Every finding on record at Luther Manor

Based on interviews and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 (R3) resident reviewed for allegations of abuse.*The facility did not thoroughly investigate an allegation of abuse from R3 on 4/21/2026.Findings include:The facility's Abuse, Neglect, Misappropriation, and Exploitation policy, dated 6/2025, documents, . An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: identifying staff responsible for the investigation; exercising caution in handling evidence . identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, poor mistreatment has occurred, the extent, and the cause; providing complete and thorough documentation of the investigation.On 7/28/2026, at 10:00 AM, Surveyor reviewed the facility reported incident (FRI) submitted to the State Agency on 4/21/2026. A summary of the incident documented R3 went to the shared resident fridge to get ice cream. Licensed Practical Nurse (LPN)- E redirected R3 from taking other residents' food. R3 became upset and began yelling. R3 stood up, LPN-E stood in front of R3 to prevent R3 from falling. R3 then hit LPN-E in the chest. R3 continued to yell and stated LPN-E was abusing R3. Certified Nursing Assistant (CNA)-H went in between R3 and LPN-E. LPN-E removed themselves from the situation. CNA-H attempted to calm R3 down. The police were called and conducted their investigation. The conclusion of the event was no staff had touched R3. R3 had hit a staff member. The allegation of abuse was unsubstantiated.Surveyor noted the facility had statements from R3, CNA-H, CNA-G, Nurse Supervisor (NS)-D, and CNA-F. Surveyor noted there was not a statement from LPN-E, who was directly involved in the incident and accused of abuse. It was documented LPN-E was out of the country and a statement could not be provided.On 7/28/2026, at 3:06 PM, Surveyor interviewed CNA-H who stated LPN-E was taking R3 back to their room and R3 was becoming more upset. CNA-H intervened in between R3, and LPN-E. NS-D and a security guard arrived shortly after. The police were called and they completed their investigation.Surveyor noted the FRI did not include the information a security guard was involved, or their statement. On 7/28/2026, at 3:32 PM, Surveyor interviewed Loss Prevention Manager (LPM)-I regarding the events on 4/21/2026. LPM-I stated they were not present at the time of the incident, but another security officer was. LPM-I stated every incident has a report, and they would find it and print out a copy for Surveyor. Surveyor received and reviewed the statement from the security guard. Surveyor noted the account confirmed other staff statements. On 7/28/2026, at 3:57 PM, Surveyor interviewed LPN-E who stated R3 went to the shared fridge. LPN-E redirected R3 away from the fridge. LPN-E was taking R3 back to their room. R3 was attempting to stand. LPN-E then went in front of R3, as R3 could fall. R3 then hit LPN-E in the chest. CNA-H went between them, and LPN-E went to the nurse's station. A security guard arrived and then NS-D arrived. Shortly after, Assisted Living Facility Administrator (ALFA)-C arrived and began getting statements from staff and R3.Surveyor noted the FRI did not include the information ALFA-C was involved, or their statement. On 7/29/2026, at 7:56 AM, Surveyor reviewed the FRI documentation and noted the security guard's report was now added to the FRI documentation.On 7/29/2026, at 9:51 AM, Surveyor interviewed ALFA-C who stated NS-D notified ALFA-C regarding the allegation of abuse. The police were notified. ALFA-C arrived on scene and began getting statements from everyone. R3 could not recall who abused him or any details of the staff member that abused R3 as they all look alike. ALFA-C offered to have R3 pick out the staff member who allegedly abused R3. R3 agreed then stated it was none of the staff at the current facility. R3 stated it was a staff member from the veteran nursing home facility. On 7/29/2026, at 10:09 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the FRI from 4/21/2026. NHA-A stated they became aware of the incident the next day on 4/22/2026. ALFA-C had sent NHA-A statements from that night and ALFA-C's abuse investigation. NHA-A stated they started their own abuse investigation and began collecting statements from staff. Surveyor asked why a statement from LPN-E was not collected. NHA-A stated LPN-E had left on vacation and was not available. Surveyor asked NHA-A why statements from other residents were not collected. NHA-A stated there were no residents that witnessed the incident. Surveyor asked why ALFA-C's abuse investigation was not included in the FRI documentation. NHA-A stated they had forgotten to add that ALFA-C had completed an investigation and did not think the facility could use ALFA-C's investigation. NHA-A provided Surveyor a copy of ALFA-C's investigation. Surveyor reviewed the documentation that ALFA-C had written. Surveyor noted the events matched the events submitted in the FRI, but contained documentation that was missing from the FRI that NHA-A had submitted. The document also contained statements from the security guard and LPN-E.On 7/29/2026, at 10:44 AM, Surveyor shared the concern with NHA-A that the FRI from 4/21/2026 was not thoroughly investigated. Surveyor shared the FRI submitted does not include the involvement or statements from the security guard or ALFA-C, ALFA-C's written investigation with statements, nor statements from residents regarding how LPN-E or staff treat them as a continuation of the abuse investigation. NHA-A acknowledged the missing information and will include it going forward.

Based on interviews and record review the facility did not ensure residents received needed care and services in accordance with professional standards of practice and the comprehensive care plan to meet each resident's physical, mental, and psychosocial needs for 1 of 1 (R4) residents reviewed for blood sugar testing.R4 had physician's orders for blood sugar testing/monitoring that was not completed as ordered.Findings include:R4 was admitted to the facility on [DATE] and has diagnoses that include Diabetes Mellitus (DM) Type 2, pulmonary embolism, dementia, depression, anxiety disorder and urine retention.The facility policy titled Blood Glucose Monitoring revised 9/25 documents (in part) . It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders.1. The facility will perform blood glucose monitoring as per physician's orders.R4's Care Plan dated 2/23/26 documents: The resident has Diabetes Mellitus (DM2). Taking Metformin PRN (as needed), Glucagon - revised 4/22/26. Interventions include Blood Sugar as ordered by doctor - revised 3/27/26. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report PRN any s/sx (signs and symptoms) of hyperglycemia; increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Monitor/document/report PRN any s/sx of hypoglycemia; sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait.On 7/28/26 at 11:15 AM, Surveyor spoke with R4's daughter/HCPOA (Power of Attorney for Healthcare) who reported concern the facility was not monitoring R4's blood sugars after she admitted to the facility. She reported that a few months ago she asked to view R4's blood sugars for the past month and found out there was nothing to view. R4's standing physician orders dated 2/26/26 document - Diabetes Management:1. PO (by mouth) DM meds: Blood sugars BID (twice a day).4. Call parameters: Blood sugar <60 (manage per hypoglycemic protocol), blood sugars >400.Surveyor noted R4's February 2026 Medication Administration Record (MAR) did not include a separate order for blood sugar testing with an area to record results. The MAR documented an order for Metformin HCL (hydrochloride) ER (extended release) 24-hour 500 mg (milligrams) give 1 tablet by mouth one time a day for DM and included an area to document the blood sugar result only once daily.Surveyor noted R4's March 2026 MAR documented the same Metformin order as above with the blood sugar test result entered only once daily.Surveyor noted the facility continued to check R4's blood sugar only once daily and not BID as ordered by the physician.On 4/20/26 a physician's order to check R4's blood sugar BID was transcribed on the MAR, however there was only a check mark entered from 4/21/26 - 4/24/26 and no blood sugar results documented on the MAR. The area to document the blood sugar result under Metformin had been removed.On 4/24/26 a physician's order to check R4's blood sugar before meals (three times a day) was transcribed on the MAR, however there was only a check mark entered and no blood sugar results documented on the MAR for the remainder of the month.Surveyor noted R4's May 2026 MAR documented the same order for blood sugar testing before meals with only a check mark and no results entered on the MAR through 5/11/26.On 7/28/26 at 2:30 PM, Director of Nursing (DON)-B told Surveyor the facility was doing R4's blood sugars once daily since admission and in April when the order was changed to BID and then TID, the Interdisciplinary Team (IDT) realized the order was not transcribed correctly. DON-B stated, There's a drop-down box to click to enter the result, so the IDT fixed it. Surveyor told DON-B of concern that R4's blood sugars were checked only daily and not BID as ordered by the physician. In addition, when the order was changed to TID on 4/24/26, the blood sugar results were not consistently documented and monitored until the IDT corrected the transcription error on 5/11/26. DON-B provided Surveyor with list of R4's blood sugar results that were documented under vital signs in point click care (PCC). Surveyor noted R4's blood sugars were not consistently documented TID in this area either. In addition, there were no blood sugar results documented on 4/25, 4/27, 4/28, 4/30, 5/1, 5/2, 5/5, 5/6, and 5/8 - 5/10/26. No additional information was provided prior to survey exit.

Based on observation, interview, and record review the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 2 (R1 and R2) of 3 residents reviewed with pressure injuries. *R2 is at risk for developing pressure injuries. Facility staff did not document multiple weekly skin checks in the weeks prior to 8/31/25 when R2 developed a facility-acquired stage 3 pressure injury of R2's Sacrum. On 10/22/25, R2 developed two additional facility-acquired stage 2 pressure injuries to R2's right and left hip. On 11/23/25, R2's two hip pressure injuries were resolved but a week later, R2's left hip pressure injury re-opened. A treatment order for R2's left hip was not placed until 11/27/25 resulting in R2 going 6 days without treatment to R2's left hip pressure injury. After the initial development of these pressure injuries, facility staff did not always follow the Wound Care Providers' treatment plan recommendations and did not always document a wound care treatment was completed as the Wound Care Provider ordered. On 1/14/26, Surveyor observed R2's pressure injuries and noted R2's sacrum pressure injury had worsened and R2's hip pressure injury went from a stage 2 to an unstageable pressure injury. *R1 developed avoidable, facility acquired, bilateral (both sides) heel pressure injuries on 12/12/2025. Contributing factors include heels not floated prior to development of bilateral heel pressure injuries, multiple absent weekly skin checks before and after discovery of heel pressure injuries and infrequent repositioning based on interview and observation. Air mattress was not provided until five days post discovery of pressure injuries on 12/17/2025. Findings include: The facility's policy titled, Wound Prevention Program and dated July 2021, last reviewed 6/14/2024, documents the following, in part: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure and non-pressure related skin injuries. Process: The licensed nurses will conduct weekly skin checks. This will be documented in the resident's electronic medical record (EMR). During routine care, the Certified Nursing Assistant (CNA) will observe the resident's skin. When abnormalities are noted, this will be communicated to the licensed nurse. The licensed nurse will proceed as mentioned in the step above and complete initiate a skin event in Risk Management. Pressure Relief: All residents will have a pressure redistribution mattress. As tolerated, needed position and reposition the resident with pillows and other supportive devices. Wheelchair cushion as indicated. The facility's policy titled Treatment/Services to Prevent/Heal Pressure Ulcer, and dated 12/22/2021, last reviewed 6/14/24, documents the following, in part: The facility's policy is to ensure it identifies and provides needed care and services that are resident-centered, per the resident's preferences, goals for care, and professional standards of practice that will meet each resident's physical, mental and psychosocial needs. Guidelines: The facility will ensure that based on the comprehensive assessment of a resident: A resident receives care, consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Procedure: Interventions will be implemented in the resident's plan of care to prevent pressure injury development. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure injury. The pressure ulcer(s) will be evaluated weekly by a Registered Nurse or Wound Physician, and the following will be documented in the resident's electronic medical record: the size, location, odor (if any), drainage (if any), and current treatment ordered. 1.) R2 was admitted to the facility on hospice on 11/6/24. R2's diagnoses include degenerative disease nervous system (progressive loss or death of nerve cells), stroke (lack of blood flow to the brain causing brain cells to die from lack of oxygen), hemiplegia following a stroke (weakness or inability to control one side of the body following a stroke), vascular dementia (cognitive decline caused by conditions damaging brain blood flow), type 2 diabetes (body doesn't make insulin properly leading to high blood sugars), severe protein calorie malnutrition (not enough protein intake causing muscle wasting and slow healing), chronic kidney disease (kidneys are damaged and can't filter waste and extra fluid from the blood), anxiety (feeling unease, fear, or worry), depression (feeling sadness or loss of interest, that may impact quality of life), hypertension (high blood pressure), and adult failure to thrive (overall decline in physical and mental function without an immediate obvious cause). R2's Quarterly Minimum Data Set (MDS) completed on 8/14/25 documents that R2 has no hallucinations, delusions or behaviors. R2's MDS documents R2 has no impairment with upper and lower extremities, uses a manual wheelchair, and requires set up assistance for eating. R2 is dependent for cares and requires partial/moderate assistance with bed mobility and transfers. R2 is frequently incontinent of bowel and bladder. R2's MDS documents R2 as being at risk for pressure injuries with no current pressure injuries. R2 was documented as having a Brief Interview for Mental Status (BIMS) score of 3, indicating that R2 has severe cognitive impairment. R2's skin integrity care plan, dated 11/6/24, documents, in part: Encourage good nutrition and hydration in order to promote healthier skin. The resident needs a pressure-relieving/reducing mattress to protect the skin while in bed. The resident needs pressure reducing Equagel cushion to protect the skin while up in chair. Turn and reposition [every] 2-3 hours and [as needed] while in bed. R2's Activity of Daily Living (ADL) care plan, dated 11/6/24, documents in part: The resident requires skin inspection during bath/shower. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. A revision on 8/15/25 included: The resident is totally dependent on 1 staff for repositioning and turning in bed. R2's Braden skin assessment (An assessment tool used to determine how at risk a resident is for developing a pressure injury) dated 8/8/25 documents a score of 16, indicating the resident is at risk for developing pressure injuries. R2's MD order with a start date of 2/17/25 documents: Weekly skin and shower check performed. If a new skin issue is identified, then a comprehensive assessment to be completed, in the morning every Monday. Surveyor reviewed facility documentation of R2's skin assessments starting in July of 2025. R2's order administration note dated 7/7/25 at 11:55 AM, documents, in part: Weekly skin and shower check. refused. Surveyor reviewed R2's medical record for a progress note of refusal and/or documentation of a completed skin assessment for 7/7/25 and did not locate documentation. R2's order administration note dated 7/14/25 at 6:53 PM, documents, in part: Weekly skin and shower check. Resident refused shower. No new skin issues noted. Surveyor noted that staff documented a refusal of shower but still documented a skin check. R2's progress note dated 7/21/25 at 1:15 PM, documents: Resident refused am shower today-several attempts made and unsuccessful. Body check completed, no new skin issues. Surveyor noted that staff documented a refusal of shower but still documented a skin check. R2's Treatment Administration Record (TAR) dated 7/28/25 documents a checkmark under weekly skin and shower check performed. R2's order administration note dated 8/4/25 at 11:39 AM, documents, in part: Weekly skin and shower check. refused. Surveyor reviewed R2's medical record for a progress note of refusal and/or documentation of a completed skin assessment for 8/4/25 and did not locate documentation. R2's order administration note dated 8/11/25 at 6:37 PM, documents, in part: Weekly skin and shower check. resident refused shower this day. Surveyor reviewed R2's medical record for a progress note of refusal and/or documentation of a completed skin assessment for 8/11/25 and did not locate documentation. R2's TAR dated 8/18/25 documents a checkmark under weekly skin and shower check performed. R2's TAR dated 8/25/25 documents the number 2, indicating a refusal. Surveyor reviewed R2's medical record for progress notes for details regarding the refusal and if R2 was reapproached to reattempt to complete a skin assessment for 8/25/25 and did not locate documentation. On 1/14/26 at 10:02 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F. CNA-F stated that skin assessments are completed by the nurse on every shower day. CNA-F stated that R2 does refuse showers at times and a bed bath will be done instead. CNA-F stated that if a skin concern is found, CNA-F would tell the nurse right away. On 1/14/26 at 10:10 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E about the facility's skin assessment policy. LPN-E indicated that skin assessments are completed weekly on shower days. Surveyor asked where they are documented. LPN-E stated that they are documented in the resident's medical record. Surveyor asked if there should be some sort of documentation of skin assessment even if a shower is refused. LPN-E stated that the skin checks should still be completed and documented in the medical record weekly. On 1/14/26 at 1:20 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what the facility policy is on resident skin assessments. DON-B stated that skin checks are completed weekly on the same day as the resident's shower. If a new issue is identified, a skin issue assessment is completed. DON-B stated the CNA will complete the shower and nurse will come in and do the skin assessment. Surveyor asked what happens if a resident refuses a shower. DON-B stated that if a resident refuses, the nurse should re-approach the resident and document the attempts. Surveyor asked where this would be documented. DON-B stated the CNA documents in the POC. Nurses would document a skin check in the TAR. If the shower was refused, the nurse should document that in a progress note and address the skin check in the progress note. Surveyor noted in the 8 weeks prior to 8/31/25, the facility did not document complete weekly skin checks, per their policy, 4 times. Surveyor noted a progress note documenting the shower refusal and completed skin assessment was not always completed in the 8 weeks prior to 8/31/25. R2's progress note dated 8/31/25 at 10:47 PM, documents, in part: . Resident has open area on [R2's] sacrum. Supervisor was made aware and assessed. Writer called. provider. new order received to cleanse sacrum open area with [Normal Saline], pat dry and apply Medi-honey, followed by bordered foam dressing. Change daily and [as needed] . Wound care to see. R2's skin issues assessment dated [DATE] at 11:20 PM, documents in part: . New skin issue. Location: sacrum. Issue type: pressure ulcer/injury. Stage 3 pressure ulcer- full thickness skin loss. Wound acquired in-house. Length 1.5 [centimeters (cm)] Width 1 cm. Depth 0.1 cm. Granulation 80%. Slough 20% . Resident reports pain when completing treatment. R2's pressure injury care plan dated 9/1/25 documents, in part: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Weekly treatment documentation to include measurement of each are of skin breakdown's (sic) width, length, depth, type of tissue and exudate. R2's MD order with a start date of 9/1/25 documents: Sacrum treatment: cleanse sacrum open area with normal saline. Pat dry. Apply Medi-honey. Followed by foam dressing. Change daily and [as needed] until wound care MD to see. Facility staff documented that treatments were addressed and completed from 8/31/25 to 9/3/25. R2's Provider wound note dated 9/3/25 documents, in part: Unstageable (due to necrosis) sacrum full thickness Pressure wound. 1.9 x 1.3 x 0.1 cm. 30% necrotic tissue. 20% slough. 50% granulation. Treatment plan: Hydrocolloid sheet (thin) apply three times per week and as needed. R2's MD order dated 9/5/25 documents, in part: [Treatment] to unstageable. wound to sacrum. Cleanse with normal saline. Pat dry and apply hydrocolloid dressing every day shift. Every Monday, Wednesday and Friday for wound care. R2's Interdisciplinary (IDT) note dated 9/5/25 at 2:51 PM, documents, in part: The IDT reviewed a new skin issue on the sacrum. The wound was initially classified as a stage III wound on 8/31/25. The physician was notified, treatment was put in place, and the mattress was changed to a Geo-Mattress Ultramax. The Wound Physician assessed the wound on 9/3/2025. The wound progressed to an unstageable pressure injury. The IDT recommended a Span-care convertible mattress, a dietitian consultation, and a change to a w/c with Ecogel Plus. The resident was on a turning schedule, had a pressure reduction mattress, and an Ecogel cushion before the initial pressure injury. The resident is in hospice due to dementia. The resident is declining oral intake, and functional needs have increased. Surveyor reviewed R2's MD orders and TAR. Surveyor noted facility staff documented R2's treatments were addressed and completed as ordered from 9/5/25 through 10/22/25. Surveyor noted through this time period the sacral wound was progressively decreasing in size. R2's Significant Change MDS completed on 9/11/25 documents the following Care Area Assessments (CAA)s: Pressure Ulcer/Injury CAA – R2 has an unstageable pressure injury due to necrosis to her sacrum and is followed by the wound team. Care plan to address and to minimize the risk for pressure ulcer impairments. R2's progress note dated 10/22/25 at 6:50 PM documents, in part: Resident has new open blisters/stage 2 pressure ulcers to the right and left lateral hip. Wound Doctor and wound Team will assess and treat resident wound. R2's Provider wound note dated 10/22/25 documents, in part: Stage 3 pressure wound sacrum full thickness. 1 x 0.5 x 0.1. 100% granulation. Treatment plan: Leptospermum honey apply once daily and as needed. Gauze island with boarder dressing apply once daily and as needed. Stage 2 pressure wound of the right, lateral hip partial thickness. Wound size 1 x 1 x 0.1. Open areas with exposed dermis. Treatment plan: Leptospermum honey apply once daily and as needed. Gauze island with boarder dressing apply once daily and as needed. Stage 2 pressure wound of the left, lateral hip partial thickness 3.5 x 2.1 x 0.1. Open areas with exposed dermis. Treatment plan: Leptospermum honey apply once daily and as needed. Gauze island with border dressing apply once daily and as needed. Surveyor noted 2 new hip pressure injuries were found on 10/22/25. R2s MD order with a start date of 10/24/25 documents, in part: . Treatment to stage 2 pressure wound of the left lateral hip: Cleanse with normal saline. Pat dry. Skin prep peri wound. Apply Leptospermum honey to wound bed and cover with foam wound dressing every day shift for wound care. R2's MD order with a start date of 10/24/25 documents, in part: . Treatment to stage 2 pressure wound of the right lateral hip: . Cleanse with normal saline, Pat dry. Skin prep peri wound. Apply Leptospermum honey to wound bed and cover with foam wound dressing every day shift for wound care. Surveyor noted that the start date of the MD orders for R2's two new pressure injuries were started 2 days after the wounds were found. Surveyor reviewed R2's progress notes and TAR and noted R2's wound treatments for the 2 new hip pressure injuries were not documented as completed on 10/23/25. R2's IDT note dated 10/27/25 documents, in part: IDT reviewed new skin issues. Treatment in place. Increased ProSource to 60 [milliliters (ml)] [two times a day]. Care plan reviewed. Surveyor reviewed R2's MD orders and TAR and noted that assessments and treatments were completed for all 3 wounds as ordered from 10/24/25 through 11/5/25. R2's skin assessment note dated 11/5/25 documents, in part: Wound team re-evaluated resident; resident being followed for stage 3 [pressure injury] to sacrum. Resident being followed for stage 2 [pressure injuries] to [both] hip[s]. Sacrum 1.4 x 0.8 x 0.1 Full thickness skin loss. Right hip 1.4 x 1.3 x 0.1 Partial-thickness skin loss with exposed dermis. Left hip 2.5 x 2.5 0.1 Partial-thickness skin loss with exposed dermis. All wounds appear stalled as evident by increased wound size. Wound team recommends changing Medihoney to Santyl for sacrum wound for debridement as wound physician is unavailable for debridement. Resident tolerated assessment and treatment well. Air mattress and heel boots in place. R2's MD order with a start date of 11/6/25 documents, in part: Santyl External Ointment 250 unit/[gram]. Apply to Sacrum topically every day shift for [pressure injury]. Skin prep peri wound. Apply foam border dressing after application. Surveyor noted the Medication/Treatment order for R2's Sacral wound did not include directions for cleansing the wound. R2's Orders Administration Note dated 11/6/25 at 12:56 PM, documents, in part: Santyl. ointment unavailable. wound cleaned and covered. Surveyor noted R2's wound was not treated as ordered on 11/6/25. R2's Provider wound note dated 11/7/25 documents, in part: Stage 3 pressure wound sacrum full thickness. 0.9 x 1 x 0.1. 20% slough. 80% granulation. Treatment plan: Leptospermum honey apply once daily and as needed. Gauze island with border apply once daily and as needed. Stage 2 pressure wound of the right, lateral hip partial thickness. 0.9 x 1.2 x 0.1. Open areas with exposed dermis. Stage 2 pressure wound of the left, lateral hip partial thickness 3 x 3.4 x 0.1. Open areas with exposed dermis. Surveyor noted the treatment to the hip pressure injuries remained the same. Surveyor noted R2's wound provider prescribed a treatment plan of Leptospermum honey for R2's sacral wound. Surveyor reviewed R2's MD orders and TAR and noted that facility staff did not change the sacral treatment order from Santyl to Leptospermum honey as the wound provider recommended on 11/7/25. R2's progress note dated 11/7/25 at 2:51 PM, documents, in part. [Treatment] to both hips completed as ordered. No pain or drainage noted. Both wounds in healing stage. Wound to sacrum cleaned and covered, ointment has not arrived. Surveyor noted R2's sacral wound is being cleansed but no treatment is being used as the Wound Provider ordered on 11/7/25. Surveyor reviewed R2's MAR and noted the Santyl ointment to R2's sacral wound was documented as completed on 11/8, 11/9 and 11/10/25. Surveyor noted facility staff were documenting that the sacral wound was being treated with Santyl instead of Leptospermum honey that the Wound Provider ordered on 11/7/25. R2's progress note dated 11/11/25 at 11:26 AM, documents, in part: [Treatment] to both [hips] completed as ordered. [Treatment] to sacrum could not be completed due to Santyl being unavailable. Sacrum however was cleaned and rebandaged. Surveyor noted that R2's sacral wound was cleansed on 11/11/25 but not treated as the Wound Provider ordered on 11/7/25. R2's Wound Provider note dated 11/12/25 documents, in part: Stage 3 pressure wound sacrum full thickness. 0.9 x 1 x 0.1. 20% slough. 80% granulation. Treatment plan: Leptospermum honey apply once daily and as needed. gauze island with border apply once daily and as needed. R2's right, lateral hip and left, lateral hip pressure injuries were documented as resolved. R2's MD order with a start date of 11/14/25 documents, in part: [Treatment] to stage 3 pressure wound sacrum: Cleanse with normal saline. Pat dry. Skin prep peri wound. Apply Leptospermum honey to wound bed [followed by] foam border wound dressing every day shift for wound care. Surveyor noted that the start date of the MD orders for R2's sacral pressure injury was started 2 days after the wound provider prescribed Leptospermum honey. Surveyor reviewed R2's TAR and noted R2's wound treatment for the sacral pressure injury was not documented as completed on 11/13/25. R2's Wound Provider note dated 11/19/25 documents, in part: Stage 3 pressure wound sacrum full thickness. 0.9 x 1 x 0.1. 20% slough. 80% granulation. Revisit to care goals: Over the past month: closely monitor, serial debridement, ultrasound mist and dressing adjusted as needed. Encourage offloading of wound. This month's approach: Continue to monitor closely. Continue [ultrasound mist]. Encourage repositioning and prompt incontinence cares. Stage 2 pressure wound of the left hip partial thickness. 2.5 x 3.5 x 0.1. Periwound radius: Surrounding [deep tissue injury] Purple/Maroon. Open areas with exposed dermis. Treatment plan: Leptospermum honey apply once daily and as needed. Gauze island with border apply once daily and as needed. Surveyor noted the previously resolved pressure injury of the left hip had reopened on 11/19/25, one week after being resolved. Surveyor reviewed R2's progress notes, MD orders and TAR. Surveyor noted the facility did not enter the 11/19/25 treatment orders to include: Treatment plan: Leptospermum honey apply once daily and as needed. Gauze island with border apply once daily and as needed for the reopened left hip pressure injury. As a result, Surveyor noted R2's left hip wound was not receiving daily treatments as Wound Provider recommended from 11/20 through 11/26/25. R2's Wound Provider note dated 11/26/25 documents, in part: Stage 3 pressure wound sacrum full thickness. 1.7 x 1.3 x 0.1. 100% granulation. Treatment plan: Iodosorb gel apply once daily and as needed. Gauze island with border apply once daily and as needed. Stage 2 pressure wound of the left hip partial thickness. 2.5 x 3.2 x 0.1. Open areas with exposed dermis. Treatment plan. Iodosorb gel apply once daily and as needed. Gauze island with border apply once daily and as needed. Surveyor noted that R2's sacral wound had almost doubled in size. Surveyor noted that the Wound provider changed the treatment from Leptospermum honey to Iodosorb gel daily for both the sacral and hip pressure injuries. R2's MD order with a start date of 11/27/25 documents, in part: Treatment for left hip: Cleanse site with normal saline and pat dry. Apply Iodosorb to the site. Cover with gauze island with border every day. R2's MD order with a start date of 11/27/25 documents, in part: [Treatment] to stage 3 pressure wound sacrum. Cleanse with normal saline. Pat dry, skin prep periwound. Apply Iodosorb to wound bed [followed by] foam border wound dressing every day. R2's Wound Provider note dated 12/17/25 documents, in part: Stage 3 pressure wound sacrum full thickness. 1.6 x 1.4 x 0.1. 30% slough. 70% granulation. Treatment plan: Iodosorb gel apply once daily and as needed. Alginate calcium apply once daily and as needed. Gauze island with border apply once daily and as needed. Stage 2 pressure wound of the left hip partial thickness. 2 x 3.1 x 0.1. Open areas with exposed dermis. Treatment plan: Iodosorb gel apply once daily and as needed. Alginate calcium apply once daily and as needed. Gauze island with border once daily and as needed. Surveyor noted the treatment recommended by the Wound Provider on 12/17/25 was not entered as a new MD order by facility staff. Surveyor reviewed R2's MD orders and TAR and noted facility staff continued to treat both wounds with just Iodosorb gel and did not include Alginate calcium as Wound Provider ordered from 12/18/25 through 12/21/25. R2's MD order with a start date of 12/22/25 documents, in part: Treatment for left hip: Cleanse site with normal saline and pat dry. Apply Iodosorb and calcium alginate to the site. Cover with gauze island with border every day. R2's MD order with a start date of 12/22/25 documents, in part: [Treatment to stage 3 pressure wound sacrum. Cleanse with normal saline. Pat dry. Skin prep peri wound. Apply Iodosorb and calcium alginate to wound bed [followed by] foam border wound dressing. Every day. Surveyor noted staff began treating both pressure injuries with the correct treatment 4 days after the Wound Provider recommended the treatment change. R2's Wound Provider note dated 12/24/25 documents, in part: Stage 3 pressure wound sacrum full thickness. 2.8 x 1.6 x 0.1. Eschar 80% Granulation tissue 20% . Treatment plan: Leptospermum honey apply once daily and as needed. Xeroform gauze apply once daily and as needed. Gauze island with border apply once daily and as needed. Stage 2 pressure wound of the left hip partial thickness. 1.6 x 3 x 0.1. Open areas with exposed dermis. Treatment plan: Leptospermum honey apply once daily and as needed. Xeroform gauze apply once daily. Gauze island with gauze island with border apply once daily and as needed. Surveyor noted R2's sacral pressure injury almost doubled in size and developed 80% eschar. Surveyor noted that this change came after the incorrect treatment was done 4 days and the correct treatment done for 2 days prior to this assessment on 12/24/25. Surveyor reviewed R2's MD orders and TAR. Surveyor noted facility staff continued to treat both of R2's pressure injuries with Iodosorb and calcium alginate instead of the new recommended treatment order of Leptospermum honey and Xeroform gauze from 12/25/25 through 12/30/25. R2's Wound Provider note dated 12/31/25 documents, in part: Stage 3 pressure wound sacrum full thickness. 2.4 x 1.4 x 0.1. Eschar 80%. Granulation 20% . Treatment plan: Leptospermum honey apply once daily and as needed. Xeroform gauze apply once daily and as needed. Gauze island with border apply once daily and as needed. Stage 2 pressure wound of the left hip partial thickness. 2.4 x 2.4 x 0.1. Open areas with exposed dermis. Treatment plan: Leptospermum honey apply once daily and as needed. Xeroform gauze apply once daily and as needed. Gauze island with border apply once daily and as needed. Surveyor noted that when facility staff did not follow the Wound Providers treatment recommendations from 12/25 through 12/30/25, R2's left hip pressure injury grew in size. R2's MD order with a start date of 1/1/26 documents, in part: Treatment for left hip. Cleanse site with normal saline and pat dry. Apply medihoney and calcium alginate to the site. Cover with gauze island with border every day. Surveyor noted that facility staff entered a new treatment order for the left hip that included medihoney (Leptospermum honey) and calcium alginate when the Wound Provider had recommended (medihoney) Leptospermum honey and Xeroform. R2's MD order with a start date of 1/1/26 documents, in part: [Treatment] to stage 3 pressure wound sacrum. Cleanse with normal saline. Pat dry. Skin prep peri wound. Apply medihoney and Xeroform to wound bed [followed by] foam border wound dressing every day. Surveyor noted facility staff entered the recommended Wound Provider orders for the sacral pressure injury. Surveyor reviewed R2's TAR and noted facility staff continued to treat R2's left hip wound with the incorrect treatment of Leptospermum honey and calcium alginate from 1/1/26 through 1/7/26. Facility staff treated R2's sacral pressure injury as ordered from 1/1/26 through 1/7/26. R2's Wound Provider note dated 1/7/26 documents, in part: Stage 3 pressure wound sacrum full thickness. 3.1 x 2.4 x 0.1. Eschar 80%. Granulation 20% . Treatment plan [remained the same from the previous week]. Stage 2 pressure wound of the left hip partial thickness. 2.1 x 1.9 x 0.1. Open areas with exposed dermis. Treatment plan: Leptospermum honey apply once daily and as needed. Xeroform gauze apply once daily. Gauze island with border apply once daily and as needed. R2's MD order with a start date of 1/10/26 documents, in part: Treatment for left hip. Cleanse site with normal saline and pat dry. Apply medihoney (Leptospermum honey) and xeroform to the site. Cover with gauze island with border every day. Surveyor noted facility staff continued to treat R2's left hip with the incorrect treatment of Leptospermum honey and calcium alginate on 1/8/26 and 1/9/26. Facility staff began treating R2's left hip with the correct Wound Provider recommended treatment on 1/10/26. On 1/14/26 at 9:55 AM, Surveyor observed R2 on back in bed. R2 had a pillow under R2's right hip. R2's air mattress was on and functioning. R2 responded to Surveyor's voice. R2 stated R2 ate breakfast, and it was good. R2 stated that R2 was not in any pain. Surveyor observed R2's heel boots on and feet elevated on pillow. On 1/14/26 at 10:02 AM, Surveyor interviewed CNA-F. CNA-F stated that R2 has had a gradual decline. R2 stays in bed more than before but was up in the chair yesterday. R2 has had a pressure reducing mattress for as long as CNA-F can remember but was changed to an air mattress after pressure injuries were found. R2 is turned every 2 to 3 hours. On 1/14/26 at 10:10 AM, Surveyor interviewed LPN-E. Surveyor asked what caused R2 to develop pressure injuries. LPN-E indicated that R2 was getting up in chair every day but started to sleep more and more. LPN-E stated that when R2 would fall asleep in R2's chair, R2 would be leaning forward and almost putting R2's head on R2's lap. For that reason, R2 spends more time in bed for R2's safety and fall risk. Now, it is up to R2 if R2 wants to sit in chair or get up. LPN-E stated that R2's wounds are treated daily. R2 always has heel boots on, and skin prep is completed on heel to prevent injury. R2 is on high caloric boost since R2 does not eat as well as before. LPN-E indicated that R2 has had a gradual decline. On 1/14/26 at 2:50 PM, Surveyor interviewed Wound Care Nurse Practitioner (WC NP)-H. Surveyor asked how R2 developed R2's current pressure injuries. WC NP-H indicated that R2 has severe protein-malnutrition and is followed by dietary. R2 is non-ambulatory and has multiple diagnosis that would contribute to the development of pressure injuries. R2 has worsening dementia and is on hospice. WC NP-H indicated that R2 is very small and bony. WC NP-H continued and stated that R2 has been on the correct mattress. WC NP-H stated that R2 has a turning schedule, R2's heel boots are always on and air mattress on when WC NP-H sees R2. WC NP-H stated the facility is good about keeping up with offl

Based on observation, interview and record review, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 1 of 2 medication rooms and 1 of 3 medication carts observed, affecting more than 3 residents but less than widespread. Findings include:The facility policy titled Labeling of Medications and Biologicals implemented 9/21 documents (in part) . 4. Labels for individual drug containers must include:h. The expiration date when applicable.8. Labels for multi-dose vials must include:a. The date the vial was initially opened or accessed (needled punctured).b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The facility policy titled Multi-Dose Vials implemented 8/21 documents (in part) . It is the policy of this facility to ensure proper and safe use of multi-dose vials of medications.2. Multi-dose vials will be re-labeled with a beyond use date, 28 days after the vial is opened or punctured (unless otherwise specified by the manufacturer). The beyond use date rule will begin on the first (1st) day the multi-dose vial is opened or punctured.3. The medication label will also include the initials of the nurse who opened the vial.6. Discard the vial accordingly if the vial is out of date (past the beyond use date/manufacturer's expiration date).7. Unit Manager will perform random checks of opened multi-dose vials for appropriate dating. The Health Direct pharmacy services list of Insulin Expiration Dates updated October 2022 documents:Expiration upon opening or removing from refrigerator: Lantus 28 days. Lispro 28 days.The Health Direct pharmacy services list of Ophthalmic Medication Beyond-use date guide dated April 2024 documents:Oflaxacin drops 0.3% expiration date 28 days from opening. Latanoprost solution 0.005% expiration date 42 days from opening. 1. On 12/11/25 at 8:00 AM, Surveyor observed the medication room on the 2500 unit. Inside the refrigerator was a metal bin and clear bag containing insulin. Surveyor located the following insulin vials that were open and used, but not dated when opened:Two Lantus insulin vials belonging to R29, a Lantus insulin vial belonging to R4, a Lantus insulin vial belonging to R28 (the label read expires 28 days once opened), a Lispro insulin vial belonging to R28, and a Lispro insulin vial belonging to R56. All the above insulin vials were open and used but not dated when opened. On 12/11/25 at 8:15 AM, Surveyor advised Licensed Practical Nurse (LPN)-K of the observed resident insulins that were not dated when opened. Surveyor advised they were placed separately in the plastic bag and placed in the refrigerator. LPN-K reported she will reorder the insulin as needed. 2. On 12/11/25 at 8:30 AM, Surveyor observed the medication cart on the rehabilitation unit. Inside the top drawer of the medication cart, Surveyor located the following:A bottle of Latanoprost 0.005% eye drops belonging to R49 which was open and used but not dated when opened. The label read Start date 9/15/25, expires 42 days after opened.A bottle of Ofloxacin 0.3% eye drops belonging to R38 which was open and used but not dated when opened. The label read Start date 10/12/25.On 12/11/25 at 11:06 AM, Nursing Home Administrator (NHA)-A provided Surveyor the facility policy and procedure for insulin and eye drops and the pharmacy list of insulin and eye drop expiration dates once opened. On 12/11/25 at 3:00 PM, during the daily exit meeting, NHA-A and Director of Nursing (DON)-B were notified of the observations and concern of the above residents' insulin and eye drops that were not dated when opened. No additional information was provided.

Based on interview and record review, the facility did not address and resolve grievances conveyed on behalf of 1 (R9) of 6 grievances reviewed.*R9 expressed care concerns. There was no documentation this was thoroughly investigated, along with an appropriate resolution.Findings include:The facility policy last revised February 2025 and titled Grievance documents:Objective of Grievance PolicyThe objective of the grievance policy is to ensure the facility makes prompt efforts to resolve grievances a resident may have in a timely manner. The intent of the grievance process is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) and to assure that after receiving complaint/grievance, the facility actively seeks a resolution and keeps the resident appreciated its progress toward resolution. E. A grievance or concern can be expressed orally to the Grievance Official or facility staff or in writing using a grievance form which will be located adjacent to the [NAME] of Rights posting located throughout the facility. G. ResponseAny employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Officer. The investigation will consist of at least the following: * A review of the completed complaint report An interview with the person or persons reporting the incident if applicable Interviews with any witnesses to the incident or concern A review of the resident medical record if indicated A search of resident room (with resident permission) An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident Interviews with the resident's roommate, family members, and visitors A root-cause analysis of all circumstances surrounding the incident. As necessary, the Grievance Official and facility leadership will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated.R9 was admitted to the facility on [DATE] with pertinent diagnoses that include diastolic (congestive) heart failure (occurs when the heart muscle doesn't pump blood as well as it should), chronic kidney disease stage 3 (kidneys are moderately damaged, filtering at 30-59% capacity), chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (persistent, excessive fear or worry in situations that are not threatening), spinal stenosis in lumbar region without neurogenic claudication (a narrowing of the spinal canal, stenosis can cause pressure on your spinal cord), and chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months).R9's Significant Change Medicare Minimum Data Set (MDS) with an assessment reference date of 9/22/2025 documents a Brief Interview for Mental Status score of 13 (cognitively intact) for R9. R9 is coded to make self understood and understands others.On 12/15/2025, at 9:18 AM, Surveyor interviewed R9 regarding a grievance R9 submitted on 9/15/25. R9 told Surveyor that there has been a couple more incidences since then with another staff member, Certified Nursing Assistant (CNA)-G. R9 reported the issues to Licensed Practical Nurse (LPN) Manager-D. The example R9 gave was R9 asked CNA-G to put R9's handbag back on the doorknob as it had fallen on the floor, CNA-G blew up at R9 and said that's not my job. R9 stated that it was very upsetting and even made R9 cry. R9 asked LPN Manager-D that CNA-G not be allowed in R9's room. Surveyor found no grievance regarding CNA-G filed on R9's behalf.On 12/15/25, at 1:30 PM, Surveyor interviewed LPN Manager-D regarding any known issues R9 has with staff members. LPN Manager-D stated that R9's care plan shows that R9 refuses cares and will send staff away. LPN Manager-D does not recall any staff not being allowed in R9's room. Surveyor asked LPN Manager-D about CNA-G and LPN Manager-D does not remember R9 reporting anything about CNA-G.On 12/15/25, at 2:44 PM, LPN Manager-D followed up with Surveyor that R9 did come and say I don't want CNA- G to take care of me anymore. This was about a month ago, LPN Manager-D stated that no grievance was completed. At the time LPN Manager-D asked CNA-G if there had been an issue and CNA-G didn't remember anything. LPN Manager-D asked CNA-G not to go in R9's room and ask R9 about it or start anything, just respect R9's wishes.Surveyor noted LPN Manager-D took complaint and acted to not have CNA-G go into R9's room, however no grievance process was initiated and investigation completed.On 12/16/25, at 8:36 AM, Surveyor interviewed Social Worker Lead-I and was told that no grievance for R9's issue with CNA-G was found. The only information Social Worker Lead-I had was what Surveyor had shared.On 12/16/25, at 9:07am, Surveyor interviewed Director of Nursing (DON)-B about no grievance being filed when R9 voiced a care concern and let DON-B know this is a concern.On 12/16/25, at 10:03am, Surveyor let Nursing Home Administrator (NHA)-A know the concern related to no grievance being filed when R9 voiced a care concern.No additional information was provided regarding no grievance being filed when a resident expressed care concerns. No documentation was provided that this was thoroughly investigated, or an appropriate resolution found.

