31 p.m. The immediate jeopardy was removed on [DATE]. The deficiency continues at a scope and severity level of an E (potential for harm/pattern) as the facility continues to monitor that food being prepared and served to the resident at each meal is consistent with resident diet prior to serving, with audits submitted to the QA Committee for review and recommendation for follow-up, if any. Findings include: The facility's established nutritional diet guideline with no date and titled, Mechanical or Dentalsoft documents, The mechanical soft dental is for individuals who have difficulty chewing regular textured foods. The speech language pathologists (SLR) has evaluated, and determined that the diet is appropriate. This diet may not be appropriate for individuals being treated for [REDACTED]. The Diet should be planned to meet 100% of RDS (Recommended Daily Serving)/AI (Adequate Intake). Generally, plan three-balanced meals plus snacks between meals to achieve individual's requirements. Diet Principles: · Use of variety of foods · Monitor diet to make certain foods offered are moist, easy to chew and swallow · Alter all foods to the highest consistency the individual can tolerate Foods allowed Vegetables: Cooked, tender, chopped, or shredded, vegetable juice, canned cream corn, Baked fries, Baked Tater Tots, stewed soft tomatoes. Foods Not Allowed Vegetables: Any potato skins, whole or large pieces, whole kernel corn, corn, peas, raw vegetables, Brussel sprouts, coleslaw, composed salads such as broccoli salad or picked vegetables. R6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6's Quarterly MDS (Minimum Data Set) dated [DATE] documents short and long term memory problems. Section G (Functional Status) documents that R6 requires limited assistance and a one person physical assist for her eating needs. Section K0100 (Swallowing Disorder) documents that R6 has coughing and choking during meals or when swallowing medications. Section K0510 (Nutrition Approach) documents that R6 is on a mechanically altered diet while a resident at the facility. R6's Nutritional Status CAA (Care Area Assessment) dated as completed on [DATE] documents under the Analysis of Findings section, Individual is on a mechanical soft diet due to hx (history of) dysphagia. Mechanically-altered diet presents a risk as there is potential for decrease intake and non-compliance to diet .Non-compliance with the diet is a risk to the resident as it could lead to choking, inability to consume adequate food and fluids, and/or aspiration. Under the Care Plan Considerations section it documents, Will proceed to care plan for continued mechanical soft, NAS (No added salt) diet. R6's hospital Discharge Summary dated [DATE] documents under the Brief History section, R6 (has) .Parkinson disease who was noted to have [MEDICAL CONDITION] activity at Linden Grove while eating. He was noted to have food in his throat above the vocal cords and some beyond. He was initially having labored breathing, which improved with the removal of the food. Under the Hospital Course section it documents, aspiration pneumonia- admitted with the history as above .Speech evaluation recommended dysphagia level 2 diet which he tolerated well during his hospital stay. He had no further episodes of choking. R6's Speech Therapy Plan of Care (Evaluation Only) dated [DATE] documents, Reason For Referral: This (resident) was referred to therapy due to recent hospitalization for aspiration pneumonia secondary to [MEDICAL CONDITION] with food in mouth during his noon meal. Patient has a history of dysphagia where he consumed thin liquids and mechanical soft diet with no s/sx (signs or symptoms) of aspiration/choking. Previous Therapy: Patient had speech therapy during recent inpatient hospitalization where a VFSS (Video Fluoroscopic Swallowing Study) was completed and indicated recommendation for thin liquids/mechanical soft diet. Swallow guidelines include assistance with feeding, teaspoon portions no cups or straws, eat/drink slowly, medication with puree, upright for meals and remain upright 30 minutes after. Mechanical soft is highest, safest level diet due to lethargy and progressing dementia diagnosis. Initial Assessment: SLP (speech language pathologist) facilitated therapeutic meal assessment with mechanical soft diet and thin liquids during noon meal while he was upright and alert in his wheelchair . Pt (patient) demos (demonstrates) poor bolus control warranting verbal cues to slow down and take smaller bites. Per nursing, this is his baseline prior to hospital. SLP (speech language pathologist) discussed swallow guidelines, including supervision with verbal cues, teaspoon portions, no straws, eat/drink slowly, medication with puree, upright for meals and remain upright 30 minutes after. R6's Nutritional Status care plan dated as effective on [DATE] documents under the Interventions section, Provide mechanical soft, NAS (no added salt) diet as ordered, EFFECTIVE: [DATE]; Follow swallow guidelines: verbal cues, teaspoon portions, eat/drink slowly, upright for meals, meds (medications) with puree, EFFECTIVE: [DATE]. R6's nursing noted dated [DATE] documents, Late entry pm charting of critical event. Writer summoned at approximately 1815 (6:15 PM) to South dining room, for this resident choking. Writer observed resident drooling and could without stethoscope hear wheezing-Writer asked resident if he could look at me and his eyes did track and writer asked him to open his mouth and spit out his food, and he did this and then writer did a finger sweep, to clear airway. He was then noted to be tremoring more than usual and had a clonic/tonic [MEDICAL CONDITION] for approx. (approximately) 1.5 minutes, high flow oxygen via mask was started and crash cart was brought to room staff continues to try and clear airway with [MEDICATION NAME] suction. He had radial pulses during entire event, mucous and partially chewed broccoli was coming from mouth- he again was asked by writer to squeeze her hands which he did. Supervising now in dining room and VS (vital signs) obtained while writer summoned FD (Fire Department)-Paramedics. Arrival within minutes he continued with drooling mucous and food remained conscious but now getting cyanotic in extremities. FF (Firefighter)/PM (Paramedic) transferred (3 person FF (firefighter) carry from W/C (wheelchair) to their stretcher without incident except small approx. (approximately) 1 in. (inch) skin tear to right outer elbow from w/c arm rail during lifting minor bleeding. Writer handed Paramedic team necessary transfer paperwork .At approximately 1925 (7:25 PM) writer rec'd received a phone communication that resident had expired in the ED (emergency department). RN (Registered Nurse) stated to writer she was familiar with R6 because she had also been his nurse approx. (approximately) ,[DATE] weeks earlier at similar episode where we had sent him to this ER (emergency room ) after choking. 1. On [DATE] at 1:29 p.m., Surveyor interviewed RD (Registered Dietician) O regarding R6's choking incident on [DATE]. Surveyor asked RD-O what type of diet R6 was receiving on [DATE] and the specific meal items R6 received for dinner on [DATE]. RD-O informed Surveyor that R6 was on a mechanical soft diet and that on [DATE], R6 should have received a ground sirloin steak with ground mushroom and onions, parsley potatoes and ground steam fresh broccoli. 2. On [DATE] at 11:37 a.m., Surveyor interviewed Dietary Manager-N regarding the differences between mechanical soft broccoli and the general diet broccoli served to residents. Surveyor asked Dietary Manger-N what the differences are between the mechanical soft and general style broccoli served to residents. Dietary Manager-N informed Surveyor that mechanical soft broccoli is overcooked and maybe be chopped if too large in size. Dietary Manager-N informed Surveyor that general broccoli is not overcooked and not chopped if too large in size. Surveyor asked Dietary Manager-N if the facility cook is supposed to make a separate batch of broccoli for residents whom receive mechanical soft diets. Dietary Manager-N informed Surveyor that the facility cook is supposed to prepare a separate batch of mechanical soft broccoli for residents whom receive mechanical soft diets. 3. On [DATE] at 10:49 p.m., Surveyor interviewed CNA-K regarding R6's choking episode on [DATE]. CNA-K informed Surveyor that she was present in the dining room when R6 began choking. CNA-K informed Surveyor that on [DATE] during dinner time, the CNAs on the floor were commenting about the size of the broccoli being served to residents and that at the time she (CNA-K) did not observe any mechanical soft broccoli being served to resident who were on mechanical soft diets. 4. On [DATE] at 11:18 a.m., Surveyor interviewed Dietary Aide-L, the dietary aide who served R6's plate during dinner time on [DATE], regarding R6's choking episode on [DATE]. Surveyor asked Dietary Aide-L what she had served residents whom received a mechanical soft diet for dinner on [DATE]. Dietary Aide-L informed Surveyor that the mechanical soft meal she served for dinner on [DATE] was ground Salisbury steak with gravy, mashed potato, fruit and broccoli. Dietary Aide-L informed Surveyor that she did not serve ground broccoli to resident who received a mechanical soft diet for dinner on [DATE]. Dietary Aide-L informed Surveyor that she usually has two batches of broccoli to serve, one for residents receiving a regular diet and one for residents received mechanical soft diets. Dietary Aide-L informed Surveyor that for dinner on [DATE], she only had one batch of broccoli which was large in size and not overcooked or chopped for mechanical soft diet residents. Dietary Aide-L informed Surveyor that she served the general diet broccoli to residents whom received mechanical soft diets for dinner on [DATE]. Surveyor asked Dietary Aide-L to describe the consistency and the size of the broccoli that was served on [DATE] for dinner. Dietary Aide-L informed Surveyor that the broccoli served for dinner on [DATE] was larger than a teaspoon size and informed Surveyor that the some of the larger pieces were difficult to cut into. 5. On [DATE] at 12:07 p.m., Surveyor interviewed Cook-M who prepared the dinner meal that was served to R6 on [DATE]. Surveyor asked Cook-M if he (Cook-M) had prepared a mechanical soft broccoli batch for residents receiving mechanical soft diets for dinner on [DATE]. Cook-M informed Surveyor that for dinner on [DATE], he did not prepare mechanical soft broccoli for residents receiving mechanical soft diets. Cook-M informed Surveyor that he usually prepares two separate batches of broccoli, with the mechanical soft broccoli being overcooked and chopped if large in size. Cook-M informed Surveyor that he did not prepare mechanical soft broccoli for dinner on [DATE] as the broccoli batch he tested was overcook and soft enough to cut through. Cook-M informed and confirmed to Surveyor that there was no mechanical soft broccoli prepared or served for dinner on [DATE]. 6. On [DATE] at approximately 12:22 p.m., Surveyor informed Administrator-A and DON-B (Director of Nursing) of the above findings. Surveyor asked DON-B if residents receiving mechanical soft food should receive mechanical soft food according to their plan of care and swallowing guidelines. DON-B informed Surveyor that residents receiving mechanical soft food should received mechanical soft food according to their plan of care and swallowing guidelines. 7. On [DATE] at 4:02 p.m., Surveyor interviewed RN Supervisor-C regarding R6's choking incident on [DATE]. RN-C took over the care of R6 when he was summoned to the second flood dining room by facility staff for what he originally was told to be a [MEDICAL CONDITION]. RN Supervisor-C informed Surveyor that when he arrived to the second floor dining room, he observed R6 slumped over to his right side in his wheelchair visibly choking on large pieces of broccoli which R6 was attempting to spit out his mouth with the help of CMA-P. RN Supervisor-C informed Surveyor that he observed R6 to be conscious but confused and that he obtained vitals on R6 and placed oxygen via a mask on R6. RN Supervisor-C informed Surveyor that he observed R6 coughing up large pieces of whole broccoli. RN Supervisor-C informed Surveyor that after the incident, he voiced concerns to RN House Supervisor-Q regarding the size of the broccoli served to R6. (Per interview on [DATE] at 10:10 AM, House Supervisor Q did not recall RN Supervisor-C informing him of concerns regarding the size of the broccoli.) On [DATE] at 3:31 p.m., Surveyor informed Administrator-A and DON-B of the above findings. The failure to follow the menu and ensure the resident received a mechanically altered diet, created a finding of Immediate Jeopardy. The facility removed the jeopardy on (MONTH) 27, 2019, when it had completed the following: - For all residents with a mechanically altered diet, the Dietary Services Manager, or designee, is monitoring that food being prepared and served to the resident at each meal is consistent with resident diet prior to serving. NHA or designee initiated auditing meal service daily at alternating meals for one month, then three times per week at alternating meals for two months for compliance. Audit results will be submitted to QA Committee for review and recommendation for follow-up, if any. - Education was provided to dietary staff (cooks, prep and servers) and nursing staff (RN, LPN and CNA) regarding food being prepared and served consistent with resident diet. Education started effective prior to evening meal on [DATE]. Staff will not be present during meal service until education is completed.

Based on interview and record review, the facility did not provide basic life support to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 (R6) of 1 residents reviewed in accordance with resident's advanced directives. The facility did not administer the [MEDICATION NAME] maneuver to R6 when R6 began choking during the dinner meal service on [DATE]. Additionally, staff could not suction R6 because the suction machine that was on the crash cart did not have all the pieces needed to assemble it. R6 later expired in the emergency room . The facility's failure to provide basic life support, including suctioning and the [MEDICATION NAME] maneuver, created a finding of immediate jeopardy that began on [DATE]. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on [DATE] at 3:31 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity level of D (potential for harm/isolated) as the facility monitors nursing staff adherence with the use of the [MEDICATION NAME] maneuver should the need arise. Findings include: The facility's policy revised (MONTH) (YEAR) and titled, [MEDICATION NAME] Maneuver documents under the Policy section, The emergency nature of an airway obstruction cannot be exaggerated. Immediate recognition, prompt action and the use of proper techniques are critical in aiding choking victims. The [MEDICATION NAME] Maneuver will be performed by LindenGrove staff on any person choking or suspected choking. The [MEDICATION NAME] Maneuver (sub diaphragmatic abdominal thrust) is recommended in relieving foreign body obstruction in adult. Under the Purpose section it documents, To provide guidelines to staff in the event that a person is choking or that choking is suspected. To dislodge or expel an obstructing foreign object from the person's airway. Under the Procedure section it documents, I. Assess the person for obstructed airway (signs of choking); (A) If resident is able to speak, encourage him/her to try clearing the object by coughing. Do not pat the choking person on the back.; (B) If the victim is coughing forcefully, allow them to expel the object on their own. Immediately summon for help: (A.) Call for Nurse STAT (Immediately);(B.) Direct Staff to Call 911; (C.) Ask victim if they are choking- tell them you can help; (D.) ADMINISTER THE [MEDICATION NAME] MANEUVER; (E.) While waiting for Paramedics/EMS (Emergency Medical Services) the RN (Registered Nurse) should direct the staff to do the following: (a.) To clear the immediate area; (b.) To secure an oxygen E-tank and tubing; (d. (sic)) To secure the Emergency Cart; (e.) To initiate CPR (cardiopulmonary resuscitation) if the victim experiences cardiac or respiratory arrest. R6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6's CPR (Cardiopulmonary Resuscitation) form dated [DATE] documents, NO, I do not want Cardio-Pulmonary Resuscitation attempts (DNR) .I further understand LindenGrove employees will continue to provide comfort measures and supportive care (including oxygen if needed and pain control) allowing for my natural death. I understand my preference for No CPR applies only if I suffer cardiopulmonary arrest and does not affect treatment that will be provided if I am choking or suspected to be choking. I understand that if I am choking or suspected to be choking, the [MEDICATION NAME] Maneuver will be performed, and if it is ineffective, emergency personnel will be summoned. R6's nursing noted dated [DATE] documents, Late entry pm charting of critical event. Writer summoned at approximately 1815 (6:15pm) to South dining room, for this resident choking. Writer observed resident drooling and could without stethoscope hear wheezing-Writer asked resident if he could look at me and his eyes did track and writer asked him to open his mouth and spit out his food, and he did this and then writer did a finger sweep, to clear airway. He was then noted to be tremoring more than usual and had a clonic/tonic [MEDICAL CONDITION] for approx. (approximately) 1.5 minutes, high flow oxygen via mask was started and crash cart was brought to room staff continues to try and clear airway with [MEDICATION NAME] suction. He had radial pulses during entire event, mucous and partially chewed broccoli was coming from mouth- he again was asked by writer to squeeze her hands which he did. Supervisor now in dining room and VS (vital signs) obtained while writer summoned FD (Fire Department)-Paramedics. Arrival within minutes he continued with drooling mucous and food remained conscious but now getting cyanotic in extremities. FF (Firefighter)/PM (Paramedic) transferred (3 person FF (firefighter) carry from W/C (wheelchair) to their stretcher without incident except small approx. (approximately) 1 in. (inch) skin tear to right outer elbow from w/c arm rail during lifting minor bleeding. Writer handed Paramedic team necessary transfer paperwork .At approximately 1925 (7:25 PM) writer rec'd (received) a phone communication that resident had expired in the ED (emergency department). RN (Registered Nurse) stated to writer she was familiar with R6 because she had also been his nurse approx. (approximately) ,[DATE] weeks earlier at similar episode where we had sent him to this ER (emergency room ) after choking. 1. On [DATE] at 2:36 p.m., Surveyor interviewed CNA (Certified Nursing Assistant)-E regarding R6's choking incident on [DATE]. CNA-E informed Surveyor that she was feeding another resident and that R6 was sitting in the dining room in his wheelchair, eating independently like he usually does. CNA-E informed Surveyor that she observed R6 choking and that she observed RN (Registered Nurse)-D walk into the room and attempt to verbally direct R6 to spit out the food he had in his mouth. CNA-E informed Surveyor that she observed R6 having difficulty breathing and spitting up large amounts of broccoli. CNA-E informed Surveyor that she then observed RN Supervisor-C arrive and then attempt to suction R6's mouth with the suction machine but that she observed RN Supervisor-C be unable to suction R6's mouth due to the suction machine on the crash/emergency cart missing pieces. CNA-E informed Surveyor that she did not observe any staff member provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode on [DATE]. 2. On [DATE] at 2:49 p.m., Surveyor interviewed CNA-G regarding R6's choking incident on [DATE]. CNA-G informed Surveyor that she was feeding another resident and that she did not witness R6 begin choking as she had her back towards R6. CNA-G informed Surveyor that she heard R7 yell out that R6 needed help and that she observed CNA-K go and summon RN-D who arrived and attempted to verbally direct R6 to spit out the food he had in his mouth. CNA-E informed Surveyor that she observed R6 choking, coughing and spitting up large amounts of broccoli. CNA-G informed Surveyor that she observed CMA (Certified Medication Assistant)-P giving R6 back slaps and perform a finger sweep on R6. CNA-G informed Surveyor that she then began to take residents out the dining room and that she did not observe any staff member use the crash/emergency cart equipment. CNA-G informed Surveyor that while she was in the dining room, she did not observe any staff member provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode on [DATE]. 3. On [DATE] at 3:54 p.m., Surveyor interviewed CNA-F regarding R6's choking incident on [DATE]. CNA-F informed Surveyor that she was not present in the second floor dining room when R6 choked on [DATE] during dinner time and that she was between the two second floor dining rooms assisting residents to eat. CNA-F informed Surveyor that while she was in the larger second floor dining room, she observed R6 appear to be choking and that she observed RN-D and RN Supervisor-C attempt to coach R6 to spit out food from his mouth. CNA-F informed Surveyor that she observed LPN-H attempt to put together the suction machine on the crash/emergency cart and hearing LPN-H inform RN Supervisor-C that the crash/emergency cart was missing items and that the suction machine could not be used on R6. CNA-F informed Surveyor that she observed CMA-P give R6 back slaps while R6 appeared to be choking and having difficulty breathing. CNA-F informed Surveyor that while she was in the dining room, she did not observe any staff member provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode during dinner time on [DATE]. 4. On [DATE] at 4:52 p.m., Surveyor interviewed RN-D regarding R6's choking incident on [DATE]. RN-D informed Surveyor that on [DATE] she was summoned by facility staff to the second floor dining room because she was told R6 was choking. RN-D informed Surveyor that when she arrived to the second floor dining room, she observed R6 sitting in his chair with CMA-P at this side. RN-D informed Surveyor that she attempted to coach and cue R6 to spit out whatever he had in his mouth as R6 was still conscious and responding appropriately. RN-D informed Surveyor that she then observed R6 have what appeared to be a [MEDICAL CONDITION] but that R6 was still able to squeeze her hands and remained conscious. RN-D informed Surveyor that R6 then coughed up large pieces of broccoli and that CMA-P was delivering back slaps to R6 in an attempt to clear his airway. RN-D informed Surveyor that she observed R6 have labored breathing but that R6 was still able to squeeze her (RN-D) hand. RN-D informed Surveyor that she then performed a finger sweep of R6's mouth and that afterwards RN Supervisor-C arrived and took over R6's care while she (RN-D) left the dining room to call 911. RN-D informed Surveyor that R6 remained conscious and with a pulse during the entire episode while she was caring for R6. RN-D informed Surveyor that she (RN-D) did not attempt to provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode because she believed R6 had spit up large amounts of broccoli and meat from his mouth and that doing the [MEDICATION NAME] maneuver on R6 would have required her (RN-D ) to stand R6 up from his wheelchair. RN-D informed Surveyor that she did not witness any staff member, during the time she was present in the dining room, attempt to provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode during dinner time on [DATE]. 5. On [DATE] at 4:02 p.m., Surveyor interviewed RN Supervisor-C regarding R6's choking incident on [DATE]. RN Supervisor-C informed Surveyor that he was summoned to the second flood dining room by facility staff for what he originally was told to be a [MEDICAL CONDITION]. RN Supervisor-C informed Surveyor that when he arrived to the second floor dining room, he observed R6 slumped over to his right side in his wheelchair, visibly choking on large pieces of broccoli which R6 was attempting to spit out his mouth with the help of CMA-P. RN Supervisor-C informed Surveyor that he observed R6 being verbally coached by RN-D and that upon arrival he took over R6's care and that RN-D left to call 911. RN Supervisor-C informed Surveyor that he observed R6 to be conscious but confused. RN Supervisor-C informed Surveyor that he obtained vitals on R6 and placed oxygen via a mask on R6. RN Supervisor-C informed Surveyor that he observed R6 coughing up large pieces of whole broccoli and that he requested from facility staff the crash/emergency cart so that he (RN Supervisor-C) could suction R6's mouth. RN Supervisor-C informed Surveyor that he was unable to suction R6's mouth due to the suction tubing missing on the crash/emergency cart. RN Supervisor-C informed Surveyor that while obtaining vitals, he observed R6 shaking but did not see R6 experience a [MEDICAL CONDITION]. RN Supervisor-C informed Surveyor that he recalled R6's SPO2 (Peripheral Capillary Oxygen Saturation) to be around 50% and that he observed CMA-P deliver back slaps to R6 in an attempt to clear R6's airway and mouth of large pieces of broccoli. RN Supervisor-C informed Surveyor that R6 remained conscious and with a pulse during the entire episode and that he handed care to EMS (Emergency Medical Service) personnel when they arrived. RN Supervisor-C informed Surveyor that he (RN Supervisor-C) did not attempt to provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode because during the choking episode, a member of the staff, whom he was unable to recall their name, stated R6 was a DNR (Do Not Resuscitate) patient. RN Supervisor-C informed Surveyor that he did not witness any staff member, during the time he was present in the dining room, attempt to provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode during dinner time on [DATE]. Surveyor asked RN Supervisor-C if he was aware that he could still provide the [MEDICATION NAME] maneuver to residents whom were DNR patients if they still had a pulse and were breathing. RN Supervisor-C informed Surveyor that he was aware that he could still provide the [MEDICATION NAME] maneuver to residents whom were DNR patients but that since it was his first time at the facility, he was unsure of the facility's policy. 6. On [DATE] at 7:28 a.m., Surveyor interviewed CNA-I regarding R6's choking incident on [DATE]. CNA-I informed Surveyor that she was not initially present when R6 started choking and that she was walking in the hallway when she heard a commotion in the second floor dining room and that she went to see what was going on in the dining room. CNA-I informed Surveyor that she was then told by RN-D to go and get RN Supervisor-C from downstairs as RN Supervisor-C was not answering the phone. CNA-I informed Surveyor that she went downstairs and informed RN Supervisor-C to come upstairs because she had been told by RN-D that R6 was having a [MEDICAL CONDITION]. CNA-I informed Surveyor that she then went back upstairs to the second floor dining room with RN Supervisor-C and that she observed RN Supervisor-C obtain vitals on R6 and place oxygen on R6 via a mask. CNA-I informed Surveyor that she then personally went to go get the crash/emergency cart and that when RN Supervisor-C requested the suction machine, she was unable to put the suction machine together as she was unsure what to do and how the machine worked and that LPN-H then took over the crash/emergency cart and suction machine. CNA-I informed Surveyor that while she was in the dining room, she did not observe any staff member provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode on [DATE]. 7. On [DATE] at 9:10 p.m., Surveyor interviewed LPN-H regarding R6's choking incident on [DATE]. Surveyor asked LPN-H if she was present in the second floor dining room when R6 choked and if so to describe to Surveyor what she observed happened on [DATE] during dinner time to R6. LPN-H informed Surveyor that she was in the medication room when she was asked for help setting up the suction machine on the crash/emergency cart by a CNA whom she could not recall the name of. LPN-H informed Surveyor that she then went with the CNA to the dining room on the second floor and that she (LPN-H) then attempted to set up the suction machine on the crash/emergency cart. LPN-H informed Surveyor that she was unable to set up the suction machine because the suction tubing that connected the [MEDICATION NAME] tip to the suction machine was missing from the crash/emergency cart. LPN-H informed Surveyor that she observed R6 choking while being assisted by RN Supervisor-C. LPN-H informed Surveyor that she observed R6 coughing up large chunks of broccoli while remaining conscious but confused. Surveyor asked LPN-H if she had observed, while in the dining room, any staff member provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode during dinner time on [DATE]. LPN-H informed Surveyor that while she was in the dining room, she did not observe any staff member provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode on [DATE]. 8. On [DATE] at 10:49 a.m., Surveyor interviewed CNA-K regarding R6's choking episode on [DATE]. CNA-K informed Surveyor that she was present in the dining room when R6 began choking. CNA-K informed Surveyor that on [DATE] during dinner time, the CNAs on the floor were commenting about the size of the broccoli being served to residents and that at the time she (CNA-K) did not observe any mechanical soft broccoli being served to residents who were on mechanical soft diets. CNA-K informed Surveyor that while she fed other residents, she observed R6 begin choking and then observed RN-D walk into the dining room and then begin to cue and coach R6 to spit up what he (R6) had in his mouth. CNA-K informed Surveyor that she observed R6 coughing up large pieces of broccoli from his mouth and that she then observed RN Supervisor-C arrive and take over R6's care while RN-D called 911. CNA-K informed Surveyor that she observed CMA-P deliver back slaps to R6 in an attempt to help R6 stop choking. CNA-K informed Surveyor that she heard someone (unable to remember who) request the suction machine and that she observed facility staff being unable to use the suction machine because she heard it was missing parts. CNA-K informed Surveyor that while she was in the dining room, she did not observe any staff member provide R6 with the [MEDICATION NAME] maneuver during R6's choking episode on [DATE]. 9. On [DATE] at approximately 12:22 p.m., Surveyor informed DON-B (Director of Nursing) of the above findings. Surveyor asked DON-B if facility staff should provide the [MEDICATION NAME] maneuver to residents whom are choking even if they have a DNR status. DON-B informed Surveyor facility staff should provide the [MEDICATION NAME] maneuver to residents whom are choking even if they have a DNR status. 10. On [DATE] at approximately 10:00 a.m., Surveyor observed the facility's second floor emergency/crash cart and noted that the check list for (MONTH) 2019 documented, (MONTH) 2019; Daily Emergency Equipment Checklist; The night nurse is to make sure that the equipment on the desk is located on the cart. Sign your name on the correct dated line. Equipment List; 1. Blood pressure cuff; 2. Stethoscope; 3. Yank Auer catheter; 4. O2 mask and tubing; 5. Glovebox; 6. Blood spill kit; 7. Amber bag; 8. Flashlight; 9. Suction catheter; 10. Suction Machine; 11. CPR mask; 12. Back board. Surveyor noted that the facility's second floor emergency/crash cart Equipment Checklist was not initialed or signed by any facility staff on [DATE]. The failure to provide emergency medical care (i.e., suctioning and the [MEDICATION NAME] maneuver) while awaiting emergency personnel, created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: -The facility audited all licensed nursing staff (RN and LPN) to ensure CPR certification, which includes [MEDICATION NAME] maneuver. Education was provided to all licensed nursing staff (RN and LPN) on performance of the [MEDICATION NAME] maneuver prior to the start of his/her next scheduled shift. Education was started [DATE]. The [MEDICATION NAME] Maneuver Policy and Procedure is included in agency orientation binder.