Based on interview and record review, the facility did not ensure a resident who uses a psychotropic PRN (as needed) drug had an order limited to 14 days for 1 (R9) of 6 residents reviewed for medications.R9 had an order for PRN Lorazepam with a start date of 11/14/2025 and no end date.Findings include:The facility policy and procedure implemented 9/3/25 and titled, Use of Psychotropic Medication documents:Policy Explanation and Compliance Guidelines:16. Psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted:a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration.R9 was admitted to the facility on [DATE] with pertinent diagnoses that include diastolic (congestive) heart failure (occurs when the heart muscle doesn't pump blood as well as it should), chronic kidney disease stage 3 (kidneys are moderately damaged, filtering at 30-59% capacity), chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (persistent, excessive fear or worry in situations that are not threatening), spinal stenosis in lumbar region without neurogenic claudication (a narrowing of the spinal canal, stenosis can cause pressure on your spinal cord), and chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months).R9's Significant Change Medicare Minimum Data Set (MDS) with an assessment reference date of 9/22/2025 indicates R9 had a Brief Interview for Mental Status score of 13 (cognitively intact). R9 is coded to make self understood and understands others.R9's care plan documents The resident uses anti-anxiety medications scheduled Hydroxyzine, Sertraline, Buspirone (PRN Lorazepam medications) r/t (related to) anxiety disorder, Date Initiated: 03/10/2025, Revision on: 09/01/2025.Pertinent interventions include: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q (per)-SHIFT. Date Initiated: 03/10/2025 Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Clonazepam, Lorazepam, Buspirone, Sertraline: antianxiety medication drugs being given). Date Initiated: 03/10/2025 Monitor the resident (every shift for safety. The resident is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. Date Initiated: 03/10/2025.R9's physician order dated 11/14/25 documents Lorazepam Oral Tablet 0.5 mg. Give 0.5 mg by mouth every 12 hours as needed for anxiety.Surveyor noted that the PRN order date was beyond 14 days with no end date indicated. Surveyor noted according to the State Operations Manual, the need to limit the timeframe for PRN psychotropic medications, which are not antipsychotic medications, to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner. Surveyor noted this was not documented.On 12/16/25, at 9:06am, Surveyor interviewed Director of Nursing (DON)-B regarding the PRN Lorazepam order for R9 not having a stop date. DON-B responded will look for documentation and get back to Surveyor.On 12/16/25, at 10:00am, Surveyor let Nursing Home Administrator (NHA)-A know of concern that a PRN psychotropic medication was ordered without a 14 day stop date or documentation of why a longer timeframe would be appropriate.On 12/16/25, at 11:05am, DON-B followed up and stated that the provider said the order for Lorazepam has been filled multiple times so is relevant. The most recent Psychiatry Follow Up was provided to Surveyor which states no changes to psychiatric medications were made at this visit. Surveyor explained this does not provide a stop date or document a reason why a longer timeframe would be appropriate.No additional information was provided regarding the PRN Lorazepam physician order R9 had without a stop date.

Based on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 2 (R6 and R5) of 5 residents reviewed for falls. *R6 has a history of falls and is at high risk for falls. R6 experienced falls while at the facility. R6's fall care plan was not updated timely after a fall. R6 has an active intervention for a seat belt while in the wheelchair. On 10/24/25, R6 slid out of R6's wheelchair at the dining room table. After the fall, facility staff entered a new intervention on R6's care plan that documented, Locate [wheelchair] with seat belt, ensure positioning of [wheelchair] on [dining room] table appropriate and close to the table. R6's seat belt was not on the wheelchair at the time of the fall. During interviews, Surveyor was informed that R6's wheelchair with the seatbelt was out for repair and R6 did not have a seatbelt on at the time of the 10/24/25 fall. Surveyor observed R6's fall care plan interventions not in place during survey. *R5 had a fall on 8/2/25 and the facility did not revise the care plan interventions timely. Findings include: The facility policy with a last reviewed/revised date of 8/2024 and titled, Fall Prevention Program, documents: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will: Assess the resident. complete a fall packet. review the resident's care plan and update as indicated. 1.) R6 was admitted to the facility on [DATE] with diagnosis that includes Parkinsons disease, Dementia, Orthostatic hypotension, Cancer and History of falling. R6's admission Minimum Data Set assessment dated [DATE], documents R6 is cognitively intact and that R6 requires substantial/maximum assistance for transfers. The MDS also documents that R6 had falls in the 2 to 6 months before admission to the facility. R6's high risk for falls care plan initiated on 1/19/25 documents the following pertinent interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bed in locked and lowered position. Ensure adequate lightning is appropriate and/or per resident request. Ensure that the resident is wearing appropriate footwear. Follow facility fall protocol. R6's Fall Risk Evaluation dated 3/15/25 documents R6 is at high risk for falls. R6's progress note dated 4/10/25 at 3:10 PM, documents: Writer was called to resident's room after [R6] was noted on the floor next to his recliner. Writer assessed resident and noted no skin, musculoskeletal or head trauma complications. Surveyor reviewed the facility's fall investigation. Surveyor noted R6 fell in R6's room because of trying to complete a self-transfer from R6's recliner. R6 did not sustain an injury. R6's progress note dated, 5/1/2025 at 2:14PM documents: [Interdisciplinary team (IDT)] reviewed fall from 4/10/2025. Interventions in place, care plan updated. On 5/1/25, R6's fall care plan was updated with the following intervention: Encourage participation in group activities and provide a sensory lap apron to reduce instances of self-transfer in his room. Surveyor noted R6's fall from 4/10/25 was reviewed by the IDT team on 5/1/25 and R6's care plan was reviewed and updated on 5/1/25, which is 21 days after the fall occurred. On 12/15/2025 at 10:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F. Surveyor asked when a resident's care plan should be updated after a fall. LPN-F stated that the nurse can put in an intervention right away. Surveyor asked if it is typical to put in an intervention days to weeks after a fall. LPN-F stated that it should be put in the care plan right away. On 12/15/2025 at 1:38 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what the workflow is if a resident falls. DON-B stated that if a resident is found by a Certified Nursing Assistant (CNA), the CNA will alert a nurse. There is an RN assessment completed, notifications made, and the nurse will complete all the documentation. The IDT team will meet and review each fall. The team meets every weekday and will make sure that the investigation is complete and will review and revise the care plan. Surveyor asked how long it takes to get the new intervention onto the resident's care plan. DON-B stated that DON-B cannot speak to an amount of time. DON-B continued and stated that IDT will typically talk about a fall within a couple days of the fall occurring. At that meeting, the interventions would be reviewed and a new one placed. Surveyor asked about R6's 4/10 fall and if it is typical for it to take 21 days for the care plan to be updated with a new intervention. DON-B stated that it is not normal and that 4/10/25 to 5/1/25 is an abnormally long time to go without updating the care plan with an intervention after a fall. R6's progress note dated 4/27/25 at 9:28 PM documents, in part: Writer notified by [Certified Nursing Assistant] that the resident was laying on the floor next to his bed. Resident is alert. laying on [R6's] right-side on the floor. [Registered Nurse (RN)] supervisor assessed the resident. Injury Noted, Closed hematoma to Right cheekbone. Closed Hematoma over right eyebrow. Surveyor reviewed the facility fall investigation and noted R6 fell in R6's room because R6 was trying to complete a self-transfer out of bed. R6's progress note, dated 5/1/2025 2:32 PM documents, in part: IDT reviewed fall from 4/27/2025. Interventions and care plan updated. As a result of this fall, Physical Therapy was consulted to build R6's strength. On 5/1/25, R6's fall care plan was updated with the following intervention: Trial seat belt when in wheelchair to remind resident not to attempt to self-transfer. Surveyor noted, R6's care plan was reviewed and updated on 5/1/25, which is 4 days after the fall occurred. R6's progress note dated 7/9/2025 at 3:42 PM, documents: Resident transferred [R6's self-] into bed, as none of the aides stated that they helped [R6]. A few minutes later [writer] walked past and saw [R6] on the floor between the wheelchair and bed. Resident was placed in dining area for supervision. Surveyor reviewed the facility fall investigation. R6 was able to get to R6's room from the dining room. R6 was able to remove the seatbelt and transfer into bed. Later, R6 was trying to self-transfer out of bed and into the wheelchair and that is when R6 fell. R6 did not sustain any injury. On 7/16/25, R6's fall care plan was updated with the following intervention: Stop sign to be placed across doorway for visual reminder. Surveyor noted, R6's care plan was reviewed and updated on 7/16/25, which is 7 days after the fall occurred. R6's progress note dated 8/8/2025 at 7:51 PM documents, in part: Writer notified by CNA that the resident was sitting on the floor next to [R6's} bed. RN supervisor assessed the resident . No injury noted. Surveyor reviewed the facility fall investigation. Fall interventions were documented as being in place. R6 stated that R6 was going to bed. R6 was able to get from the dining room to R6's room and was trying to self-transfer to bed when R6 fell. R6 did not sustain an injury. On 8/14/25, R6's fall care plan was updated with the following intervention: Resident to be offered to go to bed right after dinner. Surveyor noted R6's care plan was reviewed and updated on 8/14/25, which is 7 days after the fall occurred. On 9/3/25, R6's fall care plan was updated with the following intervention: Keep the room door closed when the resident is not in the room with a stop sign in place. R6's progress note dated, 10/24/2025 at10:52 PM, documents, in part: Resident was in the dining room eating, when [resident] slid out of [the] wheelchair and onto the floor. Surveyor reviewed the facility fall investigation. Surveyor noted facility staff did not document that R6's seat belt was on and in place at the time of the fall. R6 did not sustain an injury. On 10/29/25, R6's fall care plan was updated with the following intervention: Locate [wheelchair] with seat belt, ensure positioning of [wheelchair] on [dining room] table appropriate and close to the table. Surveyor noted R6's care plan was reviewed and updated on 10/29/25, which is 5 days after the fall. In addition, Surveyor noted that according to this intervention, R6's wheelchair with seat belt was not in use at the time of the fall because the intervention reads that staff need to locate it. On 12/10/2025 at 1:25 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-H. Surveyor asked if there was a time that R6 did not have a seat belt in place. LPN-H stated that the wheelchair with the seat belt was missing for about 2 to 3 months. On 12/15/2025 at 8:41 AM, Surveyor interviewed CNA-E. Surveyor asked how long R6 has had a seat belt in the wheelchair. CNA-E stated that CNA-E was not sure. CNA-E stated that CNA-E works with R6 occasionally. CNA-E stated that R6 always has a wheelchair but does not always have a seatbelt in place. CNA-E acknowledged that there was a time that the seatbelt was missing but did not know how long it was gone. On 12/16/25 at 9:10 AM, Surveyor interviewed DON-B. Surveyor asked if R6's wheelchair and seatbelt were missing for a period of time. DON-B stated that the wheelchair and seatbelt were not missing but they were out for repair. Surveyor asked when the wheelchair was being serviced and for how long it was not in repair. DON-B stated that DON-B could not find that time frame. Surveyor asked about the intervention placed on 10/29/25 as a result of R6's fall on 10/24/25 at the dining room table. DON-B agreed that the intervention for locating R6's wheelchair with seatbelt would not have been added if the wheelchair with seatbelt was in place at the time of R6's fall on 10/24/25. On 12/10/2025 at 11:18 AM, Surveyor observed R6's room. R6 was not in the room or bathroom. R6's door was open and there was not a stop sign noted across R6's entry way door per R6's care plan interventions. On 12/10/2025 at 1:18 PM, Surveyor observed R6's room. R6 was not in the room or bathroom. R6's door was open and there was not a stop sign noted across R6's entry way door per R6's care plan interventions. On 12/10/2025 at 1:20 PM, Surveyor observed R6 at the common dining room table. R6 is not wearing a seatbelt. On 12/10/25 at 1:25 PM, Surveyor interviewed LPN-H. Surveyor asked if R6 was wearing a seatbelt. LPN-H stated that R6 is not wearing a seatbelt. On 12/16/25 at 9:15 PM, Surveyor informed DON-B of the concerns that after R6's falls, the care plan was not updated timely. On 10/24/25, R6's seatbelt was not in place at the time of R6's fall per R6's care plan intervention. In addition, through interviews, Surveyor found that R6's wheelchair with seatbelt was not in place for an unknown period of time while the wheelchair was being serviced. Surveyor had observations of care plan interventions not in place while on survey. DON-B understood the concerns. On 12/26/25 at 10:06 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the above concerns. No additional information was provided as to why R6's fall care plan interventions not in place during survey. 2.) R5 was admitted to the facility on [DATE] with pertinent diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (hemiplegia refers to paralysis on one side, while hemiparesis refers to weakness on one side, both occurring after a stroke to affect the left side) and history of falling. R5's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/19/2025 indicates R5 had a Brief Interview for Mental Status score of 15 (cognitively intact). R5 is coded to have adequate hearing and clear speech and is able to make self understood and understands others. R5's care plan documents The resident had an actual fall 8/2/25 no injury. Date Initiated: 08/06/2025. Pertinent interventions added after the fall include: Continue interventions on the at-risk plan. Date Initiated: 08/06/2025 Encourage resident and spouse to sit in the common area when spouse is visiting. Date Initiated: 08/07/2025 Family/caregiver or resident education on fall safety protocol. Date Initiated: 08/06/2025 Follow toileting plan and ensure to toilet before and after meals. Date Initiated: 08/06/2025 Remind resident and spouse will request for assistance related to add ADLS and transfers. Date Initiated: 08/07/2025 R5's unwitnessed fall report dated 8/2/25 documents resident husband put her in the bathroom and she tried to use restroom by herself and fell. R5's progress note written 8/2/2025, at 4:49 PM, documents: Staff alerted writer that resident was found on the floor. Upon arrival, writer found resident with head under the sink lying supine. Resident had neck brace in place. Resident is alert and verbal. Surveyor noted that R5's fall occurred on 8/2/25 and interventions to prevent future falls were not added to R5's care plan until 4 and 5 days later. On 12/16/25, at 9:07 AM, Surveyor interviewed (Director of Nursing) DON-B and informed of concern that R5 fell on 8/2/25 and R5's care plan was not updated until 8/6/25 and 8/7/25 which is a delay and safety concern for R5. On 12/16/25, at 10:04 AM, Surveyor informed Nursing Home Administrator (NHA)-A of concern related to delay in R5's care plan being updated after fall. Surveyor noted no additional information on why R5's care plan was delayed in being updated was provided.

Based on observation, interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services, and ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments was received for 1 (R51) of 1 residents reviewed.Findings include:The facility's Hemodialysis policy implemented 9/21 and revised 8/24 documents:Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the person-centered care plan and the residents' goals and preferences to meet the special medical, nursing, mental and psychosocial needs of residents receiving hemodialysis.Purpose: The facility will ensure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments. monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices; and ongoing communication of collaboration with the dialysis facility regarding dialysis care and services. 4. The facility will monitor and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes.5. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form that will include, but not limit itself to:b. Physician/treatment orders, laboratory values, and vital signs.e. Dialysis treatment provided and resident's response, including declines in functional status, falls and the identification of symptoms that may interfere with treatments.f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site.R51 admitted to the facility on [DATE] and has diagnoses that include Venous insufficiency and Hypertensive Chronic Kidney Disease stage 5 or end state renal disease. R51 receives dialysis every Tuesday, Thursday and Saturday. R51's December 2025 Treatment Administration Record (TAR) documents:Monitor hemodialysis access device for bleeding, infection and pain. If profuse bleeding, apply tourniquet above fistula site and call MD (medical doctor) every shift. Monitor hemodialysis access site for Bruit/Thrill every shift for CKD (chronic kidney disease). If absent, notify MD. Surveyor noted this was signed out as completed with a + sign, indicating the bruit/thrill present. (Bruit is the sound heard with a stethoscope over an atrioventricular fistula. Thrill is the vibration felt over an atrioventricular fistula. This indicates good blood flow).Surveyor noted R51 does not have an atrioventricular fistula, instead R51 has an access port in the upper right chest.On 12/11/25 at 11:43 AM, Surveyor asked Licensed Practical Nurse (LPN)-F how the facility communicates with the dialysis center. LPN-F reported they do nurse to nurse report every shift and R51 has a binder in a bag on the back of his wheelchair for facility to dialysis communication. LPN-F stated, We look at the binder when he returns to see if there are new orders or anything abnormal. We are supposed to do vital signs before and after dialysis. He has an access site in his chest, but we don't do anything with it, we don't change the dressing, just make sure it's clean and dry. The communication forms are kept in the binder.Surveyor reviewed the facility/dialysis communication forms in the binder, noting only 2 forms dated 12/2/25 and 12/4/25. Both forms contained pre-dialysis vital signs only. There was no documentation from the dialysis center staff and no assessment or vital signs documented from facility staff upon return from dialysis. On 12/11/25 at 11:47 AM, Surveyor spoke with LPN Manager-J who reported the facility communicates with dialysis with the binder on the back of his wheelchair. Surveyor asked what the expectation regarding assessment is. LPN Manager-J stated, We monitor his dialysis site for bleeding and such every shift. We should be doing vital signs before and when he returns from dialysis. They should be documenting on the form. Surveyor reviewed the dialysis communication forms in R51's binder with LPN Manager-J, noting there were only 2 forms dated 12/2 and 12/4 with pre dialysis vitals only, no other documentation from dialysis and no assessment or vital signs documented from facility staff after dialysis. Surveyor asked where the communication forms for 11/29, 12/6 and 12/9 are. LPN Manager-J stated. I don't know, let me look into this. I don't want to mis-speak on the process.Surveyor review of R51's medical record and nursing progress notes revealed no evidence or documentation an assessment or vital signs are completed after dialysis.On 12/15/25 at 9:51 AM, Surveyor spoke with LPN Manager-J and asked if she had any additional information. LPN Manager-J stated, No, it's the same as I told you. The expectation is that vital signs be done before dialysis, they should document on the form, dialysis should document on the form any of their information or new orders and we should be doing an assessment and vital signs when he returns from dialysis. LPN Manager-J reported she has not been able to locate any other forms completed. She stated, The expectation is that all the communication forms should stay in his binder until he discharges, then we will scan them in. We should be looking at the forms to see if there are any new orders or changes from dialysis and document our assessment and vital signs on the form.Surveyor advised LPN Manager-J that R51 has a dialysis port in his chest and asked if she was aware staff was signing in the TAR that they are assessing bruit/thrill for atrioventricular fistula, which R51 does not have. LPN-J stated, I thought he had a shunt in his arm. Surveyor advised he does not. LPN-J stated, I don't know why they would be documenting that then. The only explanation I have is that they enter standard orders for dialysis and maybe that got entered, but it should have been discontinued if he doesn't have the shunt. On 12/15/25 at 3:13 PM, during the daily exit meeting, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of concern regarding communication between the facility and dialysis center and concern the facility is not completing a post-dialysis assessment or vital signs.No additional information was provided.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure staff members timely reported an allegation of suspected abuse to the Administrator for 4 (Residents #1, #2, #3, and #4) of 4 sampled residents related to 2 incidents (01/12/2025 and 07/01/2025) of 3 sampled for abuse. The facility also failed to ensure the facility timely reported an allegation of suspected abuse to the state agency for 2 (Resident #1 and Resident #2) of 4 sampled residents related to 2 incidents (05/20/2025 and 07/01/2025) of 3 sampled for abuse.Findings included:The facility's policy titled, Abuse, Neglect, Misappropriation, and Exploitation, implemented June 2025, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed the section titled, Policy Explanation and Compliance Guidelines, included, 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The policy revealed the section titled, VII. Reporting/Response, included, A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, Nurse Manager, Director of Nursing Services, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia, for example], law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.1.) Resident #1 was admitted to the facility on [DATE] with a medical history that included diagnoses of dementia without behavioral disturbance, generalized anxiety disorder, and major depressive disorder.Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident used a wheelchair and propel it 50 feet with two turns independently. The MDS also indicated the resident had no behaviors during the assessment's lookback period and required set-up and clean-up assistance with eating.Resident #1's Care Plan Report, included a problem statement initiated on 12/11/2024, that indicated the resident had episodes of forgetfulness and confusion related to dementia. Interventions directed staff to ask yes/no questions in order to determine the resident's needs. Resident #2 was admitted to the facility on [DATE] with a medical history that included diagnoses of dementia with mood disturbance and anxiety disorder.Resident #2's quarterly MDS, with an ARD of 06/30/2025, revealed Resident #2 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident utilized a wheelchair and required substantial to maximum assistance to propel the wheelchair 50 feet with two turns. The MDS also indicated the resident had verbal behaviors during the assessment's lookback period and could eat independently. Resident #2's Care Plan Report, included a problem statement initiated on 09/18/2024 and revised on 07/11/2025, that indicated the resident had actual physical aggressiveness toward harming others related to anger, dementia, and poor impulse control, and on 07/03/2025 the resident was offered a new dining room experience in relation to a facility reported incident. Interventions directed staff that for communication provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff member when agitated. The interventions instructed staff that the resident's triggers for physical aggression were related to loud noises/sensory overload towards other and the resident's behaviors were de-escalated by removing the resident from heightened situations to avoid conflict. A facility Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 05/20/2025 at 1:29 PM, revealed that on 05/20/2025 at 1:08 PM Resident #2 attempted to push themselves in their wheelchair through the dining room where other residents were. The report revealed Resident #2 could not get through and became frustrated and made contact with Resident #1. The report did not indicate the police or state authorities were notified.A document titled, Physical Aggression Received, dated 05/20/2025 at 12:45 PM, for Resident #2, revealed Certified Nursing Assistant (CNA) A reported that after lunch Resident #2 was trying to move away from the table and bumped into another resident. The document revealed the other resident yelled at Resident #2 and then Resident #2 hit the other resident on the left side of their face. The document did not indicate the police or state authorities were notified.A document titled, Physical Aggression Received, dated 05/20/2025 at 12:45 PM, for Resident #1, revealed CNA A reported that after lunch another resident was trying to move away from the table and bumped into Resident #1. The document revealed Resident #1 yelled at the other resident and the other resident hit Resident #1 on the left side of their face. The document did not indicate the police or state authorities were notified.During an interview on 07/30/2025 at 4:27 AM, regarding the incident on 05/20/2025, the Administrator stated she reported the incident to the state on 05/20/2025 at 1:29 PM. She stated they did not call the police or adult protective services. A facility Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 07/03/2025, revealed that the Administrator was made aware on 07/03/2025 that on 07/01/2025 at 6:50 PM, Resident #1 backed their wheelchair into Resident #2 and Resident #2 made contact with Resident #1's back area. The report indicated the Administrator submitted the report to the state agency on 07/03/2025 at 10:55 AM. The document did not indicate the police were notified. A document titled, Physical Aggression Received, dated 07/01/2025, for Resident #1, revealed CNA A reported that Resident #1 was involved in a physical altercation after Resident #1 ran into another resident's wheelchair and that resident punched Resident #1's back. The document did not indicate the Administrator or the police were notified.A document titled, Physical Aggression Received, dated 07/01/2025, for Resident #2, revealed CNA A reported that Resident #2 was involved in a physical altercation after another resident ran into Resident #2's wheelchair and then Resident #2 punched that resident in the back. The document revealed Resident #2 was unable to recall the incident. The document did not indicate the Administrator or the police were notified.During a telephone interview on 07/28/2025 at 5:00 PM, CNA A stated that she was standing there and Resident #1's chair got caught up in Resident #2's chair. She stated she separated the residents and reported it to LPN B.An undated Licensed Practical Nurse [LPN] Statement, indicated LPN B reported that she did not see the incident (on 07/01/2025) and that CNA A told her about it. The statement revealed LPN B indicated they separated Resident #1 and Resident #2, and they were fine.During an interview on 07/28/2025 at 3:22 PM, LPN B stated she did not witness the incident (on 07/01/2025), but that CNA A said Resident #2 hit Resident #1 in the back and she assisted with moving the residents. She stated she reported this to her supervisor, Registered Nurse (RN) C, not the Administrator.During an interview on 07/28/2025 at 3:33 PM, RN C stated they were to report abuse as soon as possible, and the same expectation was for the CNAs to report abuse to the nurses.During an interview on 07/29/2025 at 10:49 AM, the Director of Nursing Services (DNS) stated she received a text related to the 07/01/2025 incident from RN C. She stated he let her know Resident #1 and Resident #2 had an altercation and were separated and were okay. She stated RN C described it as the residents were trying to pass by each other and ran into each other unintentionally. She stated it seemed as though it frustrated Resident #2, and Resident #2 lashed out and punched Resident #1 in the back. She stated the incident was not a serious situation where she had to come in because both residents were safe and unharmed. She stated she did not look at the situation as an abuse situation. She stated she did not report it to the Administrator because she did not think it was abuse. She stated if the situation were considered abuse, her expectation would be that the Administrator would be notified. During an interview on 07/28/2025 at 4:38 PM, the Administrator confirmed the incident between Resident #1 and Resident #2 that occurred on 07/01/2025 was not reported to her until 07/03/2025. She said she believed staff did not think reporting resident-to-resident incidents needed to be reported immediately to her. She confirmed she did not notify the police or adult protective services for that facility-reported incident. During an interview on 07/29/2025 at 8:30 AM, the Administrator stated she did not remember who reported the incident on 07/03/2025 to her for the incident involving Resident #1 and Resident #2 on 07/01/2025. She stated her expectation was that the nurse and nurse supervisor should tell her about an allegation of abuse, but that at least one of them should have told her.2.) Resident #3 was admitted to the facility on [DATE] with a medical history that included diagnoses of degenerative disease of the nervous system, Alzheimer's disease, and dementia agitation. Resident #3's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) scare of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had physical and verbal behaviors during the assessment's lookback period. Resident #3's Care Plan, included a problem statement initiated 08/10/2021 and revised on 01/20/2025, that indicated the resident had an alteration in neurological status related to Alzheimer's dementia with behavioral disturbance and degenerative disease of the nervous system. The interventions directed staff to cue and reorient as needed. The Care Plan Report also included a problem statement initiated on 01/16/2025 that indicated the resident had a potential to be verbally aggressive related to dementia. The interventions directed staff that when the resident became agitated to intervene before agitation escalated and guide away from the source of stress. Resident #4 was admitted to the facility on [DATE] with a medical history that included diagnoses of degenerative disease of the nervous system, vascular dementia without behavioral disturbance, and anxiety disorder. Resident #4's admission MDS, with an ARD of 11/13/2024, revealed Resident #4 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had no behaviors during the assessment's lookback period. Resident #4's Care Plan Report, included a problem statement initiated on 11/22/2024, that indicated the resident could be verbally aggressive towards staff related to dementia. Interventions directed staff to assess and anticipate resident's needs to include food, thirst, toileting needs, comfort level, body positioning, and pain. The Care Plan Report included a problem statement initiated on 01/16/2025 that indicated the resident had a potential to be physically aggressive related to dementia. The interventions directed staff to assist with verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff member when agitated and when the resident became agitated to intervene before agitation escalates and guide away from the source of distress.An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 01/13/2025, revealed that the Administrator was made aware on 01/13/2025 that on 01/12/2025 at 4:38 PM Resident #3 attempted to spit toward Resident #4 and at that time Resident #4 made contact with Resident #3. The report indicated the Administrator submitted the report to the state agency on 01/13/2025 at 10:26 AM.During an interview on 07/29/2025 at 12:18 PM, Certified Nursing Assistant (CNA) D stated Resident #3 always acted like the resident was going to spit but never did. She stated that Resident #4 was the aggressor during the 01/12/2025 incident. She stated she reported this to the nurse at the nurses' station. She could not remember who. She stated that the next day, the Administrator called her into her office to make a statement. During an interview on 07/29/2025 at 11:04 AM, the Director of Nursing Services (DNS) stated she could not remember when she was notified by staff about the incident between Resident #3 and Resident #4. She stated if there was abuse the staff should notify her in a reasonable amount of time. The DNS stated that she and the supervisor should report abuse to the Administrator, and it should be reported to the Administrator that day. During an interview on 07/28/2025 at 4:50 PM, the Administrator stated the incident occurred on 01/12/2025 and was discovered by her on 01/13/2025. She stated she believed the delay in reporting to her was that the staff was not aware to call her right away. During an interview on 07/29/2025 at 2:40 PM, the Administrator stated her expectation was to report abuse the same day. She stated her expectation was to report abuse to the police and state authorities, and her expectation would be that the social worker or nurse in charge would call the police if there was an allegation of abuse if she was not available or if she delegated the task.No additional information was provided.

Based on observation, interviews, and record review the facility did not address and resolve grievances conveyed on behalf of 1 (R1) of 5 residents reviewed for grievances. * On 12/11/2024, a grievance was initiated for R1 regarding R1 requesting to be transferred to bed from R1's wheelchair. R1's grievance stated that a Certified Nursing Assistant (CNA), refused to transfer R1due to the request being too close to the shift change. The refusal resulted in R1 having to wait one hour to be transferred into bed. The grievance packet involving the above grievance was missing information and did not have a clear resolution. Findings include: The facility's policy, titled Grievance Policy, with the last reviewed date of 2/2020 documents: G. Response Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within the role and authority. If a complaint cannot be immediately resolved employee shall escalate the complaint to their supervisor and the facility grievance official . The investigation will consist of at least the following: a review of the completed complaint report, on interview/statement with the person or persons reporting the incident if applicable, interviews/statements with any witnesses to the incident or concern, . An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident. 1.) R1 was admitted to the facility on [DATE] with diagnoses that include fracture of T9-T10 vertebra, multiple fracture of ribs (left side), displaced fracture of lower end of left humerus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R1's Admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 15, indicating R1 is cognitively intact. The MDS documents R1's mobility as dependent, as the helper does all the effort, as R1does none of the effort to complete this activity. R1's grievance, dated 12/11/2024, with an occurrence date of 12/10/2024documents that R1 requested from a CNA to get transferred into bed from a wheelchair. The response from the CNA is documented as: it was too close to shift change to move R1. It is documented that R1 had to wait for one hour to be transferred into bed. The resolution is documented in part as: Residents were educated on call light process, call response times, and provided with the social workers contact information for questions and concerns. It is not indicated on the form if R1 was notified of resolution, this portion was left blank. The next page in the grievance packet was to be signed by grievance official and reviewed by the Director of Nursing (DON) and Nursing Home Administrator (NHA) to ensure the grievance was addressed and resolved, but Surveyor noted that this page was left blank. On 5/13/2025, at 10:50 AM, Surveyor interviewed Social Worker (SW)-C, who indicated being the one the staff member who worked on this grievance. SW-C stated not being able to remember the grievance, but SW-C stated SW-C would have to look at the soft files for more information on the grievance and get back to the surveyor. On 5/13/2025, at 12:14 PM, SW-C informed Surveyor that she could not locate any more information on this grievance. On 5/13/2025, at 12:36 PM, Surveyor interviewed SW-C, who stated SW-C did not have any statements from the CNA alleged in the grievance and could not recall if the CNA was interviewed or if an interview as conducted. SW-C stated that all grievances should be brought to NHA-A to review, but that did not occur with R1's grievance. SW-C stated that NHA-A would have signed the grievance if it was brought to NHA-A. SW-C indicated that with this grievance a CNA interview should have been conducted. On 5/13/2025, at 12:44 PM, Surveyor informed NHA-A of the concern with the grievance that was submitted to SW-C on 12/11/2024, regarding R1. Surveyor informed NHA-A that after interview with SW-C, there was no evidence that a complete investigation of the grievance occurred. Surveyor informed NHA-A, of the concern that SW-C did not speak with or could not recall speaking with the alleged CNA. SW-C also indicated not being able to recall if the results of the resolution were reported to R1 or NHA-A. NHA-A indicated an understanding of the concern mentioned above. No additional information received as to why R1 was not informed of resolution or NHA-A. There was no additional information as to why the staff involved in the grievance for R1 were not interviewed.

Based on record review, review of hospital discharge summary, interview, and facility document review, the facility failed to ensure orders were transcribed correctly for one of three residents (Resident (R) 4) reviewed for medication orders out of 13 sample residents to ensure medications were administered as ordered. This had the potential for the residents to have unmet health care needs. Findings include: Review of R4'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 a diagnosis of cytomegaloviral disease (CMV/common virus). The resident discharged from the facility on 12/23/24. Review of R4's hospital After Visit Summary, dated 11/26/24 to 12/11/24 and located in the EMR under the Misc tab, revealed the resident was to continue to receive ganciclovir (antiviral medication to treat viruses) 2.5 milligrams (mg/kg [kilogram]) = 250 mg in dextrose 100 ml (milliliter) bag by intravenous (IV) route two times a day. There was no stop date indicated. Review of R4's Care Plan, initiated 12/11/24 and located in the EMR under the Care Plan tab, revealed the resident was on an antiviral therapy ganciclovir related to CMV infection. Interventions included administering the antiviral medication as ordered by the physician. Review of R4's Progress Note, dated 12/12/24 located in the EMR under the Progress Note tab, revealed an order was received from the Infectious Disease Clinic to change the ganciclovir to once a day. There was no stop date indicated. Review of R4's Medication Administration Record (MAR), located in the EMR under the Orders tab, revealed an order for ganciclovir, intravenous solution. Use 250 mg IV one time a day for CMV infection until 12/18/24. Start date 12/13/24. The MAR documented the resident received the ganciclovir everyday with the last dose given on 12/18/24. Review R4's Progress Note, dated 12/23/24 and located in the EMR under the Progress Note tab, revealed a call was received from the Registered Nurse (RN) from the Infection Disease Clinic who wanted to know who gave authorization for the resident's ganciclovir to stop on 12/18/24. The RN indicated she gave specific instructions that the anticipated completion date would be 12/23/24 dependent on the repeat antiviral levels and his follow up appointment. A Risk Management was completed for the medication error. Review of the facility's investigation provided by the facility revealed at the time of admission, the resident was to receive IV antiviral daily infusion through 12/23/24. When he went to his appointment on 12/23/24 it was noted that there was a discrepancy in medication administration regarding the IV antiviral stopping on 12/18/24. In conclusion, although there was a medication administration error, the error did not cause a negative outcome to the resident. Licensed nurses were involved in education of the five rights of medication administration as well as order clarification. During an interview on 03/26/25 at 1:00 PM with the Administrator, she confirmed RN1 transcribed R4's orders received from the Infectious Disease Clinic incorrectly and put a stop date for the ganciclovir on 12/18/24 and the resident should have received the medication until his next appointment on 12/23/24. During an interview on 03/26/25 at 1:20 PM, the Director of Nursing (DON) confirmed a medication error occurred for R4 when RN1 put a stop date on his ganciclovir of 12/18/24. She confirmed the resident was to receive the medication until 12/23/24 and he missed five doses of the antiviral medication. She confirmed licensed nurses were educated on medication errors and order transcription. She confirmed all residents' orders were not reviewed after the medication error was found by the Infection Disease Clinic to ensure there were no other medication errors. She confirmed a Performance Improvement Plan (PIP) had not been developed. During an interview on 03/26/25 at 1:40 PM with RN1, she confirmed she put a stop date on the ganciclovir of 12/18/24 and the resident should have received the medication through 12/23/24, until his follow up appointment with Infectious Disease. Review of the undated document titled, How do you ensure accuracy of physician order transcription? provided by the facility revealed, Physician order transcription is a crucial step in the delivery of quality patient care .1. Understand the order: You need to pay attention to the details, such as .duration .3. Check for errors .check for errors and inconsistencies. You need to proofread you transcription and compare it with the original order.

Based on interview and record review, the facility did not ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 1 of 1 Residents reviewed (R58). * R58 was prescribed Seroquel, 12.5 mg (milligrams) 2 times daily, an antipsychotic medication for agitation related to Delusional Disorder diagnosis on 9/27/24. On 10/8/24, Seroquel was increased to 12.5 mg 3 times daily. The facility did not have a written, signed consent explaining the risks and benefits of Seroquel by R58's activated power of attorney (POA). Findings Include: 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor noted the facility was not able to provide Surveyor with documentation of the competency evaluation for R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there are 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's Admission Minimum Data Set (MDS) dated [DATE] documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's Admission MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58 has not been assessed for a new MDS assessment since admission. On 8/9/24, R58 was evaluated by Psychologist (Psych)-D who diagnosed R58 with Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent, Moderate. On 9/27/24, Psych-D documents a diagnosis of Psychotic Disorder with Delusions for R58 after a regular psychology visit. On 10/1/24, Psychiatrist (Psych)-E agreed with the Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent Diagnoses and added Generalized Anxiety Disorder and Unspecified Dementia, Unspecified Severity with Mood Disturbance as a diagnosis. R58's physician orders document that R58 was prescribed Seroquel 12.5 mg tablet two times a day with a start date of 9/27/24. On 10/8/24 R58's Seroquel was increased to 12.5 mg three times a day and remains currently at that dose. Surveyor reviewed R58's electronic health record (EHR) and could not locate a written consent for the reason for the antipsychotic medication, alternative modes of treatment, the risks of taking the medication and the benefit of taking the medication. On 10/30/24, Surveyor requested documentation for signed consent of R58's Seroquel from Nursing Home Administrator (NHA)-A. On 10/30/24 at 3:07 PM, Surveyor shared the concern with NHA-A, that there is no documentation that R58's consent for Seroquel which includes the reason for the antipsychotic medication, alternative modes of treatment, the risks of taking the medication and the benefit of taking the medication. NHA-A stated the facility will look for R58's signed consent. On 10/31/24 at 11:36 AM, Medical Records (MR)-I was interviewed by Surveyor. MR-I confirmed that MR-I is responsible for making sure consents are signed either by the Resident or responsible party. MR-I stated the nurse reviews the medication and gets the signature either at admission or when a new medication is prescribed that requires consent. MR-I informed Surveyor that MR-I spoke to R58's activated HCPOA this morning and R58's activated HCPOA had further questions but gave verbal consent for the Seroquel. MR-I stated 're-training' needs to be completed. On 10/31/24 at 12:04 PM, MR-I informed Surveyor that MR-I was further able to answer R58's activated HCPOA questions and gave verbal consent for the Seroquel and will come in to the facility and sign the consent. Surveyor shared the concern that the consent for the Seroquel should have been obtained back on 9/27/24, when the Seroquel was first prescribed to R58. MR-I agreed the consent should have been obtained and signed. On 10/31/24 at 1:58 PM, Surveyor reviewed the concern with NHA-A that R58's Seroquel consent had not been obtained when first prescribed on 9/27/24. NHA-A acknowledged the concern and has no additional information. NHA-A informed Surveyor there is no facility policy and procedure for obtaining consents for required medications. No additional information was provided as to why the facility did not ensure that R58 had written consent explaining the risks and benefits of psychotropic medications that were prescribed.