Based on interview and record review, the facility did not provide adequate supervision for 1 (R6) of 1 residents reviewed to prevent accident accidents when facility staff did not supervise R6 while eating to ensure he did not take larger than teaspoon sized broccoli during the dinner service on [DATE]. R6 choked on the broccoli and expired in the emergency room . The failure to supervise the resident while he ate and to ensure he did not try to eat more than teaspoon-sized bites as indicated in his care plan created a finding of Immediate Jeopardy that began on [DATE]. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on [DATE] at 3:31 p.m. The immediate jeopardy was removed on [DATE]. The deficiency continues at a scope and severity level of an E (potential for harm/pattern) as the facility continues to audit meal services provided which are consistent with specific dietary inteventions. Audits will be submitted to the QA Committee for review and recommendation for follow-up, if any. Findings include: R6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6's Quarterly MDS (Minimum Data Set) dated [DATE] documents short and long term memory problems. Section G (Functional Status) documents that R6 requires limited assistance and a one person physical assist for her eating needs. Section K0100 (Swallowing Disorder) documents that R6 has coughing and choking during meals or when swallowing medications. Section K0510 (Nutrition Approach) documents that R6 is on a mechanically altered diet while a resident at the facility. R6's hospital Discharge Summary dated [DATE] documents under the Brief History section, R6 has a past history of Parkinson disease who was noted to have [MEDICAL CONDITION] activity at Linden Grove while eating. He was noted to have food in his throat above the vocal cords and some beyond. He was initially having labored breathing, which improved with the removal of the food. Under the Hospital Course section it documents, aspiration pneumonia- admitted with the history as above .Speech evaluation recommended dysphagia level 2 diet which he tolerated well during his hospital stay. He had no further episodes of choking. R6's Speech Therapy Plan of Care (Evaluation Only) dated [DATE] documents, Reason For Referral: This resident was referred to therapy due to recent hospitalization for aspiration pneumonia secondary to [MEDICAL CONDITION] with food in mouth during his noon meal. Patient has a history of dysphagia where he consumed thin liquids and mechanical soft diet with no s/sx (signs or symptoms) of aspiration/choking. Previous Therapy: Patient had speech therapy during recent inpatient hospitalization where a VFSS (Video Fluoroscopic Swallowing Study) was completed and indicated recommendation for thin liquids/mechanical soft diet. Swallow guidelines include assistance with feeding, teaspoon portions no cups or straws, eat/drink slowly, medication with puree, upright for meals and remain upright 30 minutes after. Mechanical soft is highest, safest level diet due to lethargy and progressing dementia diagnosis. Initial Assessment: SLP (speech language pathologist) facilitated therapeutic meal assessment with mechanical soft diet and thin liquids during noon meal while he was upright and alert in his wheelchair . Pt (patient) demos (demonstrates) poor bolus control warranting verbal cues to slow down and take smaller bites. Per nursing, this is his baseline prior to hospital. SLP (speech language pathologist) discussed swallow guidelines, including supervision with verbal cues, teaspoon portions, no straws, eat/drink slowly, medication with puree, upright for meals and remain upright 30 minutes after. R6's Nutritional Status care plan dated as effective on [DATE] documents under the Problems section, Alteration in Nutritional Status R/T (related to) hospitalization for pneumonia AEB (as evidenced by) swallow guideline in place, need for cuing/supervision during meals, mechanically-altered diet. Under the Interventions section it documents, Provide mechanical soft, NAS (no added salt) diet as ordered, EFFECTIVE: [DATE]; Follow swallow guidelines: verbal cues, teaspoon portions, eat/drink slowly, upright for meals, meds (medications) with puree, EFFECTIVE: [DATE]. R6's nursing noted dated [DATE] documents, Late entry pm charting of critical event. Writer summoned at approximately 1815 (6:15pm) to South dining room, for this resident choking. Writer observed resident drooling and could without stethoscope hear wheezing-Writer asked resident if he could look at me and his eyes did track and writer asked him to open his mouth and spit out his food, and he did this and then writer did a finger sweep, to clear airway. He was then noted to be tremoring more than usual and had a clonic/tonic [MEDICAL CONDITION] for approx. (approximately) 1.5 minutes, high flow oxygen via mask was started and crash cart was brought to room staff continues to try and clear airway with [MEDICATION NAME] suction. He had radial pulses during entire event, mucous and partially chewed broccoli was coming from mouth- he again was asked by writer to squeeze her hands which he did. Supervising now in dining room and VS (vital signs) obtained while writer summoned FD (Fire Department)-Paramedics. Arrival within minutes he continued with drooling mucous and food remained conscious but now getting cyanotic in extremities. FF (Firefighter)/PM (Paramedic) transferred (3 person FF (firefighter) carry from W/C (wheelchair) to their stretcher without incident except small approx. (approximately) 1 in. (inch) skin tear to right outer elbow from w/c arm rail during lifting minor bleeding. Writer handed Paramedic team necessary transfer paperwork .At approximately 1925 (7:25 PM) writer rec'd (received) a phone communication that resident had expired in the ED (emergency department). RN (Registered Nurse) stated to writer she was familiar with R6 because she had also been his nurse approx. (approximately) ,[DATE] weeks earlier at similar episode where we had sent him to this ER (emergency room ) after choking. 1. On [DATE] at 2:36 p.m., Surveyor interviewed CNA (Certified Nursing Assistant)-E regarding R6's choking incident on [DATE]. CNA-E informed Surveyor that she was feeding another resident and that R6 was sitting in the dining room in his wheelchair, eating independently like he usually does. CNA-E informed Surveyor that she observed R6 choking and that she observed RN (Registered Nurse)-D walk into the room and attempt to verbally direct R6 to spit out the food he had in his mouth. CNA-E informed Surveyor that she observed R6 having difficulty breathing and spitting up large amounts of broccoli. CNA-E informed Surveyor that she did not observe any staff member feeding R6 prior to R6 choking during dinner time on [DATE]. 2. On [DATE] at 2:49 p.m., Surveyor interviewed CNA-G regarding R6's choking incident on [DATE]. CNA-G informed Surveyor that she was feeding another resident and that she did not witness R6 begin choking as she had her back towards R6. CNA-G informed Surveyor that she heard R7 yell out that R6 needed help and that she observed CNA-K go and summon RN-D whom arrived and attempted to verbally direct R6 to spit out the food he had in his mouth. CNA-E informed Surveyor that she observed R6 choking, coughing and spitting up large amounts of broccoli. CNA-G informed Surveyor that R6 ate independently, did not have any special eating devices and that staff did not have to feed or assist R6 when eating. CNA-G informed Surveyor that she did not observe any staff member feeding R6 prior to R6 choking during dinner time on [DATE]. 3. On [DATE] on 3:04 p.m., Surveyor interviewed R8 about R6's choking incident during dinner time on [DATE]. Surveyor asked R8 if he usually sat next to R6 in the dining room. R8 informed Surveyor that he usually sat and ate next to R6 in the dining room and that recently R6 had choked while in the dining room. R8 informed Surveyor that he had observed R6 eating by himself in the dining room like always and that he had observed R6 take a large amount of broccoli and stuff it into his mouth. R8 informed Surveyor that he then observed R6 begin coughing loudly and that he (R8) began to yell for help for the attendants (CNAs) to help R6. 4. On [DATE] at 3:54 p.m., Surveyor interviewed CNA-F regarding R6's choking incident on [DATE]. CNA-F informed Surveyor that while she was in the larger second floor dining room, she observed R6 appear to be choking and that she observed RN-D and RN Supervisor-C attempt to coach R6 to spit out food from his mouth. CNA-F informed Surveyor that she did not observe any staff member feeding R6 prior to R6 choking during dinner time on [DATE]. 5. On [DATE] at 4:52 p.m., Surveyor interviewed RN-D regarding R6's choking incident on [DATE]. RN-D informed Surveyor that on she was summoned by facility staff to the second floor dining room because she was told R6 was choking. RN-D informed Surveyor that when she arrived to the second floor dining room, she observed R6 sitting in his chair with CMA-P at this side. RN-D informed Surveyor that she attempted to coach and cue R6 to spit out whatever he had in his mouth as R6 was still conscious and responding appropriately. RN-D informed Surveyor that she then observed R6 have what appeared to be a [MEDICAL CONDITION] but that R6 was still able to squeeze her hands and remain conscious. RN-D informed Surveyor that R6 then coughed up large pieces of broccoli and that CMA-P was delivering back slaps to R6 in an attempt to clear his airway. RN-D informed Surveyor that she observed R6 have labored breathing but that R6 was still able to squeeze her (RN-D) hand. RN-D informed Surveyor that she then performed a finger sweep of R6's mouth and that afterwards RN Supervisor-C arrived and took over R6's care while she (RN-D) left the dining room to call 911. RN-D informed Surveyor that R6 remained conscious and with a pulse during the entire episode while she was caring for R6. Surveyor asked RN-D if she had observed any staff member feeding R6 prior to R6 choking during dinner time on [DATE]. RN-D informed Surveyor that she did not observe any staff member feeding R6 prior to R6 choking during dinner time on [DATE]. Surveyor asked RN-D if R6 required supervision during eating. RN-D informed Surveyor that she was unsure if R6 required supervision during eating and that she believed R6 had overloaded himself with broccoli and that he had put too much broccoli into his mouth. 7. On [DATE] at 10:49 p.m., Surveyor interviewed CNA-K regarding R6's choking episode on [DATE]. Surveyor asked CNA-K if she was present in the second floor dining room when R6 choked and if so to describe to Surveyor what she observed happened on [DATE] during dinner time to R6. CNA-K informed Surveyor that she did not personally serve R6's dinner plate on [DATE], but that she was sitting at the table where residents whom required feeding assistance to eat were seated. CNA-K informed Surveyor that R6 did not sit at this table because R6 ate independently. CNA-K informed Surveyor that she did not observe R6 being fed by any facility staff prior to R6 choking during dinner time on [DATE]. On [DATE] at approximately 12:22 p.m., Surveyor asked DON-B how facility staff ensured that R6 received teaspoon size bites if R6 was not being fed by any facility staff for dinner time on [DATE], and as per speech therapy's swallowing guidelines and per care plan intervention dated [DATE]. DON-B informed Surveyor that she was not sure how facility staff ensured that R6 received teaspoon size bites if R6 was not being fed by any facility staff for dinner time on [DATE]. On [DATE] at 3:31 p.m., Surveyor informed Administrator-A and DON-B of the above findings. The failure to supervise the resident while he ate and to ensure he did not try to eat more than teaspoon-sized bites created a finding of Immediate Jeopardy. The facility removed the jeopardy on (MONTH) 27, 2019, when the facility completed the following: - For all residents with a mechanically altered diet, the Program Director or RN Supervisor, or designee, has been monitoring the food being served to residents at each meal ensuring it is consistent with resident-specific dietary interventions prior to serving. The Nursing Home Administrator (NHA) or designee has initiated auditing meal service daily at alternating meals for one month, then three times per week at alternating meals for two months for compliance. Audit results will be submitted to Quality Assurance (QA) Committee for review and recommendation for follow-up, if any. - Education has been provided to dietary and nursing staff (RN, LPN and CNA) regarding consistency of mechanically altered food and compliance with resident-specific dietary interventions. Education was started effective prior to evening meal on (MONTH) 26, 2019. Staff will not be present during meal service until education is completed. - The facility has audited the crash carts to confirm all necessary equipment is in place. RN Supervisor on PM shift, or designee, is completing emergency equipment checklist located on the crash cart daily. Training has been provided to RN Supervisors effective [DATE] prior to start of shift by DON or designee. Checklist and directions are included in agency orientation binder. DON or designee will audit compliance daily for one month, weekly for two months and then monthly. Audit results will be submitted to QA Committee for review and recommendation for follow-up, if any.

Based on interview and record review the facility did not ensure that 1 (R1) 3 residents reviewed for falls received adequate supervision and assistance devices to prevent accidents. R1 was admitted to the facility on [DATE] following hospitalization for three falls in one week and increased confusion and hallucinations. Following the admission the facility provided intermittent one to one (1:1) supervision to R1 however the needed level of supervision needed was not assessed or care planned to ensure safety. Review of R1's record indicates R1 typically did not attempt to go to sleep until approximately 1:30 am most nights and was actively hallucinating and agitated throughout the day into the night. On 2/20/19 staff indicate they were providing heightened supervision to R1 that was discontinued after R1 was in her room. Staff heard a thud and found R1 on the floor. The initial finding was R1 had reopened a laceration that she had upon admission and was sent to the hospital to receive new sutures. The hospital documentation dated 2/20/19 indicates: (R1) was admitted to the hospital following her fifth fall this month. Imaging of (R1's) head and neck show a cervical spine fracture of C1 and C2, large hematoma to the left frontal region and 4 cm (centimeter) linear laceration to the left forehead that was sutured. Findings include: The facility policy, entitled Resident Safety: Supervision Types and dated (MONTH) (YEAR), states: Policy: Lindengrove understands that the identification of individual risk factors forms the basis for the type and amount of supervision required to prevent and/or limit the number of falls or other injuries. Purpose: The intent of this policy is to describe types of supervision in order to provide guidance in decision-making on the type and frequency of supervision required to assist with preventing injuries and accidents (e.g.) (for example) falls and unsafe behaviors) but yet respecting resident privacy and resident rights. Supervision/Adequate supervisions refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the resident's assessed needs and identified hazards in the resident's environment. Adequate supervision may vary from resident to resident. Procedure: I. Risk assessment i.e. (in other words) Elopement/Wandering, Falls and other pertinent evaluations i.e. [MEDICAL CONDITION], behaviors, are reviewed to identify resident specific areas which would require further assessment/information gathering to determine an initial plan of care for the prevention of accidents and/or injuries. This is an interdisciplinary team activity. II. Based on the information obtained through assessment of accident/injury related risk factors, a type and frequency of supervision is determined. Constant Supervision- continuous visual supervision is required when a resident cannot be left alone. Distance may vary based on the residents response to supervision i.e. increased agitation-distance may vary i.e. arm's length, 6-8 feet. The goal is to reach the resident within seconds when an unsafe behavior occurs. Intervention example: 1:1 provided. R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1's Hospital Discharge Summary, dated 2/12/19, documents: .Principle Problem: Recurrent falls, [MEDICAL CONDITION] without behavioral disturbances (with visual hallucinations); stroke . Important Issues for Outpatient Follow Up: Patient admitted with multiple frequent falls and hallucinations secondary to her dementia, discharge on 12.5 mg (milligrams) of [MEDICATION NAME] at bedtime for her hallucinations and dementia. Patient has a skin laceration on the left forehead status [REDACTED]. On 2/12/19, at 5:58 pm, R1's medical record documents: Patient admitted for rehab (rehabilitation), has dementia and HS (hour of sleep) behavioral disturbances and was started on [MEDICATION NAME] 12.5 mg. R1's Nursing Comprehensive Assessment, dated 2/12/19, documents: .Fall Risk Assessment: Level of Consciousness/Mental Status/Behavioral Issues- 4= Intermittent confusion; Has resident's cognitive status changed during the last assessment period- Admission assessment; Does the resident display any of the following behaviors: Wandering, abusive, resists care, easily distracted, easily distracted, periods of altered perception of awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental health function varies over the course of the day = Yes; History of falls (Past 3 months) - 4 = 3 or more falls in the past 3 months; Ambulation/Elimination Status -2 = Chair Bound/Requires assist with elimination; Moderately Impaired-limited vision; not able to see newspaper headlines but can identify objects; Gait/Balance - 2 = N/A (not applicable) - not able to perform function; Blood Pressure (Systolic) = 147 Blood Pressure (Diastolic) = 86 . Medication: left blank; Medication change or change in dosing scoring: left blank; Predisposing Disease Scoring: left blank; Total Fall Risk Assessment Score: left blank; Interventions: left blank; Fall Risk Summary: left blank R1's undated Baseline Care Plan, documents: At risk for falls r/t (related to) (this area is left blank). Interventions include: Encourage R1 to self-propel w/c (wheelchair) on unit; Individualized fall prevention measures on RST (Resident Summary Template/Certified Nursing Assistant) Care Card; Footwear will fit properly and have non-skid soles; Keep areas free of obstructions to reduce the risk of falls or injury; Place call bell/light within easy reach; Provide reminders to use ambulation and transfer assist devices as needed; Remind resident to call for assistance; Respond promptly to calls for assist to the toilet; Complete Fall Risk Assessment per policy. The baseline care plan also includes: Wandering behavior, wears wander guard. Interventions include: Assess potential physical caused for wandering; Check location/whereabouts of resident every 30 minutes on each shift; Provide diversional activities (folding, rummaging box, packing/unpacking); Record behaviors on Behavior Tracking Form; Redirect resident behavior/activity when wandering is observed; use wander guard/location monitor day. R1's Comprehensive Care Plan, dated 2/12/19, documents the same care plan for falls as the baseline care plan. R1's RST (Certified Nursing Assistant Care Card), dated 2/12/19, 2/18/19, and 2/20/19 all document: Safety Precautions: left blank; Safety Comments: left blank; Targeted Behaviors: left blank; Interventions to Use: left blank; Things That (MONTH) Worsen Behaviors: left blank. On 2/13/19, at 5:31 am, R1's medical record documents: Resident admitted to rehab with hx (history) of multiple falls, dementia, and sutures to a large laceration on the left side of head. On 2/13/19, 2:07 pm, R1's medical record documents: Resident is alert and oriented to self, confused and forgetful, hallucinations noted throughout shift, speaking to objects as people, speaking to dogs and people that are not there. Sitting at nursing station most of shift. Resident will continue to be monitored. On 2/13/19, at 4:00 pm, R1's medical record documents: Resident here for rehab. Dx (diagnoses): Falls, laceration to head, poor vision. Resident is alert to self. Resident is yelling to children that are not here. Resident appears to be more agitated as time progresses. All staff provide one to one interventions that are not always effective. Surveyor noted there is no indication about one to one supervision on R1's baseline, comprehensive or CNA care card plans of care. On 2/13/19, at 6:47 pm, R1's medical record documents: Resident placed on 24 hour board. Wander guard placed on wheelchair. Resident is agitated and has made multiple attempts to self-transfer. Visual hallucinations of grandchildren being next to her and running away. Asking to get out of here. Not easily redirected. Activities provided but not effected. Placed on MD (Medical Doctor) board. On 2/14/19, at 6:56 am, R1's medical record documents: Pt (patient) on 24 hour board for new admission and behaviors. Pt awake until 0130 (1:30 am). Confused and easily provoked. In w/c (wheelchair) and on 1:1 supervision while awake. Hallucinating. Visual hallucinations. Pt refused any fluids early on night shift. Thought we were poisoning her. Slept short intervals. Up early wandering on unit in w/c (wheelchair). Needed 1:1 supervision. Less Paranoid this am. Surveyor again noted there is no documented individualized plan of care regarding 1:1 supervision to indicate when, how long and what 1:1 supervision means for R1. R1's Physician's Admission note, dated 2/14/19, documents, Reason for admission: Frequent falls, dementia. History of present illness: Patient admission from 2/10-12 with frequent falls (3 falls in less than 1 week) and hallucinations secondary to dementia. Psychiatry was consulted while inpatient started on [MEDICATION NAME] for her hallucinations. On 2/15/19, at 4:37 am, R1's record indicates: Pt awake and on 1:1 supervision until 0130. Holding doll. Actively hallucinating. Visual types. In w/c. Wander guard in place and functioning. R1's Comprehensive Care Plan for Wandering dated 2/15/19, documents the same care plan for wandering behavior as the baseline care plan. R1's Admission Minimum Data Set (MDS) assessment, dated 2/18/19, documents: Brief Interview of Mental Status (BIMS) score of 11, indicating R1 has mild cognitive impairment; Personnel Health Questionnaire (PHQ-9) score of 3, indicating R1 has minimal depressive symptoms; R1 demonstrates hallucinations and delusions; 1-3 times per week demonstrates behaviors not directed towards others that significantly interferes with R1's care and participation in activities or social interaction and significantly disrupts the living environment; 1-3 days a week R1 rejects staff assistance with cares and exhibits wandering that places R1 at significant risk for getting into a potentially dangerous place; R1 requires extensive assist of two staff for: bed mobility, transfers, dressing and toilet use; requires extensive assist of one staff for: walking, eating and personal hygiene; documented to have had falls within the last month prior to admission; received an antipsychotic and antianxiety medication during the last 7 days or since admission. On 2/18/19, at 4:49 am, R1's medical record documents: . Resident awake all N[NAME] (night) shift, multiple interventions (toileting, 1:1, reduced stimuli, PRN's (as needed) offered) attempted throughout the shift to help resident sleep. Resident having verbal and visual hallucinations; resident talking to her children and seeing her children this shift. At 04:30 resident was brought out into the common area r/t (related to) multiple times found sitting on the edge of the bed. Resident was asked if she would like to fold some laundry; resident has been content with this activity thus far. On 2/18/19, at 6:13 pm, R1's medical record documents: Patient has been hallucinating most of the shift, talking to herself, the baby or family. Patient has been a 1:1 supervision due to attempts to self- transfer, agitation and confusion. On 2/18/19, at 9:30 pm, R1's medical record documents: Patient was severely agitated tonight 1:1 all shift with CNA and writer. Attempting to walk around without walker multiple times, hallucinating that doctors are beating her baby, having multiple crying episodes where she is concerned about her baby being shaken by the doctor. Patient yelling at anyone who approaches her. Patient refuses her pm meds (medications). Multiple attempts needed for HS (hour of sleep) meds. On 2/20/19, at 9:24 pm, R1's medical record documents: Resident being monitored for behaviors. Continued having verbal and visual hallucinations. Resident is agitated and multiple attempts to get out of chair. Refusing meds, was able to give scheduled [MEDICATION NAME]. Not effective. Was able to contact son to help calm resident down. Will continue to monitor. Surveyor noted there is no indication what the level of supervision R1 required on this day given documentation on previous dates of needing 1:1 supervision and no clear, individualized plan of care for safety/supervision of R1. On 2/20/19, at 10:13 pm, R1's medical record documents: Staff heard thud and resident calling out. Staff found resident lying on her left side parallel to the end of the bed. Staff noted resident has a laceration to the left side of forehead that has scant amount of bleeding. Staff also noted a large hematoma above the left eye. Resident transferred to the hospital on [DATE] after the fall and did not return to the facility. R1's Emergency Department Impression, dated 2/20/19, documents: (R1) was admitted to the hospital following her fifth fall this month. Imaging of (R1's) head and neck show a cervical spine fracture of C1 and C2, large hematoma to the left frontal region and 4 cm (centimeter) linear laceration to the left forehead that was sutured. The Care Area Assessment (CAA) completed in conjunction with R1's Admission MDS was signed as complete by a facility RN on 2/21/19. Surveyor noted this is the day after R1 fell . The CAA indicates: Resident triggers for falls related to her current balance status as well as related to her recent hospitalization for multiple falls related to progressive decline due to multiple medical factors including her [MEDICAL CONDITION]. She is alert to self but confused and does present with hallucinations. She is extensive assist with staff for most aspects of care, she does participate in therapy to make gains in functional independence, she is toileted per schedule, request and PRN (as needed) and does have incontinence care provided with any episodes of incontinence. She is kept in supervised areas as much as possible with 1:1's, is given laundry to fold and doll to hold as diversions to behaviors. She does have wander guard on w/c (wheelchair) to prevent elopement attempts and possible falls out of line of sight. She has had no falls on unit since admit. She does have bed in low position at all times, call light in reach, and frequently used items within reach. Staff will continue to observe for any changes in mood, behavior or risk factors and continue to adjust P[NAME] (plan of care) to promote independence . Surveyor noted R1's comprehensive care plan was initiated/dated 2/12/19 prior to the completion of R1's CAA. Surveyor also noted the information noted in the CAA was not part of the comprehensive plan of care. On 3/20/19 at 2:36 PM, Surveyor interviewed, Registered Nurse (RN) - E, who stated, she was on duty on 2/20/19, the night R1 fell . RN-E stated, R1 was alert, forgetful, calling out, screaming and was disruptive prior to the fall. RN-E asked staff to provide 1:1 supervision for R1 in her room due to her agitated and disruptive behavior. At some point in the evening R1 became calmer and was no longer disruptive, so RN-E told staff that 1:1 supervision of R1 was no longer needed and R1 was left in her room. RN-E stated that nurse on duty along with the supervisor are able to determine if a resident requires 1:1 supervision. When 1:1 supervision is found to be necessary the staff on the unit would take turns providing the 1:1 supervision. On 2/20/19 a new employee was in training on the unit and RN-E instructed the new employee to provide 1:1 supervision for R1 this freed up R1's assigned nursing assistant to care for other residents. RN-E stated that staff report off from shift to shift about R1's behaviors and if 1:1 supervision is needed or if close supervision near the nursing station was required. RN-E stated that she determined that R1 no longer required 1:1 supervision the night of 2/20/19 once R1 was briefly quiet and not disrupting others. RN-E stated that she wasn't sure if the facility had a policy on starting or ending 1:1 supervision for a resident. RN-E stated, at times she provides nursing supervision for the facility and believes it is a unit manager or unit nurse decision to determine when a resident requires 1:1 supervision. RN-E stated, looking back at the situation she does not believe R1 was safe in her room as R1 would refuse to go to bed and would become agitated and have hallucinations. On 3/20/19, at 2:51 pm, Surveyor interviewed Certified Nursing Assistant (CNA)-F, who stated, she was assigned to care for R1 on 2/20/19, the evening of the fall. CNA-F, stated R1 was totally confused, would try to get up and sometimes she could be calm. Usually R1 was kept by the nursing station and 1:1 supervision was needed at times. When it was time to go to bed R1 would at times refuse and R1 would stay up late at night. CNA-F stated, she had a new staff (trainee) assigned with her that evening (2/20/19). The nurse asked staff to provide 1:1 supervision of R1 and the trainee was assigned to provide the 1:1 since the other staff needed to take care of the other residents. CNA-F could not state who told the trainee to provide the 1:1 supervision for R1 or when the 1:1 of R1 ended on that shift. CNA-F stated, she doesn't know at the start of a shift which resident would need 1:1 supervision or not. CNA-F stated the unit nurse might just tell the CNA's later in the shift that someone needed 1:1 supervision. On 3/21/19, at 9:01am, Surveyor interviewed Director of Nursing (DON)-B and Nurse Manager (NM)-C, who stated R1's Fall Risk Assessment was not completed correctly and R1's Fall Risk Score was not calculated. The fall risk assessment, per facility policy, is one of the assessments used to determine the initial plan of care for prevention of accident and/or injuries and type and frequency of supervision needed. On 3/21/19, at 9:35 am, Surveyor interviewed DON-B, who stated she didn't believe R1 was truly receiving 1:1 supervision because the staff would have needed to contact her to arrange for staff to be available for 1:1 supervision and that had not happened. DON-B stated that R1 required increased supervision due to behavior concerns. DON-B stated that R1 had a huge change in condition with the last fall and the agitated behaviors and hallucinations were new for R1. Surveyor asked DON-B if she would expect R1's new behaviors and interventions to be addressed on the care plan. DON-B stated no, due to R1 being new to the facility and only a baseline care plan would have been created and it should be addressed in the baseline care plan at this time. DON-B stated that R1's behaviors and interventions would not be added to the CNA care card or until after R1 was evaluated by psychiatric services since staff did not know what interventions worked for R1 until the evaluation. R1 was scheduled to see psychiatric services on 2/21/19 when she was admitted to the facility on [DATE]. Surveyor asked DON-B how staff, including in-house pool staff, would know how to provide care and interventions for R1 when behaviors were demonstrated from the first night of R1's admission. DON-B stated it should all be addressed on R1's baseline care plan and by verbal report from staff to staff. Surveyor informed DON-B of interview with CNA-F, assigned to care for R1 the night of the fall, and CNA-F not being aware R1 required 1:1 supervision and did not know why the 1:1 supervision was ended before R1's fall. DON-B stated that she would need to look into the issue but believes staff use the term 1:1 supervision too loosely. Surveyor informed DON-B, staff have documented that R1 required 1:1 supervision multiple times from R1's date of admission to the date of the fall. DON-B stated that this could be confusing for staff and she would need to look into this concern as to how staff would be alerted to the level of supervision a resident would need and when the increased supervision needs would end to allow residents' to remain safe. On 3/21/19, at 10:20 AM, Surveyor informed Administrator-A of the concerns regarding, R1's baseline and comprehensive care plan and CNA Care Card not addressing R1's behavior concerns of agitation, hallucinations, rejection of care, need for increased supervision and 1:1 supervision and interventions that are effective. Surveyor informed Administrator-A of the concern that staff are not aware of how to communicate to other staff the need for a resident to receive increased supervision and how to assess when the increased supervision is no longer required. R1 was documented to be agitated on 2/20/19 experiencing hallucinations and agitation requiring 1:1 supervision. The 1:1 supervision was ended and the R1 fell about 35 minutes later. Staff assigned to care for R1 the evening of the fall could not give criteria for why the 1:1 supervision ended shortly before R1's fall. Administrator-A, stated she believes the term 1:1 supervision is used loosely at the facility and she would expect staff to be aware of a residents behavior concerns, interventions and need for increased supervision and for care plans and the CNA Care Cards to be updated to reflect such information and is not sure why that wasn't completed for R1. No further information was provided.

Based on observation, interview and record review the facility did not ensure 1 of 1 Resident (R22) reviewed for abuse, was free from Resident to Resident sexual abuse. On 8/29/18, the facility did not protect R22 from inappropriate sexual abuse contact after becoming aware of an earlier incident of inappropriate sexual contact between R79 and R22, which occurred on 8/24/18. After the 8/24/18 (first) incident of inappropriate sexual contact between R79 and R22, the facility did not implement effective measures to protected R22 from a second incident of sexual abuse occurring on 8/29/18. On 8/24/18, R79 was observed inappropriately, intimately touching R22 and was placed on close supervision. Close supervision allowed R79 intervals of time not in direct observation of staff with vulnerable peers on the same unit. On 8/29/18, R79 was observed inappropriately, intimately touching R22 and was placed on 1:1 supervision while in a wheelchair. R79's care plan continues to include 1:1 supervision while in wheelchair. On 9/10/18 and 9/11/18, R79 was observed sitting in his wheelchair without 1:1 supervision. Findings include: The facility policy entitled, Resident Safety: Supervision Types, dated (MONTH) (YEAR), states: Facility understands that the identification of individual risk factors forms the basis for the type and amount of supervision required to prevent and/or limit the number of falls or other injuries. The purpose: The intent of this policy is to describe types of supervision in order to provide guidance in decision-making on the types and frequency of supervision required to assist with preventing injuries and accidents (e.g. (example) falls and unsafe behaviors) but yet is respecting resident's privacy and resident rights. Based on the information obtained through assessment of accident/injury related risk factors, a type and frequency of supervision is determined. Increased supervision-visual supervision at specified intervals as required in anticipation of resident needs or unsafe behavior. Intervention Example: Visual checks of resident when in his/her room every 30 minutes. Constant supervision-continuous visual supervision is required when a resident cannot be left alone. Distance may vary based on resident response to supervision i.e. (example) increased agitation-distance may vary i.e., arm's length, 6-8 feet. The goal is to reach the resident within seconds when an unsafe behavior occurs. Intervention Example: 1:1 provided. R79 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R79's Quarterly MDS with an Assessment Reference Date (ARD) of 8/28/18, documents a BIMS (Brief Interview of Mental Status) assessment score of 4, indicating R79 is severely cognitively impaired. R79 demonstrates behavior symptoms of physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, rejection of staff assistance with care and wandering. R79's Care Plan, dated 5/17/18, with a target date of 11/30/18, states: Alteration in mood/cognition/behaviors/physical well-being- potential for difficulty in adjustment to placement. Potential for yelling at staff, swearing at staff, verbally aggressive with others, rejecting cares, refusing therapy, becoming easily upset. Potential for little interest/pleasure in doing things, trouble sleeping, poor appetite, trouble concentrating, inappropriate sexual touching towards staff and residents, inappropriate sexual comments towards staff. Interventions include: Monitor for signs or symptoms of depression; maintain eye contact during interactions; speak calmly use gentle mannerisms; encourage resident to express sadness or frustration; offer support and understanding and reassurance; provide reassurance as needed; nonverbal communication: use gentle touch, music, mirror their body language, match the emotion, observe their gut emotion, bend or stoop to face sitting residents; pleasant and cheerful communication and conversation; encourage residents involvement in daily decision making; reassure resident during periods of distress/anxiousness. Speak in a calm voice; validate feelings; educate and inform resident of care to be provided. Encourage his involvement in care-praise him for attempts. Due to hx (history) of inappropriate touching of staff, staff to be aware during care. If inappropriate, be firm and ask him to please stop this is not appropriate; verbal communication: repeat key words, reminisce, validate feelings, ask simple questions, maintain eye contact, speak in slow, calm voice; provide cues and reminders; praise efforts to complete tasks; use simple commands and directions; calmly approach resident. Re-approach resident as needed if rejection cares. Attempt familiar caregivers and attempt to follow his preferred routine; encourage deep breathing when anxious or upset; involve in activities of interest when anxious; if upset, assess to ensure all physical needs have been met. Monitor that environment is not too stimulating. Staff may offer drinks' snack assess for comfort, assess for toileting needs; may enjoy watching birds, news, current events, car magazine music (50's, 60's- Fats Domino and Chuck Barry); encourage family visits for additional support; encourage activities that give resident a sense of value as tolerated-may become agitated with activities; encourage friendship with peers and families (enjoys socializing with others); reassure resident that his wife is fine and she/family know where he is. Tell him she usually visits every day and maybe running an errand. Resident often has aggressive outbursts when observing group programs and often disrupts other residents in activity. Wears a wander guard. Needs great deal of redirection. Target date of 11/27/18. Interventions include: Invite, remind and transport the resident to and from activities of choice. Redirect him when necessary; provide the staff with material to do leisure activities as requested; provide the resident with monthly activity calendar and point out activities of interest; Focus on: music and animals; provide unhurried space; try smaller groups with resident for a more controlled environment; redirect resident from other residents when having behavior problems; resident is having behavior problems, have resident not in dining room; 1:1 when in wheelchair. A Misconduct Incident Report documents: On 8/24/18 at approximately 5:00 PM, R79 was sitting near the nursing station and was observed with his hands on a female resident's, R22's, thigh and down the front of the slacks, on the outside of the incontinent product. Per facility investigation, R22 did not appear to have a negative reaction to the incident. The residents were separated. R79 was placed on increased supervision. This intervention was not placed on R79's care plan. The facility has no documentation that close supervision was provided to R79 following this incident. This incident was reported to the Administrator and the state agency on 8/25/18 at 12:50 PM, with the results of the facility's investigation submitted to the state agency on 8/30/18. A second Misconduct Incident Report documents: On 8/29/18 at 3:10 PM, a staff person reported that R79 had placed his hands in the front of and inside a female resident's, R22, incontinent product. R22 is the same resident that was involved in the 8/24/18 incident. The Facility self-report documents R22 did not report fear of R79 and no physical signs of injury were noted on R22. It is documented in the self-report that R79 was placed on and remains on 1:1 supervision. The police were contacted and arrived at the facility to interview staff and resident. No further action was taken was taken by the police. The incident was reported to the Administrator and state agency on 8/29/18 at 5:21 PM with the results of the facility's investigation submitted on 9/4/18. Review of R22's record indicates R22 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R22's Quarterly Minimum Data Set (MDS), with an ARD of 7/10/18, documents a Staff Assessment of Mental Status of, severely cognitively impaired. R22 is also totally dependent on one staff person for locomotion on and off the unit. On 9/10/18 at 11:28 AM, R79 was observed sitting in his wheelchair at the nurses station unsupervised. No facility staff was observed at or around the nursing station. R79 was not provided with 1:1 as per his care plan. R79 was seated in a wheelchair with 3 other peers in close proximity. No staff was within 6-8 feet of R79 thus allowing R79 the potential to engage in another resident to resident altercation with peers. On 9/10/18 at 11:56 AM, R79 was observed sitting in a wheelchair unsupervised by facility staff, sitting next to the nursing station. Staff was visible half way down a hallway assisting another resident into their room. Three peers were seated in close proximity to R79. R79 was not provided with 1:1 as per care plan. No staff was within 6-8 feet of R79 thus allowing R79 the potential to engage in another resident to resident altercation with peers. On 9/11/18 at 08:26 AM, R79 was observed being assisted into the dining room by staff. R79 was seated at a table next to the entrance to the Dining Room and seated with a male peer at the table. The staff walked away from R79 and assisted peers with breakfast distribution. R79 was observed in his wheelchair and was not provided 1:1 as per care plan. No staff sat with R79 while in the Dining Room. No staff was within 6-8 feet of R79 thus allowing R79 the potential to engage in another resident to resident altercation with peers. On 9/13/18 at 11:22 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated: staff should be within 5 feet of any resident that the facility has assessed to required 1:1 supervision and residents should not be left without 1:1 supervision at any time. Surveyor informed DON-B of the observations that R79 was left unsupervised and not within 5 feet of staff. DON-B stated that R79 remains on 1:1 supervision at this time, due to his sexual behavior and staff should not have been further than 5 feet from R79. DON-B stated she would expect staff to maintain 1:1 supervision of R79 and is not sure why this wasn't the case. On 9/13/18 at 11:28 AM, Surveyor interviewed Administrator-A, who stated that R79 was involved in resident to resident altercations. The facility believes the altercations are related to R79's advanced dementia and that the facility has an over stimulating environment. The facility is assisting R79's family with more appropriate placement at a smaller, less stimulating environment. Administrator-A stated the facility staff reviewed the investigations and provided appropriate interventions to provide safety to the residents involved in altercations. Administrator-A stated the facility is aware of the safety concerns with R79 and that is why the police were called and the facility is assisting the family with more appropriate placement. Surveyor asked Administrator-A what interventions were put into place to protect residents from further abuse after R79's resident to resident altercation on 8/24/18. Administrator-A stated the facility increased R79's supervision. Surveyor expressed concern to Administrator-A that the intervention did not prevent another resident to resident altercation from occurring 5 days later between R79 and R22. Administrator-A stated she was aware and that is why the facility called the police after the incident on 8/29/18. On 9/13/18 at 1:55 PM, Surveyor informed Administrator-A of the concern that the intervention of increased supervision following R79's resident to resident sexual contact with R22 on 8/24/18 did not prevent the same altercation from occurring with R22 on 8/29/18, thus the facility did not prevent further resident to resident abuse. Surveyor also informed Administrator-A of the on-site observations of R79 not receiving 1:1 supervision from the staff thus allowing the potential for other resident to resident altercations to occur with R79. Administrator-A stated she understood the challenges of caring for R79 and does not know why the staff isn't providing 1:1 supervision of R79. Although R22 showed minimal response to the incidents that occurred on 8/24/18 and 8/29/18, using the reasonable person concept it is likely that a vulnerable person who is unable to defend herself could experience chronic or recurrent fear or anxiety when the facility fails to protect her from unsolicited sexual advances. According to the Network of Victim Assistance's Webpage found at <http://www.novabucks.org/otherinformation/rape/>: Sexual assault takes many forms including attacks such as rape or attempted rape, as well as unwanted sexual contact or threats. Usually a sexual assault occurs when someone touches any part of another person's body in a sexual way, even through clothes, without that person's consent . .The law generally assumes that a person does not consent to sexual conduct if he or she is forced, threatened or is unconscious, drugged, a minor, developmentally disabled, chronically mentally ill, or believe they are undergoing a medical procedure. Some examples of sexual assault include .Someone touching, fondling, kissing or making any unwanted contact with your body .Since every person and situation is different, victims of sexual assault will respond to an assault in different ways. Many factors can influence an individual's response to, and recovery from, sexual assault .

Based on staff interview and record review, the facility did not ensure that the resident environment remained free from accident hazards for 1 of 7 residents (R4) reviewed with history of falls. On 3/25/17, R4 received 9 head sutures after a fall from bed. The Certified Nursing Assistant (CNA) did not follow R4's care plan, utilizing the assist of 2 staff members for bed mobility when changing R4. Findings include: Surveyor reviewed R4's medical record on 7/5/17. R4's [DIAGNOSES REDACTED]. R4's Significant Change Minimum Data Set ((MDS) dated [DATE] indicates R4 requires extensive assistance of two staff members for bed mobility. The MDS indicates R4 has no rejection of cares. The MDS reflects R4 had a fall since admission or prior assessment which ever is more recent. The MDS indicates R4 had 1 fall with injury and 1 fall with major injury. R4 scored a 12 on the BIMs (Brief Interview for Mental Status) which indicates R4 is moderately cognitively impaired. R4's Quarterly MDS' dated 2/8/17 and 5/3/17 documents R4's bed mobility as extensive assistance with 1 physical staff assistance. R4's care plan with an effective date of 11/21/16 to present addresses an Alteration in Mobility . which includes interventions such as keep free of obstructions, place call bell/light within easy reach, remind to call for assistance, proper footwear, pummel cushion etc. R4's current Resident Summary Template (CNA Care Card) updated 5/8/17, has Bed Mobility Level of Help and Toileting Level of Help as 2+ person physical help. R4's clinical notes and Resident incident follow up reports indicate the following: 10/9/16- Fall, sent to ER. Laceration to scalp. Returned same day with 6 staples .According to a Resident incident follow up, resident was in her wheelchair and reaching for something when incident occurred . Resident self propels wheelchair. Remind to use call light and will have OT (Occupational therapy) assess functional ability for use of reacher. 1/20/17 - Resident was reaching for something in bathroom and slid out of wheelchair .resident tries to be as independent as possible and do as much as she can for herself .mobility per wheelchair and assist of 2 and gait belt transfers. Action plan to add Dycem to wheelchair, remind to call for help if she cannot reach something. 3/25/17 @0507 (5:07 am) - rolled out of bed, hit head on night stand, scalp laceration. 9 sutures. Surveyor reviewed facility's Incident Report on R4's fall from bed which occurred on 3/25/17. The report indicated, on 3/25/2017 at 4:15 am, a Certified Nursing Assistant (CNA) was changing the incontinence product on R4 without any other CNA assisting. The CNA rolled R4 onto her side and R4 rolled out of the bed, hitting her head on the nightstand. R4 sustained a scalp laceration that required nine sutures, which required a hospital visit for suture placement. The Resident Incident Follow Up form completed on 3/29/2017 indicates two staff assist with bed mobility was a safety measure already in place at the time of the incident. The summary section states the staff will continue to follow care plan of assist with 2 for bed mobility. The current Resident Summary Template (CNA Care Card) continues to have Bed Mobility Level of Help and Toileting Level of Help as 2+ person physical help. The Resident Incident Follow Up summary has documented, IDT (interdisciplinary team) reviewed this incident, staff member counseled on following the care plan. On 7/6/2017 at 2:17 pm, Surveyor discussed incident with Director of Nursing (DON)-B. DON-B stated the nurse was called to the room by the CNA who did an assessment of R4. The CNA that was performing cares gave a statement to the nurse about what had happened. The CNA was counseled on following the plan of care. The DON-B indicated that no other staff was trained on following the plan of care after this incident. The incident was not self-reported to the State. DON-B stated she and Chief Clinical Officer (CCO)-G discussed the situation afterwards and agreed it should have been reported. On 7/6/17 at 2:50 p.m. at the facility exit meeting, Surveyor shared the concerns regarding R4 with CCO-G, Nursing Home Administrator-A, Interim DON-C, and DON-B. No additional information was provided.

Based on record reviews and staff interviews, the facility did not ensure it had an effective infection control program consisting of recognizing and preventing outbreaks, tracking and monitoring during an outbreak, and proper hand hygiene per current standards of practice. - The facility did not recognize and take immediate preventive measures when ARI (acute respiratory illness) symptoms were discovered. Resident #15, #16, and #17 developed ARI symptoms on [DATE]. The facility did not identify that an Influenza A outbreak had occurred until [DATE] and did not implement timely aggressive measures to prevent the spread of infection. The facility had a 2nd Influenza A outbreak identified on [DATE] with a total of 4 (Resident #27, #13, #10 and #9) residents with symptoms. Two of these residents ( #27 and #9) had symptoms prior to [DATE] without documented preventive measures. Failure to implement immediate measures to prevent the spread of an infection placed all residents at risk. - The facility did not have a documented investigation that included education during the outbreak, outbreak protocol measures and plans of care for the residents infected/ isolated. (CROSS REFERENCE F279 Residents #3, #15, #16, #9, #17 and #24). - The facility did not ensure accurate line lists during the outbreak to include onset and well dates of symptoms (Resident #27, #9 and #24). - The facility did not calculate accurate infection rates related to residents with Influenza and ARI. These concerns regarding the recognition and prevention of an influenza A outbreak in the facility [DATE] and [DATE] led to a finding of Immediate Jeopardy starting on [DATE]. On [DATE] at 2:45 p.m. the facility administration staff was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity level of an F (potential for more than minimal harm that is not immediate jeopardy/ widespread) until all components of the facility's plan of correction has been fully implemented, including ongoing monitoring for effectiveness. Continued noncompliance is also evidenced by the following: -LPN-E (Licensed Practical Nurse) did not use proper hand hygiene per standards of practice when administering eye medication to Resident #25. This was observed with 1 of 33 medication opportunities. Findings include: Surveyor # reviewed the facility's policy and procedures for Infection Control-Surveillance and Control of Influenza like Illness revised [DATE] on [DATE] at 9:40 a.m.. The policy is to provide guidance to administration and staff in accordance with accepted standards of practice in the surveillance and control of actual and/or suspected cases of Influenza and Influenza like illness. This also included ARI (acute respiratory illness), which is defined as/include 2 or more of the following: fever, cough, runny nose, sore throat and muscle aches. An outbreak is defined as 3 or more residents and/or staff from the same unit with illness onsets within 72 hours of each other and who have: Pneumonia, or ARI, or Lab confirmed viral or bacterial infection including Influenza. At this time advance infection control measures should be initiated and symptomatic residents should be isolated with standard precautions along with droplet precautions. The facility's policy and procedure for the Infection Control Program revised [DATE] was reviewed by Surveyor # . The policy indicates the facility recognizes the importance of an effective, facility-wide infection control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Surveillance will help to ensure that infections are prevented, and then controlled within the facility. Isolation procedures are defined and records are maintained of all activity related to