UNCORRECTED ON VERIFICATION VISIT Based on record review and staff interviews, the facility did not ensure that 3 allegations of abuse involving 2 residents (R2 and R58) and 1 Resident to Resident (R3 and R4) altercation were reported to the State Survey Agency within the required reporting timeframe . * R2's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting a bruise of unknown origin was submitted to the State Survey Agency on 9/3/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/16/24. * R58's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of rape was submitted to the State Survey Agency on 9/26/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/16/24. On 10/15/24, R58 called the police alleging an assault had taken place over the weekend. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report and a Misconduct Incident Report to the State Survey Agency. * An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting Resident to Resident abuse involving R3 and R4 was submitted to the State Survey Agency on 9/19/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/29/24. Findings Include: The facility Policy titled Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation revised 2/2020, documents: .Purpose -Facility will prohibit and prevent abuse, neglect, exploitation, mistreatment, injuries of unknown sources and resident to resident altercations. -Facility is in compliance with the reporting and investigation guidelines specific to each program area governed by the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) -All alleged incidents of abuse, neglect, exploitation, and misappropriation must be reported and investigated in a timely manner per program code requirements. Special Key Points 2. An initial review of the allegation prior to reporting to DQA/OCQ may be conducted to determine whether or not the incident needs to be reported to DQA/OCQ. All alleged violations involving mistreatment (including abuse, neglect, exploitation, injuries of unknown source, misappropriation of property, resident-to-resident abuse, and mistreatment by family members, visitors, volunteers or other individuals) must be reported to the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) as soon as possible, but not to exceed 24 hours from the discovery. Guidelines 1. Protect the Resident a. The safety of the resident(s) is the first priority. The resident(s) must be protected from possible subsequent injury or incidents of misconduct. b. After ensuring the safety of the resident(s), all employees are to immediately report any alleged incidents of abuse, neglect, and mistreatment to the Supervisor to ensure that appropriate notification and a timely investigation are initiated. c. The Supervisor immediately assesses the resident's personal safety and potential of harm to other residents. d. The Director of Nursing/Director of Resident and Patient Services and/or designee is to be contacted immediately for all allegations of caregiver misconduct or Resident-to-Resident abuse. The Administrator/CCO will be notified immediately . 1.) R2 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Essential Hypertension, Paroxysmal Atrial Fibrillation, and Depression. R2 has an activated Health Care Power of Attorney(HCPOA). R2's Quarterly Minimum Data Set (MDS) completed 10/4/24 does not assess R2's cognitive status. R2's MDS documents R2 has no range of motion impairment, R2 requires substantial/maximum assistance for showers, upper body dressing, and mobility. R2 is dependent for transfers, lower body dressing, and sit to stand. R2 is independent with eating. On 7/5/24, R2 had a significant change MDS completed which documents R2's Brief Interview for Mental Status(BIMS) score to be 15, indicating R2 was cognitively intact for daily decision making at that time. R2's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting a bruise of unknown origin was submitted to the State Survey Agency on 9/3/24. On 9/4/24, R2's nurse practitioner diagnosed R2 with cellulitis to the right eye and started her on an antibiotic. The facility determined this was the cause of the discoloration to the right eye. However, the facility did not submit the Misconduct Incident Report to the State Survey Agency until 10/16/24 with a summary explaining the quick conclusion to the investigation. On 10/29/24 at 2:45 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R2's Misconduct Incident Report to the State Survey Agency was not submitted until 10/16/24. NHA-A stated this report was during the transition time of the former Director of Nursing (DON) no longer being an employee at the facility. Surveyor shared that the investigation was over a month late. NHA-A agreed R2's Misconduct Incident Report to the State Survey Agency was late. The facility provided no additional information as to why the report was not submitted until 10/16/24. 2.) R58's Admission Minimum Data Set (MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS since admission. R58's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of rape was submitted to the State Survey Agency on 9/26/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/16/24. On 10/15/24, R58 called the police alleging an assault had taken place over the weekend. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the State Survey Agency and did not submit a Misconduct Incident Report. On 10/15/2024, in R58's electronic medical record (EMR) it is documented that R58 contacted the police and reported that R58 was assaulted over the weekend and that management has been made aware. On 10/29/24 at 2:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to R58's allegations. NHA-A stated these allegations occurred during transition time. NHA-A stated Department of Human Services (DHS) called and informed NHA-A that a complete investigation had not been received. NHA-A stated NHA-A had to complete an investigation all over again. NHA-A wanted to send a complete investigation in. NHA-A was unaware of R58 calling the police and alleging an assault on 10/15/24. NHA-A believes NHA-A may have triggered R58 when questioning and then R58 called the police. Surveyor shared the concern of the 9/26/24 allegation of rape Misconduct Incident Report not being submitted to the State Survey Agency within the required timeframe. Surveyor also shared the concern that R58's allegation of assault on 10/15/24 did not get reported to the State Survey Agency. On 10/30/24 at 3:07 PM, Surveyor shared the concern again with the facility reporting R58's allegations of rape and assault within the required reporting timeframes. NHA-A responded, We always screw up self reports. No additional information has been provided by the facility at this time in regard to R58's self reports being submitted. 3.) R3 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Severe, with Other Behavioral Disturbance, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Unspecified Atrial Fibrillation, and Unspecified Protein-Calorie Malnutrition. R3 has an activated Health Care Power of Attorney(HCPOA). R3's Quarterly Minimum Data Set (MDS) completed 8/14/24 documents R3's BIMS score to be 0, indicating R3 is severely cognitively impaired for daily decision making. R3 has no behaviors. R3 has range of motion impairment on one side of upper and no impairment on lower. R3 needs supervision for eating. R3 is dependent for showers, upper and lower dressing, mobility, and transfers. R4 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, with Mood Disturbance, Anxiety Disorder, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. R4 has an activated HCPOA. R4's Quarterly MDS completed 10/4/24 documents R4's BIMS score is 3, indicating R4 is severely impaired for daily decision making. R4's MDS documents that R4 has had physical behaviors for 1-3 days and verbal behaviors for 4-6 days. R4 has no range of motion impairment. R4 is independent with eating. R4's MDS documents that R4 requires substantial/maximum assistance for showers and mobility. R4 requires partial/moderate for upper body dressing. R4 is dependent for lower body dressing, transfers, and sit to stand. R3 and R4's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting a Resident to Resident altercation where R4 wheeled up and punched R3 in the face on the right side and started cursing at R4 was submitted to the State Survey Agency on 9/26/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/29/24. On 10/29/24 at 2:45 PM, Nursing Home Administrator (NHA)-A informed Surveyor that NHA-A did not know the Misconduct Incident Report was not submitted to the State Survey Agency for R3 and R4's Resident to Resident Altercation. NHA-A understands the concern that Surveyor communicated that R3 and R4's Resident to Resident altercation Misconduct Incident Report was not submitted to the State Survey Agency until 10/29/24. No additional information was provided by the facility.

UNCORRECTED ON VERIFICATION VISIT Based on record review and staff interview, the facility did not ensure all allegations involving potential abuse (R58) and Resident to Resident altercation (R3 and R4) were thoroughly investigated for 3 of 3 reviewed self reports. * R58's Facility Reported Incident (FRI) dated 9/12/24 documents an allegation of R58 being raped along with R58 sustaining blunt force trauma to the chest. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. The FRI does not contain an investigation of the blunt force trauma. Facility Reported Incident (FRI) dated 10/16/24 documents an allegation of R58 being raped by a male caregiver. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. On 10/15/24, R58 called the police alleging an assault had taken place over the weekend. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report and a Misconduct Incident Report to the State Survey Agency. Consequently, the facility did not complete a thorough investigation of this allegation. * R3 and R4's Facility Reported Incident (FRI) dated 10/29/24 documents an allegation of R4 wheeling up and punching R3 on the right side of the face and cursing at R3. The FRI does not contain other resident statements, all staff statements, the reasoning for why the local law enforcement was not notified, or a root cause analysis of the circumstances of the allegation. Staff statements were not obtained prior to the incident to evaluate both R3 and R4's pattern of behavior/agitation prior to Resident to Resident altercation. Findings Include: Surveyor reviewed the facility's Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation policy and procedure last revised 2/2020 and notes the following in regards to a thorough investigation: Thorough investigation and corrective action ensures that the safety of the Resident has not been jeopardized. Purpose -Facility is in compliance with the reporting and investigation guidelines specific to each program area governed by the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) -Thorough investigation and corrective action ensures that the safety of the Resident has not been jeopardized. -Corrective action will be taken when appropriate. Guidelines 2. Assess the Effect on the Resident a. The Resident(s) must be interviewed and a body assessment completed as necessary. b. An assessment for psychosocial changes will be completed and document findings. c. Physician is made aware, as needed. Family is made aware if appropriate. Case management organizations notified as needed. d. Follow-up Resident interviews should be conducted. 2. Investigate the Allegation a. Contact law enforcement or other regulatory authority if appropriate. b. Obtain written, signed statements from all witnesses or persons with information. c. Obtain a written, signed statement from the accused individual. 4. Conclude the Investigation a. Review all components of the investigation. b. Inform accused caregiver that a report to another agency has been submitted. If the accused is a Resident, inform Resident and responsible party of the report to DQA has occurred. c. The conclusion must be written on the Investigation Summary form once employee interviews and a chart review have been completed. 5. Follow-up a. All the completed forms must be submitted to the Director of Nursing/designee. b. Contact the person who reported the incident. c. Reassure the Resident and family if the caregiver. e. If Resident to Resident abuse has occurred, Social Services will work with Residents and their responsible parties to determine if relocation/other interventions are needed. 1.) R58's Admission Minimum Data Set (MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 requires partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS since admission. Surveyor reviewed the Misconduct Incident Report submitted to the State Survey Agency dated 9/12/24. On 9/3/24, R58 voiced an allegation of being raped and punched in the chest. The facility did not obtain all staff statements. The facility did not obtain any resident statements to determine if there was a pattern. R58's emergency room documentation dated 9/4/24 documents a diagnosis of blunt force trauma. The facility's Misconduct Incident Report summary does not document a thorough investigation of the R58's diagnosis of blunt force trauma was completed. Surveyor reviewed the Misconduct Incident Report submitted to the State Survey Agency dated 10/16/24. On 9/26/24, R58 made an allegation that R58 had been raped by a male caregiver. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. On 10/15/2024, it is documented in R58's electronic medical record (EMR) that R58 contacted the police department and stated R58 was assaulted over the weekend. Management has been made aware. On 10/15/24, R58 called the police alleging an assault had taken place over the weekend. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report and a Misconduct Incident Report to the State Survey Agency. The facility did not complete a thorough investigation of this allegation. On 10/29/24 at 2:45 PM, Surveyor shared the concern that thorough investigations had not been completed with R58's allegations. Nursing Home Administrator (NHA)-A was not aware of R58's allegation of assault on 10/15/24. NHA-A stated maybe NHA-A triggered R58 to say that when NHA-A had questioned R58 about the 9/26/24 allegation of being raped by a male caregiver. On 10/30/24 at 3:07 PM, Surveyor shared the concern again with NHA-A that a thorough investigation has not been completed in regards to R58's allegations. NHA-A agreed and stated that NHA-A did not like how the investigation was completed. No further information was provided by the facility at this time. 2.) R3 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Severe, with Other Behavioral Disturbance, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Unspecified Atrial Fibrillation, and Unspecified Protein-Calorie Malnutrition. R3 has an activated Health Care Power of Attorney (HCPOA). R3's Quarterly Minimum Data Set (MDS) completed 8/14/24 documents R3's Brief Interview for Mental Status (BIMS) score to be 0, indicating R3 is severely cognitively impaired for daily decision making. R3 has no behaviors. R3 has range of motion impairment on one side of upper and no impairment on lower. R3 needs supervision for eating. R3 is dependent for showers, upper and lower dressing, mobility, and transfers. R4 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, with Mood Disturbance, Anxiety Disorder, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. R4 has an activated HCPOA. R4's Quarterly MDS completed 10/4/24 documents R4's BIMS score to be a 3, indicating R4 is severely impaired for daily decision making. R4's MDS documents that R4 has had physical behaviors for 1-3 days and verbal behaviors for 4-6 days. R4 has no range of motion impairment. R4 is independent with eating. R4's MDS documents that R4 requires substantial/maximum assistance for showers and mobility. R4 requires partial/moderate for upper body dressing. R4 is dependent for lower body dressing, transfers, and sit to stand. On 9/18/24, R4 wheeled up to R3 and punched R3 on the right side of the face and started cursing at R3 in the dining room while both were waiting for dinner. A staff statement documented that R4 did not like how loud R3 had been during the day. The facility did not obtain staff statements from the day shift to establish a pattern of behavior or possible increased agitation from either R4 or R3. The facility did not obtain any resident statements and the facility did not notify the police of the Resident to Resident altercation. The facility did not complete a Misconduct Incident Report until 10/29/24, when Surveyor brought it to the facility's attention. The Misconduct Incident Report does not include a thorough investigation of the Resident to Resident altercation. On 10/29/24 at 2:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to R3 and R4's Resident to Resident altercation. NHA-A informed Surveyor that NHA-A was not aware that a Misconduct Incident Report had not been submitted. NHA-A stated the former Director of Nursing made that decision. NHA-A stated that R3 can be vocal and stated that R3's Broda chair is up higher than R4 in the wheelchair and does not think R4 could have caused any injury to R3. NHA-A did inform Surveyor that R4 hit R3 with an open hand. On 10/30/24 at 3:07 PM, Surveyor shared the concern with NHA-A that R3 and R4's Resident to Resident altercation was not thoroughly investigated. Surveyor asked NHA-A why the police had not been notified. NHA-A stated, That's a good question. NHA-A understands the concern of the facility not completing a thorough investigation and provided no further information at this time. No additional information was provided.

Based on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R58) of 1 Resident reviewed with PASARR level 2 recommendations. *R58's PASARR dated 10//21/24 determination states R58 requires specialized psychiatric rehabilitation services to address R58's mental illness. Findings Include: The facility's policy Resident Assessment-Coordination with PASARR Program dated 10/22/21 documents: Policy: This facility coordinates assessments with the preadmission screening and resident review(ASA) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level 1-Initial pre-screening that is completed prior to admission i. Negative Level 1 Screen-permits admission to proceed with and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level 1 Screen-necessitates PASARR Level 11 evaluation prior to admission b. PASARR Level 11-a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 5. If a Resident who not screened due to an exception above and the Resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level 1 screening process and refer to any Resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level 11 PASARR evaluation and determination. b. The Level 11 Resident review must be completed within 40 days of admission. 6. The Social Services shall be responsible for keeping track of each Resident's PASARR screening status, and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level 11 determination and/or PASARR evaluation report will be incorporate into the Resident's assessment, care planning, and transitions of care. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor notes the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there is 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's Admission Minimum Data Set(MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58 has not been assessed for a new MDS since admission. On 8/9/24, R58 was evaluated by Psychologist (Psych)-D who diagnosed R58 with Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent, Moderate. On 9/27/24, Psych-D documents a diagnosis of Psychotic Disorder with Delusions for R58 after a regular psychology visit. On 10/1/24, Psychiatrist (Psych)-E agreed with the Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent Diagnoses and added Generalized Anxiety Disorder and Unspecified Dementia, Unspecified Severity with Mood Disturbance as a diagnosis. R58's current physician orders documents R58 is prescribed: -Buspar 9/24/24 -Duloxetine 7/16/24 -Remeron 10/22/24 -Seroquel 10/8/24 R58's original Level 1 PASARR screen dated 7/15/24 documents R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. R58's Level 1 PASARR screen documents R58 is only expected to be at the facility 30 days or less. A new Level 1 PASARR screen was re-submitted on 10/16/24 documenting R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. R58's Level 11 PASARR Evaluation Summary dated 10/21/24 documents: .R58 was referred due to R58's diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood, Delusional Disorder, and Adjustment Disorder with Mixed Disturbance of Emotions. R58 currently receives Buspar, Duloxetine, Remeron, Seroquel and Gabapentin for Neuropathy. R58 is in need of specialized psychiatric rehabilitation services(SPRS). The focus of SPRS is to maintain or improve current level of functioning. SPRS should include a thorough assessment of this individual's unique capabilities, psychiatric symptoms, and behaviors, if any, by a Qualified Mental Health Professional(QMHP). -frequently refuses care -displays paranoid and accusatory behavior towards others -frequent yelling out, threatening behavior noted -consulting psychiatrist completing medication review notes that: SNRI clinicians to monitor for worsening depression and suicidal ideation; Gabepetin history has been reportedly associated with rare cases of depression and suicidal ideation. R58 may benefit from group therapy, 1:1 talk therapy, medication management, coping skill/problem solving techniques, behavioral management, and therapy for building self esteem. R58's comprehensive care plan is noted not to be person-centered and does not incorporate the need for specialized psychiatric rehabilitation services with person-centered interventions. All interventions except for one were implemented prior to the determination on 10/21/24 that R58 required specialized psychiatric rehabilitation services. R58's care plan documents with interventions: -Alteration in mood evidenced by intermittent episodes of anxious demeanor/verbalizations 8/1/24 No interventions have been updated since 10/22/24 -Resident has behavior problem due making untrue accusations of harm/abuse 9/5/24 No interventions have been updated since 9/5/24 -R58 experiences loneliness and/or isolation 9/6/24 No interventions have been updated since 9/6/24 -R58 is resistive to care bedside cares due to adjustment to nursing home 9/6/24 No interventions have been updated since 9/18/24 -R58 is at risk for signs/symptoms of resident relocation stress syndrome 9/25/24 No interventions have been updated since 9/25/24 -R58 has potential to be verbally aggressive due to ineffective coping skills, mental/emotional illness 10/15/24 No interventions have been updated since 10/15/24 -Potential for anxiety due to traumatic life event due to sexual assault 10/15/24 No interventions have been updated since 10/18/24 Surveyor notes there have been no updated person centered interventions for R58 since 9/5/24. Surveyor notes that R58's comprehensive care plan is concentrated on R58's behaviors and what is perceived as R58's negative responses to facility interventions. The facility has not examined why R58 may be responding to triggering situations or boundaries in what the facility perceives as 'behaviors', thus the facility has not facilitated R58 to increase self independence physically and emotionally or promote physical and emotional health overall. On 10/30/24, at 10:26 AM, Surveyor interviewed Social Worker (SW)-C in regards to R58's Level 11 PASARR determination for the need for specialized psychiatric rehabilitation services. SW-C informed Surveyor that Psychologist (Psych)-D would continue to see R58 for the next 30 days. SW-C is not aware of any other services that are being provided to R58. SW-C confirmed that SW-C is not a QMHP. SW-C also confirmed that the IDT has not worked together to develop a person-centered care plan to include the need for specialized psychiatric rehabilitation services. On 10/30/24, at 11:20 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who cares for R58 on a regular basis. LPN-G informed Surveyor that LPN-G is not aware that R58 requires specialized psychiatric rehabilitation services and has not been oriented to person-centered interventions to help decrease and approach R58's behaviors. On 10/30/24, at 12:45 PM, Surveyor interviewed Psych-D. Psych-D stated that R58's behavior has deteriorated since being admitted to the facility. R58 is very angry, anxious, and depressed. R58 has had limited episodes of delusions and paranoia. Psych-D was notified about a week ago that R58 required specialized psychiatric rehabilitation services, however, the plan was for Psych-D to see R58 on a weekly basis for 4 weeks at a time. Psych-D stated Psych-D was already treating R58 and stated nothing will change for treatment for R58. Psych-D also informed Surveyor that Psych-D has not been asked to be a part of any IDT discussion of R58's need for specialized psychiatric rehabilitation services. On 10/30/24, at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R58's Level 11 PASARR determination found R58 requires specialized psychiatric rehabilitation services. Surveyor shared there is no documentation that specialized psychiatric rehabilitation services has been developed and implemented through R58's assessment, care planning, and transitions of care. NHA-A stated NHA-A is not familiar with specialized psychiatric rehabilitation services and questioned if the facility could provide specialized psychiatric rehabilitation services. NHA-A understands the concern and has no further information at this time. On 10/31/24, at 1:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J. CNA-J does not know what specialized psychiatric rehabilitation services and how it relates to R58. CNA-J stated it would be good to have an IDT meeting to discuss R58's behaviors and how to approach R58. CNA-J stated R58 is not motivated to do anything at this time. On 10/31/24, at 2:57 PM, Surveyor interviewed Psychiatrist (Psych)-E. Psych-E confirmed Psych-E has evaluated R58 for medication review. Psych-E was not notified that R58 requires and would benefit from specialized psychiatric rehabilitation services. On 10/31/24, LPN-F informed Surveyor of the following: I wish R58 would get a mental health evaluation and treatment. I wish R58 would get help. The facility assessment reviewed 6/13/24 documents that the facility is capable of caring for Residents with Major Depressive Disorder, Single Episode. Of all the Residents, 56% have a psychiatric diagnosis. Psychology services are provided. Quarterly IDT behavior management meetings are held to discuss both non-pharmacological and pharmacological interventions to assist with achieving the Resident's highest practical mental well being. The facility has a comprehensive process to assess Resident needs. The facility utilizes a comprehensive admission, readmission, and required assessment process in which the IDT identifies individualized Resident care needs. On 10/30/24, at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R58's Level 1 PASARR screen which documented R58 was admitted to the facility on a 30 day exemption should have re-submitted no later that 8/25/24. Surveyor shared that a new Level 1 PASARR screen for R58 was not submitted until 10/16/24, which determined that R58 requires specialized psychiatric rehabilitation services. NHA-A understood the concern. No additional information was provided.

Based on interview and record review, the facility did not complete a Preadmission Screening and Resident Review (PASARR) for individuals with a mental disorder for 1 (R58) of 1 residents reviewed for PASARR screening. * R58 was admitted on [DATE] and the Level I PASARR was completed indicating R58 would be in the skilled nursing facility for less than 30 days. R58 is currently a Resident in the facility. A Level I PASARR was not resubmitted/updated indicating R58 was going to be at the facility longer than the 30 exemption period triggering a Level II PASARR to be completed until 10/16/24. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. Findings include: The facility's policy Resident Assessment-Coordination with PASARR Program dated 10/22/21 documents: Policy: This facility coordinates assessments with the preadmission screening and resident review(ASA) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level 1-Initial pre-screening that is completed prior to admission i. Negative Level 1 Screen-permits admission to proceed with and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level 1 Screen-necessitates PASARR Level 11 evaluation prior to admission b. PASARR Level 11-a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 5. If a Resident who not screened due to an exception above and the Resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level 1 screening process and refer to any Resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level 11 PASARR evaluation and determination. b. The Level 11 Resident review must be completed within 40 days of admission. 6. The Social Services shall be responsible for keeping track of each Resident's PASARR screening status, and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level 11 determination and/or PASARR evaluation report will be incorporate into the Resident's assessment, care planning, and transitions of care. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor notes the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there is 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's Admission Minimum Data Set(MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58 has not been assessed for a new MDS since admission. On 8/9/24, R58 was evaluated by Psychologist (Psych)-D who diagnosed R58 with Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent, Moderate. On 9/27/24, Psych-D documents a diagnosis of Psychotic Disorder with Delusions for R58 after a regular psychology visit. On 10/1/24, Psychiatrist (Psych)-E agreed with the Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent Diagnoses and added Generalized Anxiety Disorder and Unspecified Dementia, Unspecified Severity with Mood Disturbance as a diagnosis. R58's current physician orders documents R58 is prescribed: -Buspar 9/24/24 -Duloxetine 7/16/24 -Remeron 10/22/24 -Seroquel 10/8/24 R58's original Level 1 PASARR screen dated 7/15/24 documents R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. R58's Level 1 PASARR screen documents R58 is only expected to be at the facility 30 days or less. A new Level 1 PASARR screen was re-submitted on 10/16/24 documenting R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. On 10/30/24, at 9:29 AM, Surveyor interviewed Admissions Director (AD)-H who confirmed AD-H is responsible for the Level 1 and Level 11 PASARR screens. AD-H explained that the Level 1 PASARR screen is completed at time of admission. Once the results of the screen is forwarded from the state agency, social services is notified of the determination. AD-H was notified by MDS Coordinator (MDS)-O that R58 needed a new Level 1 PASARR screen completed. AD-H stated, R58's Level 1 PASARR screen may have been over the 30 day exemption period. On 10/30/24, at 10:26 AM, Social Worker (SW)-C confirmed that SW-C is alerted of Level 11 PASARR determinations. SW-C stated SW-C believes the breakdown in the process was that R58's HCPOA was being activated. On 10/30/24, at 10:37 AM, Surveyor interviewed MDS-O who stated MDS-O checked the status of R58's Level 1 PASARR screen determination because the Interdisciplinary Team(IDT) was discussing R58's behaviors. I looked to see R58's Level 1 PASARR screen and noticed R58's Level PASARR screen was past the 30 day exemption. I sent AD-H an email right away which was on 10/16/24. On 10/30/24, at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R58's Level 1 PASARR screen which documented R58 was admitted to the facility on a 30 day exemption should have re-submitted no later that 8/25/24. Surveyor shared that a new Level 1 PASARR screen for R58 was not submitted until 10/16/24, which determined that R58 requires specialized psychiatric rehabilitation services. NHA-A understood the concern. No additional information was provided as the facility did not complete a Preadmission Screening and Resident Review (PASARR) for R58.

UNCORRECTED ON VERIFICATION VISIT Based on interview and record review, the facility did not update the person-centered care plan and ensure the comprehensive care plan was implemented to meet a resident's psychosocial needs for 1 (R58) of 1 resident. * R58's comprehensive care plan has not been updated with person-centered interventions including incorporating Level II PASARR recommendations of requiring 'specialized psychiatric rehabilitation services'. Findings Include: The facility policy titled Comprehensive Care Plans revised 9/23, documents: .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. The facility policy Care Plan Revisions Upon Status implemented 9/21 documents: .Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those Residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a Resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a Resident experiences a status change: b. The MDS Coordinator and the the IDT(Interdisciplinary Team) will discuss the Resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the Resident will report Resident response to new or modified interventions. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the Resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all Residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect Resident needs. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney (HCPOA). Surveyor notes the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there are 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's Admission Minimum Data Set (MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS since admission. R58's original Level I PASARR screen dated 7/15/24 documents R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. R58's Level I PASARR screen documents R58 is only expected to be at the facility 30 days or less. A new Level I PASARR screen was resubmitted on 10/16/24 documenting R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. R58's Level 11 PASARR Evaluation Summary dated 10/21/24 documents: R58 was referred due to R58's diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood, Delusional Disorder, and Adjustment Disorder with Mixed Disturbance of Emotions. R58 currently receives Buspar, Duloxetine, Remeron, Seroquel and Gabapentin for Neuropathy. R58 is in need of specialized psychiatric rehabilitation services(SPRS). The focus of SPRS is to maintain or improve current level of functioning. SPRS should include a thorough assessment of this individual's unique capabilities, psychiatric symptoms, and behaviors, if any, by a Qualified Mental Health Professional(QMHP). -frequently refuses care -displays paranoid and accusatory behavior towards others -frequent yelling out, threatening behavior noted -consulting psychiatrist completing medication review notes that: SNRI clinicians to monitor for worsening depression and suicidal ideation; Gabapentin history has been reportedly associated with rare cases of depression and suicidal ideation. R58 may benefit from group therapy, 1:1 talk therapy, medication management, coping skill/problem solving techniques, behavioral management, and therapy for building self esteem. R58's comprehensive care plan is noted not to be person-centered and does not incorporate the need for specialized psychiatric rehabilitation services with person-centered interventions. All interventions except for one were implemented prior to the determination on 10/21/24 that R58 required specialized psychiatric rehabilitation services. (Cross Reference F644 and F645) R58's Admission MDS completed 7/22/24 documents that active discharge planning is in the process. R58's comprehensive care plan includes the following documentation: R58 would like to discharge home-Initiated 7/16/24 On 8/1/24, R58's care plan was revised and documented R58 would like to discharge to the most appropriate level of care. Interventions: Encourage R58 to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. 7/16/24. Evaluate R58's motivation and ability to safely return to the community 7/16/24 : Evaluate/record R58's abilities and strengths, with family/caregivers/Interdisciplinary Team(IDT). Determine gaps in abilities which affect discharge. Address gaps by making community referral, pre-discharge PT/OT(physical/occupational therapy) or internal referral 7/16/24 Surveyor notes R58's discharge plans have not been updated since 7/16/24 and per documented care plan interventions it has not been updated at a minimum of every quarter. (Cross Reference F660) R58's care plan documents with interventions: -Alteration in mood evidenced by intermittent episodes of anxious demeanor/verbalizations 8/1/24 No interventions have been updated since 10/22/24 -Resident has behavior problem due making untrue accusations of harm/abuse 9/5/24 No interventions have been updated since 9/5/24 -R58 experiences loneliness and/or isolation 9/6/24 No interventions have been updated since 9/6/24 -R58 is resistive to care bedside cares due to adjustment to nursing home 9/6/24 No interventions have been updated since 9/18/24 -R58 is at risk for signs/symptoms of resident relocation stress syndrome 9/25/24 No interventions have been updated since 9/25/24 -R58 has potential to be verbally aggressive due to ineffective coping skills, mental/emotional illness 10/15/24 No interventions have been updated since 10/15/24 -Potential for anxiety due to traumatic life event due to sexual assault 10/15/24 No interventions have been updated since 10/18/24 Surveyor noted there have been no updated person centered interventions for R58 since 9/5/24. Surveyor noted that R58's comprehensive care plan is concentrated on R58's behaviors and what is perceived as R58's negative responses to facility interventions. The facility has not examined why R58 may be responding to triggering situations or boundaries in what the facility perceives as 'behaviors', thus the facility has not facilitated R58 to increase self independence physically and emotionally or promote physical and emotional health overall. On 10/30/24 at 10:26 AM, Surveyor interviewed SW-C. SW-C stated SW-C is responsible for discharge, mood, behavior, cognition, and code status care plans. SW-C confirmed the expectation is to make revisions. On 10/30/24 at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA-A) that R58's comprehensive care plan has not been revised with person-centered interventions to assist R58 in reaching the highest practicable psychosocial well-being, receiving 'specialized psychiatric rehabilitation services', discharge planning, and achieving emotional health. NHA-A understands the concern. No additional information was provided as to why the facility did not update the person-centered care plan and ensure the comprehensive care plan was implemented for R58.

Based on interview and record review, the facility did not develop and implement an effective discharge planning process focusing on resident discharge goals, and preparation for transition for 1 (R58) of 1 residents reviewed for discharge planning. * R58 was admitted to the facility on [DATE] with a Left Femur Fracture with the goal to discharge home and/or a lesser restrictive environment. R58 has not had consistent and active discharge planning since admission. Findings Include: The facility's policy Transfer and discharge date d 10/21 documents: .The comprehensive, person-centered care plan shall contain the Resident's goals for admission and desired outcomes and shall be in alignment with the discharge. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor notes the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there is 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's Admission Minimum Data Set(MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS since admission. R58's care plan documents: R58 would like to discharge home-Initiated 7/16/24 On 8/1/24, R58's care plan was revised and documented R58 would like to discharge to the most appropriate level of care. Interventions: Encourage R58 to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. 7/16/24. Evaluate R58's motivation and ability to safely return to the community 7/16/24 : Evaluate/record R58's abilities and strengths, with family/caregivers/Interdisciplinary Team(IDT). Determine gaps in abilities which affect discharge. Address gaps by making community referral, pre-discharge PT/OT(physical/occupational therapy) or internal referral 7/16/24 The following is documented is regards to R58's discharge planning: 7/19/24 Care Conference Note documented by Social Worker (SW)-C: R58's goals are to move back in R58's apartment independently. 7/31/2024 IDT Medicare A Meeting documented by Registered Nurse (RN)-Q: Goal to discharge home with son. Plan B looking into assistive living facility. SW-C documented on 10/9/24 that HCPOA was contacted in regards to goals of care for discharge. On 10/11/2024, SW-C documented that R58 was informed that no assistive living facility appropriate then SW-C will work to find a long term care placement at another facility that fits R58's needs. At this time, R58 will remain in the facility until the next care conference and decision on long term care placement. On 10/15/2024, SW-C documented that SW-C will make referrals for long term care at another facility per R58's request. Surveyor notes there is no other documentation that referrals have been made in regards to whether or not R58 is assistive living appropriate or that referrals have been made to other long term care facilities per R58's request. On 10/29/24 at 11:40 AM, Surveyor interviewed R58. R58 informed Surveyor that R58 wishes to be discharged . R58 stated: I can't take it. I just lay in bed and watch the leaves come off the trees. Its pure misery. No one gives a crap. I can't stay here. Its making me crazy. Surveyor observed R58 crying throughout the interview. On 10/30/24 at 10:26 AM, Surveyor interviewed SW-C. SW-C informed Surveyor that no one will take R58 because of R58's behaviors. SW-C stated referrals have been sent to other facilities. On 10/30/24 at 12:45 PM, Surveyor interviewed Psychologist (Psych)-D. Psych-D stated that R58 has told Psych-D multiple times that R58 does not want to be at the facility. On 10/31/24, Surveyor reviewed R58's electronic medical record(EMR) again and notes there is no documentation that SW-C has sent out referrals to other facilities. On 10/30/24 at 1:10 PM, Surveyor interviewed R58 again. R58 informed Surveyor: I don't know what to do anymore. I hate it here. I want to leave desperately. Surveyor observed R58 crying throughout the interview. On 10/30/24 at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that documentation of active discharge planning has not occurred for R58. Surveyor reviewed that R58's discharge care plan is not person-centered and has not been updated with interventions to ensure R58 has a safe discharge to the most appropriate placement. NHA-A stated that NHA-A believed SW-C was finding a place for R58, but no one will take R58 because of R58's behaviors. Surveyor shared the concern that R58 clearly does not want to be at the facility, and R58's psychosocial well being continues to be at risk. SW-C has not actively assisted R1 to identify and prepare for alternate placement. NHA-A acknowledged the concern. On 10/31/24, at 10:29 AM, Surveyor interviewed SW-C again in regards to R58's discharge planning. SW-C stated that an outside agency completed a referral blast, however, there is no documentation of this. SW-C does not recall when this was completed and stated, if there is no documentation, then its not there. No additional information was provided.

Based on interview and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R150) of 8 residents reviewed for ADL's (Activity of Daily Living). On 10/29/24, R150 was not provided with incontinence care every two hours and was observed with a saturated incontinence product. Findings include: The facility's policy titled, Incontinence and dated 10/21 under Policy Explanation and Compliance Guidelines documents 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. 1.) R150's was admitted to the facility with a diagnosis that includes diabetes mellitus, chronic kidney disease, history of malignant neoplasm of prostate, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, quadriplegia and depression. The functional bladder incontinence care plan initiated 1/4/24 & revised 1/5/24 documents the following interventions: * Clean peri-area with each incontinence episode. Initiated 1/4/24. * Encourage fluids during the day to promote prompted voiding responses. Initiated 1/4/24. * INCONTINENT: Check Q (every) 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Initiated 1/4/24. The Urinary Incontinence and Indwelling Catheter CAA (care area assessment) dated 1/16/24 under analysis of findings for nature of the problem/condition documents During the look back period, [150's first name] was incontinent of urine. He requires assistance with bed mobility, sit up at edge of bed, and transfers. Currently using EZ stand to transfer. He also requires assistance with toileting cares, dressing and bathing/showering. He was admitted following long hospitalization for sepsis associated MSSA (methicillin resistant staphylococcus aureus) bacteremia d/t (due to) poor source control from previous cellulitis leading to infective endocarditis, and complicated by GI (gastrointestinal) bleeding and acute ischemic septic emboli associated infarcts involving L (left) caudate and R (right) cerebellum. Has residual L sided hemiplegia/hemiparesis. Other diagnosis includes Polyneuropathy, cramps and spasms, acute posthemorrhagic anemia, HTN (hypertension), CKD (chronic kidney disease), PDM (personal diabetes manager) with diabetic nephropathy, hyperlipidemia, depression and GERD (gastroesophageal reflux disease). He receives daily scheduled antihypertensives, antiplatelet, statin, antidepressant, diuretic, PPI (proton pump inhibitors), oral hypoglycemic, insulin, and multivitamin and potassium supplements. The Quarterly MDS (minimum data set) with an assessment reference date of 10/11/24 has a BIMS (brief interview mental status) score of 15 which indicates that R150 is cognitively intact. R150 is assessed as not having any behavior including refusal of care. R150 is assessed as requiring partial/moderate assistance for toileting hygiene, and supervision or touching assistance for chair/bed to chair transfer & toilet transfer. R150 is frequently incontinent of urine and bowel. The CNA (Certified Nursing Assistant) Visual/Bedside Kardex Report as of 10/29/24 under the Bladder/Bowel section documents * INCONTINENT: Check Q 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Under the Toileting section documents * Check resident every two hours and assist with toileting as needed. * Clean peri-area with each incontinence episode. * Provide pericare after each incontinent episode. * TOILET USE: The resident requires min (minimal) assist. On 10/29/24 at 9:45 a.m., Surveyor spoke with R150 who was sitting in a wheelchair in his room. R150 informed Surveyor his progress is slow as he had a massive stroke. R150 informed Surveyor he can pivot out of bed with staff and a gait belt. R150 informed Surveyor he uses the toilet in his room and uses the call light. R150 informed Surveyor staff used to answer his call light right away but now it takes a minute. On 10/29/24 at 10:47 a.m., Surveyor observed R150 sitting in the wheelchair in his room with his cell phone in his hand. On 10/29/24 at 1:07 p.m., Surveyor observed R150 sitting in the wheelchair in his room with his cell phone in his hand. On 10/29/24 at 1:48 p.m., Surveyor observed R150's call light on. Surveyor asked R150 why he placed his call light on. R150 informed Surveyor to go to the bathroom as he wants to go to a therapy group. On 10/29/24 at 1:49 p.m., Surveyor observed CNA (Certified Nursing Assistant)-K enter R150's room stating sorry I was with someone else. R150 informed CNA-K he wants to go to the bathroom. CNA-K placed a gait belt around R150, shut R150's room door, and removed the foot rests from R150's wheelchair. R150 wheeled himself into the bathroom. CNA-K placed gloves on, R150 placed his hands on the grab bar and assisted R150 to stand, lowered the incontinence product & shorts, and sit on the toilet. CNA-K removed R150's incontinence product which Surveyor observed was saturated with urine. CNA-K removed her gloves, asked R150 if he was going to be awhile, and washed her hands. R150 informed CNA-K about 5 minutes. CNA-K closed the bathroom door indicating she would give R150 privacy. Surveyor asked CNA-K what is R150's routine for toileting. CNA-K informed Surveyor R150 usually let us know. Surveyor informed CNA-K Surveyor observed R150's incontinence product was pretty saturated with urine. CNA-K informed Surveyor she usually checks R150 every two hours but that didn't happen today. CNA-K informed Surveyor R150 dribbles urine and usually puts his call light on. Surveyor asked CNA-K why she didn't check R150 every two hours. CNA-K replied this is my fault, I should of ask if he was wet or has to go. On 10/29/24 at 1:57 p.m., R150 placed on his call light & CNA-K entered the bathroom. On 10/30/24 at 11:09 a.m., Surveyor asked R150 yesterday when Surveyor observed [name of CNA-K] assist him with going to the bathroom prior to going to group therapy had he been to the bathroom before this time. R150 informed Surveyor once when he got up. Surveyor verified with R150 he was taken to the bathroom when he first got up and then when Surveyor observed prior to going to the group therapy. R150 replied yes. On 10/31/24 at 11:43 p.m., Surveyor asked LPN/UM (Licensed Practical Nurse/Unit Manager)-L what is the expectation if a Resident's care plan has they should be checked every two hours. LPN/UM-L informed Surveyor they should be changed every two hours. Surveyor informed LPN/UM-L of the observation on 10/29/24 with R150's incontinence product being saturated with urine and was not checked every two hours. On 10/31/24, at 12:21 p.m., NHA (Nursing Home Administrator)-A & DON (Director of Nursing)-B were informed of R150's incontinence product being saturated with urine and not being check & changed every two hours according to the care plan and Kardex. No additional information was provided to Surveyor as to why R150, whom is unable to carry out activities of daily living, received the necessary services to maintain good grooming.