infection control. The facility utilizes McGeer's definitions as one of the criteria for management of infections. The facility includes CDC (centers for disease control) for outbreak criteria. On [DATE] at 1:43 p.m. Surveyor # spoke with ADON-C (Assistant Director of Nurses) who is the facility's Infection Preventionist. ADON-B indicated the facility had an Influenza A outbreak in [DATE] on Unit C and provided the outbreak summary. The outbreak summary indicates the outbreak started on [DATE] with 4 residents on Unit C, 3 of the residents were swabbed for Influenza and all 4 were isolated. On [DATE], 2 of the 3 residents tested were positive for Influenza A and by the end of the day there was now a total of 14 residents with symptoms on Unit C and 1 resident on Unit D with symptoms. On [DATE] Unit C residents were now considered an outbreak and their protocol was started. On the Resident line list it indicates on [DATE] Resident #15, #16 and #17 had ARI symptoms. This would indicate that symptoms started before the outbreak protocol was started to prevent the spread of infection. ADON-C indicated that they were made aware of residents with symptoms on [DATE]. When going through the medical records and 24 hour reports of the 4 residents, it was noted that they had symptoms on [DATE]. ADON-C indicated that they would not consider that an outbreak until they had 3 confirmed Influenza A swabs, which occurred on [DATE]. The facility had another Influenza A outbreak in [DATE]. The outbreak summary indicates that on [DATE] four residents on Unit A had symptoms of ARI and were swabbed for the flu. The unit was placed in isolation, including the affected residents. The swabs showed 3 of the 4 residents were positive for Influenza A on [DATE]. However the resident line list indicates Resident #27 had symptoms on [DATE] and Resident #9 had no specific onset dates for symptoms besides the month and year (,[DATE]). Appropriate precautions were not put in place when care for these residents to prevent the spread of an infection. Resident #10 and #13 developed symptoms on [DATE]. ADON-C indicated that on [DATE] when there were now 3 residents with symptoms, swabs were done, and when all 3 (Resident #27, #13 and #10) were positive for Influenza A the outbreak protocol started. On [DATE] at 9:40 a.m. Surveyor # and # spoke with ADON-C and DON-B (Director of Nurses) regarding the infection control program and facility outbreaks. ADON-C indicated that when 3 residents on Unit C came back with positive Influenza A the outbreak protocol was started. ADON-C indicated that 3 positive swabs are considered an outbreak. ADON-C and DON-B indicated that they did not receive any phone calls related to the 3 residents with symptoms on [DATE]. However they would not indicate an outbreak unless 3 residents who tested positive for Influenza A were identified. This was also for the [DATE] Influenza A outbreak. The facility's policy and procedures were reviewed along with request for Unit C and D 24 reports for the outbreak period. DECEMBER INFLUENZA OUTBREAK 2014 The 24 hour reports and progress notes for [DATE] on Resident #15, #16 and #17 were reviewed for the [DATE] outbreak by Surveyor # . Resident #15 had symptoms of not feeling well, chills, general discomfort and occasional cough documented for day shift on [DATE]. Resident #16 had symptoms of tired, general malaise, cough, elevated temperature documented for the evening shift. Resident #17 had symptoms of cough with tan sputum, wheeze and being tired. There is no indication on the 24 hour reports or the progress notes that any of these residents were placed in isolation and any outbreak protocol was initiated. On [DATE] at 2:15 p.m. Surveyor # spoke with RN-L (Registered Nurse) who was the day supervisor on [DATE]. RN-L indicated that if they had any residents on isolation it would be charted on the 24 hour reports and in the progress notes. RN-L would consider an outbreak if there were 3 people of like symptoms in the same area. RN-L does not recall the day's events on [DATE]; however if anyone was on isolation it would be on the 24 hour report. RN-L would call DON-B if there were 3 residents with symptoms. On [DATE] at 2:20 p.m. Surveyor # spoke with LPN-J (Licensed Practical Nurse) who worked the day shift on Unit C on [DATE]. LPN-J indicated there were a couple residents with cold symptoms but no fevers. There were no residents in isolation because they just had cold symptoms. LPN-J indicated they would chart it on the 24 hour report and call the supervisor. On [DATE] at 2:45 p.m. Surveyor # spoke with CNA-M (Certified Nursing Assistant) who worked on [DATE] the evening shift on Unit C. CNA-M remembers a couple residents were sick; however does not recall seeing or using any isolation equipment. On [DATE] at 3:05 p.m. Surveyor # spoke with CNA-N who worked on [DATE] on the evening shift on Unit C. CNA-N remembers a couple residents were sick or had a cough. CNA-N does not recall seeing or using any isolation equipment. On [DATE] at 8:46 a.m. Surveyor # spoke with RN-I who supervised the evening shift on the [DATE]. RN-I indicated that they had seen 1 of the Residents (#16) earlier in the shift because the family expressed a concern with a cough. They assessed and felt Resident #16 was fine. If Resident #16 developed more symptoms later in the shift they were not aware of them. RN-I indicated they do make rounds later in the shift and review the 24 hour reports. RN-I indicated that 2 or more residents with like symptoms in the same area would be concerning. However nothing that shift was alarming. The 24 hour report for Resident #16 lists: congestion, general malaise, poor appetite and elevated temperature. RN-I does not recall this information. On [DATE] at 10:00 a.m. spoke with RN-K who was the evening nurse on [DATE] on Unit C. RN-K recalls placing Resident #16 on the 24 hour report for general malaise, not feeling well with a poor appetite. Took vitals after supper and they had an elevated temperature. RN-K indicated that supervisor makes rounds and reviews the 24 hour reports and would have told the supervisor when adding Resident #16. RN-K indicated that there was no isolation used. RN-K indicated that if there were 2 residents on the unit with symptoms they would tell the supervisor. RN-K does not remember specifics from that shift. Despite the fact that three residents were ill with two or more symptoms on [DATE], the facility did not isolate the residents or begin using appropriate standard and droplet precautions until [DATE]. The failure to implement immediate aggressive measures created an opportunity for the infection to spread. The Division of Public Health has noted that "Facilities should immediately institute aggressive infection control measures anytime an outbreak is suspected" and that "When appropriate prevention and control measures are not implemented immediately, outbreaks can continue for weeks causing many illnesses, some hospitalization s and the occasional death from dehydration and other complications of vomiting and diarrhea." According to <http://www.flu.gov/at-risk/seniors/>, "As you age, your immune system weakens. This weakening makes seniors-adults [AGE] years and older- more susceptible to the flu. For seniors, the seasonal flu <http://www.flu.gov/about_the_flu/seasonal/index.html> can be very serious, even deadly. Ninety percent of flu-related deaths and more than half of flu-related hospitalization s occur in people age 65 and older." One of the residents who became ill on [DATE] was Resident #24. The influenza outbreak line list incorrectly indicates Resident #24 well date (date when resident is symptom free) as [DATE]. The progress note dated [DATE] indicates Resident #24 still had a temperature of 99.3 F and continued to be on [MEDICATION NAME] (antiviral medication). The progress note dated [DATE] indicates Resident #24 had a temperature of 98.9 F and inspiratory and expiratory diminished bilateral lung sounds. The progress note dated [DATE] indicates Resident #24 continued to have moist non-productive cough, appetite and fluid intake poor. No vital signs were documented. The progress note dated [DATE] indicates Resident #24 had a temperature of 100.4 F. The progress note indicates Resident #24 continued to have occasional increased temperatures, poor breath sounds, poor appetite and fluid intake until her death on [DATE]. JANUARY INFLUENZA A OUTBREAK 2015 On [DATE] at 9:10 a.m. Surveyor # and # spoke with ADON-C and DON-B. ADON-C indicated that outbreak protocols started on [DATE] when 3 residents had symptoms and tested positive for Influenza A. No protective equipment or appropriate precautions were used on Resident #27 and #9 prior to [DATE]. The line list does not indicate a specific onset date of symptoms for Resident #9. Resident #9 was noted to have symptoms on [DATE]. Resident #27 is noted on the line list to have symptoms on [DATE]; however, it was not until 2 more residents had symptoms on [DATE] that the outbreak protocol was started. Resident #27, #13 and #10 had confirmed Influenza A on [DATE]. The line list and summary documentation of the outbreak did not include accurate and preventive measure for ARI symptoms. DOCUMENTED PLAN OF CARE AND EDUCATION On [DATE] at 9:10 a.m. Surveyor # and # spoke with ADON-C and DON-B. When queried about any staff education regarding [DATE] Influenza A outbreak, DON-B indicated there is no documented infection control training for December. DON-B indicated staff was verbally told about outbreak and handwashing face to face. There is no documented staff training for the [DATE] outbreak. When queried about plan of cares for the residents with infections and the residents on isolation, DON-B thought they were on a care card. ADON-C did not know. The plan of care would identify the infection, isolation and services the staff would provide. There was not information provided on why there were no resident plans of care related to the illness. The medical record indicates Resident #24 developed influenza A on [DATE]. The physician was notified and prescribed [MEDICATION NAME] 75 mg twice a day for 5 days. The progress note indicates the staff was monitoring Resident #24 symptoms. Surveyor # was unable to locate a care plan that addressed Resident #24 care while she was ill with Influenza A. On [DATE] Surveyor # asked ADON C if there was a care plan developed for Resident #24 while she was sick with Influenza A. ADON C stated she would have to look for it. On [DATE] at 1:30 p.m. ADON C stated a care plan was not developed for Resident #24 while she was ill with Influenza A. MONTHLY BASE LINE INFECTION RATES Surveyor # reviewed the facility's December infection rates. The category for type of infections does not include a section for Influenza. On [DATE] at 12:10 p.m. Surveyor # spoke with ADON-B and reviewed the December infection rates. ADON-B indicated the facility uses McGeer's criteria for definitions of infections. However, ADON-B groups Influenza with other lower respiratory infections. ADON-B indicated they did not make an additional section to place the Influenza rates. McGeer's definitions are not the same for other lower respiratory infections and Influenza. These are 2 different criteria. Therefore the rates are not accurate to capture the residents with Influenza A in December. Failure to implement appropriate precautions when necessary, failure to identify when an outbreak had occurred, and the failure to immediately and aggressively implement precautions to contain an outbreak created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when the facility: The deficient practice continues at severity level 2 (potential for harm that is not immediate jeopardy) as the facility implements its action plan and as evidenced by the following: By [DATE] the facility had completed a review of the residents currently residing in the facility to assess for signs and symptoms of an acute respiratory illness (ARI) or influenza like illness (ILI). Based upon the review of the Residents the facility determined that an ARI outbreak existed on Unit C and Unit D of the facility. Following this, the facility implemented appropriate isolation protocols, developed care plans, posted appropriate signage and implemented appropriate infection control monitoring processes. Additionally, the facility established measures to provide additional training and oversight regarding infection prevention and control processes. HAND HYGIENE On [DATE] at 7:40 a.m. Surveyor # observed LPN-E (Licensed Practical Nurse) administer medication to Resident #25. LPN-E started by washing their hands and donning gloves. LPN-E then with gloves touched the outside container the eye medication was in, the medication administration record and their pen when checking the label. LPN-E then administered the eye medication. LPN-E did not use gloves appropriately when administering eye medication. On [DATE] at 11:00 a.m. Surveyor # reviewed the facility Hand Hygiene policy and procedure revised ,[DATE]. The policy indicates to utilize hand hygiene before and after any physical contact with residents' equipment or personal articles. On [DATE] at 3:30 p.m. Surveyor # shared Resident #25 hand washing concerns at the facility exit meeting.

Based on observation, record review and staff interview, the facility did not ensure residents received preventive measures and accurate and complete assessments of pressure ulcers upon identification to ensure that pressure ulcers did not develop or worsen. This was observed with 5 (Resident #2, #3, #4, #9 and #20) of 6 residents with facility acquired pressure ulcers. Resident #2 did not have an initial documented assessment, or plan of care upon identification of avoidable, facility acquired bilateral unstageable heel pressure ulcers that are covered in eschar. Resident #3 did not have documented preventative measures to prevent bilateral Stage 2 heel pressure ulcers from developing. Resident #4 did not have documented bilateral heel prevention measures prior to and after identification of facility acquired unstageable bilateral heel pressure ulcers. Resident #20 did not have documented prevention measures or a plan of care for treatment for [REDACTED]. Resident #9 did not have a documented assessment or plan of care upon identification of a Stage 2 pressure ulcer. Findings include: On 1/20/15 at 8:03 a.m. Administrator-A provided the facility's policy and procedure for Wound Care Prevention, Management and Documentation revised 8/14. The policy purpose is to provide an interdisciplinary program for assessing a resident's risk for skin breakdown and implement a comprehensive care plan to maintain or improve skin integrity which may include treatment and services to promote healing, prevent infection, and prevent further skin breakdown. The National Pressure Ulcer Advisory Panel 2014 indicates: Repositioning for Preventing Heel Pressure Ulcers: 1. Ensure the heels are free from the surface of the bed sometimes called "floating Heels." Pressure Ulcer Assessment: 1.1 Document the results of all wound assessments. A two-week period is recommended for evaluating progress towards healing. However, weekly assessments provide an opportunity to assess the ulcer more regularly, detect complications and adjust the treatment plan. 3. Assess and document physical characteristics that include (not all inclusive): location, stage, size, tissue type, color and periwound condition. The National Pressure Ulcer Advisory Panel 2014 also defines an Unstageable pressure ulcer, depth unknown as: Full thickness tissue loss which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. A Category/Stage 2: Partial Thickness Loss is defined as: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or shallow ulcer without slough or bruising*. This Category/Stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates suspected deep tissue injury. 1.) Resident #2's medical record was reviewed by Surveyor # . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Admission MDS (minimum data set) completed on 9/23/14 indicates Resident #2 is at risk for pressure ulcers. The section for bed mobility and transfers, indicate a 3/3 (extensive assist with 2 staff). The most recent Quarterly MDS completed on 12/5/14 indicates a current stage 2 pressure ulcer and 2 unstageable pressure ulcers. The section for bed mobility and transfers indicates a 3/3 (extensive assist with 2 staff). The progress note on 10/31/14 indicates that the Nurse Practitioner was updated on new areas to bilateral heels and that boots will be applied and skin prep twice a day. The assessment of the bilateral heel areas are not documented until 11/5/14 in the skin/wound notes, and indicate the following: Left heel 1 cm (centimeter) by 1 cm dark/eschar 100% - unstageable due to no visible wound base; Right heel 1.5 cm by 1 cm purplish colored/ eschar 100% - unstageable due to no visible wound base. Resident #2's plan of care initiated 11/22/14 indicates At Risk for Impaired Skin Integrity but does not identify bilateral heel pressure ulcers until 1/8/15, along with heel prevention until 1/8/15. There was no documentation of heel prevention prior to identification on 10/31/14. There was no documented comprehensive assessments of the new heel pressure ulcers until 11/5/14. There was not a plan of care that identified and addressed the heels until 1/8/15. On 1/13/15 at 8:22 a.m. Surveyor # observed Resident #2's heels during morning cares with CNA-G (Certified Nursing Assistant). Resident #2 had gripper type socks on and when they were removed, there was dry eschar on each heel. On 1/14/15 at 11:28 a.m. Surveyor # spoke with DON-B (Director of Nurses) and RN-D (Registered Nurse). RN-D is the manager that oversees Resident #2 health status, including assessments and plan of care. There was no additional information provided. DON-B indicated that typically staff contact her and they document in the skin/wound notes upon discovery of a skin concern and the nurse manager will start or revise the plan of care. Surveyor # shared the pressure ulcer concerns with Resident #2 at the daily exit meeting on 1/14/15 at 3:30 p.m. 2.) Resident #3's medical record was reviewed by Surveyor # . Resident #3 was readmitted to the facility on [DATE] following a left [MEDICAL CONDITION] and has [DIAGNOSES REDACTED].#3 was originally admitted to the facility on [DATE] and went out to the hospital on [DATE]. Resident #3's Annual MDS (minimum data set) completed on 12/15/14 indicates the resident was not at risk for pressure ulcers and had no current pressure ulcers. The section for bed mobility and transfers indicates a 3/2 (extensive assist with 1 staff). The Significant Change in Status MDS completed on 12/31/14 indicates that Resident #3 is now at risk for pressure ulcers. The section for bed mobility and transfers indicate a 3/3 (extensive assist with 2 staff). The skin/wound progress notes on 12/29/14 indicates the following: Left heel redness (no measurement) skin prep and heel-lift boots applied; Right heel redness (no measurements) skin prep and heel-lift boots applied. The skin/wound progress notes on 12/31/14 (Register Nurse actual assessment documentation) indicates the following: Left heel 2 cm (centimeters) by 2.5 cm red area; Right heel 2 cm by 2 cm red area with fluid filled blister. The skin/wound progress notes on 1/6/15 indicates that both heels are healed; however there is not a RN (Registered Nurse) assessment regarding this finding. The skin/wound progress note on 1/19/15 indicates a new finding of right heel and left heel discolorations. No measurements and no RN assessment are documented. The skin/wound progress notes do not include an RN assessment of the heels until 1/21/15 and this is only for the right heel. There is no documentation of a comprehensive assessment of the left heel pressure ulcers after 12/31/14. The skin/wound progress notes for the right heel on 1/21/15 indicate a suspected deep tissue injury in evolution 1.8 cm by 1.6 cm and a dry scab is present that was previously a deflated blister. The current plan of care does not identify any past or current pressure ulcers on the heels. The plan of care for Potential for Impaired Skin Integrity related to incontinence, arthritis and history of [MEDICAL CONDITION] dated 11/15/13 does not address the immobility of utilizing a A-frame in bed related to recent [MEDICAL CONDITION]. The plan of care does not address pressure ulcer heel prevention until 12/30/14. On 1/13/15 at 8:55 a.m. Surveyor # observed LPN-H (Licensed Practical Nurse) apply skin prep to Resident #3 heels. The left heel was maroon/ purplish colored and the right heel was also marooned colored. On 1/13/15 at 11:05 a.m. DON-B (Director of Nurses) provided a list of current residents with pressure ulcers. Resident #3 was not on the list. When DON-B was queried they indicated that the heels were healed as of 1/7/15. Surveyor # did relay observation of Resident #3's heels from this morning's observation. No further information was provided. On 1/14/15 at 11:28 a.m. Surveyor # spoke with DON-B and RN-D (Registered Nurse). RN-D is the manager of Resident #3 health status that includes assessing and developing a plan of care. DON-B and RN-D indicated that Resident #3 was on a pressure relief air mattress. This mattress included pressure ulcer prevention for the heels. Resident #3's heels were not "floated" per current standards of practice. The heel lift boots were not applied until 12/29/14 upon identification of pressure ulcers on both heels. There was no additional information related to the plan of care not being reflective of bilateral heel ulcers or preventive measures prior to discovery. On 1/14/15 at 3:30 p.m. Surveyor # shared Resident #3's pressure ulcer concerns at the daily exit meeting. On 1/22/15 Surveyor # received additional information from DON-B. DON-B assessed Resident #3 heels on 1/13/15 after discussing they were healed and the resident care observation by Surveyor # . The information indicates the electronic record system did not have the pressure ulcer assessment for some reason for 1/13/15. The pressure ulcer assessment for 1/13/15 is the following: Left heel presents as a deflated fluid filled blister measuring 2.4 cm (centimeters) by 1.4 cm. Area is dark pink in color. Area appears to be reabsorbed fluid blister on a previously healed area. Wound stage is 2. MD called to change treatment from skin prep to [MEDICATION NAME].; Right heel presents as a deflated fluid filled blister measuring 2.2. cm by 1.8 cm. Area is dark pink in color. Area appears to be a reabsorbed blister from a previously healed area. Wound stage is 2. MD called to change treatment from skin prep to [MEDICATION NAME]. According to the facility's policy and procedure for Wound Care Prevention, Management and Documentation revised August 2014, it indicates the following classification of pressure ulcers: Suspected Deep Tissue Injury- is purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear.; Stage 2- is partial skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. 3.) Resident #4's medical record was reviewed by Surveyor # . Resident #4 was admitted to the facility on [DATE] with pain, arthritis in the left knee, back and left ankle and history of [MEDICAL CONDITION]. The Braden assessment completed by the facility on 9/8/14 indicates areas of concern related to Resident #4 being chairfast, very limited mobility, probable inadequate nutrition, and Resident #4 has a potential for problems related to shearing. The total score for this assessment is 16 indicating Resident #4 was at low risk for developing pressure ulcers. Braden assessments completed on 9/10/14 and 9/24/14 indicate changes in scoring related to Resident #4's nutrition status raising her overall total score and decreasing her risk for pressure ulcers. Surveyor # noted that the Braden Assessment indicates improvement in Resident #4's nutritional status however, this is not consistent with Resident #4's plan of care dated 9/12/14 which identifies an area of concern to be related to Resident #4's alteration in nutrition related to decreased intakes with a goal for Resident #4 to increase her meal intakes to at least 60-70%. The Admission MDS (minimum data set) completed on 9/19/14 indicates that Resident #4 is nonambulatory and has limited range of motion in her lower extremities. Resident #4 requires extensive assistance of 2 staff for bed mobility and is totally dependent upon 2 staff for transfers. Review of the section related to skin integrity indicates that Resident #4 is not at risk for pressure ulcers however, the Care Area Assessment (CAA) for pressure ulcers was triggered related to Resident #4's dependence for bed mobility. The Braden assessment dated [DATE] indicates a total score of 15 - again indicating that Resident #4 is at low risk for pressure ulcer development. Resident #4's Quarterly MDS dated [DATE] indicates that Resident #4 continues to require extensive assistance from 2 staff for bed mobility. This MDS indicates that Resident #4 is at risk for pressure ulcers. The plan of care, dated 9/8/14, for Alteration in Skin Integrity/Actual due to CKD ([MEDICAL CONDITION]) as evidenced by dry, flaky skin and [MEDICAL CONDITION]. There are no interventions documented regarding prevention of heel ulcers despite Resident #4's limited range of motion in her lower extremities and extensive assistance needed for bed mobility. The plan of care for Impaired Physical Mobility, dated 9/8/14, indicates assist of staff with bed mobility, 2 staff with transfers and toileting. The skin/wound progress notes on 10/12/14 indicate the following: New (1st recording) for site 488. Present on right heel is area of pressure. The following findings were documented. Length in cm=3.55, Width in cm=6. Skin is not blanchable, no odor is apparent, drainage consistency is thin, scant drainage is present, color is red tinged. This wound was not present upon admission. General comments: Notified by floor nurse to look at heels d/t (due to) scant amount of blood noted on sheets. R (Right) heel with majority of heel black/purple coloring, mushy to touch, few areas where skin is broken open. Both legs were propped up on pillows under knees when first looked at this am. Skin prep applied to both areas of heels where skin intact, allevyn f/b (followed by) [MEDICATION NAME] tape applied for extra protection. Black heel lift boots applied to float heels, to be worn at all times, wound base is not visible, Eschar tissue type=100%, no itching or discomfort, no foreign bodies present, surrounding tissue is normal, skin tissue temperature is consistent with surrounding tissue, margins are irregular, Resident has no pain, mucous membranes are moist, mucous membranes are pink. Skin turgor is fair pressure reducing or relieving devices are in place, other pressure reducing or relieving devices are in place: heel lift boots. Likelihood of healing due to overall condition, fair. Risk factors: Co-morbidities, decreased mobility. The Skin Condition/Wound Progression documentation dated 10/12/15 indicates for Resident #4's left heel: New (1st recording) for site 408. Present on the left heel is an area of pressure. The following findings were documented, Length in cm=4.5, Width in cm=7, Skin is not blanchable, no odor is apparent, drainage consistency is thin, scant drainage is present, color is red-tinged. This wound was not present on admission. General comments: Notified by floor nurse to look at heels d/t scant amount of blood noted on sheets. L (left) heel with majority of heel black/purple coloring, mushy to touch, few areas where skin is broken open. Both legs were propped up on pillows under knees when first look at this am. Skin prep applied to areas where skin intact, allevyn f/b [MEDICATION NAME] tape applied for extra protection. Black heel lift boots applied to float heels, to be worn at all times, wound base is not visible , Slough tissue type = 100%, no itching or discomfort, no foreign bodies present, surrounding tissue is normal, skin tissue skin tissue temperature is consistent with surrounding tissue, margins are irregular, Resident has no pain, mucous membranes are moist, mucous membranes are pink. Skin turgor is fair pressure reducing or relieving devices are in place, other pressure reducing or relieving devices are in place: heel lift boots. Likelihood of healing due to overall condition, fair. Risk factors: Co-morbidities, decreased mobility. Review of Resident #4's plan of care for skin integrity indicates that the plan of care with a start date of 10/24/14 indicates: Impaired skin integrity related to pressure areas to bilateral heels. Approaches include with a start date of 10/24/14 air bed, body check with weekly bath, boots on both feet at all times. Skin Condition/Wound Progression notes document on 10/15/14: right heel: Present on right heel is area of pressure. The following findings were documented, unable to accurately stage - slough and or Eschar covered, Length in cm=3.9, Width in cm=7.0, skin is not blanchable, no odor is apparent, minimal drainage is present, color is bloody, wound base is visible, black wound base=100%, General comments: open area measuring 2.5 x 2.0 IDT reviewed, pressure reducing devices are in place, devices used on the bed surface, extremity device or shoe used, Risk factors: (blank). Left heel: Present on left heel is an area of pressure. The following findings were documented: Unable to accurately stage - slough and/or eschar covered, Length in cm=3.9, Width in cm=5.8, skin is not blanchable, a faint odor is apparent, scant drainage is present, color is bloody, wound base is not visible, surrounding tissue is normal, The affected area has an absence of hair, skin tissue to consistent with surrounding tissue, margins are irregular, pressure reducing or relieving devices are in place, devices used on the bed surface, extremity device or shoe used. Risk factors: General Comments: no pedal pulses. IDT reviewed today on wound rounds. Review of weekly Skin Condition/Wound Progression reports indicate that Resident #4 was seen in a wound clinic and that dressings were applied to both heels to only be changed in the wound clinic. Skin Condition/Wound Progression report dated 11/5/14 indicate: Seen at wound clinic on 11/4. Right heel measures 2.5 x 3.5 x 0.1. Offload heels when in wheelchair and when in bed, return next week. The left heel indicates: measurements: 3 x 3.2 x 0.1 and to offload heels when in wheelchair and bed. Review of Resident #4's records indicate Resident #4 continued to be seen in wound clinic. On 12/17/14 the facility documents for Resident #4's right heel: Present on the right heel is a pressure ulcer...Unable to accurately stage - slough and/or eschar covered, Length in cm=2.8, Width in cm=5.0, a moderate odor is apparent, moderate drainage is present, color is brown, wound base is not visible, Yellow wound base = 50%, black wound bases = 50%, Eschar tissue type = 100%, General Comments: IDT reviewed today on wound rounds, will go to wound clinic next week. PUSH Tool 3.0 Total Score = 15. The left heel indicates: Unable to accurately stage - slough and/or eschar covered, Length in cm=3.0, Width in cm=3.0, a moderate odor is apparent, moderate drainage is present, color is brown. General Comments: IDT reviewed today on wound rounds. She will return to wound clinic next week, wound base is not visible, black wound base = 100%, eschar tissue type = 100%, Risk Factors:, PUSH Tool 3.0 Total Score=14. Review of Resident #4's notes indicate ongoing follow up in wound clinic with the clinic completing dressing changes. Due to this, Resident #4's heels were not observed by the Surveyor during the survey. On 1/14/15 at 11:16 a.m. Surveyor # spoke with DON-B (Director of Nurses) and RN-D (Registered Nurse). RN-D is the manager and oversees Resident #4 health status, including assessing and developing a plan of care. DON-B indicated that Resident #4 was admitted on the rehab unit and has a paper plan of care versus a computerized plan of care. This was reviewed and did not include any pressure ulcer prevention for the heels despite Resident #4 requiring extensive assistance for bed mobility and limited lower extremity range of motion. DON-B indicated that part of skin care is to float heels and was not able to give a direct answer on preventive measures that were used prior to discovery of unstageable pressure ulcers both of Resident #4's heels. There was no additional information regarding the plan of care/preventative measures. On 1/14/15 at 3:30 p.m. Surveyor # shared the pressure ulcer concerns regarding Resident #4 at the daily exit meeting. 4.) Resident #20 was admitted to the facility on [DATE] and then readmitted on [DATE] after a short hospital stay. Resident #20 came in with [DIAGNOSES REDACTED]. The admitting MDS (minimum data set) with assessment reference date (ARD) of 10/25/14 indicates Resident #20 is cognitively alert and oriented and needs limited assistance with transfers, bed mobility and ambulation. It also indicates Resident #20 is occasionally incontinent of urine. The MDS does indicate Resident #20 is at risk for pressure ulcers and a pressure relief cushion was in her wheelchair and pressure relief mattress. The 12/3/14 progress note indicates Resident #20 expressed little interest or pleasure in doing things and is tired with little energy. The medical record indicates on 12/6/14 the nursing staff observed "reddened bottom" on Resident #20. The progress note indicates the physician was called and ordered for "Nutrashield to bottom BID" (twice a day). There is no documentation of measurements to the area. On 12/10/14, the progress note indicates Resident #20 still has a "reddened bottom." There is no follow up documentation after 12/10/14 as to the measurement of the area, characteristics of the area such as whether the skin was blanchable, etc. or if the area had healed. There were no changes to the plan of care. The progress note dated 12/15/14 indicates Resident #20 prefers to eat in her room because the resident is "just too tired to go to the dining room." The progress note dated 12/18/14 indicates Resident #20 has a history of staying in her chair or bed most of the time. A progress note dated 12/27/14 indicates: a pressure ulcer was noted to right upper buttocks. The note describes the wound as unstageable due to slough in wound bed and the wound measures 0.7 cm by 0.4 cm depth is 0.1 cm. This pressure ulcer was not assessed by an RN until 12/31/14. The 12/27/14 documentation of the pressure ulcer to the right upper buttocks indicates there is 100% slough in the wound bed. It also indicates the risk factors that may have contributed to the pressure ulcer development is decreased mobility and inactivity. It also indicates the resident was educated to make frequent position changes when up in chair and when in bed to position self side to side. It indicates the physician was notified and a treatment was ordered. The 12/30/14 and 12/31/14 documentation indicates the wound bed still has 100% slough. The 1/7/15 documentation indicates the wound size is 0.4 cm by 0.5 cm and describes the wound bed as pink with possible [MEDICATION NAME] tissue. On 1/13/15 Surveyor # asked for a list of all Residents with pressure ulcers in the facility. The list indicates Resident #20 has an unstageable pressure ulcer on the right gluteal. DON B, who is wound care certified, stated she didn't think this wound is pressure related because it is in the gluteal cleft. On 1/15/15 at 10:00 a.m. Surveyor # observed Nurse Manager W perform the treatment to Resident #20's wound. Surveyor # observed Resident #20 to be laying on her back and very sleepy. Surveyor # observed the wound bed to be clean and no evidence of slough. Also the wound was observed to be over the coccyx area which is a bony prominence. On 1/15/15 Surveyor # asked for a copy of Resident #20's care plan. On 1/15/15 at 10:30 a.m. Surveyor # received Resident #20's care plan. The care plan indicates on 1/6/15 an alteration in skin impairment care plan was started. The care plan also indicates an air mattress was put into place on 1/6/15. Surveyor # noted that this is all after Resident #20 developed the unstageable pressure ulcer. On 1/14/15 at 11:28 a.m. Surveyor # along with the survey team spoke with DON B. DON B states the Nurse Managers are responsible for updating the care plan and for assessing the wounds. DON B states she only looks at the wounds if the Nurse Managers need assistance or if the wound isn't healing. On 1/15/15 at 2:00 p.m. Surveyor # explained to Nursing Home Administrator (NHA) A the concern that Resident #20 was at high risk for pressure ulcers based on the 12/6/14 observation of a reddened bottom and then a pressure ulcer developed on 12/27/14. On 12/27/14 an RN did not assess the pressure ulcer and the care plan for her wound was not implemented until 1/6/14. On 1/20/15 at 4:00 p.m. Surveyor # did not receive any additional information. 5.) On 1/12/15 Surveyor # began record review for Resident #9 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's Admission Minimum Data Set ((MDS) dated [DATE] indicates that Resident #9 requires extensive assist of 2 staff for bed mobility and toileting. Resident #9 is totally dependent upon 2 staff for all transfers. The MDS also indicates that Resident #9 is at risk for pressure ulcers. The PPS 30 day MDS dated [DATE] continues to indicate that Resident #9 is at risk for pressure ulcers and now indicates that Resident #9 is at risk due to having a Stage 1 or greater pressure ulcers or a scar over a bony prominence. The skin/wound progression sheet dated 11/14/14 indicates that a red area on Resident #9's coccyx was identified but there were no measurements taken at this time. The 11/19/14 entry on the wound document indicates that the wound was observed on this date as being dark purple with measurements of 6 cm x 4.5 cm. The 12/3/14 entry states that the wound is now purple/pink in color and measures at 6 cm x 4.5 cm. According to the wound sheet dated 12/10/14 the area is now healed. An entry dated 12/15/14 states that the area is now an open lesion measured at 1.5 cm x 1.5 cm and [MEDICATION NAME] was applied. The note also states that the physician needs to be updated regarding the change to the wound. Review of Resident #9's record does not indicate that Resident #9's physician was notified of the change in Resident #9's wound on 12/15/14. An entry dated 12/17/14 states that the area is open with measurements of 1 cm x 1.3 cm, and is listed as a Stage 2 pressure ulcer. The entry dated 12/30/14 states that the area is open and is now measures 3.4 cm x 1 cm and the facility is applying [MEDICATION NAME] to the area and changing the dressing every 3 days. Surveyor # noted that this is a decline in Resident #9's pressure ulcer. Surveyor # noted with each documented entry there are no details documented regarding the characteristics of the wound. An entry dated 1/7/15 states that the area still remains open however, there were no measurements taken. The documentation also does not indicate if there are any dark areas or discoloration. The entry dated 1/14/15 states that the area is open with a pink wound base=70% and a black brown base=30%, no measurements noted. On 1/14/14 at 11:21am Surveyor # interviewed Director of Nursing-B who stated that the area was discovered after the initial skin assessment was done. She then stated that in her opinion this area was not a pressure ulcer but an old injury that the resident had and continued to scratch. Surveyor # asked why the area was being staged as a stage 2 pressure ulcer by nursing staff and she stated that she was not sure. A care plan was requested and provided but pressure ulcers were not listed as an area of concern until after the start of the survey, dated 1/13/15. Surveyor # asked DON-B what interventions were implemented prior to 1/13/15 to ensure that the area did not develop or worsen. DON-B stated that Resident #9 was provided with an air mattress and other pressure relieving devices. She stated that the resident was moved from the rehabilitation unit to a different unit as of 12/24/14 and the facility was still using the initial care plan. Upon the review of the initial care plan it is noted that there were no dates listed for the interventions and surveyor was unable to confirm when the interventions were implemented. On 1/14/15 at approximately 11:30 am Surveyor also interviewed Nurse Manager-W who stated that she had not updated the current care plan when the resident was moved to her unit, and used the initial care plan for guidance. Surveyor # also asked DON-B why there were several dates listed on Resident #9's wound documentation with no measurements and she stated that she had previously tried to enter the measurements but the computer wouldn't allow her to do so. The facility measured the area on 1/14/15 which was now measured at 2 cm x 2 cm and placed an order to the doctor to have the treatment changed. The treatment change was not completed until 1/16/15. On 1/15/15 at 9:45 a.m. Surveyor # observed Nurse Manager W perform a wound dressing for Resident #9. Nurse Manager W stated that she along with the wound team assessed Resident #9's wound yesterday on 1/14/15. Surveyor # observed the wound to be on the buttocks very near the anus area and the wound bed to be very moist. Surveyor # observed the wound base to have 2 small darkened brown areas approximately 1.0 cm each in length. Surveyor # asked Nurse Manager W if those dark areas were on the wound when she observed it on 1/14/15. Nurse Manager W stated that it was observed but the team thought it was "scabs." Nurse Manger W started to rub on the dark areas but the areas did not fall off. Surveyor # explained to Nurse Manager W that the wound base is very moist, if those areas were "scabs" they would have fallen off. Nurse Manager W stated the wound was not moist yesterday and was going to call the physician because this would be considered a change in his wound. Surveyor # asked Nurse Manager W did she consider the dark areas in the wound to be a change and Nurse Manager W stated no because they are "scabs." Surveyor # noted the areas that the facility is considering "scabs" to be more consistent with eschar. On 1/15/15 at 3:00 p.m. during the daily exit meeting with DON B and NHA A. Surveyor # explained the concern with Resident #9's wound observation. As of 1/20/15 at 4:00 p.m. Surveyor # did not receive any additional information.