Based upon observation, interview and record review, the facility did not ensure 1 (R58) of 4 residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being. * R58 has a history of trauma as identified in a trauma assessment completed on [DATE]. The facility social worker (SW)-C did not establish an individualized plan of care to address R58's trauma. On [DATE], a Level II PASARR screen determined that R58 requires specialized psychiatric rehabilitation services to promote the highest practicable psychosocial well-being for R58. The facility did not update R58's comprehensive care plan with person-centered interventions. SW-D has not actively assisted R58 to identify and prepare for alternate placement. Findings include: 1.) Surveyor requested a medically related social service policy and procedure and the facility was not able to provide a policy to Surveyor. The facility's assessment review completed [DATE] documents: .The facility is capable of caring for Residents with Major Depressive Disorder, Single Episode. Of all the Residents, 56% have a psychiatric diagnosis. Psychology services are provided. Quarterly IDT behavior management meetings are held to discuss both non-pharmacological and pharmacological interventions to assist with achieving the Resident's highest practical mental well being. The facility has a comprehensive process to assess Resident needs and determine required care and services. The facility utilizes a comprehensive admission, readmission, and required assessment process in which the IDT identifies individualized Resident care needs. Over the past year, the facility has developed numerous customized assessments, such as a Behavioral Intervention Summary, a GPEP Behavioral Assessment, and a Smoking Assessment. Due to out patient population and facility workflow, we also developed facility-specific Baseline Care Plans and Discharge Instructions. R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor noted the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred [DATE], however, there are 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's Admission Minimum Data Set(MDS) completed on [DATE] documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS assessment since admission. On [DATE], R58 was evaluated by Psychologist (Psych)-D who diagnosed R58 with Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent, Moderate. On [DATE], Psych-D documents a diagnosis of Psychotic Disorder with Delusions for R58 after a regular psychology visit. On [DATE], Psychiatrist (Psych)-E agreed with the Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent Diagnoses and added Generalized Anxiety Disorder and Unspecified Dementia, Unspecified Severity with Mood Disturbance as a diagnosis. R58's current physician orders documents R58 is prescribed: -Buspar [DATE] -Duloxetine [DATE] -Remeron [DATE] -Seroquel [DATE] Surveyor reviewed R58's Medication Administration Record(MAR). The MAR is directed to record behaviors in relation to medications. However, Surveyor notes that R58's MAR were not accurately completed. R58's MAR based on documentation indicates that R58 has had no behaviors since admission to the facility. R58's electronic medical record(EMR) does not document frequent behaviors or interventions applied to R58's behavior. R58's original Level 1 PASARR screen dated [DATE] documents R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. R58's Level 1 PASARR screen documents R58 is only expected to be at the facility 30 days or less. A new Level 1 PASARR screen was re-submitted on [DATE] documenting R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. On [DATE], it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. R58's Level II PASARR Evaluation Summary dated [DATE] documents: R58 was referred due to R58's diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood, Delusional Disorder, and Adjustment Disorder with Mixed Disturbance of Emotions. R58 currently receives Buspar, Duloxetine, Remeron, Seroquel and Gabapentin for Neuropathy. R58 is in need of specialized psychiatric rehabilitation services(SPRS). The focus of SPRS is to maintain or improve current level of functioning. SPRS should include a thorough assessment of this individual's unique capabilities, psychiatric symptoms, and behaviors, if any, by a Qualified Mental Health Professional(QMHP). -frequently refuses care -displays paranoid and accusatory behavior towards others -frequent yelling out, threatening behavior noted -consulting psychiatrist completing medication review notes that: SNRI clinicians to monitor for worsening depression and suicidal ideation; Gabepetin history has been reportedly associated with rare cases of depression and suicidal ideation. R58 may benefit from group therapy, 1:1 talk therapy, medication management, coping skill/problem solving techniques, behavioral management, and therapy for building self esteem. R58's comprehensive care plan is noted not to be person-centered and does not incorporate the need for specialized psychiatric rehabilitation services with person-centered interventions. All interventions except for one were implemented prior to the determination on [DATE] that R58 required specialized psychiatric rehabilitation services. (Cross Reference F644 and F645) R58's care plan documents with interventions: -Alteration in mood evidenced by intermittent episodes of anxious demeanor/verbalizations [DATE] No interventions have been updated since [DATE] -Resident has behavior problem due making untrue accusations of harm/abuse [DATE] No interventions have been updated since [DATE] -R58 experiences loneliness and/or isolation [DATE] No interventions have been updated since [DATE] -R58 is resistive to care bedside cares due to adjustment to nursing home [DATE] No interventions have been updated since [DATE] -R58 is at risk for signs/symptoms of resident relocation stress syndrome [DATE] No interventions have been updated since [DATE] -R58 has potential to be verbally aggressive due to ineffective coping skills, mental/emotional illness [DATE] No interventions have been updated since [DATE] -Potential for anxiety due to traumatic life event due to sexual assault [DATE] No interventions have been updated since [DATE] Surveyor notes there have been no updated person centered interventions for R58 since [DATE]. Surveyor notes that R58's comprehensive care plan is concentrated on R58's behaviors and what is perceived as R58's negative responses to facility interventions. The facility has not examined why R58 may be responding to triggering situations or boundaries in what the facility perceives as 'behaviors', thus the facility has not facilitated R58 to increase self independence physically and emotionally or promote physical and emotional health overall. (Cross-reference F657). Discharge Planning: R58's Admission MDS completed [DATE] documents that active discharge planning is in the process. R58's comprehensive care plan includes the following documentation: R58 would like to discharge home-Initiated [DATE] On [DATE], R58's care plan was revised and documented R58 would like to discharge to the most appropriate level of care. Interventions: Encourage R58 to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. [DATE]. Evaluate R58's motivation and ability to safely return to the community [DATE] : Evaluate/record R58's abilities and strengths, with family/caregivers/Interdisciplinary Team(IDT). Determine gaps in abilities which affect discharge. Address gaps by making community referral, pre-discharge PT/OT(physical/occupational therapy) or internal referral [DATE] Surveyor notes R58's discharge plans have not been updated since [DATE] and per documented care plan interventions it has not been updated at a minimum of every quarter. (Cross Reference F660) R58's social history completed on [DATE] was completed 35 days after admission to the facility. The social history does not evaluate any psychosocial information pertinent to R58 maintaining the highest practicable physical, mental, and psychosocial well-being. A Brief Trauma Questionnaire was completed on [DATE]. The Trauma assessment documents R58 has had trauma that has impacted R58. Surveyor notes that this was not addressed by Social Worker (SW)-C and incorporated into R58's person-centered care plan with interventions. In response to R58's allegations of sexual misconduct, the facility developed a behavior problem outlining R58 making untrue accusations of harm/abuse on [DATE]. On [DATE], a care plan was implemented documenting R58 has the potential for anxiety due to traumatic life event due to sexual assault after the facility learned of past sexual traumatic events in R58's life. A new trauma assessment was not completed and a person-centered care plan was not implemented. On [DATE], Social Worker (SW)-C documented in R58's EMR that R58 continues to have behaviors and that R58 appears depressed. On [DATE] at 11:40 AM, Surveyor interviewed R58. R58 was at times crying during the interview and Surveyor observed facial grimacing. R58 stated R58 wants to be discharged . Its been pure misery. I can't take it. I just lay in bed and watch the leaves come off the trees through the window. What a life to wake up and count the leaves falling all day. No one gives a crap. I can't stay here. Its making me crazy, crazier than I've ever been. On [DATE] at 10:26 AM, Surveyor interviewed SW-C. SW-C informed Surveyor that SW-C would not complete a new trauma assessment even after learning of new identified trauma. SW-C stated SW-C is responsible for discharge, mood, behavior, cognition, and code status care plans. SW-C stated that R58 is so complex and a sad case. SW-C stated that R58 is accusatory, depressed, and has refusals of cares. SW-C stated R58 has mental health issues and is stuck in a mental health crisis. SW-C believes R58 just wants to be heard. On [DATE] at 11:20 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G regarding R58. LPN-G stated LPN-G frequently takes care of R58. LPN-G stated that R58 requires a lot of reassurance and benefits from physical comfort touch. LPN-G also shared that R58 enjoys compliments. LPN-G confirmed that R58 has not gotten out of bed in a long time. On [DATE] at 12:45 PM, Surveyor interviewed Psychologist (Psych)-D. Psych-D has been treating R58 on a weekly basis. Psych-D stated that R58 shared with Psych-D that there was an incident from the past but will not elaborate at this time. Psych-D recommended to the facility that staff complete cares with the 'buddy system'. On [DATE], at 1:10 PM, Surveyor interviewed R58 again. R58 shared that R58 attempted to speak to daughter on the phone this morning, but was not able to finish the conversation because R58 was crying so much. R58 shared that R58 woke up thinking about R58's oldest son who died of COVID. R58 stated, Who would think retirement would be like this. I hate it here. On [DATE] at 1:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J. CNA-J confirmed that R58 is on the buddy system for cares. CNA-J stated that R58 is not motivated to do anything and is not getting out of bed. On [DATE] at 2:57 PM, Surveyor interviewed Psychiatrist (Psych)-E who has evaluated R58 two times. Psych-E described R58 as being very irritable. On [DATE], at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R58 has not been provided medically related social services in order for R58 to maintain the highest practicable physical, mental, and psychosocial well-being. NHA-A informed Surveyor that a new trauma assessment should have been completed upon learning that R58 has past sexual trauma. NHA-A informed Surveyor that NHA-A believes the buddy system is triggering to R58 and NHA-A stated that it is clear that R58 does not want to be at the facility. NHA-A stated, I am concerned about R58. On [DATE], at 9:35 AM, Surveyor interviewed LPN-F. LPN-F informed Surveyor that LPN-F wished R58 would get a mental health evaluation and treatment. LPN-F stated that R58 is constantly on the call light and needs reassurance. On [DATE] at 9:54 AM, NHA-A explained how the licensed staff should be filling out the MAR in regards to behavior monitoring. NHA-A agreed that R58's MAR detailing R58's behaviors has not been filled out correctly thus it appears R58 has had no behaviors. Surveyor shared the concern with NHA-A that non-pharmalogical interventions have not been implemented in order for R58 to maintain the highest practicable physical, mental, and psychosocial well-being. NHA-A understands the concern and at this time, the facility did not provide any additional information.

Surveyor: [NAME], [NAME] Based on observation, record review and interviews, the facility did not ensure that 1 (R62) of 5 residents reviewed received care, consistent with professional standards of practice to prevent the development of pressure injures and or to promote healing, prevent infection and prevent additional pressure injuries from developing. * R62 developed a pressure injury on the right buttock on 6/30/24 that was not comprehensively assessed and did not have physician notification for a treatment until 7/10/24. R62's pressure injury declined during this time, and on 7/10/24, the wound physician assessed the pressure injury as unstageable. The wound physician ordered a debriding treatment. On 7/17/24, the pressure injury was mechanically debrided to a stage 4 pressure injury. R62 was not assessed for weight loss prior to this pressure injury development. Cross reference F692. The failure of the facility to provide services to prevent pressure injury development and to ensure prompt treatment created a finding of immediate jeopardy that began on 7/17/24. Surveyor notified the (Nursing Home Administrator) NHA-A on 9/04/24 at 9:11 AM. The immediate jeopardy was removed on 9/11/24. The deficient practice continues at a scope of severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy and procedure dated 6/14/24 and titled Treatment/Services to Prevent/Heal Pressure Ulcer documents: Intent-The facility will ensure that based on a comprehensive assessment of a resident: a.) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and b.) A resident with pressure ulcers receives necessary treatment and services, consistent with a professional standards of practice, to promote healing, prevent infection and prevent new ulcers on developing. The (National Pressure Injury Advisory Panel) NPIAP 2019 Prevention and Treatment of Pressure Ulcers/Injuries state; Recommendations and Good Practice Statements: - Consider the impact of impaired nutritional status. - Develop and implement a risk-based prevention plan for individuals identified as being at risk for pressure injuries. - Develop and implement an individualized nutrition care plan for individuals with, or at risk of, of a pressure injury who are malnourished or who are at risk of malnutrition. - Conduct a comprehensive initial assessment of the individual with a pressure injury. 1.) R62 was admitted to the facility on [DATE] with diagnoses that included severe protein malnutrition, dysphasia and severed dementia. R62 has a (Power of Attorney for Healthcare) POA-HC that is activated. R62 Admission (minimum data set) MDS assessment dated [DATE] documents that R62 is at risk for pressure injury. The assessment does not encompass the diagnosis of severe protein malnutrition for preventative interventions. R62 requires staff assist with mobility, transfers, incontinence care and assist with activities of daily living. R62's Significant Change in Status MDS dated [DATE] documents changes with eating and swallowing. R62 is at a risk for pressure injuries and Surveyor noted that there were no changes made to the plan of care for preventative measures. R62 Quarterly MDS assessment dated [DATE] does not encompass malnutrition and swallowing concerns. There are no changes to the pressure injury risk treatments as documented in the quarterly MDS. R62 had a severe weight loss of 13% from 3/13/24 to 3/20/24. There was not a comprehensive assessment for the development of a pressure injury. On 3/13/24, R62 weighed 125 lbs and 108 lbs on 3/20/24. R62 had a severe weight loss of 28% from 6/6/24 to 7/10/24. R62 on 6/6/24 weighed 102 lbs and on 7/10/24 weighed 73 lbs. R62 Braden Skin Assessments were reviewed. The Braden Skin scale is from 6- 23. The lower the number the higher the risk for pressure injury development. R62's Braden assessments document the following scores: - 2/13/24 a 15 a mild risk. - 2/20/24 a 14 a moderate risk. - 3/11/24 a 13 a moderate risk. - 4/7/24 a 13 a moderate risk. - 6/7/24 a 12 a high risk R62's plan of care Potential impairment to skin integrity related to nutrition, Alzheimer's dementia and decreased mobility date as initiated 2/13/24 documents under the interventions section: - 2/13/24 Encourage good nutrition and hydration in order to promote healthier skin. - 2/13/24 Turn and reposition every 2 - 3 hours and as needed while in bed. The next intervention initiated on 2/27/24 documents: - Apply house barrier cream every shift and/or with incontinence episodes; Keep skin clean and dry. Use lotion on dry skin. This intervention was added a week after R62's skin risk assessment changed from a mild risk to a moderate risk for skin ulcers. The following interventions were subsequently added: - 3/18/24 Use a draw sheet or lifting device to move resident. There is no change to the plan of care to prevent skin impairment with the severe weight loss on 3/20/24. - 6/14/24 Apply heel boots in bed. - 6/14/24 The resident needs pressure reducing EquaGel cushion to protect the skin while up in chair. (There is not documentation of what preventative measure was used in the chair prior to this intervention.) -6/18/24 The resident needs an air mattress to protect skin while in bed. (There is not documentation of the type of mattress.) On 8/28/24 at 2:48 PM, Surveyor interviewed NHA-A. NHA-A indicated the facility changed R62's wheelchair cushion to an EquaGel but stated that NHA-A did not have information on what had been in place prior to this. NHA-A changed the air mattress. NHA-A indicated that they will get the exact dates. NHA-A provided on paper that on 6/28/24 an alternating air mattress was added to the resident for a pressure prevention related to weight loss and poor nutritional intake and that an EquaGel cushion was ordered for the wheelchair. NHA-A stated that on 7/11/24, a Panncea low air loss mattress was put in place and a EquaGel II cushion was added. R62's Progress Note on 6/30/2024 documents: Writer called into room regarding right buttock skin issue. Area is 0.4 cm x 0.4 cm. Wound bed is white with no drainage. Surrounding skin has erythema. Area is on bony prominence. Placed Allevyn for protection until seen by wound care team for further assessment and treatment. R62's Skin Only Evaluation dated 6/30/2024 documents: Skin: Skin warm & dry, skin color WNL (with in normal limits), mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer / Injury. Skin Issue Location: right buttocks Pressure Ulcer / Injury Stage: Unstageable. Length: 0.4 cm Width (cm): 0.4 cm Depth: 0.1 Wound Bed: Epithelial. Wound Exudate: None. Peri Wound Condition: Erythema. Dressing Saturation: None. No wound odor. No tunneling. No undermining. Area found on right buttocks. Area is 0.4 cm x 0.4 cm. Wound bed is white with no drainage. Surrounding skin has erythema. Area is on bony prominence. Placed Allevyn for protection until seen by wound care team. Clinical Suggestions: Evaluated for pain, discomfort. Dressing changes/treatments performed as ordered. Resident is turned, ambulated, moved at least every 2 hours. PRN (as needed) medication administered and effectiveness evaluated. There is no documentation the physician was contacted for treatment on 6/30/24. The description of the wound bed is white with no percentage of coverage. The definition of a white wound bed is necrotic tissue. The necrotic tissue would need to be removed to promote healing of the wound. There is not a comprehensive assessment on 6/30/24 to identify possible causative factors. There were no changes in interventions to promote healing upon discovery. R62's progress note dated 7/2/2024 documents: Skin/Wound Note. This is a late entry from 7/16/24 from NHA-A. The 7/2/24 documents : The (interdisciplinary team) IDT met to discuss the resident's new skin injury. The resident has a diagnosis of Dementia and dysphasia. Due to her diagnosis, she is only consuming 25% of her meals. The resident has a consult for speech therapy and is followed by the dietician. It was recognized that her Braden score moved from a moderate risk to a high risk. An air mattress was in place d/t (due to) the change. The resident was on a turning schedule and had a pressure reduction cushion on her wheelchair. Other skin prevention interventions in place were incontinence care and feeding assistance. Based on the interventions in place, the wound is classified as unavoidable. The IDT team recommends adding heel boots as an extra level of protection. R62 plan of care for ADL (activity of daily living) self-care performance deficit related to Alzheimer's dementia initiated date of 2/13/24. The interventions on 2/13/24 include: - Provide milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or mug where appropriate. - The resident requires physical assistance by 1 staff to eat. There is no changes to the ADL plan of care related to obtaining appropriate nutrition and assistance to promote wound healing. R62's plan of care Has an unstageable pressure ulcer right buttock. Now a stage 4 (7/17/24) initiated date 6/30/24. This plan of care does not include any preventative interventions related to positioning and nutrition. Surveyor noted that there is not a nutrition assessment until 7/16/24. This assessment by (Registered Dietician) RD- N documents a significant weight loss and severely underweight. A prosource protein supplement was added twice a day. There was no documentation of interventions to increase oral intake. This could include favorite foods, high caloric foods, or other individualized needs. Surveyor also noted that there was not a comprehensive assessment of R62 nutritional needs to implement an individual plan of care to promote wound healing on 6/30/24. On 7/3/2024, a Skin Only Evaluation for R62 was completed by NHA-A as a late entry on 7/16/24. The evaluation documents an increase in the pressure injury with a necrotic wound bed. There is not a percentage of necrotic tissue and is classified as an unstageable wound. The assessment documents Skin: Skin warm & dry, skin color WNL and turgor is normal. Resident does not have an external device. New. Issue type: Pressure ulcer/ injury. Location: Right buttock. Length (cm): 2.6 Width (cm): 2.9 Depth (cm): 0.9 Wound bed: Necrotic. Wound Exudate: Serosanguineous - thin, watery, pale, red/pink drainage. Peri wound: Normal. Dressing saturation: None 0%. Wound odor: No. Tunneling: No. Undermining: No. Treatment schedule: Daily. Pressure ulcer staging: Unstageable pressure ulcer / injury - obscured full thickness skin and tissue loss. Painful: No. Skin tissue: Warm. Skin note: Weekly skin assessment There is no documentation the physician was notified of this decline in the wound to implement an appropriate treatment. R62's initial wound physician assessment dated [DATE] documents: The type of wound is a pressure injury. It is assessed as a unstageable wound due to necrosis. The duration of wound is greater than 10 days. The wound size is 2.4 x 2.7 x 0.8 cm (centimeters). There is light serous sanguineous drainage. The characteristics are thick adherent devitalized necrotic tissue: 60 %; Slough: 30 %; Granulation tissue: 10 %. R62's wound physician assessment dated [DATE] is the first comprehensive assessment of this pressure injury since discovery on 6/30/24. The wound physician ordered Santyl apply once daily and as needed; recommended to off-load wound, reposition and group II mattress. Also recommended sharp debridement. The factors complicating wound healing is malnutrition. R62 had a severe weight loss that was discovered on 7/10/24 however, there was no nutritional assessment until 7/16/24. The additional measures were to add prosource protein supplement twice a day. A low air loss alternating mattress was added on 7/11/24. There were no changes in turning/positioning times. There were no additional nutritional interventions to promote oral intake. R62 was admitted to hospice on 7/16/24 with a primary diagnosis of severe protein malnutrition. The 7/17/24 wound physician assessment documents the wound has been debrided. The pressure injury is now a stage 4. There is no change in the treatment plan. R62 pressure injury has been assessed weekly from this point by the wound physician. On 8/28/24 at 2:17 PM, Surveyor observed R62 pressure injury treatment by Wound (Registered Nurse) RN-D. RN-D stated they do not do anything with the care plans. RN-D was not aware how R62 developed the pressure injury or any changes in the mattress. RN-D completed the treatment as ordered by the physician. The pressure injury was observed to be a stage 4 wound. R62 was positioned with pillows off the area. R62 was on the appropriate air mattress. On 8/28/24 at 2:48 PM, Surveyor interviewed NHA-A. NHA-A stated they noticed a change in R62 before the development of the pressure injury on 6/30/24. NHA-A stated they were rotating time up in the chair with laying down. They put heel boots in place at this time. NHA-A stated the skin is an organ, and with end stage of life there will be deterioration. NHA-A did not know the origin of pressure for the pressure injury. NHA-A did not indicate what nutritional interventions were started when the pressure injury was discovered 6/30/24. On 8/29/24 at 10:40 AM, Surveyor interviewed RN (Registered Nurse Unit Manager) RN UM-E. RN UM-E started this position in May 2024 and is still getting to know the residents. RN UM-E is not sure what was in place prior to weight loss, and pressure injury discovery. RN UM-E stated that towards the end of June R62's appetite decreased, and they would pick at their food. R62 was getting nutritional supplements. RN UM-E does not know anything about air mattress changes. RN UM-E stated that if R62 is not eating they are offered an additional supplement, and that sometimes R62 will drink this. The IDT meeting on 7/2/24 discussed the new pressure injury and to have Speech Therapy assess for not eating. RN UM-E did not have any additional information related to positioning or origin of the pressure injury. On 8/29/24 at 11:22 AM, Surveyor interviewed RD-N. RD-N they were aware of the weight loss right away. RD-N stated they were doing reweighs and could not believe the severe weight loss. R62 is up and down with eating. RD-N stated R62 is affected by their dementia and will eat food at times. R62 was already getting supplements 3 x a day. R62 is in the dining room for meals. On 7/16/24 pro-source supplement was added twice a day. RD-N increased the pro-source today to 3 x a day because the pressure injury is declining. This week R62 has been eating more with fingers. They also added finger foods this week. R62 varies in eating abilities, will use utensils, however, uses hands more. RD-N feels R62 has advanced dementia and has been eating less. RD-N stated they are in the facility 5 days a week. RD-N did not indicate any other nutritional approaches were attempted to promote nutrition. RD-N does not know how the severe weight loss occurred. RD-N was aware of the new wound, however, did not implement any changes in nutritional management until 7/16/24. The new wound was discovered on 6/30/24. R62's nutritional status is a factor in skin integrity. On 8/29/24, at 11:47 AM, Surveyor interviewed Wound (Medical Doctor) MD-O. MD-O stated that R62's pressure injury is an area that can be off-loaded. The facility and hospice take care of the air mattress ordering. R62 is off loaded most of the time. R62's main issue is their decline in health. R62 would develop wounds much faster with poor nutritional status and infections. R62 wound would not improve if they continue to medically decline. On 9/03/24 at 09:57 AM, Surveyor interviewed (Nurse Practitioner) NP-Q. NP-Q stated R62 has dementia and would eat on and off. R62 had a fall, with a hip fracture in February 2024 that was a factor in their decline in health. NP-Q felt R62 dementia behaviors were affecting their eating. R62 behaviors are crying and repetitive statements. They were trying to address the behaviors with medication. R62 had speech therapy on and off for swallowing and coughing. The coughing was more from bronchitis. NP-Q stated a person with dementia, can progress in the disease, for weight loss. The POA-HC did not want any artificial nutrition. NP-Q could not recall if they were notified of the pressure injury discovered on 6/30/24. NP-Q stated the wound MD drives the treatments. NP-Q stated that they can order a wound treatment, however the wound MD oversees it. NP-Q did not have any additional treatment information for the unstageable wound from 6/30/24 - 7/10/24. On 9/03/24, at 1:33 PM, Surveyor shared R62 concerns with NHA-A. NHA-A stated they notified the Nurse Practitioner and were using the Allevyn dressing until the Wound MD saw the resident. NHA-A stated they changed to an air mattress in June right before the pressure injury developed. Then they changed to a stronger air mattress after the wound MD saw the resident. NHA-A did not have additional information related to the actual cause of the pressure ulcer and what interventions were revised/implemented to promote skin integrity. On 9/03/24 at 3:00 PM, NHA-A spoke with Surveyor. NHA-A stated they did not actually see R62's pressure injury on 7/3/24. NHA-A was aware it was necrotic through review. The wound MD was off that week. Surveyor queried about the wound being larger on 7/3/24, from 6/30/24, with no changes in treatment or physician notification. On 9/03/24 at 3:15 PM, NHA-A spoke with Surveyor. NHA-A stated they did assess R62's pressure injury on 7/3/24. There was a question on wound bed. NHA-A stated the wound bed was necrotic and needed debridement. The Wound MD-O was off the first week of July and did not assess the wound until 7/10/24. The wound was debrided on 7/17/24 after permission from R62's POA-HC. NHA-A stated there was no change in treatment from 6/30/24 until 7/10/24. On 9/04/24 a 2:01 PM, Surveyor interviewed Wound MD-O in person at the facility. MD-O stated they debrided R62's wound to prevent infection. The goal is to keep infection risk down. The necrotic tissue removal helps with pain as well. MD-O stated that removing the necrotic also resolves inflammation. Surveyor noted that R62 was at high risk for pressure injury due to malnutrition with decreased mobility. The facility did not comprehensively assess R62's risk factors to develop an individualized treatment plan. R62's pressure injury was not comprehensively assessed upon discovery to provide prompt treatment. There were no changes in R62's nutritional, ADL and skin plan of cares. The failure of the facility to provide services to prevent pressure injury development, and prompt treatment created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 7/17/24. The immediate jeopardy was removed on 9/11/24 when the facility implemented the following: 1) All nursing staff (including agency staff) currently working will be re-educated on the facility wound prevention policy, which includes a comprehensive assessment that should include the following: staging of Pressure injuries, location, size, color, type of wound tissue, exudate or drainage amount and type, odor, and peri-wound condition completed by a registered nurse on all newly identified wounds and residents admitted with wounds. 2) All nursing staff currently working (including agency staff) will be re-educated on pressure injury skin prevention and proper notification of changes with skin injury. They will also be educated on the use of proper pressure prevention interventions. 3) All residents with pressure injuries will be seen by the wound physician and a comprehensive assessment will be completed. Based on his wound round notes the resident will be assessed for the proper skin prevention equipment i.e air mattress and heel boots. The care plan will be adjusted to reflect the pressure injury and pressure prevention equipment. 4) All residents and braden that are high risk for pressure injury care plan will be reviewed and and necessary adjustment will be made to reflect pressure prevention interventions. 5) All training noted above is to be completed by non-working staff by the beginning of the working shift. Any nurses who do not complete the competency will not be scheduled until completed. Competencies and education will be conducted by the DON, NHA, or Staff Development department. 6) RD was re-educated on the dietician responsibilities to assess residents with risk and pressure injuries for nutritional statues and interventions. 7) On 9/6/2024 the wound program and wound prevention policy were reviewed with the medical director and wound physician to ensure the policy meets current standards of practice. No additional information was provided as to why the facility did not ensure that R62, received care, consistent with professional standards of practice, to prevent the development of pressure injures and or to promote healing, prevent infection and prevent additional pressure injuries from developing.