Based on record reviews, and interviews, the facility did not ensure that 1 of 6 residents (Resident #1) did not develop pressure ulcers and that the pressure ulcers that developed received appropriate services and treatment to promote healing. Resident #1 re-admitted to the facility on [DATE] without pressure ulcers, after hospitalization for surgical repair of the left hip as the result of a fall occurring at the facility on [DATE]. Upon return to the facility following his [MEDICAL CONDITION], Resident #1 declined quickly. Resident #1 was less mobile, placing him at greater risk for pressure ulcer development. Resident #1 developed two stage two pressure ulcers that deteriorated after the facility failed to accurately stage the pressure ulcer according standards of practice when first observed, failed to notice that the system (PUSH) they utilized to monitor the pressure ulcers indicated the ulcers were getting worse and provided no change in interventions and, failed to inform the physician of the deteriorating pressure ulcers. Findings include: Resident #1 was originally admitted to the facility from the hospital after sustaining a fall at his previous residence. A review of the clinical record, specially the initial MDS (Minimum Data Set) of [DATE] noted that Resident #1 was alert and oriented to self, short and long term memory deficits with no recall after five minutes and trouble concentrating. The initial MDS of [DATE] assessed the resident's cognition at a 4 out of 15 identifying severe cognitive impairment with ability and understanding. On [DATE], Resident #1 sustained a fall that resulted in a fractured left hip with surgical repair. Resident #1 was hospitalized on [DATE]. After three days the resident returned back to the facility on [DATE] and began a decline as the resident was now less mobile and at greater risk for pressure ulcer development and decreased his food and fluid intake. Per clinical record, the facility conducted a Braden Scale for Predicting Pressure Sore Risk assessment on Resident #1 on [DATE]. The Braden Scale for Predicting Pressure Sore Risk assessment indicates a score of 13 which places Resident at "moderate risk." The Braden Scale for Predicting Pressure Sore Risk assessment indicates the resident's sensory perception is slightly limited, the resident is chairfast, very limited mobility, probably inadequate nutrition and potential problem with friction and shearing of the skin, putting the resident at "moderate risk." The facility placed a Joerns PrevaMatt Elite support surface on the resident's bed. As well as a Comfort Gel cushion to the wheelchair after the resident's initial admission of [DATE]. Upon return from the hospital to the facility on [DATE] these same type of devices remained on the resident's bed and chair. Per clinical record on [DATE] at 6:14 a.m. it is documented on Resident #1 the following "new...present on right lower buttocks is a pressure ulcer...stage 2, length in cm=2, width in cm=2, depth in cm=0.1, no odor is apparent, no drainage is apparent." "Resident denies pain/discomfort associated with open area, wound base is visible, pink wound base=60%, white wound base=40%, Slough tissue type =40%, [MEDICATION NAME] tissue=60%....surrounding tissue is reddened, surrounding tissue is macerated....skin tissue temperature is consistent with surrounding tissue, margins are irregular. This was documented by RN-K (Registered Nurse). On [DATE], the facility obtained an order for [REDACTED]. There is no evidence that this product offered pressure ulcer healing benefits. There was no treatment initiated for the treatment of [REDACTED]. The above description indicates that the area is a "stage 2 and has slough tissue type at 40%." According to the National Pressure Ulcer Advisory Panel (NPUAP) a stage 2 pressure ulcer is "without slough." Slough is identified by the NPUAP to be necrotic/avascular tissue in the process of separating from the viable part of the wound. According to the 2009 National Pressure Ulcer Advisory Panel (NPUAP), Stage 2 is "partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough." The NPUAP also recommends that this category not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration (excessive exposure to moisture on the skin) or excoriation. According to the 2009 NPUAP, a Stage 3 is "full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling..." A Stage 4 is "full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling...exposed bone/muscle is visible or directly palpable." It was also noted that the facility utilized the PUSH (pressure ulcer scale for healing, a low score the wound is healing, high score the wound is deteriorating) method. The PUSH tool assesses and scores on three elements length x width score from ,[DATE]. The exudate amount is scored 0 (none) to 3 (heavy). The tissue type scored from 0 (closed) to 4 (necrotic). On [DATE] the resident's PUSH score was 9 for the right lower buttocks. Per clinical record on the next day, [DATE] at 3:54 a.m. it is documented on Resident #1 "new...present on the left lower buttocks is a pressure ulcer...stage 2, length in cm=2.6, width in cm=2.4, depth in cm=0.1, no odor is apparent, scant drainage is present, color is bright red." "Resident denies pain/discomfort associated with open area, wound base is visible, pink wound base=80%, white wound base=20%, granulation tissue type =80%, slough tissue type=20%." The PUSH is 11 for the left lower buttocks. Surveyor noted that according to the NPUAP a stage 2 pressure ulcer is "without slough." Per clinical record [DATE] at 8:43 a.m. for the left lower buttocks it is documented, "stage 2 length in cm=2, width in cm=1.2, no odor is apparent, drainage consistency is thin, scant drainage is present, color is bright red, wound base is visible, red wound base 100%, granulation tissue type=100% per LPN-L (Licensed Practical Nurse). The PUSH score is 8. The right lower buttocks remains at stage 2, Length in cm=2.3, width in cm=1.2, no odor is apparent, drainage consistency is thin, scant drainage is present, color is bright red, wound base visible, red wound base=100%, granulation tissue type=100%. The PUSH score is 8. Per clinical record [DATE] at 10:28 p.m. the right lower buttocks is stage 2, length in cm=2.4, width in cm=1.5, no odor is apparent, drainage consistency is thin, scant drainage is present, color is clear, wound base is visible, red wound base=50%, white wound base=50%, slough tissue type= 50%, [MEDICATION NAME] tissue type=50%, pressure reducing or relieving device are in place, devices used on the bed surface, devices used on the chair surface..."likelihood of healing due to overall condition, fair, risk factors, cognition, decreased nutrition, inactivity." The PUSH score was 10 an increase of 2 points since [DATE] indicating deterioration of the wound. This deterioration also includes the increase presence of slough that is now at 50% and evidence that the wound measurements have increased with no evidence of changes in the services and treatment to promote healing noted. The left lower buttocks on [DATE] remains a stage 2 per documentation at a length of 2.5 cm, width in cm=2.5, no odor present, drainage consistency is thin, scant drainage is present, color clear, wound base is visible, red wound base=50%, yellow wound base=50%, slough tissue type=50%, [MEDICATION NAME] tissue type =50%, surrounding tissue is normal, skin tissue temperature is consistent with surrounding tissue, margins are irregular, mucous membranes are moist, mucous membranes are pink." The PUSH score was 11 an increase from the [DATE] measurements and and increase of sloughing at 50%. Review of the literature provided by the facility on [DATE] per email, of the Joerns PrevaMatt Elite support surface on Resident #1's bed noted that this support surface is recommended for prevention and treatment of [REDACTED]. There was no evidence that the facility attempted to alter the surface support to promote healing, even though Resident #1's pressure ulcers are noted to be deteriorating in size and with increasing slough. On [DATE], the facility commenced the use of Santyl followed by the use of Polymem and [MEDICATION NAME] with orders to change daily and prn until healed. This order was given by PA-N (Physician Assistant). Per telephone interview with PA-N on [DATE] at 10:45 a.m., PA-N acknowledged that she has "never seen the pressure ulcers." PA-N further acknowledged that RN-E would make recommendations and run it by me and I wrote the orders, I never actually saw the wounds." On [DATE] at 9:23 p.m. RN-M documented that the left lower buttocks "unable to accurately stage, slough and /or eschar covered, length in cm=3, width in cm=3, skin is blanchable, a faint odor is apparent, no drainage is apparent...area deteriorating , open area non stagable, covered with black slough tissue, complain of pain with dressing change, wound base is not visible, pink wound base=20%, black wound base=80%, skin tissue temperature is consistent with surrounding tissue, margins are irregular, acute pain level is ,[DATE]. The PUSH score is 11. The right lower buttocks on [DATE] at 9:24 p.m. is noted to be "unable to accurately stage, slough and/or eschar covered, length in cm=4, width=3, faint odor is apparent, no drainage is apparent, area deteriorating, open area non stagable, covered with black slough tissue, complain of pain with dressing change, wound base is not visible, pink wound base =20%, black wound base=80%, granulation tissue type=20%, slough tissue type=80%, surrounding tissue is reddened. The PUSH score is 11. As the size of the pressure ulcers increased along with the PUSH scores increasing, the facility had no evidence that it updated the attending physician that the areas were "deteriorating." Review of the initial care plan of [DATE] indicates undated intervention to "float heels." Intervention dated [DATE] "posey heel boot on when in bed right foot, elevate right extremity while up and in bed." On [DATE], "side to side turning schedule when in bed." As the residents wound measurements increased along with the PUSH scores, the care plan was not updated. On [DATE] at 8:08 p.m. it is documented by LPN-P that the left lower buttocks is now length in cm=3.2, width in cm=3.5 a faint odor is apparent, drainage consistency is this, scant drainage is present, color is red tinged, wound base is visible, pink wound base =10%, red wound base=40%, black wound base=50%, granulation tissue type=20%, slough tissue type =80%, pressure reducing or relieving device in place, devices used on the bed surface, devices used on the chair surface...tub bath given, treatment done per order, positioned side to side while in bed." The PUSH score is now 12 and the area has become larger along with an increase in slough. On [DATE] at 8:15 p.m. it is documented also by LPN-P that the right lower buttocks is "unable to accurately stage, slough and /or eschar covered, length in cm=4.5, width in cm=3.5, a faint odor is apparent, red wound base-20%, black wound base-80%, eshcar tissue type=25%, slough tissue type=75%. It is documented that the PUSH score is now 13 for the right lower buttocks, this is an increase since the previous weeks score, giving indication per the tool that the wound is deteriorating. As the size of the pressure ulcers increased along with the PUSH scores increasing, the facility had no evidence that they updated the attending physician that the areas were "deteriorating." On [DATE] at 9:21p.m the right lower buttocks "unable to accurately stage, is 4cm x 3cm with a depth of 1.5cm, granulation tissue type =25 %, eschar tissue type=60%, slough tissue type =15%, surrounding tissue is macerated, PUSH score of 12. The left lower buttocks is "unable to accurately stage, slough and /or eschar covered, length in cm=3, width in cm=4, no odor is apparent, scant drainage is present, color is red tinged, wound base is visible, eschar tissue type=90%, slough tissue type=10%, deterioration noted in site. The PUSH score was now 13. On [DATE] at 7:40 a.m. the lower left buttocks is documented 6cm x5cm, no odor present, scant drainage, color red tinged, complained of pain to area, wound base not visible, red wound base=20%, black wound base=80%, granulation tissue type=20%, slough tissue type=80%. The PUSH score is 14. The right lower buttocks is documented is now" 6cm x 4.5cm with 1.5cm depth, complain of pain, wound base is not visible, red wound base=20%, black wound base=80%, granulation tissue type=20%, slough tissue=80%, PUSH score is 13. As the size of the pressure ulcers increased along with the PUSH scores increasing, the facility had no evidence that the physician was updated regarding the areas were "deteriorating." On [DATE] at 8:00 a.m. it is documented by RN-E (Registered Nurse), "left lower buttocks is a pressure ulcer...called down by staff nurse to look at wound, now 100% necrotic with foul smelling odor." PA-N "was updated, new treatment received as well as new order for resident to go to wound clinic for evaluation." The new treatment orders included "discontinue current treatment to bilateral gluteal folds, start Santyl followed by [MEDICATION NAME] Blue followed by Polyymen and [MEDICATION NAME] to bilateral gluteal folds everyday and PRN until healed, referral for wound clinic." Per telephone interview with RN-E on [DATE] at 10:35 a.m. RN-E indicated that she was "called down to see the wound." It was noted that per documentation, RN-E made observations and documented on this wound only on this date. The resident was seen in the wound clinic at the local hospital on [DATE] and the surgeon recommended surgical treatment to the pressure ulcers. Upon return to the facility, the physician orders [REDACTED]. There was an order of treatment for [REDACTED]. Per interview with RN-C on [DATE] at 10:00 a.m., RN-C indicated that the family of Resident #1 did not want the surgical treatment to the wound and opted to have the resident discharged from the facility. Per telephone interview with the complainant on [DATE] at 8:03 a.m., the resident was placed in hospice service and expired on [DATE] as a result of the fall complications resident sustained [REDACTED]. According to Resident #1's death certificate, Resident #1 passed away on [DATE]. Part 1 of the death certificate identifies the immediate of death as, "complications of left [MEDICAL CONDITION]." Part II of the death certificate indicates other significant conditions contributing to death but not resulting in the underlying cause as given in Part 1, is "Dementia; Hypertension: [MEDICAL CONDITION]." During this time, from [DATE] until discharge, Resident #1's nutritional intake declined as the resident refused food and fluids. Evaluation by speech therapy noted that the resident was pocketing his food. The resident went from 209 lbs on [DATE] to 197 lbs on [DATE].