Based on observation, record review, and interview, the facility did not ensure that 1 of 3 residents (R62) reviewed, based on a comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. * R62 was admitted with severe protein malnutrition. R62's nutritional assessments did not include actual weights that were obtained by facility staff and/or individualized interventions to provide adequate nutrition. R62 developed two periods of severe weight loss (130 lbs to 69.2 lbs, a 46.7% weight loss) that factored into the development of a stage 4 pressure injury and R62 being placed on hospice services. The facility's failure to conduct comprehensive assessments, to develop an individualized plan of care, and to provide adequate nutrition created a finding of immediate jeopardy that began on 3/20/24. Surveyor notified the (Nursing Home Administrator) NHA-A on 9/04/24 at 9:11 AM. The immediate jeopardy was removed on 9/9/24, however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: The facility's policy and procedure dated October 2021 and titled Weight Monitoring documents: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. 1.) R62 was admitted on [DATE] with diagnoses to include severe protein malnutrition, dysphasia, and severe dementia. R62 has an activated Power of Attorney for Healthcare (POA-HC.) R62's Admission MDS (minimum data set) assessment dated [DATE] documents that R62 requires set-up for eating and has had a recent weight gain. The MDS documents that the assessment weight for R62 is 130 lbs. R62's documented weights at the facility for February were as follows: - 2/13/24 130 lbs - 2/14/24 130.4 lbs - 2/15/24 130 lbs R62's Nutrition/Dietary Admission assessment dated [DATE] and written by (Registered Dietician) RD-N documents: R62 is on a mechanical soft diet, consuming ~ (approximately) 35% of meals since admit. Weight is 130 lbs on 2/15 (question accuracy of the weights obtained & requested another weight), was 95.7 lbs in the hospital, and R62's niece said R62 is typically ~95# and Froedtert MyChart had a weight of 106 lbs and she was surprised to see a weight that high. BMI (body mass index): 23.8, WNL (within normal limits) - however, R62 appears closer to underweight and weight of 130 lbs does not seem accurate. R62 has her own teeth, which are in poor condition. No oral sores nor pain with chewing noted. Appears to be tolerating mechanical soft diet but ST (Speech Therapy) is ordered with history of dysphasia. Discussed Boost and R62 said chocolate or vanilla would be okay. Can feed self but assist and encouragement/cues are helpful. No pressure injuries noted. Braden: 15, at risk. R62 diagnosis: Alzheimer's dementia, HTN (hypertension), asthma, dysphasia, protein-calorie malnutrition Meds (medications): sertraline, quetiapine. Estimate nutrition needs based on UBW (usual body weight) of 95 lbs: 1295 kcal (kilocalorie) (30 kcal/kg (kilogram) for wt gain), 43 g (grams) protein (1 g/kg), and 1080-1295 mL (milliliter) of fluids (25-30 mL/kg). Nutrition diagnosis: Inadequate oral intake related to poor-fair po (oral) intake, dementia as evidenced by consuming ~35% of meals, Alzheimer's. Intervention: add Boost/house supplement 240 ml BID (twice a day) for 480 kcal, 20 g protein/day. Goals: consume 25%+ of meals/supplement, skin will not break down, no significant wt triggers, no s/s (sign/symptoms) of dehydration. Surveyor noted that R62's nutritional assessment calculations were not based off the weights obtained by facility staff. This assessment did not include vitamins or mineral supplements that could be provided to R62 to maintain R62's nutritional status. This assessment did not include alternate high calorie food choices, fortified foods, favorite foods or snacks, or any other foods that could be offered as part of R62's personalized diet plan. R62's care conference note dated 2/27/24 and written by RD-N documents: R62's family does not believe R62's weight at the facility. R62 was around 100 lbs at home and do not believe R62 gained 30 lbs. R62 only eats 30 % of their meals and nutritional supplement twice a day. R62 family does not want tube feeding, however they do want R62 to be provided assistance at meals, given cues and encouragement to eat, to keep weight above 95 lbs. The family did not want an appetite stimulant medication unless absolutely necessary. (Note: Despite the family's belief that the resident's weight was probably around 100 lbs., repeated weights at the facility thus far had shown R62's weight to be 130 lbs.) R62's nutritional plan of care dated as initiated on 2/16/24 documents: Resident is at nutritional risk related to need for mech (mechanical) soft diet, need for nutritional supplement, poor-fair po intake, Alzheimer's dementia, dysphasia, pro-cal malnutrition, risk for dehydration and risk for malnutrition. Under the interventions section it documents that on 2/16/24 the following interventions were initiated: - Staff to assist with meal set up and eating prn (as needed). - Allow adequate time for R62 to consume food served. - Monitor oral intakes and record in the electronic record. - Offer a minimum of 1400 ml of fluids at meals/day. R62 mainly prefers milk, juice, water and coffee. - Offer house supplements as ordered. - Provide mechanical soft diet. - Weigh monthly and PRN (as needed) as ordered. R62's plan of care dated as initiated on 2/13/24 documents: ADL (activity of daily living) self-care performance deficit related to Alzheimer's dementia. Now on Hospice care. The interventions section documents the following interventions for eating were in place on 2/13/24: - 2/13/24 R62 requires physical assistance of 1 staff to eat. - 2/15/24 an intervention was initiated to provide milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate. R62's documented weights at the facility continued as follows: - 2/19/24 130.2 lbs - 2/21/24 130.2 lbs - 3/6/24 128.6 lbs - 3/12/24 125.9 lbs - 3/12/24 125.9 lbs R62's Significant Change in Status MDS dated [DATE] documents that R62's weight was 126 lbs and there are coughing and swallowing concerns when eating for R62. R62's Nutritional Nutrition/Dietary Note dated 3/12/24 documents: R62 is downgraded to mildly thick liquids per ST (Speech Therapy) recommendation. R62 with swallowing difficulty and working with ST. R62 received ST for an evaluation one time on 3/11/24 for swallowing concerns by (Speech Therapist) ST-P. R62's speech therapy assessment recommendations are: Mechanical soft textures; nectar thick liquids; close supervision; to facilitate safety and efficiency. It is recommended R62 use the following strategies and/or maneuvers during oral intake: alternate liquid/solids, rate modification and bolus size, upright posture during meals and 30 minutes after eating. No further consult or exam indicated. The results would not change clinical management of R62. R62's nutritional plan of care revised on 3/12/24 documents: mildly thick liquids as ordered. The ST recommendations were not documented in R62's plan of care. R62's documented weights at the facility continued as follows: - 3/12/24 125.9 lbs - 3/13/24 125 lbs - 3/20/24 125 lbs - 3/20/24 108.2 lbs Surveyor noted that from 3/13/24 to 3/20/24, R62 experienced a 13% weight loss. This would be considered severe weight loss. R62's Nutrition/Dietary Note dated 3/28/24 and written by RD-N documents: Weights ranged 125-130 from 2/13/24 to 3/20/24 but weight also obtained at 108.2 on 3/20/24. Weights now 103.2-103.8 for past week. Continues on mechanical soft with nectar liquids. Sertraline increased on 3/22/24. Needs varying level of assistance at meals. Acceptance of meals and supplements somewhat decreased this past week, about 25%. Visited with R62 before dinner, R62 appeared hydrated but frail. Aide noted R62 seemed unchanged, accepted fluids well. RD-N spoke with R62 POA-HC. R62 had swallow study this week, existing diet/liquids was the recommendation. Discussed weights and POA-HC agreed 103 pounds was more consistent with R62 usual body weight recently as an elderly person. The POA-HC said R62 may have gotten up to 120-125 lbs in their younger adulthood. The POA-HC said R62 got as low as 89 pounds in the past few years but would like to see R62 stay above 100 pounds. The POA-HC was agreeable to increasing house supplement to TID (three times a day) and continuing to monitor weight. Boost/Ensure TID will provide 720 kcals and 30 g protein/day. Updated (Nurse Practitioner) NP-Q. Surveyor noted that R62's above nutritional assessment does not include any snacks, favorite foods, fortified foods, high calorie or other food choices that can be offered as part of R62's personalized diet plan. R62's additional documented weights were as follows: - 3/20/24 108.2 lbs - 3/21/24 103.8 lbs - 3/26/24 103.8 lbs - 3/27/24 103.2 lbs - 4/1/24 102.2 lbs - 4/2/24 102.2 lbs - 4/10/24 101.4 lbs - 4/14/24 99.8 lbs - 5/10/24 101.8 lbs - 5/10/24 101.2 lbs - 6/6/24 102.3 lbs R62's Nutrition/Dietary quarterly assessment dated [DATE] and written by RD-N documents: R62 is on a mech soft diet with mildly thick liquids, consuming ~45% of meals over the last 7 days. Wt: 102.3 lbs on 6/6, 101.2 lbs on 5/10, 130 lbs obtained at facility on 2/13, but the POA-HC reported all R62 doctor appointments and regular weights were ~95-100 lbs so her current weight is about where it usually had been. BMI: 18.7, WNL (within normal limits). R62 has their own teeth, which are in poor condition. No oral sores nor pain with chewing noted. Appears to be tolerating mech soft diet. R62 is offered house supplement 240 mL TID for ~720 kcal, 30 g protein/day to help maintain weight. Can feed self but assist and encouragement/cues are helpful, and at times she is fed at meals depending on her level of engagement. No pressure injuries noted. Estimated nutritional needs: 1162-1395 kcal (25-30 kcal/kg), 47 g protein (1 g/kg), and 1162-1395 mL of fluids (25-30 mL/kg). Fluid intake averages ~1230 mL of fluids/day, which should be meeting est. needs. Nutrition diagnosis: Inadequate oral intake related to poor-fair po (oral) intake, dementia as evidenced by consuming ~45% of meals, need for encouragement/cues/occasionally needs to be fed, Alzheimer's, need for supplements, low BMI of 18.7. Intervention: continue current POC (plan of care). Goals: consume 25%+ of meals/supplement, skin will not break down, maintain weight above 95 lbs. R62's next documented weight on 7/10/24 was 73.2 lbs. Surveyor noted that from 6/6/24 to 7/10/24, R62 suffered a severe weight loss of 28%. Surveyor noted that there were no revisions in the individualized plan of care to provide nutritional support for R62. Surveyor noted that there is no comprehensive assessment to identify causative factors for R62's severe weight loss. Surveyor also noted that there is not a comprehensive assessment to identify additional nutritional measures to provide nutrition for R62. On 7/10/24, R62 was prescribed an antibiotic for bronchitis. R62 was experiencing coughing prior to this being ordered. R62 was placed in droplet isolation for 5 days. Surveyor noted that there were no changes in the plan of care for additional nutritional support with an infection. R62's Nutrition/Dietary assessment dated [DATE] and written by RD-N documents: Weight/wound note - R62 is on a mech soft diet with mildly thick liquids, consuming ~30% of meals over the last 7 days. Wt: 66.8 lbs on 7/15, 68.4 lbs on 7/12, 75.4 lbs on 7/11, 73.2 lbs on 7/10, 102.3 lbs on 6/6, 101.2 lbs on 5/10, 130 lbs obtained at facility on 2/13, but POA-HC reported all R62 doctor appointments and regular weights were ~95-100 lbs so 130 lbs was likely incorrect. Significant wt loss from 6/6 to 7/10, not desirable. BMI: 12.2, severely underweight. R62 has increased difficulty chewing and swallowing per staff and ST (Speech Therapy) consult ordered. ST recommends VSS (video swallow study). Per therapy director R62 POA- HC does not want R62 sent out for VSS. Writer notified IDT (interdisciplinary team) on 7/11 that R62 needed a reweigh due to significant wt loss from the previous month. Reweigh obtained but requested another reweigh just to confirm due to the amount of weight lost in 1 month. Notified NP-Q regarding the weight loss and that reweighs were requested to confirm. NP-Q recommends discussing goals of care/hospice with POA-HC. R62 is offered house supplement 240 mL TID for ~720 kcal, 30 g protein/day. R62 needs assist with eating, has poor attention and needs encouragement to eat. No pressure injuries noted. Estimated nutrition needs: 1162-1395 kcal (25-30 kcal/kg), 47 g protein (1 g/kg), and 1162-1395 mL of fluids (25-30 mL/kg). Fluid intake averages ~1230 mL of fluids/day, which should be meeting est. needs. R62 is assisted with eating, receiving nutritional supplements, working with ST. Nutrition diagnosis: Increased nutrient needs related to demands of wound healing as evidenced by unstageable PI (pressure injury) to right buttock. Secondary Nutrition diagnosis: Involuntary weight loss r/t dementia, decline, poor po intake as evidenced by skin breakdown, need for assist with meals, need for supplements, working with ST, severely underweight with BMI of 12.2. Intervention: working with ST, add Prosource 30 ml BID for 200 kcal, 30 g protein/day to aid in wound healing. Goals: consume 25%+ of meals/supplement, skin will not break down, no further wt (weight) loss. Surveyor noted that there is no documentation that includes R62's poor nutritional intake with severe weight loss and how it was assessed. The assessment did not include any increased staff assistance with eating, finger foods, drinkable fortified snacks, or high calorie foods. There is not documentation of food likes or dislikes for R62. There is no assessment that includes vitamins or minerals for added nutritional support for R62. R62 had speech therapy from 7/11/24 to 7/15/24. The speech therapy assessment on 7/11/24 by (Speech Therapist) ST-P documents under the Recommendations section: Mechanical soft textures; nectar thick liquids; close supervision; to facilitate safety and efficiency. It is recommended R62 use the following strategies and/or maneuvers during oral intake: alternate liquid/solids, rate modification and bolus size, upright posture during meals and 30 minutes after eating. On 8/29/24 at 1:24 PM, Surveyor interviewed ST-P. ST-P stated there were variances in R62's oral intake. R62 has no physical barriers to eating. R62 has dementia and does not understand how to eat. ST-P assessed R62 due to more swallowing and coughing concerns. R62 had bronchitis and that would cause more coughing. R62 would take additional liquid supplements. R62 would at times take finger foods. Encouragement did not change R62's intake. ST-P felt R62's dementia was the main reason for not eating. R62 developed an unstageable pressure injury on 6/30/24. This pressure injury evolved into a stage 4 pressure injury on 7/17/24. The primary factor is severe protein malnutrition. Cross reference F686. R62's Nutrition/Dietary note dated 7/16/2024 and written by RD-N documents: Writer spoke with POA-HC regarding the weight loss d/t multiple reweighs confirming the weight loss. POA-HC is adamant that R62 is not 66 lbs and does not believe that R62 has lost that much weight. The POA-HC feels the scales are inaccurate. The POA-HC was just visiting R62 2 weeks ago and would've noticed if R62 had lost that much weight. Writer discussed all the reweighs obtained and that R62 continues with poor po (oral) intake. Discussed that R62 is working with ST (speech therapy) for swallowing, discussed R62 new unstageable wound to right buttock and that Prosource 30 ml BID was added. The POA-HC agreed ProSource is a good idea. The POA-HC is agreeable to hospice for R62 and feels that is what R62 would want, The POA-HC is noticing R62 decline as well. R62's progress note dated 7/17/24 and written by RN UM (Registered Nurse Unit Manager)-E documents: Writer contacted POA-HC regarding requested reweigh of R62 to ensure accuracy. Writer weighted resident today at 69.4 lbs and noted that resident's pants were very loose with at least 4 inches of extra space. Writer provided these updates to POA-HC. On 8/29/24 at 10:40 AM, Surveyor interviewed RN UM-E. RN UM-E stated they started their position in May and are still learning about the residents. RN UM-E was not sure what interventions were in place prior to May regarding R62's weight loss. RN UM-E stated that when R62's weight loss was identified, the POA-HC did not believe it. RN UM-E stated that R62's appetite was decreased and R62 would pick at their food and that this occurred at the end of June. RN UM-E stated that R62 was on house supplements and Boost. RN UM-E stated that if R62 is not eating, R62 is offered another liquid supplement and sometimes drinks it. R62 was not consuming meals and speech therapy was consulted. R62 is also followed by the RD. RN UM-E did not have information on various methods to provide nutrition related to R62's dementia. Surveyor did share there were no changes in the plan of care, no additional information was provided. R62 was admitted to hospice services on 7/19/24 with a primary diagnosis of severe protein-calorie malnutrition. At that time of the survey, R62's weight continues to decrease: - 7/11/24 75.4 lbs - 7/12/24 68.4 lbs - 7/15/24 66.8 lbs - 7/17/24 69.4 lbs - 7/26/24 69.4 lbs - 8/1/24 69.2 lbs On 8/28/24 at 2:48 PM, (Nursing Home Administrator) NHA-A spoke with Surveyor. NHA-A stated that R62 has advanced dementia and that the hospital weight for R62 was different than R62's admission weight. The facility admission weight was 130 lbs and the family said, No way. NHA-A stated that the facility had calibrated the scales and that R62's weight on 3/6/24 was 128.6 lbs. NHA-A stated that the RD did a reweigh on 3/12/24 of 125.9 lbs and that the RD indicated that R62 was losing weight and RD ordered supplements. The supplements that were added were Pro-cal upon admission for at risk for malnutrition. NHA-A stated that R62's weight on 3/13/24 was 125 lbs and that R62 was on weekly weights. NHA-A stated that on 3/20/24, R62's weight was 125 lbs and R62 was reweighed the same day and found to weigh 108 lbs. Then on 3/21/24, R62 was 103.8 lbs and kept going down in weight. On 7/10/24, there was a significant weight loss. NHA-A stated at that time, the RD did not believe R62 had that much of a weight loss. NHA-A stated that R62 was weighed on 7/10/24 and found to have weighed 73.2 lbs. On 7/11/24, R62 weighed 75.4 lbs. NHA-A stated that the RD was in contact with R62's POA-HC. NHA-A indicated that at the time, the facility needed to complete a significant change assessment as R62 was also having trouble swallowing. NHA-A stated that R62 did not have a change in intake prior to the significant weight loss and that speech therapy notes indicated R62 was not swallowing properly. NHA-A stated that facility staff met with R62's family to pursue hospice services at the time. NHA-A did not have any additional causative factors, or interventions, for the severe weight loss. On 8/29/24 at 11:22 AM, Surveyor interviewed RD-N. RD-N stated they were aware of R62's weight loss right away as a resident weight loss would show as a PCC (Point Click Care) alert. At the time, RD-N stated they wanted a reweigh to confirm the weight loss in R62 and that R62's POA-HC did not believe the weight loss. RD-N stated that R62 is very up and down with oral intakes and that sometimes R62 will drink fluids. RD-N stated that R62 does not want to touch food at times and will eat when they want. RD-N felt R62's dementia affected their eating and that R62's POA-HC did not want any tube feeding put in place. RD-N does not know how someone could lose that much weight and stated that NP (Nurse Practitioner)-Q recommended hospice. RD-N stated that R62 was already getting supplements 3 x a day and that R62 would be in the dining room for mealtimes. RD-N stated on 7/16/24, they added ProSource supplements twice a day and that this morning (8/29/24) the ProSource was increased to 3 times a day due to R62's pressure injury declining. RD-N stated that this week R62 has been eating more with their fingers and that the facility added finger foods. RD-N stated that R62 varies in eating and that R62 will use utensils at times, however uses hands more and that due to R62's advanced dementia, R62 has been eating less. RD-N is at the facility 5 days a week and stated that they have facility meetings every day. RD-N stated that R62's POA-HC does not want any further workup and that on 7/19/24, R62 started hospice services for severe protein malnutrition. RD-N did not have any additional information regarding R62's severe weight loss. There were no revisions to the plan of care to provide resident nutrition related to their dementia diagnosis. On 9/03/24 at 9:57 AM, Surveyor interviewed NP-Q. NP-Q stated R62 had weight loss in the hospital and eating was an issue. NP-Q stated that R62 had dementia and that R62 would eat on and off. NP-Q stated that R62 sustained a hip fracture just after admission to the facility that contributed to R62's decline. NP-Q indicated that R62 had a lot of crying and repetitive behaviors and that the hospital did adjust medication to address behaviors to assist with eating, and that the facility wanted to treat the behaviors first. NP-Q stated that R62 was seen by speech therapy on and off and that R62 was coughing was more related to a bronchitis. NP-Q felt that R62's dementia contributed to the weight loss and that the POA-HC did not want artificial nutrition. NP-Q stated that the RD will send an email to notify them about a weight loss. NP-Q indicated they were notified of the weight loss on 7/3/24 via email. The RD increased the nutritional supplements on 7/15/24. NP-Q did not have any information related to R62's severe weight loss. NP-Q requested a care conference to discuss hospice. No additional information was provided. On 9/03/24 at 1:33 PM, Surveyor spoke with NHA-A regarding concerns with R62's weight loss. Surveyor informed NHA-A that R62's plan of care was not revised with changes in their clinical status and that there was not a comprehensive assessment to determine potential factors contributing to the severe weight loss, along with individualized interventions to address R62's severe weight loss. On 8/27/24 at 9:23 AM, Surveyor observed R62 in a wheelchair at the dining room table. R62 was drinking from a glass on their own. There were no staff assisting R62 with eating. On 8/28/24 at 8:40 AM, Surveyor observed R62 in a wheelchair at the dining room table. R62 had a breakfast tray in front of them. R62 had thickened liquids. R62 was holding the glass themselves and drinking from it. There was no staff feeding R62. When staff cues R62 to eat solid food, R62 said no no no. R62 continued to talk non-sensical out loud. Surveyor noted that R62 was admitted with known malnutrition with eating concerns. R62's admission assessment did not calculate the resident's actual weight. Surveyor noted that R62's speech therapy recommendations were not implemented in a plan of care. Surveyor noted that R62's dementia, with behaviors, was not encompassed in the nutritional assessments to develop an individualized approach. R62 was noted to not being eating, along with having loose clothing, in June. There were no changes in the plan of care until mid-July when the nutritional supplement was added. This was also due to a new pressure injury development on 6/30/24. The nutritional assessments do not include a personalized plan to promote nutrition. No additional information was provided as to why the facility did not ensure that R62, based on a comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. The facility's failure to conduct comprehensive assessments, to develop an individualized plan of care, to provide adequate nutrition, created a finding of immediate jeopardy 3/20/24. Surveyor notified the (Nursing Home Administrator) NHA-A on 9/04/24 at 9:11 AM. The immediate jeopardy was removed on 9/9/24 when the facility completed the following: 1) RD (Registered Dietician), DON (Director of Nursing), and IDT (interdisciplinary team) members were reeducated on the facility's weight loss policy, which includes a nutritional assessment. 2) The RD reassessed all residents at risk for weight loss and applied the necessary nutritional interventions according to best practices. 3) Current residents with weight loss were reassessed and care plans were reviewed and/or updated to reflect those interventions. 4) The facility will validate that weights are accurate. Licensed staff will assist with obtaining and verifying the weights and ensure scales are calibrated by manufacture's recommendation. 5) During the nutritional assessment, residents' food preferences and assistance level will be identified and communicated to the caregivers. 6) DON, QA (Quality Assurance) nurse, and NHA will audit residents that trigger for weight loss using PCC (point click care) daily Monday - Friday to ensure proper interventions are applied and care planned. No additional information was provided as to why the facility did not ensure that R62, based on a comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R7, R2, and R5) of 3 residents reviewed for pressure injuries. * On 5/14/24, R7 was identified as having a DTI (deep tissue injury) pressure injury to the right gluteal fold measuring 6 cm (centimeters) by 5 cm. A treatment of soap and water followed by Allevyn dressing every 72 hours continued through 6/2/24. On 5/15/24, APNP (Advance Practice Nurse Prescriber)-R assessed R7 to have an open area to the left ischial with necrotic tissue, odor, and drainage. APNP-R ordered CBC (complete blood count), CMP (comprehensive metabolic panel), CRP (C reactive protein), ESR (erythrocyte sedimentation rate), X-ray of pelvis/Left hip, and to start Doxycycline 100 mg (milligrams) twice daily for 7 days. R7's labs were not drawn until 5/21/24, the x-ray of pelvis/left hip was not done, and the antibiotic was administered for 5 days not 7 days. On 5/17/24, Wound Physician-U assessed R7 with an unstageable left ischium pressure injury and a Stage 1 sacrum pressure injury. Treatments were ordered. The facility implemented the left ischium treatment but did not implement the treatment to R7's sacrum. On 5/22/24, Wound Physician-I assessed R7 with a Stage 4 left ischium pressure injury and a Stage 2 sacrum pressure injury. The facility did not revise the potential skin integrity care plan or develop an actual pressure injury care plan until 5/28/24, 14 days after R7's pressure injury was identified. * R2 was admitted to the facility and found to be at risk for pressure injuries. R2 developed multiple facility acquired pressure injuries including an unstageable right heel pressure injury. R2's unstageable right heel pressure injury deteriorated and became infected while residing at the facility. R2 was hospitalized due to infection of unstageable right heel pressure injury which led to an above the knee amputation of their right lower extremity. The facility's failure to provide care to prevent the development of pressure injuries and promote the healing of pressure injuries R7 & R2, the failure to develop and/or update residents' pressure injury care plans, and the failure to implement and carry out treatments in accordance with doctors' orders created a finding of Immediate Jeopardy (IJ) which began on 5/15/24. Surveyor notified NHA (Nursing Home Administrator)-A & DON (Director of Nursing)-B of the immediate jeopardy on 6/5/24 at 2:56 p.m. The immediate jeopardy was removed on 6/7/24. The deficient practice continues at a scope and severity of G (harm/isolated) related to the example involving R5 and as the facility continues to implement its action plan. * R5 developed a Stage 2 pressure injury on 4/30/24 that was not comprehensively assessed until 5/22/24 when R5 was seen by the wound physician. The wound physician's assessment of the wound indicated the wound had declined to Unstageable with slough in the wound bed and had doubled in size from when it was initially discovered. R5's Skin Integrity Care Plan was not revised with the development of the pressure injury. The dietician was not involved with R5 when the new pressure injury developed. R5 was observed to not have incontinence care or repositioning every two hours as care planned. Findings include: The facility's Treatment/SVS to Prevent/Heal Pressure Ulcer Policy & Procedure revised 3/4/24 under purpose documents: The facility's policy is to ensure it identifies and provides needed care -and services that are resident-centered, per the resident's preferences, goals for care, and professional standards of practice that will meet each resident's physical, mental and psychosocial needs. Under procedure documents: 1. Upon admission, the resident will receive a head-to-toe skin check as soon as possible to identify any skin issues. 2. All residents will have a Braden Scale evaluation completed at the time of admission, in conjunction with each quarterly and annual assessment, with any significant change assessment and as deemed necessary by the Interdisciplinary Team. 3. Interventions will be implemented in the resident's plan of care to prevent pressure injury development. 4. When the resident is admitted with a pressure ulcer(s), the admitting nurse will document the size, location, odor (if any), drainage (if any). 5. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure injury. 6. The admitting nurse will notify the attending physician or wound physician to obtain a treatment order. 7. The pressure ulcer(s) will be evaluated weekly by a Registered Nurse or Wound Physician, and the following will be documented in the resident's electronic medical record: the size, location, odor (if any), drainage (if any), and current treatment ordered. 8. The nurse will notify the physician any time the pressure injury shows signs of non-healing or infection and request treatment order changes. 9. The resident and or the resident's representative will be notified of any changes related to the improvement, deterioration, and/or treatment changes on an ongoing basis. Surveyor noted the facility's policy & procedure does not include for evaluation of pressure injuries the stage or description of the wound bed. On 6/5/24 at 3:05 p.m., Surveyor asked NHA (Nursing Home Administrator)-A what standard of practice the facility's pressure injuries policy & procedures is based on. NHA-A informed Surveyor National Pressure Ulcer Association. 1.) R7 was admitted to the facility on [DATE]. R7's POA (Power of Attorney) for health care was activated on 5/30/24. R7's diagnoses includes hemiplegia & hemiparesis following cerebral infarction, vascular dementia, hypertension, and diabetes mellitus. The resident has potential for impairment to skin integrity r/t (related to) decreased mobility, residual L (left) sided hemiparesis with L hand contracture, incontinence, and terminal condition - on hospice care initiated 6/4/21 & revised 5/28/24 documents the following approaches/tasks: * Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated 3/13/18. * Encourage good nutrition and hydration in order to promote healthier skin. Initiated 3/13/18. * Use a draw sheet or lifting device to move resident. Initiated 3/13/18. * Please provide INC (incontinent) cares for resident at midnight and 0600 (6:00 a.m.). Initiated 9/27/18 & revised 11/16/21. * Heels Up pad when in bed or heel lift boot on at HS (hour sleep) as tolerated. Initiated 8/20/21 & revised 1/4/22. * The resident has pressure relieving mattress, Equa gel cushion on wheelchair and reposition Q (every) 2 hours or PRN when on [sic] (in) bed as tolerated. Initiated & revised 1/4/22. The Quarterly MDS (minimum data set) with an assessment reference date of 3/15/24 has a BIMS (brief interview mental status) score of 5 which indicates severe impairment. R7 is assessed as not having any behaviors, including refusal of cares. R7 is assessed as requiring set up or clean up assistance for eating and toileting, hygiene is dependent, and chair/bed to chair transfer and toilet transfer is assessed as substantial/maximal assistance. R7 uses a wheelchair and is dependent for wheeling. R7 is assessed as always incontinent of urine and frequently incontinent of bowel. R7 is at risk for pressure injury development and is assessed as not having any pressure injuries. Under skin & ulcer treatment, the following approaches are checked: pressure reducing device for bed, pressure reducing device for chair, and applications of ointments/medications other than to feet. The COMS skin only evaluation dated 3/18/24 answers no for current skin issues. For general notes documents skin intact. The Braden assessment dated [DATE] has a score of 18 which indicates at risk for pressure injury development. The May 2024 TAR (treatment administration record) includes weekly shower and skin check Tuesday AM (morning) before 10:00am, if refused shower update resident son. every day shift every Tue (Tuesday) with a start date of 9/26/23. Surveyor noted 5/7 is blank and not checked with initials as being completed. There are no nurses initials on 5/7/24 for refusal of shower/skin check. Surveyor reviewed R7's amount eaten from 5/7/24 to 5/14/24 and noted under the task section documents the following: On 5/7/24 & 5/8/24 all three entries are 76-100%. 5/9/24 all three entries are 51-75% 5/10/24 51-75%, 76-100% & 26-50% 5/11/24 25-50%, 51-75% & 76-100% 5/12/24 26-50%, 51-75%, & 26-50% 5/13/24 51-75%, 51-75%, & 76-100% 5/14/24 all three entries are 51-75%. The nurses note dated 5/14/24 at 1350 (1:50 p.m.) documents Res (Resident) with DTI (deep tissue injury) to R (right) gluteal fold purple in color measuring 6 cm (centimeters) L (length) X (times) 5 W (width) unstageable. Area cleansed and dressed. Scheduled pain meds given [Name] NP (Nurse Practitioner) [Name] here and updated. N.O.R. TX (new order received treatment). This nurses note was written by RN (Registered Nurse)-P. R7's potential for skin integrity was not revised until 5/28/24, 14 days later. The revision on 5/28/24 does not have any changes for R7's approaches/tasks. The actual pressure injury care plan was not developed until 5/28/24, 14 days later. Surveyor was unable to interview RN-P as RN-P is no longer employed at the facility. The physician orders dated 5/14/24 document: Soap & water wash follow by Allevyn dressing to DTI (R) gluteal fold change every 3 days and PRN (as needed) in the morning. The COMS skin only evaluation dated 5/14/24 at 14:01 (2:01 p.m.) documents Skin: Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Deep Tissue Pressure Injury (DTPI). Skin Issue Location: R-gluteal fold Pressure Ulcer/Injury Stage: Unstageable. Length: 6 Width (cm): 5 DTI noted to R-gluteal fold. Area cleansed & dressed. Clinical Suggestions: Evaluated for pain, discomfort. Dressing changes/treatments performed as ordered. This evaluation was completed by RN-P. The nurses note dated 5/14/24 at 14:38 (2:38 p.m.) documents: Son [Name] updated on DTI and TX order. This nurses note was written by RN-P. The nurses note dated 5/14/24 at 22:04 (10:04 p.m.) documents Res rt (right) gluteal fold tx ongoing f/u (follow up) wound team. This nurses note was written by LPN (Licensed Practical Nurse)-Q. The nurses note dated 5/15/24 at 10:23 (10:23 a.m.) documents: F/U (follow up) DTI to R-gluteal fold: Dressing CDI (clean dry intact). Denies pain/discomfort. This nurses note was written by RN-P. APNP (Advanced Practice Nurse Prescriber)-R's progress note dated 5/15/24 under history of present illness documents: [R7's name] 97 Y (year) female at [Facility's name]. History significant for CVA (cerebral vascular accident) with left side hemiplegia, dysphagia, subdural hemorrhage, hypertension, aortic stenosis, type 2 diabetes L (left) urethral stone (stent removed 9/28), shingles with postherpetic neuralgia, chronic leukocytosis, anemia. Resident is seen today for review of chronic conditions and follow up of functional deficits in mobility, safety and ADLs (activities daily living). Under Interval History documents: Approached by son [Name] in hall. Informed of possible open area to left side of buttocks. Discussed with facility staff, noted 5/14 treatment initiated. Patient with complaints of pain to left side of bottom. On Tramadol PRN. Left sided hemiplegia at baseline. Was previously ambulatory with restorative, functional decline recently due to complaints of left ankle pain. Wheelchair dependent at baseline. Appetite and weight stable. No recent ER (emergency room ) visits or hospitalization over the past quarter. Under Physical Exam for skin documents open area to left ischial with necrotic tissue present to wound bed. + (positive) odor and drainage. Wound of left buttock, initial encounter Rapid progress of wound noted by staff. Indicator of decline. CBC (complete blood count), BMP (basic metabolic panel), CRP (C reactive protein), ESR (erythrocyte sedimentation rate). XR (x-ray) pelvis/L hip Start Doxycycline Offload pressure Air mattress Broda chair Wound treatment: dakins kerlix, cover with ABD (abdominal) pad change BID (twice daily) and PRN Wound MD (medical doctor) at facility to follow up Comfort focused care Paint management: scheduled Tylenol. Schedule Tramadol TID (three times daily), continue PRN Tramadol. Under advance care planning documents: Goals of care discussion had at bedside with patient and son [Name]. Rapid decline in wound to left ischium with necrotic tissue, likely to bone. Discussed skin failure as an indicator of decline. Unfortunately patient with functional decline complicated by left sided hemiplegia. Due to multiple co-morbidities, favor comfort focused plan of care. Does not want aggressive interventions or work up outside of facility. Plan as above. Hospice consult. The physician orders dated 5/15/24 documents: Doxycycline Hyclate 100 mg (milligrams) give 1 tablet by mouth every 12 hours for infection for 7 days. Surveyor noted according to R7's May 2024 MAR (medication administration record) R7 started receiving Doxycycline Hyclate 100 mg on the PM (evening shift) on 5/15/24 with the last dose being administered on 5/19/24 on the AM (morning) shift. Surveyor noted this medication was not administered for 7 days according to physician orders. The physician order dated 5/15/24 documents: May have air mattress to promote wound healing. On 6/4/24 at 9:01 a.m., Surveyor asked Maintenance Director-DD if he could tell Surveyor when the air mattress was placed on R7's bed. At 9:09 a.m. Maintenance Director-DD informed Surveyor the air mattress was placed on R7's bed on May 15th. Surveyor asked Maintenance Director-DD if he could find out what type of mattress was on R7's bed prior to the air mattress. At 9:11 a.m., Maintenance Director-DD informed Surveyor he doesn't know what type of mattress was on prior. The nurses note dated 5/15/24 at 22:08 (10:08 p.m.) documents: Res rt gluteal fold DTI necrosis foul smelling started ABT (antibiotic) therapy f/u wound team. This nurses note was written by LPN-Q. The nurses note dated 5/16/24 at 12:03 (12:03 p.m.) documents: Dressing CDI to wound R-gluteal. Doxycycline 100 mg started DX (diagnosis) wound infection without adverse reactions. T (temperature) 97.8 P (pulse) 70 R (respirations)-16 B/P (blood pressure) 122/70 O2 94%. Intervention in place R/T (related to) wound. Hospice eval (evaluation) pending. This nurses note was written by RN-P. The nurses note dated 5/17/24 at 09:44 (9:44 a.m.) documents: Resident alert and resting in bed. Dressing changed to Glut (gluteal) area as ordered. Remains on ABT (antibiotic) for wound with no adverse reactions noted or reported. Temp 97.8 Small amount of drainage and odor noted. Writer noted that resident appears comfortable while resting and does call out with cares and dressing changes. Resident receives scheduled/PRN pain medication. This nurses note was written by LPN-S. The nurses note dated 5/17/24 at 18:02 (6:02 p.m.) documents: Resident seen by wound MD (medical doctor). New tx order placed for left ischium. See MD notes. This nurses note was written by LPN-T. Wound Physician-U initial wound evaluation & management summary dated 5/17/24 under Focused Wound Exam (Site 1) documents: Unstageable (due to necrosis) of the left ischium full thickness. Etiology is Pressure, MDS 3.0 Stage Unstageable Necrosis, Wound Size (L x W x D) (length times width times depth) 5 x 5 x 0.1 cm (centimeters), exudate moderate serous, and thick adherent devitalized necrotic tissue 100%. Under additional wound detail documents: Unavoidable secondary to general decline, possible Kennedy ulcer (secondary to rapid progression). Possible skin failure with multiple new wounds. Under procedure note documents: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 12.5 cm2 of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 50 percent. Hemostasis was achieved and a clean dressing was applied. Focused Wound Exam (Site) 2 documents: Stage 1 pressure wound sacrum. Etiology is Pressure, MDS 3.0 Stage 1, Wound size (L x W x D) 1 x 1 x Not measurable cm, Exudate none and skin Intact with non-blanching redness. Under treatment plan documents: Border foam apply three times per week for 30 days. The facility did not implement this dressing for R7's stage 1 sacrum pressure injury. The facility still has not revised R7's potential for skin integrity care plan or developed an actual skin integrity care plan after Wound Physician-U's evaluation on 5/17/24. The nurses note dated 5/19/24 at 21:41 (9:41 p.m.) documents: Resident is lethargic. Decreased appetite. Able to make needs known. Denies pain or discomfort. Hospice team notified. Comfort cares per NP order. Tx to left ischium done per MD orders. Necrotic tissue, drainage with odor observed. Resident is resting in bed at the moment. This nurses note was written by LPN-W. The Braden assessment dated [DATE] has a score of 10 which indicates high risk for pressure injury development. The doctors order dated 5/20/24 documents: Admit to hospice. The nurses note dated 5/22/24 at 08:50 (8:50 a.m.) documents: Alert orientated X 2 with forgetfulness. Recent decline in condition with hospice care & comfort measures in place. Appetite & fluid intake remains poor. Supplements encouraged. Open area to L gluteal fold with Tx & interventions in place. POA [Name] involved and kept updated on changes in TX & care. Total care with all cares. Difficulty sitting in Broda chair R/T (related to) pain from L-ischium. Incontinent of B & B (bowel and bladder). This nurses note was written by RN-P. Wound Physician-I's wound evaluation & management summary dated 5/22/24 under Focused Wound Exam (Site 1) documents: Stage 4 Pressure Wound of the left ischium full thickness. Etiology is Pressure, MDS 3.0 Stage 4, Wound Size (L x W x D) (length times width times depth) 4.5 x 6 x 2 cm (centimeters), exudate moderate Sero-sanguineous, and thick adherent devitalized necrotic tissue 100%. Under expanded evaluation performed documents: The progress of this wound and the context surrounding the progress were considered in greater depth today. Patient requiring an increase in the level of care. The patient needs debridement under GA (general anesthesia) for Necrotizing Fasciitis. The discussion done with the hospice nurse to discuss the plan of sending the patient out to the hospital with the family. Under procedure note documents: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick ups were used to surgically excise 8.10cm2 of devitalized tissue and necrotic muscle level tissues were removed at a depth of 2.7 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 70 percent. Hemostasis was achieved and a clean dressing was applied. Focused Wound Exam (Site) 2 documents: Stage 2 pressure wound sacrum partial thickness. Etiology is Pressure, MDS 3.0 Stage 2, Wound size (L x W x D) 1 x 1 x 0.1 cm, Exudate none and dermis: open areas with exposed dermis. Under treatment plan documents: Primary dressing(s) Leptospermum honey apply once daily for 30 days Secondary dressing(s) Gauze island w/ (with) bdr (border) apply once daily for 30 days. Under recommendations documents: Antibiotic choice: Doxycycline 100 mg BID for 10 days; off-load wound; reposition per facility protocol. The facility still has not revised R7's potential for skin integrity care plan or developed an actual skin integrity care plan after Wound Physician-U's evaluation on 5/22/24 documents R7's left ischium declined to Stage 4 and sacrum to a Stage 2. The nurses note dated 5/22/24 at 17:40 (5:40 p.m.) documents: [Wound Physician-I's name] per wound round assessment suggest that resident goes to hospital for further wound evaluation. Hospice contacted; hospice verified that resident and family doesn't want hospitalization for wound care per hospice/code status agreement. [RN Manager-J's first name], (unit nurse) hospice nurse, wound support nurse and Wound Physician-I made aware. This nurses note was written by RN-G. The nurses note dated 5/22/24 at 17:58 (5:58 p.m.) documents: Resident seen by wound MD. See MD notes for additional information. New order for Tx for unstageable (due to necrosis) of the left ischium full thickness: skin prep surrounding area. Dakins half strength dampened kerlix Pack cavity with wet kerlix. Cover w/ border gauze. New order for Tx for stage 2 pressure wound to sacrum: Medihoney with border gauze. New order for Doxycycline 100mg po BID x 10 days. Wound MD recommended communication with hospice regarding left ischium wound being necrotizing fasciitis and recommending resident be sent to ER for debridement and IV (intravenous) abx. This note was written by RN Manager-J. The nurses note dated 5/22/24 at 18:12 (6:12 p.m.) documents: Writer contacted Hospice per wound MD recommendation to discuss left ischium wound being early necrotizing fasciitis and recommendation to be sent to ER for debridement and IV abx. Hospice stated that when resident was admitted to hospice they had extensive conversation with resident's son/POA who expressed at that time that he did not want resident to be sent to the hospital for treatments. Hospice stated that they would follow up with resident's son/PA regarding the wound MD's recommendation and goals of care. This nurses note was written by RN Manager-J. The significant change MDS with an assessment reference date of 5/23/24 has a BIMS of 00 which indicates severe cognitive impairment. R7 is assessed as not having any behaviors including refusal of care. R7 is assessed as being dependent with eating, toileting, hygiene, roll left and right, and chair/bed to chair transfers. R7 is always incontinent of urine and bowel, is at risk for pressure injuries, and is assessed as having one Stage 2 and one Stage 4 pressure injury. The pressure ulcer/injury CAA (care area assessment) dated 5/28/24 for analysis of findings under nature of the problem/condition documents: [R7's first name] has a Stage 4 pressure injury to L ischium with current infection and on oral antibiotic treatment, and Stage 2 PI to sacrum. Has daily ordered treatment/dressing change and is being followed by visiting wound MD (medical doctor). She requires total assistance with most of her ADLs (activities of daily living). See ADL CAA. Also is totally incontinent of urine and bowel. Poor oral intake, taking 0-25% during meals. Recently enrolled to hospice care. Diagnosis includes hemiplegia/hemiparesis following cerebral infarction affecting L non-dominate side, vascular dementia without behavioral nor psychotic nor mood disturbances nor anxiety, HTN (hypertension), nonrheumatic aortic valve stenosis, hyperlipidemia, anemia, Type 2 DM (diabetes mellitus), Vit (vitamin) D deficiency, osteoarthritis, slow transit constipation, glaucoma, and other age related cataract. Receives oral and topical analgesics including narcotic analgesic, and antibiotic, otherwise most of her medication has been discontinued. Braden Score = 10 (high risk). The nurses note dated 5/24/24 at 13:05 (1:05 p.m.) documents: F/U open area L-gluteal fold & sacral; Alert & responsive. Comfort measures in place. TX completed per MD order. ABT without adverse reactions. This nurses note was written by RN-P. The resident has Stage 4 pressure injury to L (left) ischium and Stage 2 to Sacrum r/t (related to) Terminal Condition, poor oral intake, and immobility initiated & revised on 5/28/24 documents the following approaches/tasks: * Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated 5/28/24. * Administer treatments as ordered and monitor for effectiveness. Initiated & revised 5/28/24. * Assess/record/monitor wound healing weekly. Wound consult/follow up as needed. Initiated & revised 5/28/24. * Inform the resident/family of any new area of skin breakdown. Initiated and revised 5/28/24. * Monitor dressing each shift to ensure it is intact and adhering. Initiated & revised 5/28/24. * Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated & revised 5/28/24. * Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X (times) width X depth), stage. Initiated & revised 5/28/24. * Pressure relieving/reducing device on bed and chair. Initiated & revised 5/28/24. * The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. Initiated & revised on 5/28/24. * The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Initiated 5/28/24. * Treat pain as per orders prior to treatment/turning etc. to ensure the Resident's comfort. Initiated 5/28/24. * Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. Initiated 1/4/22. * Turn & reposition q 2 hours and PRN while in bed. Initiated 11/25/22. * Apply house barrier cream every shift and/or with incontinence episode(s). Initiated 2/1/23. Wound Physician-I's wound evaluation & management summary dated 5/29/24 under Focused Wound Exam (Site 1) documents: Stage 4 Pressure Wound of the left ischium full thickness. Etiology is Pressure, MDS 3.0 Stage 4, Wound Size (L x W x D) (length times width times depth) 4.1 x 5.4 x 2.9 cm (centimeters), exudate light Sero-sanguineous, thick adherent devitalized necrotic tissue 100% wound progress: Improved evidenced by decreased surface area. Under procedure note documents: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick ups were used to surgically excise 15.50cm2 of devitalized tissue and necrotic muscle level tissues were removed at a depth of 3.8 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 30 percent. Hemostasis was achieved and a clean dressing was applied. Focused Wound Exam (Site) 2 documents: Stage 2 pressure wound sacrum partial thickness. Etiology is Pressure, MDS 3.0 Stage 2, Wound size (L x W x D) 0.7 x 0.6 x 0.1 cm, Exudate light serous and dermis: open areas with exposed dermis. Wound progress: Improved by decreased surface area. The nurses note dated 5/31/24 at 12:49 (12:49 p.m.) documents: F/U ABT for Wd (wound) infection. Resident is alert and responsive. Resident cont. (continues) on abt for wound infection temp (temperature) was 97.1. No adverse reaction noted at this time. Tx was done as ordered some odor noted to area. Some depth and tunneling noted to wound. Drsng (dressing) C/D/I to area. Resident cont. to be turn q (every) 2 hours and as needed. Resident gets up in chair as much as tolerated. Will cont. to monitor. This nurses note was written by LPN-Z. On 6/3/24 at 1:23 p.m., Surveyor spoke with POA-AA regarding R7. POA-AA informed Surveyor R7 started to complain of pain in her bottom about a week or two before the pressure sore developed. POA-AA informed Surveyor the pressure sore wasn't open and then it was terrible. Surveyor asked POA-AA if he knew how the pressure injury developed. POA-AA replied no. POA-AA informed Surveyor the wound doctor recommended R7 go to the hospital. POA-AA informed Surveyor he said no stating they can't do anything in the hospital and no anesthesia because of her age. POA-AA informed Surveyor R7 could walk and then when she complained of pain couldn't walk, was sitting in a wet diaper all the time, supposed to be changed every two hours but didn't think that happened. Surveyor observed R7 in bed on her back with a heel lift pad under R7's lower legs and R7 was wearing pressure relieving boots. R7 is on an air mattress which is on. On 6/4/24 at 7:14 a.m., Surveyor observed R7 awake in bed on her back with the head of the bed elevated, there is a heel lift pad under R7's lower legs but R7's heels are resting directly on the mattress. R7's air mattress is on. On 6/4/24 at 7:22 a.m., Surveyor observed CNA (Certified Nursing Assistant)-BB & CNA-CC enter R7's room. Staff informed Surveyor they were going to reposition R7. Surveyor asked R7 if it was alright that Surveyor was in the room with CNA-BB & CNA-CC. R7 shook her head no and Surveyor left R7's room. On 6/4/24 at 7:39 a.m., Surveyor asked CNA-CC what they did for R7. CNA-CC explained they repositioned & provided oral care. Surveyor asked CNA-CC if they did incontinence care. CNA-CC replied yes, had a small BM (bowel movement). On 6/4/24 at 9:29 a.m., Surveyor observed R7 in bed on her right side. Surveyor observed R7 is not wearing pressure relieving boots and R7's heels are resting on the heel lift pad. On 6/4/24 at 9:31 a.m., Surveyor observed CNA-CC enter R7's room informing R7 she is going to lower her head and reposition her. On 6/4/24 at 10:27 a.m., Surveyor observed R7 in bed position on the left side. R7's son is sitting next to R7's bed holding her hand. Surveyor observed R7 is not wearing pressure relieving boots and has the heel lift pad under R7's lower legs. On 6/4/24 at 1:01 p.m., Surveyor entered R7's room with RN-EE & CNA-CC. R7's son was in the room. R7's son and R7 gave Surveyor permission to observe R7's pressure injury treatments. RN-EE & CNA-CC placed gloves on. The sheet was removed and Surveyor observed R7 is not wearing pressure relieving boots and R7's heels are resting on the edge of the heel lift pad. R7's bed was moved away from the wall & the bed was raised up. CNA-CC removed the pillow from under R7's left side, R7 was moved to the right, the incontinence product was unfastened and R7 was positioned on the left side. RN-EE wiped the stool off R7's buttocks using the incontinence product, removed her gloves and placed new gloves on. Surveyor noted while RN-EE was wiping off the stool R7's dressing on the left ischium was also removed. Surveyor noted there is foam dressing on the sacrum which is not dated. Using multiple disposable wipes, RN-EE wiped off BM from R7's buttocks & rectal area. RN-EE removed her gloves, washed her hands, and placed gloves on. RN-EE removed the packing from R7's left ischium pressure injury which also contained stool on the packing. RN-EE removed her gloves, washed her hands, and placed gloves on. RN-EE stated she sees some fascia and tendon. RN-EE opened a new bottle of dakins, poured the dakins on four by four gauze, removed her gloves while telling R7's son what she is going to do and placed gloves on. RN-EE then cleansed R7's left ischium pressure injury with four by four with dakins and removed her gloves. RN-EE did not perform hand hygiene. RN-EE poured dakins on kerlix, placed gloves on, cut the kerlix, had CNA-CC pull back on R7's left buttocks and packed the left ischium pressure injury with kerlix. While RN-EE was packing the pressure injury RN-EE stated she c [TRUNCATED]

Based on observation, record review, and interview, the facility did not ensure care plans were implemented for residents determined to be at risk for falls and did not ensure residents were comprehensively assessed after a fall to implement preventive measures based on the assessment for 2 (R1 and R3) of 4 residents reviewed for falls. *R1 was admitted to the facility after sustaining a fractured left hip from a fall in the community. R1 was assessed to be a high risk for falls and no care plan was developed to address the fall risk. On 4/22/2024, R1 fell from bed and sustained a fracture to the right hip. *R3 fell on [DATE] and sustained a fractured to the right hip. The fall was not thoroughly investigated as to the root cause and no care plan interventions were implemented to prevent future falls. Observations were made during the survey of fall interventions not in place per care plan. Findings include: 1.) R1 was admitted to the facility on [DATE] with diagnoses of fractured neck of the left femur, post hemorrhagic anemia, encephalopathy, Alzheimer's disease, and anxiety. R1's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R1 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6 and assessed as being dependent for toileting hygiene and transferring, and maximal assistance with dressing and bathing, and moderate assistance for bed mobility. R1's Fall Care Area Assessment with the admission MDS indicated falls were to be addressed in a care plan to minimize risks. R1 had an activated Power of Attorney (POA). On 3/7/2024, R1's Admission Data Collection and Baseline Care Plan Tool was completed by Licensed Practical Nurse (LPN)-N. LPN-N documented in the Physical and Functional Status section of the form that R1 was at risk for falls. Interventions were listed as possible fall prevention measures and no fall planning interventions were selected on the form. On 3/7/2024, R1's Fall Risk Evaluation form was completed by LPN-N. LPN-N documented R1 was a t risk for falls with a score of 13. The top of the form in the computer charting system indicates any score above 10 indicates the resident is at high risk for falls. Surveyor reviewed R1's comprehensive Care Plan. The Care Plan did not include any fall risk or interventions to prevent future falls. On 3/9/2024 at 2:19 AM, in the progress notes, nursing charted R1 did not attempt to self-transfer or get out of bed. On 3/9/2024 at 11:39 PM, in the progress notes, nursing charted the call light was within reach and the bed was locked and at lowest position. On 3/10/2024 at 9:48 PM, in the progress notes, nursing charted the call light was within reach and the bed was locked and at lowest position. On 3/12/2024 at 7:40 AM, in the progress notes, nursing charted R1 was alert to self, confused to time and place. R1 had been removing the linen off the bed and had undressed in bed. R1 had a nervous laugh as R1 rubbed the left hip and leg. Pain medication was administered along with one-on-one and position changes. R1 denied pain when asked but showed nonverbal pain such as the nervous laugh, rubbing the hip, restlessness, and moaning. R1 had poor safety awareness. Decreased stimuli was provided. On 4/9/2024 at 4:55 AM, in the progress notes, nursing charted R1 had made several attempts to get out of bed unassisted. R1 was weight-bearing as tolerated but at that time was not ambulating. R1 calls out for help and has a laughter that resembles that of a nervous laugh. Even when nurses or Certified Nursing Assistants (CNAs) did some one-on-one with R1, that did not stop R1 from calling out help, help, oh no. R1 had been changed and is dry, fluids and a snack were provided. Diminished stimuli was provided. R1 continued with anxiety and restless ness. CNA/nurse provided a safe environment so that R1 would not fall or injure themselves. On 4/10/2024 at 5:32 AM, in the progress notes, nursing charted R1 was restless and called out help me, help me, help me. Staff in with R1 to anticipate and assist with R1. R1 made several attempts to get out of bed unassisted. R1 remained restless even after toileting. Due to safety, R1 was washed up and got ready for the morning. R1 was brought to the common area and given a magazine to look at and a sandwich and apple juice to eat. R1 continued to be anxious and restless. On 4/14/2024 at 5:50 AM, in the progress notes, nursing charted R1 called out help, help, help. The CNA went into the room and R1 was sitting at the edge of the bed. When asked what R1 was doing, R1 did not know and then had a nervous laughter. R1 asked the CNA to please help and when the CNA asked what R1 would like the CNA to do, R1 did not know. R1 had poor safety awareness at night. On third shift R1 does not walk independently; R1 is a max assist of two to transfer to the wheelchair. Safety checks were done related to R1 attempting to get out of bed. Despite being taken care of, R1 continued to demonstrate anxiety and restlessness. On 4/15/2024 at 2:59 AM, in the progress notes, nursing charted R1 had been up since the change of shift. R1 was repetitive, restless, and anxious. Decreased stimuli was provided, one-on-one was given when able, and snacks and fluids were given. All interventions provided short-term relief for restlessness, but it was not effective for the anxiety. The Nurse Practitioner was notified. On 4/22/2024 at 10:07 PM, in the progress notes, LPN-L was informed by the Supervisor that R1 was on the floor. LPN-L and the Supervisor went to R1's room and observed R1 sitting on the floor with legs straight leaning with R1's back on the recliner chair facing the bed. Range of motion was within normal limits to all extremities. Neurological checks were initiated and were negative. R1 could respond to questions but could not remember what happened as R1 has impaired memory and is forgetful. This was normal for R1 as R1 had diagnoses of dementia with anxiety. No changes in consciousness or conditions were noted. No acute distress was observed. Scheduled Tylenol was administered for complaints of pain. R1 had a skin tear with hematoma to the right arm that measured 11 cm x 6.5 cm. The area was cleansed with normal saline and a wet to dry dressing was applied followed by Kerlix. A cold pack was placed on the area. R1 was put back in bed with a Hoyer lift by two CNAs and the assigned CNA. Vital signs were stable and remained with baseline. Interventions were put in place: a bed bolster placed on the left side of R1 under the fitted sheet. The bed was at low level and call light was in place. R1 is forgetful and reminded to call for assistance. The POA, Nurse Practitioner, Director of Nursing (DON) were updated and aware of the fall. On 4/22/2024 at 11:01 PM, in the progress notes, the LPN Nursing Supervisor charted R1 was sitting on the floor facing the bed with the back against the recliner. R1 had gripper socks on, and the call light was on the bed. R1 had scabbing along the right lateral arm with bleeding and a bruise. The unit nurse measured the wound 11 cm x 6.5 cm and cleaned the wound and applied a dressing. A cold pack was placed on the arm and a bed booster was placed on the left side of R1 under the fitted sheet. The Supervisor notified the Nurse Practitioner and the POA of the situation. The POA requested an x-ray. (Surveyor attempted to interview the LPN Nursing Supervisor, but they were unavailable for interview.) On 4/23/2024 at 8:00 AM, in the progress notes, nursing charted the nurse was called into R1's room by the CNA at 7:45 AM. R1 was lethargic and screaming with complaints of excruciating pain in the right leg. R1 had a hematoma to the right arm. Blood pressure 96/56, temperature 98.1, pulse 95, oxygen saturation 95% on room air, and respirations 18. R1 was unable to move lower extremities per baseline. The nurse contacted R1's POA and explained it would be in the best interest if R1 was sent to the hospital for further evaluation. R1 was sent to the hospital and communication between the hospital and the facility showed R1 had a right hip fracture. At 1:42 PM in the progress notes, nursing charted R1 went to the hospital at 8:30 AM. The AM shift CNA stated that when the CNA tried to get R1 dressed, R1 complained of severe pain and the AM shift nurse sent R1 to the hospital where R1 was diagnosed as having a right femur fracture and waiting for possible surgery. No documentation was found of an RN doing an assessment of R1 after the fall on 4/22/2024. R1 did not return to the facility and was not a resident at the time of the survey. In an interview on 6/3/2024 at 3:35 PM, Surveyor asked LPN-L to describe the events of 4/22/2024 when R1 fell in R1's room. LPN-L stated R1 was found on the floor and was not sure if R1 fell from the bed or from the recliner in the room. LPN-L stated R1 had a skin tear and bruising to the upper arm. LPN-L stated R1's legs were straight and R1 did not complain of any pain to the legs. LPN-L stated R1 was lifted back to bed using a Hoyer lift and did not complain of any pain to the leg when R1 was moved. LPN-L stated the LPN supervisor came to R1's room after R1 fell . LPN-L stated if there is no RN in the building, the facility assigns an LPN to be the supervisor. Surveyor asked LPN-L if an RN came to assess R1 after the fall. LPN-L could not recall if any other nurse came to the room. LPN-L reiterated R1 did not complain of any pain to the leg or have any range of motion problems at the time of the fall. In an interview on 6/4/2024 at 10:34 AM, Surveyor asked LPN MDS-M what the facility process was for completing the MDS assessments and creating care plans. LPN MDS-M stated LPN MDS-M works with a Registered Nurse (RN) to complete all the MDS assessments for the facility. LPN MDS-M stated each discipline completes the appropriate section of the MDS and then if a Care Area Assessment (CAA) is triggered, that discipline would complete the CAA to address the triggered area. Surveyor asked LPN MDS-M who initiates care plans for new residents. LPN MDS-M stated the nurse on the floor opens a baseline care plan and then the MDS nurses make sure all areas are completed on the care plan. LPN MDS-M stated the baseline care plans are part of the admission assessment. Surveyor shared with LPN MDS-M the concern R1's Fall CAA was triggered, was assessed to be at risk for falls, the CAA documented falls were to be addressed in the care plan to minimize risks, and no falls care plan was initiated. LPN MDS-M stated a fall care plan should have been initiated and would look to see if one could be located. At 11:35 AM, LPN MDS-M stated R1 did not have a fall care plan on file. LPN MDS-M stated the RN supervisor helps the floor nurse with the baseline care plan. LPN MDS-M stated the MDS nurse, when completing the Fall CAA, should have caught R1 did not have a fall care plan. In an interview on 6/4/2024 at 2:21 PM, DON-B stated an RN is always called in to assess a resident after a fall. Surveyor reviewed the staff schedule for 4/22/2024 and an RN was listed as being on the second shift at the time of R1's fall. DON-B stated the RN on the schedule was an agency RN and the agency staff do not always chart even though they are instructed to do so. DON-B stated the RN should have charted an assessment and agreed no documentation was found indicating R1 was assessed by an RN after the fall. On 6/4/2024 at 2:36 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B R1 was assessed on admission to be at risk for falls per the Fall Risk Assessment and no Falls Care Plan was initiated on the baseline care plan. R1 triggered the Fall CAA on the Admission MDS, and no Fall Care Plan was initiated at any time while R1 was a resident at the facility by either the nurse unit manager, supervisor, or MDS nurse. Surveyor shared the concern when R1 fell on [DATE], R1 was not assessed by an RN at the time of the fall and R1 sustained a right hip fracture requiring hospitalization . At 3:16 PM, NHA-A stated fall care plan interventions include low beds, and all beds are low beds except for ones that have not been swapped out as the building is being renovated so R1 would have had a low bed even without a care plan in place for falls. NHA-A stated each new admission is reviewed to make sure care plans are addressed. NHA-A stated NHA-A looked at the admission checklist for R1 and the Fall Care Plan was checked as being completed. NHA-A agreed R1 did not have a Fall Care Plan in place at any time while a resident of the facility. On 6/5/2024 at 9:37 AM, Surveyor interviewed LPN-N. LPN-N was the nurse that admitted R1 to the facility on [DATE]. Surveyor asked LPN-N what the process was for a newly admitted resident. LPN-N stated the electronic charting system generates all the admission forms that need to be completed including the Admission Data Collection and Baseline Care Plan Tool. Surveyor asked LPN-N if that tool is what creates the baseline care plan with interventions. LPN-N was not sure. Surveyor showed LPN-N R1's Admission Data Collection and Baseline Care Plan Tool that LPN-N had completed with the possible fall interventions not selected. LPN-N stated LPN-N does not do anything with care plans per facility policy because LPN-N is an LPN. Surveyor shared with LPN-N R1 did not have a Fall Care Plan in place even after being assessed at risk for falls. LPN-N was not aware R1 did not have a Fall Care Plan. In an interview on 6/5/2024 at 10:05 AM, Surveyor asked CNA-O what CNA-O could recall of R1's fall on 4/22/2024. CNA-O stated CNA-O had put R1 to bed and then R1 was on the floor after hearing yelling coming from R1's room. CNA-O did not know how R1 fell . CNA-O stated R1 had a bruise and was bleeding from the arm. CNA-O stated nothing else was wrong or injured. CNA-O stated an LPN and one other nurse came to look at R1. Then R1 was put back in bed using a Hoyer lift. CNA-O stated R1 did not complain of any pain and remembered the nurse moving R1's legs without any difficulty. CNA-O stated when R1 was put back in the bed, they put pillows on the side to protect R1 from falling again. No additional information was provided as to why R1 was assessed to be a high risk for falls and no care plan was developed to address the fall risk. On 4/22/2024, R1 fell from bed and sustained a fracture to the right hip. 38829 Surveyor reviewed the facility's policy and procedure last reviewed 4/23 and notes the following in regards to falls: .Policy: Each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a Resident's fall risk. a. The risk assessment categorizes Residents according to low, moderate, or high risk. b. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. 2. Upon admission the nurse will complete a fall risk assessment along with the admission assessment to determine the Resident's level of fall risk. 3. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of Resident falling, including but not limited: i. A clear pathway to the bathroom and bedroom doors ii. Bed is locked and lowered to a level that allows the Resident's feet to be flat on the floor when the Resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. v. Wheelchairs and assistive devices are within reach b. Implement routine rounding schedule. c. Monitor for changes in Resident's cognition, gait, ability to rise/sit and balance. d. Encourage Residents to wear shoes or slippers with non-slip soles when ambulating. e. Ensure eye glasses, if applicable, are clean and the Resident wears them when ambulating. f. Monitor vital signs in accordance with facility policy. g. Complete a fall risk assessment every 90 days and as indicated when the Resident's condition changes. 4. High Risk Protocols: a. The Resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan b. Implement interventions from Low/Moderate Risk Protocols c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the Resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/caregiver or Resident education ix. Therapy services referral 5. When a Resident who does not have a history of falling experiences a fall, the Resident will be placed on the Facility's Fall Prevention Program. 6. Each Resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 7. When any Resident experiences a fall, the facility will: a. Assess the Resident b. Complete a post-fall assessment c. Complete an incident report d. Notify physician and family e. Review the Resident's care plan and update as indicated f. Document all assessments and actions g. Obtain witness statements in the case of injury 2) R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia with Psychotic Disturbance, Generalized Anxiety Disorder, Essential Hypertension, Type 2 Diabetes, Pulmonary Fibrosis, and Type 2 Diabetes Mellitus. R3 has a legal guardian. R3's Quarterly Minimum Data Set(MDS) dated [DATE] documents that R3's Brief Interview for Mental Status(BIMS) could not be assessed as well as the Patient Health Questionnaire(PHQ-9). R3's delusions and hallucinations are not documented. R3's MDS documents that R3 has physical and verbal symptoms which occurred 1-3 days, wandering 1-3 days, and rejection of care 4-6 days during the assessment period. R3 has no range of motion issues. R3 utilizes a walker and wheelchair. The MDS also documents that R3 requires supervision for upper and lower dressing and chair/bed-to-chair transfer. R3 is independent with mobility and transfers. Surveyor reviewed R3's Kardex as of 6/3/24 only documents to ensure R3 has unobstructed path to the bathroom. The following care plans related to falls for R3 are in place: Problem 1. R3 is at risk for falls due to bladder and bowel incontinence, cognitive impairment, anxiety, medication regimen. -12/16/23 Unwitnessed Fall with injury Date Initiated: 09/25/2022 Revision on: 12/18/2023 Interventions in place o Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 09/25/2022 o Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 09/25/2022 o Ensure that the resident is wearing appropriate footwear Date Initiated: 09/25/2022 o Follow facility fall protocol. Date Initiated: 09/25/2022 Problem 2. R3 has impaired physical mobility due to right intertrochanteric fracture, status post trochanteric nailing. Also has Alzheimer's dementia, Cardiac conditions, Anxiety and Osteoarthritis. Date Initiated: 09/25/2022 Revision on: 04/02/2024 Interventions in place o The resident is WEIGHT-BEARING Date Initiated: o LOCOMOTION: The resident uses wheelchair for locomotion. Assist as needed. Date Initiated: 12/27/2023 o PT, OT referrals as ordered, PRN. Date Initiated: 09/25/2022 Surveyor notes that no new interventions were put in place after the 12/16/23 unwitnessed fall resulting in a right intertrochanteric fracture. R3's fall assessment dated [DATE] documents a score of 18, which indicates that R3 is high risk for falls. Surveyor reviewed an investigation dated 12/16/23 which documents R3 was found at 3:30 PM by a certified nursing assistant(CNA) laying on left side, screaming of pain pointed to right hip. Reluctant to move or wiggle right foot due to pain. Observed R3's right foot wearing left shoe and left foot wearing right shoe. Floor notes no debris, dry, small bag full of own personal things on floor next to R3. R3 was transported to the emergency room for evaluation. Surveyor notes that both physician and guardian were notified. Surveyor notes the investigation of R3's unwitnessed fall does not document a head to toe assessment, staff statements, and a root cause analysis. Surveyor reviewed R3's hospital discharge summary dated 12/20/23 which documents that R3 had a right intertrochanteric femur fracture status post insertion of trochanteric femoral nail. On 6/3/24 at 11:33 AM, Surveyor observed R3 in normal height bed sleeping. R3's call light was hanging down at the end of the bed not within reach of R3. On 6/3/24 at 1:47 PM, Surveyor again observed R3 in normal height bed sleeping, in same position as the morning. R3's call light was hanging down at the end of the bed not within reach of R3. On 6/5/24 at 10:05 AM, Surveyor observed R3 in normal height bed sleeping. R3's call light is on the floor in the corner of the room, far from head of bed where R3 was located. On 6/4/24 at 2:47 PM, Director of Nursing(DON-B) stated that there should be staff statements attached to the incident fall report. Statements should include last seen, last toileted, type of footwear, interventions in place etc. DON-B stated the statements should be very detailed. The interdisciplinary team(IDT) meets the next day to review the Resident falls. DON-B stated that routine rounding is defined as every 2-3 hours staff should be checking on Resident at a minimum by eyesight. Surveyor reviewed that R3's fall incident report did not have staff statements with the above details, and no documentation of an IDT meeting to discuss the root cause analysis of R3's fall. Surveyor also shared there have been new interventions since the fall which resulted in a fracture. Surveyor pointed out per policy, and based on R3's fall assessment indicating R3 is high risk for falls, R3 should be in a low bed. Nursing Home Administrator(NHA-A) explained the facility is in the process of changing all Resident beds to have the capability of being a low bed, however, NHA-A informed Surveyor that R3's unit has not been done yet. Surveyor shared the concern about R3's fall, no statements with details, no physical assessment, no care plan interventions updated, and no root cause analysis. NHA-A stated, Your aren't telling us anything we don't know already. No additional information was provided as to why the facility did not ensure that R3's fall on 12/16/23 was thoroughly investigated as to the root cause and why no care plan interventions were implemented to prevent future falls.

Based on observation, record review, and staff and resident interview, the facility did not ensure that all treatments and care was provided to 1 (Resident 8) of 1 sampled residents in accordance with professional standards of practice. * R8 presented with an open area to the right, superior buttocks. The open area was not assessed by a Registered Nurse (RN), nor was the treatment consistently completed as ordered. R8 was to be repositioned every 2 hours to relieve pressure on the open area and repositioning was not consistently completed. R8 was also incontinent of bladder. R8 had a toileting problem which was not consistently followed. As a result of R8 not receiving physician ordered wound treatments and not relieving pressure and moisture from the open wound, the wound declined from a scratch like appearance with granulation tissue in the wound bed to an open area that contained 40% slough (necrotic tissue). Findings include: According to the electronic Admission Record, R8 was admitted to the facility on [DATE] with diagnoses of Dementia, Lumbago with sciatica (right side), Morbid Obesity, and Anemia. The Progress Notes dated 12/23/23 documented at 04:10, indicated R8 has a small open area to the right waist and back, 1.5 centimeters (cm) X 1.0 cm. It looks like a small scar scratched by her. No bleeding, surrounding skin normal, no signs/symptoms of infection. Writer cleaned the area with wound wash solution (WWS), dried and small allevyn dressing applied for protection. Nurse Practitioner (NP), unit manager and supervisor notified via software system. (Entry was written by a Licensed Practical Nurse (LPN) and no follow up assessment by a RN was completed). A comprehensive assessment of the initial discovery of the open area was not completed. The NP directed staff to cleanse the effected area with WWS, pat dry, and apply Allevyn dressing one time a day every 3 days. A review of the Treatment Administration Record (TAR) indicated the treatment had not been completed on 01/08/24. A review of the Medical Record and TAR had indicated a comprehensive assessment was not completed until a wound physician assessed R8's open area on 01/10/24. The Initial Wound Evaluation and Management Summary dated 01/10/24, indicated R8 was oriented to person, place, time and situation and was not in any acute distress. The summary indicated R8 had a Stage 3 pressure wound, sacrum full thickness with wound measurements of 1.1 cm X 0.7 cm X 0.2 cm with light sero-sanguinous draining and 100% granulation tissue. The physician changed the treatment to apply leptospermum honey apply once daily for 30 days, and to place a gauze island with border every day for 30 days. The summary record indicated anemia and morbid obesity as factors complicating wound healing. The January 2024 TAR was reviewed and it was noted that on 01/11/24, the treatment for the open area was not indicated to be completed, so the treatment that was ordered by the wound physician on 01/10/24, was not completed. The treatment was also not completed on 01/12/24, 01/13/24 and 01/16/24. The TAR was not indicating the treatment was not done on 01/10/24, 01/17/24 and 01/24/24. On 02/01/24 at 11:00 AM, Surveyor interviewed LPN Unit Manager (UM) C. LPN UM C stated she accompanies the wound physician on rounds when in the facility. LPN UM indicated she does not sign out the TAR as the treatment can change and would have to change it on the TAR. LPN UM stated she did not put the new order from 01/10/24 into the computerized software system, which in turns adds the treatment to the TAR, until after 3:30 PM on 01/11/24. LPN UM C stated that triggered the software system to start the treatment on 01/12/24. LPN UM stated she does not enter the new orders right away as the wound physician has given verbal orders on the day of the assessment and then when the facility gets the written note the following day, the order is sometimes different and then LPN UM C has to call to clarify the order so now she just waits for the written note before changing treatment orders. LPN UM C stated she entered the daily treatment order to be completed on the PM shift as R8 would be in bed more and it would be easier to do the treatment at that time. LPN UM C indicated someone changed the treatment to be done on the day shift and it appears that change was made on 01/12/24 and to start on 01/13/24. LPN UM verified the treatments had not been completed on 01/11/24, 01/12/24, 01/13/24, and 01/16/24. LPN UM C stated R8 was confused and not reliable. LPN UM indicated that R8 was dependent on staff for repositioning and toileting. LPN UM stated repositioning and toileting should be done every 2-3 hours. The Wound Evaluation and Management Summary dated 01/17/24, indicated R8 continued with a stage 3 pressure wound sacrum full thickness which measured 1.1 cm X 0.7 cm X 0.2 cm with 40 % slough and 60% granulation tissue. The wound continues with light sero-sanguineous drainage and the wound progress was at goal. The wound physician indicated surgical excision debridement procedure was completed and after the procedure the slough in the wound bed decreased from 40% to 0%. Treatment was changed to apply a hydrocolloid dressing and to apply 3 times per week. Recommendations were to offload wound and to reposition per facility policy. The Progress Notes dated 01/18/24 documented at 11:10 am indicated R8 was alert and responsive. The Progress Notes dated 01/21/24 documented at 13:47 (1:47 pm) indicated R8 was alert and oriented Xs 2.Toilets per requests Encouraged to shift weight side to side while up in own recliner chair. Agreeable. The Wound Evaluation and Management Summary dated 01/24/24, indicated the wound physician changed the cause of the open area to a non pressure wound of the right sacrum full thickness because of a note dated 12/23/23, that was written by a nurse that indicated this wound was a result of scratching, so I'm changing the etiology to trauma. The evaluation indicated the wound measures 1.1. cm X 0.7 cm X 0.2 cm with light sero-sanguineous drainage, contained 40% slough and 60% granulation tissue and the wound progress was at goal. The wound physician completed surgical excisional debridement procedure and when the procedure was done the non viable tissue decreased from 40% to 0%. Treatment continued with hydrocolloid dressing to be applied every 3 days. The facility developed a care plan which included: The resident has actual impairment to skin integrity of the sacrum related to fragile skin. Care plan initiated on 12/28/23 and revised on 01/15/24. All interventions were listed to be implemented on 01/15/24. The following were listed interventions: ~ Educate resident/family/caregivers of causative factors and measures to prevent skin injury. ~ Encourage good nutrition and hydration in order to promote healthier skin. ~ Identify/document potential causative factors and eliminate/resolve where possible. ~ Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration etc to Medical Doctor (MD). ~ The resident needs to protect the skin when up in chair. ~ Turn and reposition every 2 hours and as needed (prn) when in bed (does not address repositioning when in wheelchair (w/c) . The Medical Record contained a plan of care for the potential for pressure ulcer development, dated 01/13/22. An intervention directs staff that R8 needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. On 01/31/24 at 12:15 PM, Surveyor interviewed Agency Certified Nursing Assistant (CNA) M. CNA M stated that R8 has intermittent confusion and staff need to reposition R8 every 2 hours as she is unable to reposition herself. CNA M indicated R8 was incontinent of bowel and bladder and is dependent on staff for all activities of daily living (ADLs) except R8 is able to feed herself. On 01/31/24 at 12:20 PM & 1:50 PM, Surveyor interviewed LPN UM C. LPN UM C verified the initial assessment, which included the wound bed, pain, and drainage was not completed by an RN. LPN UM C stated the nurse indicated she notified the UM, NP, and supervisor, but the supervisor was not always an RN. LPN UM C stated there was a pain note dated 01/02/24 that indicated R8 was having pain to the back and leg but the note was not specific to where the pain was located on the back. LPN UM C stated the first comprehensive assessment was completed on 01/10/24 by the wound physician. LPN UM C indicated the wound looked like an ingrown hair and wanted the wound physician to look at it. On 01/31/24 at 2:00 PM, Surveyor observed R8 lying directly on her back in bed. The Surveyor interviewed R8 while in bed. R8 stated she had a bedsore and does not know how she got it or what she should do. R8 stated she had never scratched the area. R8 indicated staff do not assist her with repositioning and due to her obesity she was unable to do herself. R8 says the area on her bottom is a little sore. On 01/31/24, Surveyor interviewed MD H. MD H stated he changed the cause from pressure to trauma due to a note that was written on 01/23/23 indicating the open area looked like a scratch. The Surveyor asked MD H if not doing the treatment for 4 days out of 7 between 01/10/24 to 01/17/24 could contribute to the deterioration of the open area. MD H stated he could not say that. On 01/31/24 at 3:30 PM, Surveyor accompanied MD H and LPN UM C to observe R8's wound and the treatment. MD H stated the wound measured 1.2 cm X 0.7 cm with 50% slough. MD debrided the area slightly. R8 was saying ouch during the treatment. When asked LPN UM C if R8 was medicated prior to the treatment, LPN UM C stated she did not know. The Medication Administration Record (MAR) did not show R8 was premedicated prior to debridement. LPN UM C completed the treatment as directed. On 02/01/24, Surveyor made a continuous observation from 7:45 AM to 10:50 AM. R8 was not assisted with repositioning or toileting. On 02/01/24 at 8:05 AM, Surveyor interviewed CNA N. CNA N stated she had gotten R8 out of bed at 7:10 AM and brought R8 to the dining room. CNA N stated R8 was dependent on staff for all ADLs except R8 was able to feed self. CNA N verified R8 has been sitting in her w/c since 7:10 AM. On 02/01/24 at 9:50 AM, Surveyor observed R8 sitting in her w/c in her room and CNA N asked R8 if she would like to use the bathroom and to let CNA N know when she needs to use the bathroom. R8 was not assisted to use the bathroom and was not checked to see if R8 had been incontinent. On 02/01/24 at 10:15 AM, Surveyor observed CNA N ask R8 if she was doing ok and R8 replied yeah. On 02/01/24 at 10:50 PM, Surveyor observed CNA N and O assist R8 onto the commode. CNA N removed R8's incontinent brief. Surveyor asked CNA N if the brief was wet and CNA N replied saying a little damp. Surveyor assessed the incontinent brief and the brief was saturated with urine. On 02/01/24 at 11:00 AM, Surveyor interviewed CNA N. CNA N stated R8 was up in her w/c before breakfast and stays in her w/c. CNA N indicated that R8 can not reposition on her own, but staff assist only at night and not during the day. CNA N stated staff assist with toileting but only toilet R8 when she asks.

Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice to prevent pressure ulcers from developing for 3 (R11, R1, and R7) of 4 residents reviewed for pressure injuries. * R11 was admitted with excoriation to the coccyx extending to the bilateral buttock which developed into an unstagable pressure injury to the sacrum that was never comprehensively assessed. R11 was admitted on [DATE] with excoriation to the coccyx extending to the bilateral buttocks, with treatment obtained. On [DATE] the Skin Only Evaluation documented open wounds to the coccy with no comprehensive assessment conducted. On [DATE] R11's care plan was initiated to include in part the provision of pressure relieving devices, mattress, chair cusion, along with weekly measurements. On [DATE] R11's care plan was revised to include in part turn and repositon every 2 hours while in bed, check incontinence every ,d+[DATE] hours. On [DATE] the Nurse Practioner (NP) E charted an active diagnosis list which included a Stage 3 pressure injury to the left buttock and a Stage 3 pressure injury to the right buttock with no other documentation. On [DATE] nursing reported an overall improvement and NP documented R11 had an air mattress in place and a wound clinic appointment. On ,d+[DATE] and [DATE] there was no documentation found from the wound clinic addressing R11's coccyx with the wound clinic addressing R11's bilateral lower extremety wounds on [DATE]. On [DATE] the progress note indicates the sacral wound worsened with measurements of 9 cm X 11.5 cm., with new treatment orders noted. This is the first time measurements of the area were documented however no comprehensive assessment was conducted at this time nor weekly thereafter. On [DATE] R11's coccyx /sacrum was assessed as 100% eschar/slough present with a new treatment for Santyl. On [DATE] the area measured 2 cm X 2.4 cm. with no depth documented. No characteristics of the wound was documented. A Foley catheter was inserted to protect the sacral wound. On [DATE] Surveyor observed R11's air mattress was deflated. As of [DATE] the pressure injury on the coccyx/sacrum has not been comprehensively assessed. * R1 did not have a comprehensive assessment after the development of a stage 3 pressure injury to the left heel on [DATE] by an RN until the wound was assessed by the wound physician on [DATE], almost 2 weeks after the discovery of the pressure injury. R1 was admitted on [DATE] and was identified at moderate to high risk for the developement of pressure injuries. R1 was assessed not to have any skin issues. A care plan initiated on [DATE] addresssed turning and repositionining every 2 hours and as needed, inspect skin weekly, pressure relieving wheelchair cushion and air mattress. On [DATE] R1 was found to have an open blister on R1's left heel measuring 3 cm X 3 cm, was cleansed with normal saline and Medihoney applied along with island border dressing. The wound was not assessed by an RN and there was no depth noted and no percentage of tissue type documented. On [DATE] the Treatment Administration Record (TAR) had an order to use heel lift boots when in bed and to sign off the treatment every shift. On [DATE] The Wound Physician conducted an initial assessment of the left heel documenting it was a Stage 3 pressure injury measuring 3.0 cm x 2.2 cm x 0.1 with 10% slough and 90% granulation, with recommendations to off load the heels and float heels when in bed. The Wound MD continued to see R1 weekly until R1 expired on [DATE]. *R7 was admitted with a Stage 4 pressure injury to the sacrum that was not comprehensively assessed for five days after admission. Findings: The facility policy and procedure entitled Treatment/SVC to Prevent/Heal Pressure Ulcer dated [DATE] states: PURPOSE: The facility's policy is to ensure it identifies and provides needed care and services that are resident-centered, per the resident's preferences, goals for care, and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. GUIDELINES: 1. The facility will ensure that based on the comprehensive assessment of a resident: a. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they are unavoidable; and b. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers om [sic] developing. PROCEDURE: 1. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. 2. All residents will have a Braden Scale evaluation completed at the time of admission, in conjunction with each quarterly and annual assessment, with any significant change assessment and as deemed necessary by the Interdisciplinary Team. 3. Interventions will be implemented in the resident's plan of care to prevent pressure injury development. 4. When the resident is admitted with a pressure ulcer(s), the admitting nurse will document the size, location, odor (if any), drainage (if any). 5. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure injury. 6. The admitting nurse will notify the attending physician or wound physician to obtain a treatment order. 7. The pressure ulcer(s) will be evaluated weekly by a Registered Nurse or Wound Physician, and the following will be documented in the resident's electronic medical record: the size, location, odor (if any), drainage (if any), and current treatment ordered. 8. The nurse will notify the physician anytime the pressure injury shows signs of non-healing or infection and request treatment order changes. 9. The resident or the resident's representative will be notified of any changes related to the improvement, deterioration, and/or treatment changes on an ongoing basis. 1. R11 was admitted to the facility on [DATE] with diagnoses of venous insufficiency, non-pressure chronic ulcers of the right and left lower legs and feet, lymphedema, chronic kidney disease, anxiety, osteoarthritis, and morbid obesity. R11's Admission Minimum Data Set (MDS) assessment dated [DATE] indicated R11 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R11 as needing maximal assistance with rolling in bed. R11's hospital discharge instructions included a treatment to a wound to the coccyx extending to bilateral buttocks. Review of the hospital documentation indicated R11 had excoriation to the coccyx extending to bilateral buttocks. On [DATE] on the Admission Data Collection and Baseline Care Plan Tool, Licensed Practical Nurse (LPN) Unit Manager (UM)-C charted in the Skin section of the form R11 had open lesions on the feet and bilateral lower extremity lymphedema was present. LPN UM-C did not document any skin integrity concerns for the coccyx or buttocks. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE], R11 had a treatment order to the coccyx extending to the buttocks: cleanse with Puracyn, no not rinse, Cavilon barrier to the peri wound, and cover with Mepilex daily. On [DATE] at 3:58 AM in the progress notes, nursing charted a treatment had been ordered for the coccyx. On [DATE], R11 was seen by Nurse Practitioner (NP)-E. NP-E charted R11 had a sacral plaque-like wound and irritant contact dermatitis and was followed by wound care while in the hospital. NP-E did not document any current concerns with R11's coccyx or bilateral buttocks. On [DATE] on the Skin Only Evaluation form, a Registered Nurse (RN) charted R11 had open wounds to the coccyx. In the Narrative Notes section of the form, the RN charted the RN and the unit nurse completed the initial admission skin assessment, R11 was aware of skin issues, treatment orders were in place and the Wound Physician would follow up on wound round day. Surveyor noted no measurements, characteristics, or etiology of the wound or wounds was documented. R11's Skin Impairment Care Plan was initiated on [DATE] with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Follow facility protocols for treatment of injury. -Monitor/document location, size and treatment of skin injury; report abnormalities, failure to heal, signs/symptoms of infection, maceration, etc. to physician. -Provide pressure relieving devices: mattress, chair cushion -Weekly documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. On [DATE], R11 had an order for House Supplement 240 ml twice daily. On [DATE], R11 had an order for Prosource 30 ml daily. On [DATE], R11 had an order for Multivitamin daily. On [DATE] on the Skin Only Evaluation form, nursing charted R11 had old non-healing wound to the sacrum and no new skin issues at that time. Surveyor noted no measurements, characteristics, or etiology of the coccyx wound was documented. R11's Skin Impairment Care Plan was revised on [DATE] with the following interventions: -Turn and reposition every two hours and as needed while in bed -Clean peri area with each incontinence episode. -Incontinent: check every ,d+[DATE] hours and as required for incontinence; wash, rinse and dry perineum; change clothing as needed after incontinence episodes. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE], R11 was seen by NP-E. NP-E charted the active diagnosis list included a Stage 3 pressure injury to the left buttock and a Stage 3 pressure injury to the right buttock. No other documentation was found regarding the coccyx or bilateral buttocks. On [DATE] at 7:42 PM in the progress notes, LPN UM-C charted the Wound Physician attempted to see R11, but R11 refused to be seen by the Wound Physician. R11's Skin Impairment Care Plan was revised on [DATE] with the following interventions: -Treatment as ordered. -Wound physician consult and follow up as needed. -Brief use: R11 uses disposable briefs; change as needed. On [DATE] at 7:19 PM in the progress notes, LPN UM-C charted the Wound Physician attempted to see R11 but R11 was not agreeable to see the Wound Physician. R11 continued to be argumentative about how the wounds should be treated and R11 stated they would be following up with an outside wound clinic. On [DATE], R11 had an order for Ensure Clear of Boost 240 ml three times daily. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE] on the Skin Only Evaluation form, nothing was documented; the form was blank. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE] on the Skin Only Evaluation form, nursing did not document any information on the coccyx or bilateral buttocks. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE], R11 was seen by NP-E. NP-E documented R11 had frequent refusals at facility and has declined labs and wound treatments. NP-E documented R11 was not being followed by the facility Wound Physician. NP-E documented the facility would try to coordinate care at the wound clinic for R11's bilateral lower extremity non-pressure wounds. NP-E did not document anything regarding the coccyx or bilateral buttocks wound. On [DATE], R11 was seen by NP-E. NP-E documented R11 had a sacral plaque-like wound and irritant contact dermatitis and was followed by wound care while in the hospital. NP-E did not document any current concerns with R11's coccyx or bilateral buttocks. On [DATE], R11 was seen by NP-E. NP-E documented R11 had a sacral plaque-like wound and irritant contact dermatitis and was followed by wound care while in the hospital. NP-E documented the current treatment to the coccyx wound that extended to bilateral buttocks that had been in place since admission on [DATE]. NP-E documented the active problem list included a Stage 3 pressure injury to the left buttock and a Stage 3 pressure injury to the right buttock. On [DATE], R11 was seen by NP-E. NP-E documented R11 was seen for a follow up of the sacral skin issue; nursing staff reported overall improvement and R11 did not want to continue with the dressing that had been in place. NP-E documented R11 had an air mattress in place and a wound clinic appointment the following week. NP-E visualized the sacral area indicating the etiology to be incontinence associated dermatitis and changed the treatment to Desitin every shift and as needed, continue offloading pressure, and will re-evaluate the following week. No measurements or characteristics of the skin were narratively charted. No re-evaluation of the wound was found for the following week. On [DATE] at 11:38 PM in the progress notes, nursing charted R11 had an appointment at the Wound Clinic that day. No documentation was provided of the consult. On [DATE], R11 was seen at the Wound Clinic. Documentation from the Wound Clinic on the Consult Sheet addressed R11's bilateral lower extremity wounds. No documentation was found addressing R11's coccyx. On [DATE] at 11:41 PM in the progress notes, an LPN charted R11's sacral wound got worse and measured 9 cm x 11.5 cm. The LPN charted NP-E was notified and a new order for Medihoney and cover with Allevyn instead of the Desitin cream was obtained. Surveyor noted this was the first time any measurements of the area had been documented. No wound characteristics were documented. On [DATE], R11 was seen by NP-E. NP-E documented R11 was seen for evaluation of the sacrum wound. NP-E documented staff had been applying Medihoney and Allevyn dressing to area with R11 refusing the dressing changes at times. NP-E documented R11 was incontinent of bowel and bladder at baseline, is on an air mattress, has overall poor appetite refusing meals at times and has had a ten-pound weight loss over the past month. NP-E documented R11's coccyx wound with 100% eschar/slough present and determined the etiology to be an Unstageable pressure injury. NP-E changed the wound treatment to Santyl to the wound bed instead of the Medihoney every other day. NP-E ordered a dietitian evaluation, lab work, and follow up by the Wound Clinic. On [DATE] at 1:42 PM in the progress notes, LPN-D charted the treatment to the sacrum was completed and the area measured 2 cm x 2.4 cm. LPN-D charted a Foley catheter was inserted to protect the sacral wound due to R11's functional incontinence status. Surveyor noted no depth of the wound was measured and no characteristics of the wound bed were documented. On [DATE], R11 was seen by NP-E. NP-E documented R11's coccyx pressure injury wound care was in progress with R11 refusing cares and resistant to changing positions and pressure relief. NP-E documented R11 was being followed by the Wound Clinic. No documentation was found that the Wound Clinic was evaluating or managing treatment to the coccyx. Surveyor noted R11's coccyx excoriation was not comprehensively assessed on admission or weekly and it developed into an Unstageable pressure injury at some point between admission and [DATE] when NP-E determined it was an Unstageable pressure injury. Documentation on [DATE] indicated a change to the wound, but a comprehensive assessment was not done at that time or weekly thereafter. In an interview on [DATE] at 2:00 PM, LPN UM-C stated LPN UM-C does rounds with Wound Physician-H weekly and if the resident is not seen by Wound Physician-H, then the nurses on the floor do the weekly assessment. On [DATE] at 11:22 AM, Surveyor observed R11 lying in bed. When Surveyor entered the room, Surveyor noted the air mattress to the bed was deflated. Surveyor asked LPN-G to come into R11's room and assess R11's air mattress. LPN-G saw the air mattress and went to get Certified Nursing Assistant (CNA)-F to assist moving R11's bed and reinflating R11's air mattress. CNA-F lowered R11's bed and LPN-G and Surveyor discovered the tubing for the air mattress had been crimped on the chair at the end of the bed, not allowing air to flow from the regulator to the air mattress. CNA-F stated the air mattress was not deflated when CNA-F was in the room earlier. Surveyor asked CNA-F how long ago CNA-F had been in R11's room. CNA-F could not recall the exact time but thought it had been within the last ,d+[DATE] minutes. R11's air mattress reinflated after being moved away from the chair at the end of the bed. In an interview on [DATE] at 3:15 PM, Surveyor asked LPN-D what the facility process was for a resident with a newly discovered open area on the skin. LNP-D stated an RN or RN supervisor needs to assess the wound and a treatment order needs to be gotten from the physician or NP. LPN-D stated all the wounds are monitored by the Wound Physician. Surveyor asked LPN-D what is done for a resident that is not seen or does not want to be seen by the Wound Physician. LPN-D stated that is tricky. LPN-D stated they encourage the resident to be seen by the Wound Physician, but sometimes they want their own wound doctor, or they go to a wound clinic. Surveyor asked LPN-D who would do the weekly measurements if not done by the Wound Physician. LPN-D stated an RN or RN supervisor does an assessment if there is a change to the wound. On [DATE] at 4:45 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R11 has not had a comprehensive skin assessment since admission on [DATE] and developed an Unstageable pressure injury that currently still has not been comprehensively assessed. Surveyor shared with NHA-A and DON-B the observation of R11 lying in bed with the air mattress deflated. Surveyor asked NHA-A and DON-B to provide any documentation showing a comprehensive assessment had been completed for R11 at any time since admission. On [DATE] at 10:00 AM, NHA-A and DON-B met with Surveyor to discuss R11's Unstageable pressure injury. NHA-A agreed R11 did not have a comprehensive assessment on admission or since. NHA-A stated NHA-A asked the nurses on the unit why R11 did not have any skin assessments completed and staff told NHA-A that R11 refused to let them measure the wound. NHA-A stated R11 requests Wound Physician-H stand at the doorway and look from afar. NHA-A stated they have had outside case managers come in to talk to R11 to educate R11 on appropriate evaluations and treatment, but R11 refuses. NHA-A stated the staff have been educated that even with refusals, they should get measurements of all wounds. In an interview on [DATE] at 11:29 AM, Surveyor asked NP-E how much involvement NP-E has had with R11's coccyx pressure injury. NP-E stated it took a while for R11 to trust NP-E enough to allow NP-E to look at R11's skin. NP-E stated the first time NP-E saw R11's coccyx area was on [DATE] and that was when R11 had contact dermatitis from incontinence. NP-E stated on [DATE], NP-E did not see R11's wound but was told by nursing staff that the treatment needed to be changed because the wound deteriorated. NP-E stated the floor nurses individually contact NP-E if a treatment needed to be changed, but there is not one nurse that is responsible for R11's wounds. NP-E stated LPN UM-C accompanies Wound Physician-H when doing rounds, but there is no system in place if a resident is not seen by Wound Physician-H. NP-E stated R11 is seen by a Wound Clinic, but they only manage wound treatments to the lower extremities and not the coccyx. No further information was provided at that time. 2. R1 was admitted to the facility on [DATE] with diagnoses of degenerative disease of the nervous system, dementia, malnutrition, fracture of the sacrum, compression fracture of the T7-T8 vertebra, congestive heart failure, chronic obstructive pulmonary disease, polyneuropathy, and spinal stenosis. R1's Admission Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had moderate cognitive impairment per staff assessment and needed extensive assistance with bed mobility. R1 was admitted on Hospice services and had an activated Power of Attorney (POA). On [DATE], R1's Braden score was 14 indicating moderate risk for pressure injury. On [DATE] on the Admission Data Collection and Baseline Care Plan Tool, nursing indicated R1 did not have any skin issues. R1's Activities of Daily Living Care Plan was initiated on [DATE] with the following interventions: -Turn and reposition every 2 hours and as needed. -Bed Mobility: R1 requires moderate assistance of one staff to turn and reposition in bed. -Skin Inspection: R1 requires skin inspection weekly and as needed; observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. R1's Potential for Impairment to Skin Integrity Care Plan was initiated on [DATE] with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Provide pressure relieving devices: wheelchair cushion, air mattress. -Turn and reposition every 2 hours and as needed while in bed. On [DATE], R1 had orders for Chocolate Pudding twice daily and Ensure 240 ml three times daily after meals. On [DATE], R1's Braden score was 10 indicating high risk for pressure injury. On [DATE], R1's Braden score was 12 indicating high risk for pressure injury. On [DATE], R1's Braden score was 11 indicating high risk for pressure injury. On [DATE] at 11:03 PM in the progress notes, a Licensed Practical Nurse (LPN) charted while providing cares, the nurse found an open blister on R1's left heel that measured 3 cm x 3 cm. The area was cleansed with normal saline and Medihoney was applied and dressed with an island border dressing. On [DATE] on the Skin Only Evaluation form, an LPN documented a blister to the left heel measured 3 cm x 3 cm with granulation tissue to the wound bed. NP-E was notified, and a treatment was obtained. Surveyor noted no depth and no percentage of tissue type was documented. The wound was not assessed by a Registered Nurse (RN). On [DATE] on the Treatment Administration Record (TAR), R1 had an order to use heel lift boots when in bed and to sign off the treatment every shift. On [DATE] on the Skin Only Evaluation form, an LPN documented R1 did not have any current skin issues. On [DATE], R1's Braden score was 12 indicating high risk for pressure injury. On [DATE], R1 was seen by Wound Physician-H. R1 had been monitored by Wound Physician-H on a previous admission and Wound Physician-H documented R1 no longer had a pressure injury to the right buttock. Wound Physician-H did not document on the left heel. On [DATE], R1 was seen by Wound Physician-H for an initial assessment of the left heel. Wound Physician-H documented the Stage 3 pressure injury to the left heel measured 3.0 cm x 2.2 cm x 0.1 cm with 10% slough and 90% granulation with light serosanguinous drainage. Wound Physician-H recommended off-loading the heels and float heels when in bed. On [DATE], R1 had an order for Prosource 30 ml twice daily. R1 was seen weekly by Wound Physician-H until [DATE] when R1 expired. In an interview on [DATE] at 3:15 PM, Surveyor asked LPN-D what the facility process was for a resident with a newly discovered open area on the skin. LNP-D stated an RN or RN supervisor needs to assess the wound and a treatment order needs to be gotten from the physician or NP. LPN-D stated all the wounds are monitored by the Wound Physician. On [DATE] at 4:45 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R1 did not have a comprehensive assessment after the development of a Stage 3 pressure injury to the left heel on [DATE] by an RN until Wound Physician-H assessed the left heel on [DATE], almost two weeks after the discovery of the pressure injury. Surveyor asked NHA-A and DON-B if there were any more assessments that had not been provided. On [DATE] at 10:00 AM, NHA-A and DON-B met with Surveyor to discuss R1's Stage 3 pressure injury to the left heel. NHA-A agreed R1 did not have a comprehensive assessment after the open blister was discovered on the left heel until R1 was seen by Wound Physician-H. NHA-A stated weekly skin checks are done for each resident and the order can be found on the TAR so administration can see that the skin checks were done. NHA-A stated if there are any new finding, the nurses have to do an incident report and that is followed up by an RN and the resident is gone through risk management. NHA-A provided an incident report for R1 dated [DATE]. Surveyor shared the concern that even with the incident report completed, R1 was not comprehensively assessed at that time. No further information was provided at that time. 3. R7 was admitted to the facility on [DATE] with diagnoses of osteomyelitis of the vertebra, sacral, and sacrococcygeal region, Stage 4 pressure ulcer of the sacral region, encephalopathy, convulsions, polyneuropathy, hemiplegia and hemiparesis of the right side, and dysphagia requiring a gastrostomy tube for nutrition. R7's Admission Minimum Data Set (MDS) assessment dated [DATE] indicated R7 was severely cognitively impaired per staff assessment and was dependent on staff for all cares and bed mobility. R7 had a Guardian. R7's hospital records indicated R7 had a Stage 4 pressure injury to the sacrum that was being treated with a negative pressure wound therapy device (wound vac). On [DATE] on the Admission Data Collection and Baseline Care Plan Tool, Licensed Practical Nurse (LPN)-D charted in the Skin section of the form R7 had bilateral foot dryness. No documentation was found of the Stage 4 pressure injury to the sacrum. On [DATE], R7's Braden score was 13 indicating moderate risk for developing a pressure injury. On [DATE] on the Skin Only Evaluation form, LPN-D charted R7 had a Deep Tissue Injury to the sacrum that was a Stage 4 pressure injury. Surveyor noted two different categories of pressure injuries were documented. No measurements were documented, and the wound bed had granulation. Surveyor noted no percentage of tissue type was documented. LPN-D charted R7's wound treatment had been completed with pain medications administered prior to the treatment. Surveyor noted the Stage 4 pressure injury to the sacrum was not comprehensively assessed by a Registered Nurse (RN) and the data collected by LPN-D was not complete. R7's Potential/Actual Skin Impairment Care Plan was initiated on [DATE] with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Provide pressure relieving devices. -Turn and reposition every 2 hours and as needed while in bed. On [DATE], R7 had orders for: -Vitamin C 500 mg daily. -Cefepime 2 Gm/1000 ml IV every eight hours for osteomyelitis. -Osmolite 1560 ml daily per gastrostomy tube (G tube) for daily nutrition. -Treatment to Sacrum: cleanse with quarter strength Dakins, pat dry with gauze, apply 3M Cavilon barrier to peri wound, apply quarter strength Dakins Kerlix to wound bed, cover with ABD and Medipore tape daily and as needed until wound vac arrives. R7's Potential/Actual Skin Impairment Care Plan was revised on [DATE] with the intervention to provide a pressure relieving device: air mattress. On [DATE] at 12:20 PM in the progress notes, LPN-D charted LPN-D called a durable medical company and left a message stating an air mattress was needed for R7. On [DATE], R7 had an order for Prosource 30 ml twice daily. On [DATE], R7's nutritional order increased the Osmolite to 500 ml four times daily per G tube totaling 2,000 ml per day. On [DATE], R7 was seen by Wound Physician-H for the initial evaluation. The Stage 4 pressure injury to the sacrum measured 10.8 cm x 7.3 cm x 7.5 cm with 20% slough and 80% granulation. This was the first comprehensive assessment of the pressure injury since admission 5 days ago. On [DATE], R7's treatment to the sacrum changed to: cleanse with normal saline, skin prep to peri wound, apply drape to the surrounding peri wound, cut black foam to fit and apply wound vac 125 mmHg continuous; change three times per week Monday, Wednesday, and Saturday. R7's Potential/Actual Skin Impairment Care Plan was revised on [DATE] with the following interventions: -Apply house barrier cream every shift and/or with incontinence episodes. -Use a draw sheet or lifting device to move R7. R7's Stage 4 Pressure Ulcer Care Plan was initiated on [DATE] with the following interventions: -Administer medications as ordered; monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing; measure length, width, and depth at least weekly; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Assist to turn/reposition at least every two hours, more often as needed or requested. -Monitor nutritional status; serve diet as ordered, monitor intake and record. -Obtain and monitor lab/diagnostic work as ordered; report results to the physician and follow up as indicated. -Treat pain as per orders prior to treatment/turning etc. to ensure R7's comfort. -Wound physician follow up as needed. R7 was seen by Wound Physician-H weekly for a comprehensive assessment and treatment changes as determined by Wound Physician-H. On [DATE], R7's wound treatment to the sacrum changed to include collagen powder to the wound bed prior to placement of the black foam and wound vac. On [DATE] at 4:00 PM, Surveyor discussed R7's wound progression with Wound Physician-H. Wound Physician-H stated R7 is seen weekly and is accompanied on rounds by Licensed Practical Nurse (LPN) Unit Manager (UM)-C. Surveyor asked Wound Physician-H what would be the expectation of a newly admitted resident that is known to have a pressure injury. Wound Physician-H stated the expectation would be to have the wound measured and described within the first 24 hours of admission. Surveyor shared with Wound Physician-H that no documentation was found of any assessment of the Stage 4 pressure injury to the sacrum until Wound Physician-H met with R7 on [DATE], five days after admission. Surveyor observed Wound Physician-H and LPN UM-C assess R7's sacral Stage 4 pressure injury. R7 had heel boots on both feet. R7's wound measured approximately 6 cm x 6 cm x 6 cm with tunneling and undermining all the way around the wound. LPN UM-C stated LPN UM-C was told R7 had some new open areas to the peri wound. Surveyor observed approximately six small open areas that were attributed to the wound vac dressing. Wound Physician-H debrided the Stage 4 pressure injury and the small open areas with a scalpel. LPN UM-C then completed the dressing change and applied the wound vac. On [DATE] at 4:45 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R7 did not have a comprehensive assessment of a Stage 4 pressure injury to the sacrum on admission until Wound Physician-H assessed the sacrum on [DATE], five days after admission when the facility was aware R7 was being admitted with an infected Stage 4 pressure injury. Surveyor asked NHA-A and DON-B if there were any [TRUNCATED]

Based on record review and interview, the facility did not ensure that a resident who entered the facility without a Pressure Injury (PI) did not develop a PI and received appropriate care and treatment to promote healing for 1 (R2) of 2 residents reviewed for PI's. * R2 was admitted to the facility on [DATE]. A Licensed Practical Nurse (LPN) completed an admission evaluation, which included an initial skin check. A blanchable redness area was noted to the coccyx on admission. There was no RN review/assessment of the initial skin check on admission conducted by the LPN. On 4/19/21, R2 developed a facility acquired unstageable pressure injury to the coccyx. The LPN who discovered R2's pressure injury on 4/19/21 did not obtain measurements or a description of the wound. R2's pressure injury was not measured or assessed by an RN on 4/19/21, although treatment was put into place. On 4/19/21 an order was obtained for an air mattress. The air mattress was not placed on R2's bed until 4/22/21. The care plan continued with the same every 2 hour turning and repositioning schedule which was originally initiated on 4/16/21 prior to R2 developing the pressure injury. On 4/27/21, R2's coccyx continued with unstageable pressure ulcer. On 5/3/21, R2 was discharged from the facility. The facility did not assess R2's coccyx wound upon discharge from the facility on 5/3/21. Immediately after discharge, R2 complained of nausea and weakness. R2 was taken to the emergency room immediately for evaluation. Hospital records indicated that R2's pressure injury was now assessed as a stage four pressure injury with foul odor. Intravenous antibiotics were initiated. Diagnostic testing confirmed R2 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 remained hospitalized until dying on 5/14/21. The facility's failure to prevent the development of a stage 4 pressure injury with [CONDITION(S)], specifically when the facility did not have an RN review the initial skin assessment upon admission, did not obtain an air mattress until three days after the air mattress was ordered, did not relook at resident's repositioning schedule when R2 developed an unstageable pressure injury within one week of admission, did not conduct a skin assessment on discharge and did not identify a foul-smelling odor, which resident's daughter identified right after she picked up R2 from the facility, created a finding of Immediate Jeopardy (IJ) that began on 4/19/21. Surveyor notified Nursing Home Administrator (NHA-A) of the Immediate Jeopardy on 5/24/21 at 4:05 PM. The facility removed the immediate jeopardy on 5/26/21 and the deficient practice continues at a scope and severity level of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: The AMDA (American Medical Directors Association) clinical practice guideline entitled 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer [Injury] is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear. Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. Step 2. Examine the patient's skin thoroughly to identify existing pressure ulcers. Examine the patient's skin upon admission or readmission, Step 3. Assess the patient's overall physical and psychosocial health and characterize the pressure ulcers. A pressure ulcer should be assessed along with the patient's overall clinical, functional, and cognitive status weekly reassessment and documentation of ulcer characteristics is recommended. More frequent assessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment. Step 4. Identify factors that can influence ulcer treatment and healing.functional status. Functional factors, including impaired mobility, a self-care deficit, and incontinence (especially fecal incontinence), may influence the severity, duration, and healing of a pressure ulcer. Step 5.Documentation should cover all pertinent characteristics of existing pressure ulcers, including location; size; depth; maceration; color of the ulcer and surrounding tissues; a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; tissue types covering the wound bed; .and a description of the peri-wound skin .including type and amount of drainage. Step 6. Identifying priorities in managing the ulcer and the patient .Pain control related to the ulcer and any comorbid conditions.The same factors that increase a patient's susceptibility to developing pressure ulcers .may also impair the healing of an existing pressure ulcer . National Pressure Ulcer Advisory Panel (NPUAP) guidelines, 3rd edition, published 2019 defines in part the following PI categories: Category/Stage I: Non-blanchable [CONDITION(S)] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured 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 are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury - depth unknown. 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. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The National Pressure Ulcer Advisory Panel (NPUAP) guidelines, 3rd edition, published 2019, states that Comprehensive Skin and Tissue Assessments are to be conducted for all individuals at risk for pressure ulcers upon admission to facility and prior to discharge from care service. The facility's Skin Assessment/Wound Care Guidelines dated 2/2018 with a revision date of 2/2020 indicates: 2. With new skin issues, the licensed nurse will notify physician/wound nurse to obtain treatment orders a. In the event that physician/wound nurse is not on site; skin care and wound management protocol to be followed by licensed nurse and physician/wound nurse to be notified 5. Treatment decisions will be based on; a. etiology of the wound I. Pressure injuries will be differentiated from non-pressure ulcers b. Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size-including depth and presence of tunneling or undermining . c. Location of the wound d. Goals and preferences of the resident/representative. R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was discharged from the facility on 5/3/21. R2's Minimum Data Set (MDS) dated [DATE], documents R2 had a BIMS (Brief Interview for Mental Status) score of 11, indicating R2 was moderately impaired for Daily decision making. R2's MDS dated [DATE] indicates R2 required extensive assistance with cares including bed mobility, transferring, toileting and personal hygiene. Upon admission to the facility on [DATE], Licensed Practical Nurse (LPN) - F completed an admission evaluation that included an initial skin/body check. LPN-F identified a blanchable redness to the coccyx and scar tissue on admission. The initial skin check indicated R2 had no pressure injuries upon admission. The facility did not have an RN review the initial skin check assessment completed by LPN - F. A Braden assessment dated [DATE] notes R2 with a score of 17, indicating R2 was at risk for development of pressure injuries upon admission to the facility. On 5/20/21 at 1:30 pm, Surveyor conducted an interview with LPN-F, who is the facility's admission and discharge nurse. LPN-F recalled performing R2's admission assessment when admitted to the facility. LPN-F thought there had been a second nurse present in the room during the admission assessment but could not recall whether or not the additional nurse was an RN or LPN. LPN performed an admission skin check and noted an area of redness and scar tissue to R2's coccyx. LPN-F did not perform measurements of this area as the reddened area was blanchable, which would indicate no pressure injury was present upon admission. LPN-F informed surveyor that she (LPN-F) was later told by RN Manager-E they believed R2's coccyx may have initially been a deep tissue injury upon admission to facility. Surveyor did not see documentation of RN Manager-E assessment R2's skin condition on 4/14/21 or that RN Manager-E observed R2's skin condition on admission. R2's baseline care plan dated 4/16/21 indicated R2 had a pressure relief wheelchair cushion, a standard (pressure redistribution mattress/Panacea mattress) and to be repositioned every 2 hours for skin integrity. On 4/19/21, LPN-K was informed that R2 had an open area to the coccyx. LPN-K notified R2's NP (Nurse Practitioner)-M, RN manager-E and RN Manager-G. A treatment was put into place for R2's pressure injury consisting of a foam dressing to be changed daily and as needed. No measurements or RN assessment was noted for R2's coccyx wound on 4/19/21. No documentation was noted on 4/19/21 of notification of R2's representative related to R2's skin integrity. On 4/19/21, a care plan was put into place identifying the pressure injury with interventions dated 4/20/21 to reposition every 2 hours and for an air mattress for R2's bed. The air mattress was not placed on R2's bed until 4/22/21. The care plan continued with the same every 2 hour turning and repositioning schedule which was originally initiated on 4/16/21 prior to R2 developing the pressure injury. The facility did not relook at R2's repositioning schedule when R2 developed an unstageable pressure injury within one week of admission. Surveyor conducted an interview with LPN-K on 5/20/21 at 10:00 am. LPN-K recalled notifying NP (Nurse Practitioner)-M, RN Manager-G (who acts as facility's treatment nurse) and RN Manager-E of R2's wound. LPN-K obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked LPN-K who would be responsible for performing wound assessments including staging, measurements and wound characteristics. LPN-K replied this would be done by the RN Managers as they are wound certified. Surveyor inquired whether or not a resident with a pressure injury should have an air mattress on their bed. LPN-K responded, Yes there should be an air mattress in place. On 4/20/21 RN Manager-G, who functions as the facility's wound nurse, assessed the wound and identified an unstageable pressure injury measuring 3.3 cm x 3.1 cm with 90% slough tissue and 10 % granulation tissue. No changes were made to R2's wound treatment at this time. Surveyor interviewed RN Manager-G on 5/20/21 at 10:30 am. RN Manager-G remembered being notified of R2's pressure injury and performing an assessment on 4/20/21. RN Manager-G stated that she was responsible for weekly wound assessments and that floor nurses would provide treatments on a daily basis. RN Manager-G indicated this was the first time she performed a skin assessment on this resident as R2 did not initially have any open areas on admission. RN Manager-G elaborated that upon assessment of the wound, it appeared that it may have once been a deep tissue injury but upon their assessment, it was noted to be an unstageable pressure injury. RN Manager-G obtained measurements and a wound assessment was completed on 4/20/21. A comprehensive skin integrity care plan dated 4/20/21 had the following care plan interventions: .pressure relieving air mattress to bed .needs monitoring and assistance of staff members to turn and reposition every 2 hours .assess/record/monitor wound healing every shift. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Inform the resident/family/caregivers of any new area of skin breakdown. On 4/21/21 the MDS indicates that R2 had a community acquired unstageable pressure injury noted upon admission to the facility however, there is no evidence to support this. Neither the hospital discharge summary nor the initial skin assessment identified a pressure injury. The MDS indicated interventions were in place including a repositioning schedule, pressure relief chair cushion and pressure relieving mattress. On 4/27/21, RN Manager-G assessed R2's coccyx wound measuring 3.3 cm x 4.4 cm with 70% slough tissue, 20% granulation tissue and 10% epithelial tissue. A new order was obtained for a topical [MEDICATION(S)] ointment to be applied to wound bed followed by a foam dressing daily and as needed. RN Manager-G did not perform additional assessments of R2's coccyx after 4/27/21. No additional wound assessments were conducted by the facility, including measurements, staging or wound characteristics after 4/27/21. On 5/3/21, R2 was discharged to the community. R2 was discharged by LPN-F and LPN-J, neither of whom performed a skin check/wound assessment upon R2's discharge from facility. On 5/24/21 at 10:45 am, Surveyor conducted an interview with LPN-J. LPN-J was the floor nurse for R2 on 5/3/21, the day of discharge. LPN-J informed Surveyor that they had not documented any nurse's notes in the medical record related to R2's discharge. LPN-J did not visualize R2's pressure injury prior to their discharge at approximately 11:00 am on 5/3/21. LPN-J recalled R2's family seemed anxious to get R2 out of facility and thought the discharge seemed rushed. Surveyor asked LPN-J if they would be allowed to assess a pressure injury, including staging, measurements and wound characteristics. LPN-J replied that the facility has a wound nurse who performs weekly wound assessments including staging of pressure injuries and measurements and that as an LPN, they would not assess a wound. On 5/20/21 at 1:30 pm, Surveyor conducted interview with LPN-F. Surveyor inquired if LPN-F performs body checks/skin assessments on residents when they are discharged from the facility. LPN-F replied that they would not typically perform a body check/skin assessment when someone leaves facility and they do not typically perform wound care as the floor nurse or wound nurse would be in charge of performing the treatments. Surveyor inquired whether or not a resident with a pressure injury should have an air mattress on their bed. LPN-F responded, Yes there should be an air mattress if there is a pressure injury. Surveyor reviewed the hospital emergency room report dated 5/3/21. The emergency room report stated after getting her mother in the car, the resident complained of nausea and weakness. The daughter noticed a foul odor. She took her mother immediately to the emergency room . A triage assessment at 12:46 pm identified a foul odor and the resident had a temperature of 100.4 degrees. The resident was subsequently diagnosed with a stage 4 pressure injury with suspected [CONDITION(S)]. R2 was admitted into the intensive care unit and passed away on 5/14/21. The cause of death was listed as [CONDITION(S)], [CONDITION(S)], and characteristics related to [CONDITION(S)] and debility. On 5/20/21 at 10:30 am, Surveyor conducted interview with LPN-L. LPN-L recalled performing dressing changes for R2's pressure injury. LPN-L characterized R2's wound as a stage 3 pressure injury and that there had been a treatment with [MEDICATION(S)] ointment in place to address slough tissue in the wound bed. Surveyor asked LPN-L if they would be allowed to assess a pressure injury, including staging, measurements and wound characteristics. LPN-L replied that the facility has a wound nurse who performs weekly wound assessments including staging of pressure injuries and measurements. Surveyor inquired if R2 had an air mattress applied to their bed after development of their wound. LPN-L recalled that an air mattress had been ordered for R2 when the pressure injury occurred and they recalled the air mattress being delivered to R2's room at the end of day shift on 4/22/21. On 5/20/21 at 9:15 am, Surveyor conducted an interview with MDS Coordinator-I. Surveyor inquired if MDS Coordinator-I recalled R2. MDS Coordinator-I responded that they had been the only MDS Coordinator in the facility during R2's stay at facility and was not sure if they remembered R2. Surveyor asked how MDS Coordinator-I would code wounds on an admission MDS. MDS Coordinator-I replied that they would base their MDS wound coding on the treatment nurse's documentation. Surveyor inquired as to why MDS Coordinator-I had not coded R2's pressure injury as facility acquired as it had occurred after admission to the facility on [DATE]. MDS Coordinator-I told Surveyor they would need to look into this matter further. No additional information was made available from MDS Coordinator-I to Surveyor at this time. On 5/24/21 at 9:20 am, Surveyor conducted a phone interview with LPN-H. LPN-H works as an agency nurse at the facility. LPN-H had contact with R2 as their nurse on the morning of 5/2/21. LPN-H recalled performing R2's treatment and recalled some slough and necrotic tissue was noted on the wound bed along with moderate serosanguineous drainage. LPN-H stated they knew little of R2 as they were with agency and only worked as R2's nurse once or twice. RN Manager-E was interviewed by Surveyors on 5/24/21 at 11:40 am. RN Manager-E informed Surveyor that an air mattress should be provided for residents with pressure injuries. RN Manager-E reported that R2's family had contacted her after their unstageable pressure injury was found as they (family) were not notified of this change in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN Manager-E responded that they would not necessarily expect R2's family to be notified of their pressure injury as they assumed they were aware of R2's skin condition on admission to facility and that R2 was their own responsible party. RN Manager-E was not involved with R2's discharge as LPN-F would perform discharges. On 5/20/21 at 10:30 am Surveyor interviewed RN Manager-G. Surveyor inquired whether or not an air mattress should have been applied to R2's bed. RN Manager-G said she would need to see if they had documentation from facility's central supply on R2's air mattress. RN Manager-G provided email documentation that an air mattress was placed on R2's bed on the afternoon of 4/22/21, even though R2's pressure injury was noted on 4/19/21 and the order for the air mattress was obtained on 4/19/21. Surveyor inquired if a wound is identified when RN Manager-G is not in the building how staff should respond. RN Manager-G responded that there is always an RN supervisor in the building on each shift available to perform assessments if RN Manager-G is unavailable. At 1:55 pm on 5/24/21, Surveyor conducted interview with Nurse Practitioner (NP)-M. NP-M did not assess R2's pressure injury during their stay at the facility. NP-M stated that the facility's wound nurse had been delegated to perform wound care and assessments. NP-M was not involved with wound care at facility and would give treatment orders if wound nurse asked her for orders. NP-M was not aware that R2 had any pressure injuries, such as a deep tissue injury, upon admission to facility. At 2:15 pm on 5/24/21, Surveyor shared the concerns with NHA-A related to R2's unstageable pressure injury. The facility's failure to not have an RN review the initial skin assessment, to not obtain an air mattress until three days after the air mattress was ordered, to not relook at R2's repositioning schedule when R2 developed an unstageable pressure injury within one week of admission, and to not conduct a skin/wound assessment on discharge created a finding of immediate jeopardy. The immediate jeopardy was removed on 5/26/21 when the facility completed the following: 1. The facility was educated on assessment being conducted by an RN, which included review of the State of Wisconsin Board of Nursing Chapter N6 Standards of Practice for Registered Nurse and License Practical Nurse. This education include reference to the Wisconsin Statutes Chapter 50.04(2)(b) the definition of a charge nurse. The facility also reviewed F686 skin integrity and pressure guidance to surveyors for further education on the assessments. The facility's Charge nurse LPN has completed competency and re-delegation of her duties as the Admission and Discharge nurse regarding completion of the Braden Scale for Predicting Pressure Sore Risk and initial skin evaluations for new admissions. The RN will review the Braden Scale for Predicting Pressure Sore Risk and initial skin evaluations for new admissions. 2. An RN assessment is completed upon the discovery of a pressure injury. The RN Wound nurse was educated regarding completing Skin Evaluation for all newly discovered pressure injury within the shift. Protocol established for pressure injuries identified off hours. This entails that the RN supervisor will initially evaluate the pressure injury including measurements as well as description and document findings within the eMAR. Two newly identified skin issues were assessed upon discovery on 5/25/21. An audit will be completed by the DON and/or designee to ensure timely assessment of any newly discovered pressure injuries. 3. The Administrator educated the Wound Certified nurse regarding individualized care plans within the EMR (Electronic Medical Record). The Wound Certified RN conducted wound rounds on Tuesday, May 25th, 2021 and Wednesday, May 26th, 2021. During these rounds, the Wound Certified nurse reviewed the Pressure Injury care plans to ensure that the care plan is updated and individualized. An audit of pressure injury care plans will be completed by the DON and/or designee. 4. A review of all residents with pressures were completed. No new residents identified to require an air mattress. Facility reviewed protocol for mattress delivery. The Wound Certified nurse will ensure any new air mattress has been in place in a timely basis by checking this at the end of the shift. If due to resident need, the air mattress is to be placed later, the Wound Nurse will notify the PM Supervisor and place the request on the 24-hour board for follow up and documentation in the EMR progress notes. An audit of the process of any new mattress delivery will be completed by the DON and/or designee ensure timeliness of the intervention. 5. There were no new residents discharging from [NAME] Manor at this time. The facility reviewed the discharge protocol. Education was provided to the nurse completing the discharge to complete an evaluation of the wound and document findings within the EMR. There were no new residents discharging from [NAME] Manor at this time. An audit of the any new discharges will be completed by the DON and/or designee to ensure the completion of a wound evaluation is completed prior to discharge. 6. The audit process began immediately and will be ongoing until quality assurance process goal is achieved and then periodically thereafter as necessary. Any negative findings will be corrected immediately. The audits will be turned into the Administrator upon completion and review. These will be reported to the quarterly Quality Assurance Committee for next four meetings.

Based on record review and interview, the facility did not provide appropriate treatment and services for 1 (R1) of 2 residents with dementia. R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Although R1 would become agitated when redirected, staff continued to redirect R1 which escalated his agitation. This resulted in staff physically restraining R1, calling 911 for assistance, and sending R1 to the hospital related to his increased agitation. Findings include: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The report from the hospital, prior to his admission, indicated that his only behavior was wandering. R1 had Brief Interview for Mental Status assessment completed on 3/5/21 that indicated he had severe cognitive impairment. The Elopement Assessment completed 3/5/21 noted that R1 was at risk for elopement. PROGRESS NOTES 3/5/21 PM SHIFT R1 was admitted to the facility at 8:08 PM. At 10:35 PM, Licensed Practical Nurse (LPN) - N documented that R1 wandered in his room, outside of his room, and frequently entered other residents' room which disturbed the residents. R1 required extensive and frequent cues to be redirected. 3/6/21 PM SHIFT LPN - N documented that R1 had chronic wandering and appeared to be more agitated on the PM shift, possibly due to another resident yelling. 3/8/21 PM SHIFT LPN - P, who was an agency nurse, noted that R1 was in and out of peers' rooms and needed to be re-directed often. R1 became upset and hit staff when staff attempted to provide redirection. Later, R1 was taking off his socks and throwing them at the staff and on the floor. R1 was impulsive and at times unable to redirect. 3/9/21 DAY SHIFT LPN - J noted that R1 was wandering in the hallways and peers' rooms and was redirected several times during the shift. Based on these progress notes, it appears that R1's agitation escalated from 3/5 - 3/9/21. When redirected, R1 attempted to hit staff. R1 had only been at the facility for 5 days, but during this time he began to display physical aggression and this should have prompted the facility to assess R1's behaviors and develop interventions to decrease his agitation. Other than redirection, there was no evidence in the medical record that the facility assessed R1's wandering with agitation and developed an individualized plan to decrease R1's agitation. Additionally, it is unclear what staff meant when they were using the term redirection. The Alzheimer's Association provides the following recommendations when dealing with an episode of agitation; Alzheimer's Association. (2020) Dementia related behaviors. https://www.alz.org/media/documents/alzheimers-dementia-related-behaviors-ts.pdfwww.alz.org Do not: Raise your voice; take offense; corner; crowd; restrain; rush; criticize; ignore; confront; argue; disagree; reason; shame; demand; condescend; force; explain; teach; show alarm; or make sudden movements; out of the person's view. Say: May I help you? You're safe here. Everything is under control. I apologize. I'm sorry that you are upset. I know it's hard. I will stay until you feel better. STAFF INTERVIEWS The surveyor attempted to interview staff to determine what was meant by the term redirection to learn if staff were not attempting to reason, teach, or explain. As noted above, these interventions are not recommended by the Alzheimer's Association. LPN - N, no longer worked at the facility. LPN - J was interviewed on 5/25/24 at 10:45 am and said that she was unable to comment on the situation. LPN - P was an agency nurse and a voice mail message was left with no return call received. On 5/24/21 at 2:05 PM, LPN - J was interviewed. When asked about her progress note on 3/9/21, LPN - J explained how she provided redirection. When R1 went near an alarmed exit door on the unit, LPN - J did not redirect R1 because he did not try to open the door. LPN - J said that when R1 attempted to go into other residents' room she would say in a calm and pleasant voice: Oh, Mr. [last name], that is not your room. LPN - J said that R1 would respond to this approach and never became upset. INCIDENT ON 3/9/21 WITH RESTRAINT USE On 3/9/21 during the PM shift, R1 was wandering and displayed agitation when redirected. It appeared LPN - N attempted to reason and teach during the redirection. These are not recommended interventions and seemed to increase R1's agitation. The progress notes and the facility's investigation provided the following information; At 4:30 PM, LPN - N documented in the progress notes that R1 was wandering into peers' rooms and throughout the unit. R1 was difficult to redirect which required LPN - N to step in front of the door and ask R1 to refrain from opening the door. At 5:30 PM during dinner, R1 attempted to pick up food off the floor that another resident had dropped. LPN - N encouraged R1, who was squatting and bending, to stand up. LPN - N told R1 that it was unsafe and he could injure himself. LPN - N also told R1 that he was disturbing another resident who was eating; as R1 attempted to reach underneath the resident's seat and feet. R1 then said to LPN - N: 'I am not standing because you said so. Get away from me. I am going to punch you in the face.' R1 stood up and grabbed LPN - N's waist. LPN - N said that she grabbed R1's hands to remove them. LPN - N asked R1 to step away and R1 charged at LPN - N and attempted to strike her. LPN - N grabbed R1's hands and R1 grabbed LPN - N's arms. LPN - N removed R1's hands from her wrists. LPN - N then grabbed R1's wrists and extended R1's arms in an attempt to prevent R1 from kicking LPN - N. LPN - N then called out to CNA - O for assistance and to obtain a wheelchair. CNA - O placed the wheelchair behind R1 and grabbed R1's waist to sit R1 in the wheelchair; as LPN - N held R1's wrists. LPN - N and CNA - O then walked away from the area. At approximately 5:45 PM, CNA - O was walking past R1 near the kitchen area. R1 grabbed a cup of water and threw it at CNA - O. CNA - O's hair , glasses, shirt, and upper body were soaked with water. CNA - O left to get some linens to wipe up the water so that R1 would not slip and fall. CNA - O bent down to wipe up the floor and had said nothing to R1. R1 charged at CNA - O and attempted to hit and kick him. CNA - O jumped up to standing and grabbed R1's hands. LPN - N called the facility's security for assistance. R1 began to kick and knee CNA - O in the groin area. LPN - N grabbed R1 from behind and instructed R1 to stop attacking CNA - O. R1 pushed his backside into LPN - N's stomach and attempted to kick LPN - N. LPN - N instructed CNA - O to stand on R1's right side and LPN - N stood on the left side. LPN - N instructed CNA - O to assist her to lower R1 to the floor to restrain R1. While on the floor, R1 was attempting to kick and strike staff. LPN - N held R1's feet. LPN - N directed CNA - O to tie R1's shirt sleeves together so that R1 could not strike out. CNA - O was then directed to take LPN - N's place and hold R1's feet so that LPN - N could call 911. Security Staff (SS) - Q, from the facility, arrived to the scene. R1 was lying on his back and was not combative. SS - Q assisted R1 to a seated position. RN Supervisor (RN) - R arrived to the scene and knelt next to R1 and asked R1 if he was okay. RN - R untied R1's shirt sleeves, held his hand, and continued to speak calmly to him. The local police and fire departments had arrived to the facility. It was determined that the police were unable to transport R1 to the hospital and it was decided that the fire department would do this. RN - R and fire department staff assisted R1 from the floor. RN - R reported that R1 displayed no physical aggression with the police, fire department or herself. R1 was transported to the local hospital at approximately 6:25 PM. R1 was admitted to the hospital on 3/9/21 and returned to the facility on [DATE]. According to the 3/9/21 Admission History and Physical from the hospital, R1 required no PRN (as needed) medication for his agitation. The 3/16/21 hospital discharge summary, documented the following information. R1 was found to be medically stable in the emergency room . R1 did well during his hospital stay and no additional interventions were provided. Unsure why pt [patient] was readmitted .

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 3 (R98, R69, & R46) of 13 Residents reviewed for pressure injuries. * R98 was admitted to the facility on [DATE] without any pressure injuries. On 4/12/18 R98 developed a Stage 2 pressure injury on her left heel which declined to unstageable. There were no interventions implemented to offload R98's heels prior to development of the pressure injury. On 4/16/18 an assessment was completed for Stage 2 right buttocks and DTI (deep tissue injury) right ischial. According to the wound assessment these were identified on 4/13/18 but there wasn't an assessment until 3 days later. On 4/17/18 the wound assessments document the right buttocks and right ischium is now Stage 3 pressure injuries. A pressure injury care plan was developed on 4/13/18 but was not revised after these areas became Stage 3. R98's right ischium pressure injury resolved on 5/1/18 and the right buttocks resolved on 5/15/18. Starting on 5/5/18 there are multiple nurses notes including 5/16, 5/20, 6/1 regarding an open blister on R98's right gluteal fold/right buttocks. The 6/3/18 & 6/13/18 nurses notes describes the right open blister has slight yellowish slough to base. There is not an assessment of this area until 6/27/18 when the wound assessment documents this area as being unstageable. On 8/8/18 the wound assessment documents the stage as Stage 4 on R98's ischial tuberosity with presence of fascia. There are no revisions to R98's care plan. R98 was observed with her heels not being offloaded and not wearing the green pressure relieving boots. R98 was observed sitting on an Equagel cushion in her wheelchair. No information was provided indicating this cushion is appropriate for a Stage 4 pressure injury. * R46 has a history of pressure injuries. On 8/7/18 R46 was identified as having a right gluteal fold pressure injury which measured 3 cm (centimeters) by 3 cm. This pressure injury was not staged. There is no evidence the physician was notified, there is no order for a treatment, and the care plan was not revised. The wound assessment dated [DATE] is not completed with the exception of the periwound change in temperature. The 8/15/18 skin observation tool only documents the measurements and does not include the stage or a description of the wound bed. There is no wound assessment completed during the week of (MONTH) 12th. R46 was observed with her heels not being offloaded, the oxygen tubing was not consistently padded to prevent pressure injuries, and R46 was observed without the Vicair cushion in her wheelchair according to the physician orders [REDACTED]. * R69 developed a facility-acquired pressure injury on his right ischium on 7/23/18 but there is no documentation until 7/24 and that was only measurements (1.0 cm. x 0.5 cm.) there was no comprehensive assessment completed until 7/25/18 when the pressure injury measured 1.0 x 1.5 cm. There was no weekly assessment for two weeks (next assessment not until 8/8/18); the 8/15/18 Wound Assessment consisted only of the wound measurements, nothing more; an order for [REDACTED]. Staff could not provide documentation indicating the wheelchair cushion was appropriate for a resident with an unstageable ischial pressure injury. R69 had a 1.75 inch Equagel Straight Comfort cushion, which is for preventative up to a Stage II. Pressure injury (right ischium) on 8/15/18 measured 1.8 x 2.1 cm, a deterioration from 7/24/18. On 8/23/18, a family member brought in a 4 inch McKesson cushion because they wanted R69 to be as comfortable as possible. Example 1 regarding R98 and Example 3 regarding R69 are examples cited at the scope and severity of a G (actual harm/isolated). Findings include: The Skin and Wound Guidelines policy and procedure developed 2/2018 under policy documents To promote wound healing of various types of wounds, it is the policy of Luther Manor to provide evidence-based treatments in accordance with current stands of practice and physician orders. Policy Explanation and Compliance Guidelines document 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. With new skin issues, the licensed nurse will notify physician/wound nurse to obtain treatment orders. a. In the event that physician/wound nurse is not on site; skin care and wound management protocol to be followed by licensed nurse and physician/wound nurse to be notified. 3. Dressing changes may be provided outside the frequency parameters in certain situations: a. Stool/Urine has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise, or is wet. 4. Dressings will be applied in accordance with manufacturer's recommendations. 5. Treatment decisions will be based on: a. Etiology of the wound i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental (i.e. skin tear, medical adhesive related skin injury). iv. Atypical (i.e . dermatological [MEDICAL CONDITION] lesion, pyoderma, [DIAGNOSES REDACTED]). b. Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size - including depth and presence of tunneling and/or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Presence of non-viable tissue. vii. Condition of peri-wound skin. c. Location of the wound. d. Goals and preferences of the resident/representative. 6. Guidelines for dressing selection may be utilized in obtaining physician orders [REDACTED]. a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. Luther Manor will follow specific physician orders [REDACTED]. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing; which may require products not on Luther Manor Wound Formulary. b. Changes in the characteristics of the wound (see above). c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 1.) Resident 98 (R98) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden assessment dated [DATE] has a score of 11 which indicates high risk for pressure injury development. The physician/NP (nurse practitioner) note dated 4/9/18 under A/P (assessment/plan) documents Dementia, advanced: poor prognosis. Given decreased intake, dysphagia and poor truncal control, I believe she is in advanced stages of dementia and feel her prognosis is poor. The admission MDS (Minimum Data Set) with an assessment reference date of 4/12/18 and signed as completed on 4/16/18 documents a BIMS (brief interview mental status) score of 4 which indicates severe cognitive impairment. R98 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two plus person for transfer, does not ambulate, is checked as having an indwelling catheter, and is frequently incontinent of bowel. R98 is at risk for pressure injury development, has one Stage 2 pressure injury which was not present on admission. The date of the oldest Stage 2 is documented as 4/12/18. Pressure reducing device for chair and bed are indicated along with pressure ulcer care, applications of ointments/medications other than to feet and applications of dressings to feet (with or without topical medication). The pressure ulcer CAA (care area assessment) dated 4/16/18 under analysis of findings documents R98 has new stage 2 pressure injury to AL (left) heel with new treatment ordered. She requires use of Hoyer lift and 2 assists with all transfers. Occasionally refuses to get up from bed and noted restlessness. On PT (physical therapy), OT (occupational therapy) and ST (speech therapy). She has an indwelling catheter but is frequently incontinent of bowel. Oral intake is fair, assisted with meals at times. Also has a chronic diabetic ulcer to R (right) foot. Braden Score = 11 (High). Under care plan considerations documents, R98 has new stage 2 pressure injury to L heel with new treatment ordered. She requires use of Hoyer lift and 2 assists with all transfers. Occasionally refuses to get up from bed and noted with restlessness. On PT, OT and ST. She has an indwelling catheter and is frequently incontinent of bowel. Oral intake is fair, assisted with meals at times. On hydration program. Also has a chronic diabetic ulcer to R foot followed by wound RN (Registered Nurse). Will proceed to care plan. The At risk for skin integrity care plan initiated 4/6/18 & revised on 7/11/18 includes approaches dated 4/6/18 including: Encourage good nutrition and hydration in order to promote healthier skin. Encourage to get up daily. PT/OT (physical therapy/occupational therapy) as ordered. Encourage to turn and reposition at least Q (every) 2 hours, assist as needed. Follow facility protocols for treatment of [REDACTED]. Keep skin clean and dry. Initiated 4/6/18 & revised 5/3/18 includes: Pressure relieving/reducing cushion to protect the skin while up in chair. Pressure relieving/reducing mattress to protect the skin while in bed. On 6/18/18 Barrier cream applied was initiated. Review of the skin observation tool dated 4/12/18 does not document any pressure injuries and under notes documents skin dry fragile poor turgor secondary to poor fluid intake bruising persists. The unstageable pressure injuries (left heel and right buttock) care plan initiated 4/13/18 & revised 7/11/18 documents approaches of: Air mattress to bed. Check function q (every) shift. Clean filter weekly and replace. Initiated 4/13/18: Provide incontinence care after incontinence episodes and apply barrier cream as ordered and Consult with PT/OT as needed for recommendations to promote off-loading. Initiated 4/16/18, Breeze sheet to assist in re-positioning in bed. Initiated 4/23/18, Complete and monitor treatment as ordered by MD (medical doctor)/Wound RN. Initiated on 4/13/18 & revised on 4/23/18: Monitor pain before, during, and after treatment. Alert MD of any changes in pain. Monitor pressure injuries q (every) shift and alert MD of any changes. Monitor skin while providing cares notify nurse/NM (nurse manager) of any changes in skin breakdown, redness, blisters, discolorations noted. Notify resident/responsible party of any new areas of skin breakdown. Initiated 4/13/18 & revised 7/11/18: Complete weekly wound assessment including: measurements tunneling/undermining (if applicable), wound bed (color, tissue type), odor, drainage, surrounding skin (redness, maceration, induration, swelling), s/sx (signs/symptoms) of infection (increased warmth, drainage, pain, odor). Alert MD of any changes. Initiated 4/23/18: Dietary supplements as ordered to promote wound healing, heel lift boots on while in bed, as tolerated and lay down after lunch. Initiated on 4/23/18 & revised on 7/11/18 Re-position every 2 hours or as needed. Initiated on 7/11/18: Monitor lab/diagnostics as ordered and alert abnormal's (sic) to MD/dietitian. Surveyor noted the plan of care for R98 appeared reactive after R98 developed pressure injuries vs. preventative and proactive. The quarterly MDS with an assessment reference date of 7/10/18 documents R98 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R98 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two plus person physical assist for transfer, does not ambulate, is checked as having an indwelling catheter and is always incontinent of bowel. R98 is at risk for pressure injury development and has 2 unstageable slough and/or eschar pressure injuries. Pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet and application of dressings to feet (with or without topical medications) are checked for skin and ulcer treatment. Left heel: The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 4/12/18 documents for type pressure, stage: Stage 2. Under location documents left heel. Exact Date: 4/12/18. Wound bed is checked for [MEDICATION NAME] 100% of wound covered, surface intact, Length 3.2 cm (centimeters) and Width 2.8 cm. Notes indicate: New pressure injury noted. Intact fluid filled blister (stage 2) MD aware for treatment orders, nutritional lab work, heel lift boots. Surveyor noted there were no interventions prior to development of this pressure injury to offload R98's heels. The PCC Skin & Wound -Wound Assessment V2.0 dated 4/17/18 documents for type pressure/stage: Stage 2 Location: left heel. Exact Date: 4/12/18. Wound bed is checked for [MEDICATION NAME] 100% of wound covered, surface intact, Length 3.0 cm (centimeters) and Width 3.0 cm. The skin observation tool dated 4/24/18 documents for site: left heel. Type: pressure, length 3.2, width 5 and Stage II (2). Left heel blister remains intact. Fluid appears to be absorbing. Area slightly larger in size d/t (due to) displacement of the fluid. Does appear to be improving as fluid is absorbing without signs or symptoms of infection. PUSH score of 9 which remains that same as last week. The PCC Skin & Wound -Wound Assessment V2.0 dated 5/1/18 documents for type: pressure/ stage: Deep Tissue Injury (DTI). Under location documents: left heel. Exact Date: 4/12/18. Wound bed is checked for [MEDICATION NAME] 100% of wound covered, surface intact, Length 4.0 cm and Width 4.1 cm. The notes section indicates: Area now noted to be a blood blister. Therefore, now classified as a DTI vs Stage 2. MD aware of change. Current treatment remains appropriate, as goal is to continue to protect and keep intact if possible. Surveyor noted this is a decline in this pressure injury. Surveyor also noted the assessment indicates the wound bed is checked for [MEDICATION NAME] with 100% of the wound bed covered despite the wound being categorized as a DTI. The PCC Skin & Wound -Wound Assessment V2.0 dated 5/8/18 documents for type: pressure/stage: Deep Tissue Injury. Location: left heel. Exact Date: 4/12/18. There is no description of the wound bed checked. Length 4.5 cm and Width 3.4 cm. The notes section indicates: Area slightly larger. Current treatment remains appropriate. MD aware. NNOR (no new orders received). The PCC Skin & Wound -Wound Assessment V2.0 dated 5/15/18 documents for type: pressure/stage: Unstageable. Left heel. Exact Date: 4/12/18. Wound bed is checked for eschar 100% of wound filled. Length 4.2 cm and Width 3.7 cm. Surveyor noted this is a further decline in R98's pressure injury. Surveyor noted there are no changes to R98's plan of care at this time. The PCC Skin & Wound -Wound Assessment V2.0 dated 5/22/18 documents for type: pressure/stage: Unstageable. Location: left heel. Exact Date: 4/12/18. Wound bed is checked for eschar, 100% of wound filled. Length: 4.4 cm and Width 3.5 cm. A nurse's note dated 5/25/18 documents: Residents right heel remains unstageable and diabetic ulcer remain stable at this time . will continue weekly treatment. Surveyor noted R98's heel pressure injury is on the left heel not the right heel as referenced in the progress note. The PCC Skin & Wound -Wound Assessment V2.0 dated 5/29/18 documents for type: pressure/stage: Unstageable. Location: left heel. Exact Date: 4/12/18. Wound bed is checked for [MEDICATION NAME]: 30% of wound covered, granulation: 60% of wound filled and eschar: 10% of wound filled. Length: 3.7 cm and Width: 2.8 cm. A nurse's note dated 5/30/18 documents: f/u (follow up) [MEDICAL CONDITION] to (R) lateral foot and pressure injury to (L) heel: [MEDICAL CONDITION] remains with stable eschar/callus to (R) lateral foot. Current treatment remains appropriate. Unstageable to (L) heel, eschar cap off with a small linear area left at 12 o'clock. Area is now classified as a stage 3 pressure injury, wound bed presents with granulation and [MEDICATION NAME] tissue. Will continue PAR (persons at risk). The CNA Care Assignment Sheet dated 6/4/18 for R98 under the section Behaviors/Misc. (Miscellaneous) documents, Heel lift boots, air mattress, breeze sheet. Tenoshapes to BLU (bilateral lower extremity) in the mornings and off at night. Lay down after lunch. The PCC Skin & Wound -Wound Assessment V2.0 dated 6/6/18 documents for type: pressure/stage: Unstageable. Location: left heel. Exact Date: 4/12/18. Wound bed is checked for slough: 100% of wound filled. Length: 0.9 cm. Width: 1.3 cm and depth 0.1 cm. There are no additional notes on the wound sheet. Surveyor noted this is a decline in this area. The nurse's note dated 6/6/18 documents: f/u wounds: Unstageable to (L) heel and DFU ([MEDICAL CONDITION]) to (R) lateral foot. Area remains with dry stable eschar. Treatment completed as ordered. Will continue PAR. The PCC Skin & Wound -Wound Assessment V2.0 dated 6/13/18 documents for type: pressure/stage: Unstageable. Location: left heel. Exact Date: 4/12/18. Wound bed is checked for [MEDICATION NAME]: 20% of wound covered, slough: 50% of wound filled, and eschar: 30% of wound filled. Length: 0.7 cm, Width: 1.0 cm, and depth is not documented. Surveyor noted there are no additional notes on the assessment despite the change in tissue to again include eschar. A nurse's note dated 6/15/18 documents: Allevyn dressing changed to left heel PI (pressure injury) . A nurse's note dated 6/15/18 documents: Allevyn dressing changed to left heel PI . Area is dry with small dry brownish area and no redness to surrounding skin. Also Allevyn dressing changed to dry healing diabetic ulcer and moist pink with sl (slight) yellowish slough blister to right buttock. No c/o pain/discomfort noted. The PCC Skin & Wound -Wound Assessment V2.0 dated 6/20/18 documents for type: pressure/stage: Unstageable. Location: left heel. Exact Date: 4/12/18. Wound bed is checked granulation: 10% of wound filled and slough: 90% of wound filled. Length: 0.6 cm, Width: 0.8 cm, and depth: 0.1 cm. The PCC Skin & Wound -Wound Assessment V2.0 dated 6/27/18 documents for type: pressure/stage: Unstageable. Location: left heel. Exact Date: 4/12/18. Wound bed is checked for slough: 100% of wound filled. Length: 0.4 cm, Width: 0.6 cm, and depth 0.1 cm. Surveyor noted there are no additional notes on the assessment to provide detail on the wound no longer having 10% granulation. The PCC Skin & Wound -Wound Assessment V2.0 dated 7/3/18 documents for type: pressure/stage: Unstageable. Location: left heel. Exact Date: 4/12/18. Wound bed is checked for [MEDICATION NAME]: 90% of wound covered. Surveyor noted there is no documentation regarding the remaining 10% of the wound bed. Length: 0.2 cm, Width: 0.2 cm. There is no depth documented. Surveyor noted there is no documentation in the notes section to explain the remaining 10% of R98's wound bed and whether there is depth to the wound. Surveyor noted the wound continues to be staged as unstageable despite documentation of 90% [MEDICATION NAME] tissue in the wound bed. On 7/6/18 the skin observation tool documents: Resident refused shower, completed bed bath given, skin has normal turgor, pressure area to right ischium, had dressing changed, right heel pressure ulcer dressing changed, Allevyn applied to left plantar foot, all pressure areas monitored and measure (sic) weekly by wound specialist. Foley catheter in place draining clear amber colored urine. Surveyor noted there is no assessment of the wounds completed at this time. There are no assessments for R98's left heel pressure injury during the week of 7/8/18 & 7/15/18. The PCC Skin & Wound -Wound Assessment V2.0 dated 7/25/18 documents for type: pressure/stage: Unstageable. Location: left heel. Exact Date: 4/12/18. Wound bed is checked for [MEDICATION NAME]: 90% of wound covered. There is no documentation for the remaining 10% of the wound bed. Length: 0.2 cm, Width 0.3 cm. Surveyor noted there is no additional detail documented in the notes section to explain the remaining 10% of the wound. Surveyor noted the wound is still staged as unstageable despite 90% [MEDICATION NAME] tissue indicated. The PCC Skin & Wound -Wound Assessment V2.0 dated 8/1/18 documents for type: pressure/stage: Unstageable. Location: left heel. Exact Date: 4/12/18. Wound bed is checked for [MEDICATION NAME]: 100% of wound covered, surface intact. Under progress documents: resolved. The notes section indicates: area now closed. Dried serous drainage present surrounding wound, could not remove with gentle irrigation. Did not want to scrub off. Will continue treatment for [REDACTED]. Right Buttocks: Review of a nurse's note dated 4/13/18 indicates: Resident noted to have an open area to right upper buttocks. Writer left message for wound nurse to evaluate. Denies pain or discomfort to area. Surveyor was unable to locate an assessment for this pressure injury for this date. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 4/16/18 documents for stage: Stage 2. Location: Right buttocks. Exact Date: 4/13/18. Length: 3.8 cm Width: 1.6 cm and Depth: 0.1 cm. The notes section indicates: New area noted. Appears to be from friction and shearing. MD aware and obtained treatment orders, nutritional lab work, air mattress, breeze sheet. Area identified and assessed on 4/13/18. Review of R98's record indicates a the nurse's note above references the pressure injury on 4/13/18 however there is no indication of an assessment including measurements, staging etc. until 4/16/18. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 4/17/18 documents for type: Pressure/stage: Stage 3. Location: right buttock. Exact date: 4/13/18. Length: 3.5 cm, Width: 1.4 cm and Depth: 0.1 cm. The notes section indicates: Area now present with bluish/purple T shaped discoloration which appears to be DTI (deep tissue injury) present. Does appear to have some re-[MEDICATION NAME] noted. Now a stage 3 pressure injury. Per staff continues to not improve in therapy or with overall improvement in health. Per staff had conversation regarding hospice but family not ready at this (sic). Will continue to monitor. Surveyor noted this is a significant change in the wound since first noted on 4/13/18. The facility staged this would as a stage 3 pressure injury despite description indicating possible deep tissue injury. The skin observation tool dated 4/24/18 documents for site: right buttocks. Type: pressure. Length 2.5, width 3, Depth 0.1 and Stage III (3). Stage 3 to right buttock: now noted with a small triangle shaped (about 5%) at 12 o'clock with slough noted. Other 95% of wound bed noted with granulation tissue. Minimal amount of bleeding noted. PUSH score of 11, last week score of 10. The nurses note dated 4/25/18 documents: f/u (follow up) wounds: Resident has a stage 2 to the right buttock . Resident being followed by wound RN. Supplements added with poor intake. Appetite is poor. Will discuss hospice consult with family. Resident moved to long term floor. Will continue to monitor in PR (persons at risk). The nurse's note dated 4/25/18 documents: Correction: both areas to right buttocks now a stage 3 pressure injury. Surveyor is uncertain which two right buttock wounds this note references as R98 had 3 right sided wounds at this time; on the right buttock, the right gluteal fold and the right ischial tuberosity. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 5/1/18 documents stage: Stage 3. Location: right buttock. Exact date: 4/13/18. Length: 0.4 cm, Width: 0.2 cm and Depth: 0.1 cm. Wound bed is checked for granulation with 100% of wound filled. The nurse's note dated 5/5/18 documents: Small PI area on right upper buttock is sl. (slight) moist and sl. bleeding area cleansed and Allevyn dressing reapplied as ordered. On right gluteal fold open area is moist and red. Area cleaned and Allevyn dressing reapplied. Dry blister like area remains on left heel. Allevyn dressing reapplied. Also dressing reapplied to right lateral foot diabetic dry ulcer. Resident denied pain when asked. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 5/8/18 documents stage: Stage 3. Location: right buttock. Exact date: 4/13/18. Length: 0.3 cm and Width: 0.3 cm. Wound bed is checked for granulation with 100% of wound filled. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 5/15/18 for right buttocks documents: Resolved. A nurse's note dated 5/25/18 documents: .PI (pressure injury) to buttocks has healed will continue weekly treatment. Right Ischial Tuberosity: The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 4/16/18 documents for type: Pressure/stage: DTI (deep tissue injury). Location: Right ischial tuberosity. Exact Date: 4/13/18. Length: 1.6 cm and Width: 1.1 cm. Wound bed is checked as [MEDICATION NAME] with 100% of wound covered, surface intact. The notes section indicates: new area noted. Consistent with friction and shearing. Breeze sheet and air mattress ordered. Per unit staff not making much progress with therapy. New area identified and assessed on 4/13/18. Surveyor was unable to locate a wound assessment dated [DATE] for this area. Surveyor noted the PCC note is dated 3 days after the area is documented as being found according to the documented exact date. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 4/17/18 documents for type: pressure/stage: Stage 3. Location: Right ischial tuberosity. Exact Date: 4/13/18. Length: 1.2 cm, Width: 1.9 cm and depth: 0.1 cm Wound bed is checked as granulation with 100% of wound covered, surface intact. Under the notes section it is documented: blood blister now open and presents as stage 3 pressure injury. Measurements larger but now stage 3 vs DTI; so improvement noted. Current treatment remains appropriate. MD aware will continue to monitor. The skin observation tool dated 4/24/18 documents for right ischium: Area improving as evidenced by smaller in size. Surrounding skin intact without signs or symptoms of infection. no redness, swelling or increase warmth noted. Minimal serous drainage noted. PUSH score of 7 improved from 8 last week. The nurses note dated 4/25/18 documents: f/u (follow up) wounds: Resident has . a DTI (deep tissue injury) to the right ischial tuberosity . Resident being followed by wound RN. Supplements added with poor intake. Appetite is poor. Will discuss hospice consult with family. Resident moved to long term floor. Will continue to monitor in PR (persons at risk). The nurse's note dated 4/25/18 documents Correction: both areas to right buttocks now a stage 3 pressure injury. Surveyor is uncertain which two right buttock wounds this note references as R98 had 3 right sided wounds at this time; on the right buttock, the right gluteal fold and the right ischial tuberosity. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 5/1/18 documents for type: pressure/stage: Stage 3. Location: Right ischial tuberosity: resolved. Review of nurse's notes dated 6/27/18 indicates: Late Entry: During dressing change to right ischium old open blister/abrasion noted brownish wound base. DON (Director of Nursing)-B/wound nurse informed and NOR'd (new order received). Resident continues to deny pain/discomfort to same. Will continue to monitor. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 6/27/18 documents for type/pressure: stage: Unstageable. Location: Right ischial tuberosity. Exact Date is blank. Length: 5.1 cm and Width: 4.0 cm. Wound bed is checked for [MEDICATION NAME]: 10% of wound covered the form also checks granulation: 20% of wound filled, slough: 30% of wound filled and eschar: 50% of wound filled. The notes section documents: Unit nurse requested to see abrasion to (R) lower buttock, as much worse than seen last week. Area started out as an abrasion caused by brief. Upon assessment, area much worse, unstageable. Area located over ischium, now pressure injury. MD aware. NOR (new order received). Surveyor noted this is the first assessment since the right ischium was documented as being healed on 5/1/18. There are multiple nurses' notes regarding open blister on right gluteal fold/right buttocks but no assessment. There is also no revision in R98's pressure injury care plan until 7/11/10 when there was a quarterly MDS completed. The nurse's note dated 6/30/18 documents: Treatment to PI right ischium applied as ordered. Wound base is dry, brown color with yellowish slough to edges. Resident denies pain. Repositioned side to side when in bed. Allevyn dressing to left heel PI and diabetic ulcer to right lateral foot is C+D+I (clean, dry, intact). Wearing heel lift boots while in bed. Denies pain/discomfort to same. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 7/3/18 documents for type: pressure/stage: Unstageable. Location: Right ischial tuberosity. Exact Date is blank. Length: 4.3 cm and Width: 4.0 cm. Wound bed is checked for slough: 40% of wound filled and checked for eschar: 60% of wound filled. Surveyor noted there are no additional notes on the assessment. On 7/6/18 the skin observation tool documents, Resident refused shower, completed bed bath given, skin has normal turgor, pressure area to right ischium, had dressing changed . Surveyor noted there is no assessment of the wounds completed at this time. The PCC (point click care) Skin & Wound -Wound Assessment V2.0 dated 7/11/18 documents for type: pressure/ stage: Unstageable. Location: Right ischial tuberosity. Exact Date is blank. Length: 5.8 cm, Width: 5.5 cm and depth:1.0 cm. Wound bed is checked for slough: 60% of wound filled and eschar: 40% of wound filled. The notes section documents: Seen by Wound Physician-GG this afternoon. Strong odor detected; which was not present on last assessment. Wound Physician-GG sharp debrided some of the loose stringy slough. Remainder adhered to the wound. Recommendations made for treatment adjustment with laying (sic) down between meals to promote wound healing. Appetite poor. Has had air mattress, heel lift boot, cushion, and wound continues to deteriorate. Have approached family regarding hospice in the past, MD has noted decline & was questioning if appropriate. The nurse's note dated 7/11/18 documents: F/u wounds: Area to (L) heel 99% healed. Area to (R) ischium smaller but 100% necrotic tissue. Area started out as an abrasion but changed to pressure. Has a (sic) air mattress, cushion, and heel lift boots in place. Does lay down for naps. Will be seen by wound MD this afternoon. Weight and appetite re (TRUNCATED)

Based on observation, interview and record review, the facility did not ensure the resident's right to request, refuse and/or discontinue treatment and to formulate an advanced directive in 17 of 162 total residents reviewed (Residents 14, 15, 35, 32, 36, 33, 34, 29, 30, 47, 39, 40, 41, 42, 43, 44, 21) and 3 of 5 closed records reviewed (Resident 24, 37, 38) as the facility's multiple systems for identifying a residents' advanced directive were not properly and consistently documented and implemented. * The facility's Health Care Center Admissions Agreement, dated [DATE], states in part: Section 2. Services provided by the Facility; Emergency Medical Services states; In the event that the Resident requires emergency medical assistance, the Facility will notify the emergency medical service providers available in the community. The Resident understands that emergency medical services are not provided by the Facility .and nor the Facility shall be required to provide such emergency medical services. This policy is outdated and contrary to DQA (Division of Quality Assurance) Memo ,[DATE] dated [DATE] CMS Clarification on Nursing Home Cardiopulmonary Resuscitation Policies. * The facility has several ways of identifying which residents want to be resuscitated if they became pulseless and non-breathing (full code) and which residents do not want to be resuscitated (DNR). Staff can determine code status by looking at the face sheet in the chart, by the presence or absence of a red heart magnet on the doorframe to the room with a red heart indicating full code, and by whether or not the resident is wearing a DNR bracelet. In addition, the residents medical records may include an advanced directive signed by the resident and physicians orders addressing residents advanced directive choice of either full code or DNR. The facility's multiple systems for ensuring the implementation of a resident's advance directives contained inconsistent information and did not always accurately reflect the resident's choices. The facility's system failed to ensure that residents' advanced directives were properly and consistently noted. Residents who were identified as full code did not always have a red heart magnet on their door frame. Residents had signed for an advanced directive for full code yet may have also signed for comfort care in which the facility does not included the provision of CPR (cardiopulmonary resuscitation) under comfort care, thus relaying conflicting information as to whether CPR should be issued or not. Face sheet information did not always correctly identify the advanced directive signed by the resident or as indicated by physician order. Nurses and Certified Nursing Assistants interviewed provided varying responses as to what they would initially look for when verifying a resident's code status. The failure to to ensure that residents' advanced directives were properly and consistently noted and for staff to accurately identify residents' code status resulted in an Immediate Jeopardy to the health and safety of Residents, who had the potential to not have their wishes implemented in the case of an emergency. The Immediate Jeopardy began on [DATE]. NHA (Nursing Home Administrator) A and Assistant Administrator-B were notified of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE]. The noncompliance at F155 continues at severity and scope level of E (potential for more than minimal harm that is not Immediate Jeopardy/pattern) as the facility continues to implement systems that ensure accuracy of Residents' advanced directives and continued monitoring with audit results being reported at quarterly Quality Assurance Committee meetings over the next four meetings. This is evidenced by the following: DQA (Division of Quality Assurance) Memo ,[DATE] dated [DATE] addressed to Nursing Homes, CMS Clarification on Nursing Home Cardiopulmonary Resuscitation Policies states in part: Per prior Department of Health Services (DHS) guidance, nursing homes in Wisconsin were allowed to have policies indicating that staff would not provide cardiopulmonary resuscitation (CPR) if a resident became pulseless and non-breathing; instead staff would call 911. Per CMS S&C Memo ,[DATE], this is no longer acceptable. Similarly, Wisconsin nursing homes were allowed to have policies indicating that staff would provide CPR only if the arrest was was witnessed. This is also no longer acceptable .CMS indicates that the effective date of memo CMS ,[DATE] is Immediately. The facility's Health Care Center Admissions Agreement, dated [DATE], did not reflect this change. It states in part: Section 2. Services provided by the Facility; 2.8 Emergency Medical Services. In the event that the Resident requires emergency medical assistance, the Facility will notify the emergency medical service providers available in the community. The Resident understands that emergency medical services are not provided by the Facility .and nor the Facility shall be required to provide such emergency medical services. The facility's policy entitled, CPR-Cardiopulmonary Resuscitation (CPR), dated ,[DATE], states in part: Guidelines: 2. CPR is initiated if Full Code or no DNR bracelet is present. 3. Delegate a staff member to verify Code status of resident. a. A Full Code or DNR sticker is located on the resident's Face Sheet in the chart. b. A red heart magnet for those that are Full Code will be located at the top of the door frame of the resident's room. Note: The staff member that transcribed the order is responsible for the placement of the red heart magnet. The staff person who notes orders will verify the red heart magnet has been placed. Note: If the resident's room changes, the red heart magnet will be transferred to the new room by the Social Worker. c. A DNR (Do Not Resuscitate) bracelet is worn by a resident who is a DNR. Note: Some residents with a valid DNR order refuse to wear the DNR bracelet. d. If resident is DNR, CPR is not continued. 1. R14 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R14's Minimum Data Set (MDS) assessment, dated [DATE], indicated that R14 is cognitively intact. R14's medical record contains an Advance Directive, signed by R14 on [DATE], that states: CPR, R14 checked YES to receive CPR, which states, CPR includes physically pushing on the chest to promote some circulation and breathing into the mouth through a mask. Paramedics will be called once CPR has been started. Treatment could include IV medications, strong electric shocks in an attempt to establish a regular heartbeat, insertion of a tube down the breathing passage and mechanical means of breathing. The survival rate for the general population who has received CPR for non-trauma episodes is only 2%. Comfort Measures Only, R14 checked YES to receive comfort measures only, which states, CPR is Not initiated when Comfort Measures Only is chosen. The resident's care would be focused on alleviating pain and suffering rather than on extending life. Measures such as pain management, oxygen administration, oral fluids, spiritual and emotional support, and maintenance of skin integrity could be used to promote comfort. R14's Certified Nursing Assistant (CNA) Care Assignment Sheet, dated [DATE], showed under Code Status: Paper work was left blank, no status listed. R14's Current Care Plan, dated [DATE] states, R14's code status is Full Code. The identified goal lists, Facility staff will follow resident code status. Approaches listed are: Advance Directives includes signature for Request for CPR. Medical Doctor (MD) order reflects Code Status. Facesheet in R14's chart has a Full Code sticker. Red Heart Magnet on top of door frame of R14's room, indicating Full Code Status. On [DATE], at 11:30am, Surveyor observed R14's doorframe. No red heart shaped magnet (which would indicate full code) was observed on R14's doorframe. On [DATE], at 11:30am, Surveyor interviewed Certified Nursing Assistant (CNA) S, who identified residents who desire to be a full code have a red heart on their doorframe and that R14 did not have a red heart on her door frame indicating R14 is a Do Not Resuscitate (DNR). On [DATE], at 2:55pm, Surveyor interviewed Licensed Practical Nurse (LPN) T who stated you look for a red heart on the resident's door frame to identify their code status and that R14 does not have a red heart placed on her door frame. On [DATE], at 2:55pm, Surveyor interviewed R14 who stated that she desires to be a full code. On [DATE], at 3pm, Surveyor interviewed Registered Nurse/Nurse Manager (RN/NM) U who reviewed the Medical Record for R14 and identified that R14's Advance Directive paperwork identified that R14 is listed as both a full code and comfort measures only. RN/NM U reviewed the Facesheet for R14 and identified that R14 is listed as a Full Code. Surveyor asked RN/NM U if R14 has a Red Heart Magnet on her doorframe and RN/NM U stated No, but that she will get one on there right away and will update the advance directive paperwork in R14's medical record. On [DATE], Surveyor observed R14's Medical Record. The Advance Directive completed on [DATE] signed by R14 is identified that R14 is a full code status and not listed as Comfort Measures Only. R14's physician's orders note on [DATE] that R14 is a Full Code. 2. R24 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R24 discharged from the facility on [DATE]. R24's Face Sheet identified that she is listed as a Do Not Resuscitate (DNR) status. R24's Advance Directive Guidelines, signed by R24 on [DATE], indicated R24 wished to receive CPR/Full code status. R24's Pre-Admission Summary to the facility, undated, identified R24 code status is listed as Full Code. R24's Care Plan, dated [DATE], shows that R24's Code Status is listed as Full Code. The goal listed is Facility staff will follow R24's code status. Approaches identified: Advance Directives includes signature for Request for CPR, Current MD order reflects code status, and Facesheet in R24's chart has a Full Code sticker. R24's Facesheet identifying R24's code status as DNR is inconsistent with R24's wishes identified on the signed Advance Directive Guidelines and the MD order. 3. R15 was admitted to the facility on [DATE]. R15's Medical Record, Facesheet identified that R15's Code Status is listed as DNR. R15's Advance Directives, signed [DATE], identify R15's Code status is No for CPR indicating a DNR status. R15's Care Plan, dated [DATE], states R15's code status is identified as Full Code. On [DATE], at 10am, Surveyor observed R15's doorframe with a Red Heart Shaped magnet on it indicating R15's code status is listed as Full Code. On [DATE], at 10:40am, Surveyor interviewed CNA Z, who stated that if she found Resident 15 unresponsive she would treat her as if she was a full code as she has the heart magnet on the door frame. R15's Code Status was not accurately recorded and made accessible as desired by the R15. R15's Facesheet and Advance Directive indicated R15's Code Status is DNR, but her Care Plan and Heart Shaped Magnet on the doorframe indicated R15's Code Status is Full Code. 4. R38's closed medical record was reviewed. R38's Facesheet has a sticker placed on it indicating R38 is a Full Code. The Advance Directives for R38, signed [DATE], identify R38 wishes to receive CPR and Comfort measures only, where CPR would not be initiated when Comfort Measures Only is chosen. R38's Care Plan, dated [DATE], indicates that R38 chose to be listed as Full Code Status. R38's Code Status was not accurately recorded and made accessible as desired by R38. R38's advance directive indicated that she chose to be both Full Code status and Comfort Measures Only where when checked CPR would not be initiated. 5. R35's medical record was reviewed. R35's Facesheet has a sticker placed on it indicating R35 chose to be a Full Code. R35's Advance Directives, signed [DATE] indicated that R35 chose to receive CPR or Full Code Status. R35's physicians orders indicate R35 is a Full Code. On [DATE], at 10:20AM, Surveyor observed R35's room. No red heart shaped magnet was noted to have been placed on the doorframe indicating that R35 is not Full Code Status. On [DATE], at 10:20am, Surveyor interviewed CNA S, who identified that if a resident was found unresponsive that she would look for the heart magnet on the door frame to determine if they were a full code. R35's Code Status was not accurately recorded and made accessible as desired by R35. R35's Facesheet and signed advance directives indicates R35 chose to be a full code. Per the Facility Policy CPR-Cardiopulmonary Resuscitation R35 should have had a red heart magnet located at the top of the door frame of her room to indicate that her code status was listed as full code, but no magnet was found. 6. R32's medical record was reviewed. No Facesheet was located in the medical record to identify R32's code status. No advance directive paperwork was completed to indicate R32's code status. No red heart shaped magnet was placed on his doorframe to indicate if R32 chose to be a full code. In the medical record the discharge paperwork from the hospital indicated that R32 was listed as Full Code status while in the hospital. On [DATE], at 10:42am, Surveyor interviewed Unit Secretary (US) V who stated while reviewing R32's medical record that she could not find any advance directives in his chart and that it should be in the front of the chart but it is not. On [DATE], at 10:45am, Surveyor interviewed RN/NM U who stated that the facility would treat any resident without an advance directive as a full code without any paperwork. Surveyor and RN/NM U viewed R32's door and RN/NM U verified that no red heart shaped magnet was placed on the doorframe to indicate R32 was a Full Code. RN/NM U stated the facility could determine code status by looking at the door, for a bracelet, and the chart. RN/NM U reviewed R32's medical record and verified that there was no physician's order found identifying what R32's advance directive is. R32's Code Status was not accurately recorded and made accessible as desired by R32. R32's medical record did not have a Facesheet or advance directives to indicate his choice of code status. On [DATE] the facility provided Surveyor a copy of advance directives for R32 indicating he chose to be identified as a full code, signed on [DATE]. 7. R36's medical record was reviewed. R36 Facesheet indicates in the top right hand corner that R36 is a Full Code. R36's Advance Directive signed [DATE], indicates that R36 chose to be a full code. On [DATE], at 10:20am, Surveyor observed R36's room and no red heart shaped magnet was found on the doorframe to indicate that R36 chose to be a full code. R36's Code Status was not accurately recorded and made accessible as desired by R36. R36's Facesheet and signed advance directives indicated R36 chose to be a full code. Per the Facility Policy CPR-Cardiopulmonary Resuscitation R36 should have had a red heart magnet located at the top of the door frame of her room to indicate that her code status was listed as full code, but no magnet was found. 8. R33's medical record was reviewed. R33's Facesheet has a sticker on the top right hand corner indicating that R33 chose to be a full code. R33's advance directives, signed [DATE], indicate that R33 chose to be a full code and receive CPR. On [DATE], at 10am, Surveyor observed R33's room, no red heart shaped magnet was located on the doorframe to indicate R33 was full code. On [DATE], at 10:56am, Surveyor interviewed CNA Y who stated if a resident was not responsive she would look on the resident's door for a heart magnet. On [DATE], at 10:58am, Surveyor interviewed LPN X who stated she would check for a resident's code status by looking at the magnet on the resident's door or the resident should have a bracelet on indicating they are a DNR. On [DATE], at 11am, Surveyor interviewed RN/NM W who verified that no red heart shaped magnet was noted on R33's doorframe. RN/NM W indicated that with no magnet on the doorframe she would expect that R33 was a DNR, but looking at his medical record that it states he is a full code. Per the Facility Policy CPR-Cardiopulmonary Resuscitation R33 should have had a red heart magnet located at the top of the door frame of her room to indicate that code status was listed as full code, but no magnet was found. 9. R34's medical record was reviewed. R34's Facesheet has a sticker on the top left corner indicating that he is listed as a Full Code. R34's Advance Directives, signed [DATE], indicate that he chose to be a full code and CPR should be performed. On [DATE], at 10am, Surveyor observed R34's room and the doorframe did not have a red heart shaped magnet placed found on it indicating R34 is not a full code. Per the Facility Policy CPR-Cardiopulmonary Resuscitation R34 should have had a red heart magnet located at the top of the door frame of her room to indicate that the code status was listed as full code, but no magnet was found. 10. R37's closed medical record was reviewed. R37's Facesheet had a sticker on the top left corner indicating that R37 chose to be a Full Code. R37's advance directive, signed [DATE], indicated that R37 chose to be a DNR and that CPR should not be performed. R37's medical record contained a physician's order, signed [DATE]; with a signed DNR bracelet attached stating R37's code status is DNR. On [DATE], at 10:07am, Surveyor interviewed RN K, who stated that R37's Facesheet should have had a DNR sticker, but it did not. RN K picked up the medical record and placed a DNR sticker on top of the Full Code sticker on the Facesheet. R37's Code Status was not accurately recorded and made accessible as desired by R37. R37's Facesheet in the medical record indicated R37 was a full code when the advance directives and physician's order indicated R37 was a DNR. 11. On [DATE] at 10:00 A.M., Surveyor observed a red heart on the doorframe for R29's room, which indicates full code. On [DATE] R29's medical record (face sheet) was reviewed. R29 was admitted to the facility on [DATE]. R29's face sheet, with a print date of [DATE], was located in R29's paper medical record at the nurses station. R29's face sheet had a sticker labeled, DNR. R29's Advance Directives Guidelines, signed [DATE] by R29's healthcare power of attorney, and had a check mark next to, CARDIOPULMONARY RESUSCITATION (CPR). The check mark indicated No for CPR. R29's signed Physician Orders stated the following order: DNR. The order start date was listed as [DATE]. Surveyor observed a discrepancy between the red heart on the doorframe indicating full code versus R29's advance directive and physician's order for no code. 12. On [DATE] at 10:10 A.M., Surveyor observed no red heart (indicating no code) on the doorframe for room R30's room. On [DATE] R30's medical record (face sheet) was reviewed. R30 was admitted to the facility on [DATE]. R30's face sheet was located in R30's paper medical record at the nurse's station. R30's face sheet had a sticker labeled Full Code. R30's Advance Directives Guidelines, signed [DATE] by R30, had a check mark next to, CARDIOPULMONARY RESUSCITATION (CPR). The check mark indicated Yes for CPR. R30's signed Physician Orders stated the order Full Code As needed. The order start date was listed as [DATE]. R30's door frame did not have a red heart indicating resident's desire to be full code. 13. On [DATE] at 10:00 A.M., Surveyor observed no red heart (indicating no code) on the doorframe for room R47's room. On [DATE] R47's medical record (face sheet) was reviewed. R47 was admitted to the facility on [DATE]. R47's face sheet was located in R47's paper medical record at the nurse's station. R47's face sheet had a sticker labeled Full Code. R47's Advance Directives Guidelines, signed [DATE] by R30's power of attorney for healthcare, had a check mark next to CARDIOPULMONARY RESUSCITATION (CPR). The check mark indicated, Yes for CPR. R47's Advance Directives Guidelines also had a check mark which indicated yes for comfort measures only. This read: CPR is not initiated when comfort measures only is chosen. R47's signed Physician Orders stated the order CPR. The order start date was listed as [DATE]. On [DATE] at 10:15 a.m. Licensed Practical Nurse-L was interviewed and indicated she would look for a DNR bracelet and a red heart sticker above the resident's room to determine if she should initiate CPR. R47 not having a red heart on the door is not consistent with R47's advanced directives and physician's orders. The above observations were shared with the Nursing Home Administrator (NHA)-A and Administrative Assistant-B on [DATE]. Additional information was requested if available. None was provided. 14. R39's medical record was reviewed [DATE]. R39's legal representative had completed the facility's Advance Directive Guidelines form on [DATE]. It indicated that R39 desired CPR (Cardiopulmonary Resuscitation) in the event of an emergency. R39's current physician's orders, dated [DATE], noted the following: DNR (Do Not Resuscitate). These orders were inconsistent with R39's advanced directive for CPR. This information was shared with Administrator - A and Assistant Administrator - B on [DATE]. 15. R40's medical record was reviewed [DATE]. R40 had a green sticker in the front of her chart that documented Full Code. She also had a heart sticker on her door, indicating that she wanted CPR (Cardiopulmonary Resuscitation) in the event of an emergency, according to the facility's policy. (See above.) R40 was observed on [DATE] at 10:52 am. She was not wearing a DNR (Do Not Resuscitate) bracelet. Again, this would indicate that that R40 wanted to have CPR in the event of an emergency. R40's [DATE] physician's orders noted: Do Not Resuscitate. These orders were inconsistent with R40's advanced directive for CPR. This information was shared with Administrator - A and Assistant Administrator - B on [DATE]. 16. On [DATE] at 10:33 A.M. and 10:45 A.M., Surveyor observed no red heart (indicating No Code) on the doorframe for room R41's room. Upon review of R41's medical record (face sheet), R41 was admitted to the facility on [DATE]. R41's face sheet, with a print date of [DATE], was located in R41's paper medical record at the nurses station. R41's face sheet had a sticker labeled Full Code. R41's Advance Directives Guidelines, signed [DATE] by R41, indicated a check mark next to CARDIOPULMONARY RESUSCITATION (CPR). The check mark indicated Yes for CPR. R41's signed Physician Orders stated the following order: Full Code As needed. The order start date was listed as [DATE]. R41 not having a red heart on the door indicates a no code status which was inconsistent with R41's advanced directives. 17. On [DATE] at 10:34 A.M. and 10:48 A.M., Surveyor observed no red heart (indicates no code status) on the doorframe for R42's room. Upon review of R42's medical record (face sheet), R42 was admitted to the facility on [DATE]. R42's face sheet was located in R42's paper medical record at the nurses station. R42's face sheet had a sticker labeled Full Code. R42's Advance Directives Guidelines, signed [DATE] by R42, indicated a check mark next to, CARDIOPULMONARY RESUSCITATION (CPR). The check mark indicated Yes for CPR. R42's signed Physician Orders stated the order: Full Code As needed. The order start date was listed as [DATE]. R42 not having a red heart on the door indicates a no code status which was inconsistent with R42's advanced directives. 18. On [DATE] at 10:34 A.M. and 10:48 A.M., Surveyor observed no red heart (indicating no code status) on the doorframe for R43's room. Upon review of R43's record, R43 was admitted to the facility on [DATE]. R43's face sheet was located in R43's paper medical record at the nurses station. R43's face sheet had a sticker labeled Full Code. R43's Advance Directives Guidelines, signed [DATE] by R43's Power of Attorney for Health Care, indicated a check mark next to, CARDIOPULMONARY RESUSCITATION (CPR). The check mark indicated Yes for CPR. R43's signed Physician Orders stated an order: Full Code As needed. The order start date was listed as [DATE]. R43 not having a red heart on the door indicates a no code status which was inconsistent with R41's advanced directives. 19. On [DATE] at 10:34 A.M., Surveyor observed no red heart (no code) on the doorframe for R44's room. On [DATE], at 10:50 A.M., Surveyor interviewed R44 regarding R44's wishes for CPR or DNR status. R44 stated, Yeah, I want CPR done. I have it on my door to do CPR. On [DATE] at 10:50 A.M., Surveyor observed no red heart on the doorframe for R44's room. Upon review of R44's record, R44 was admitted to the facility on [DATE]. This is according to R44's face sheet. R44's face sheet was located in R44's paper medical record at the nurses station. R44's face sheet had a sticker labeled Full Code. R44's Advance Directives Guidelines, signed [DATE] by R44, indicated a check mark next to, CARDIOPULMONARY RESUSCITATION (CPR). The check mark indicated Yes for CPR. R44's signed Physician Orders stated: Full Code As needed. The order start date was listed as [DATE]. R44 not having a red heart on the door indicates a no code status which was inconsistent with R41's advanced directives. 20. On [DATE] at 9:45 A.M., Surveyor observed no red heart (indicating no code status) on the doorframe for R21's room. On [DATE] Surveyor interviewed R21 regarding R21's wishes for CPR or DNR status. R21 stated, Definite CPR. I want a full resuscitation. I want to live a long life. On [DATE] at 10:34 A.M. and 10:50 A.M., Surveyor observed no red heart on the doorframe for R21's room. Upon review of R21's record, R21 was admitted to the facility on [DATE]. This is according to R21's face sheet. R21 was readmitted to the facility on [DATE]. R21's face sheet was located in R21's paper medical record at the nurses station. R21's face sheet had a sticker labeled Full Code. R21's Advance Directives Guidelines, signed [DATE] by R21, indicated a check mark next to, CARDIOPULMONARY RESUSCITATION (CPR). The check mark indicated Yes for CPR. R21's signed Physician Orders indicated: Full Code As needed. The order start date is listed as [DATE]. On [DATE], at 9:47 A.M., Surveyor interviewed Certified Nursing Assistant (CNA)-D and asked how CNA-D is able to identify if a resident is a full code or do not resuscitate (DNR) in an emergency situation. CNA-D indicated CNA-D reads the care plans in front (nurses station) and also looks for the heart on the doorframe. CNA-D indicated that if a resident wishes for a full code, they would have a red heart on the doorframe. On [DATE], at 9:49 A.M., Surveyor interviewed CNA-F and asked how CNA-F is able to identify if a resident is a full code or DNR in an emergency situation. CNA-F indicated a heart on the door means a resident is a DNR. At 10:14 A.M., CNA-F approached Surveyor and said, I said that backwards. A heart on the door is a full code. The resident is a DNR if there is no heart. On [DATE] at 10:12 A.M., Surveyor interviewed Licensed Practical Nurse (LPN)-G and asked how LPN-G can tell if a resident is a DNR or full code. LPN-G indicated to Surveyor there are hearts on the doors and bracelets. LPN-G indicated residents with bracelets are DNR. LPN-G also indicated residents with no hearts on the door are DNR. Surveyor walked with LPN-G to R21's room. Surveyor asked if LPN-G would know if R21 was a full code or DNR if LPN-G was walking past the room and saw R21 in room in distress. LPN-G indicated R21 was a DNR since there was no heart on R21's doorframe. LPN-G indicated that no heart on the doorframe means no CPR would be initiated. On [DATE], at 10:17 A.M., Surveyor interviewed Registered Nurse (RN)-E and if RN-E was walking down the hallway, how would RN-E identify if a resident is a full code or DNR. RN-E indicated to Surveyor RN-E would look above the door (doorframe). RN-E indicated a heart on the doorframe means the resident would want CPR. RN-E indicated RN-E would also look for a DNR bracelet. Surveyor walked RN-E to R21's room and asked RN-E if RN-E was walking past the room and saw R21 in distress, would RN-E do CPR. RN-E indicated to Surveyor, They are a DNR. There is no heart. I would also look for the bracelet. R21 not having a red heart on the door indicates a no code status which was inconsistent with R21's advanced directives The above observations were shared with the Nursing Home Administrator (NHA)-A and Administrative Assistant-B on [DATE]. According to a decision by the Division of Appeals Board, It is crucially important that nursing homes have in place, policies and procedures designed to ensure that the wishes of their residents, both for DNR (do not resuscitate) and CPR (cardio-pulmonary resuscitation), are accurately recorded, made accessible and implemented as desired by the residents. The Immediate Jeopardy was removed on [DATE] when the facility: * Administrator pulled the schedule of nurses for the PM and NOC shift. Education has verified that all nursing staff is up to date with CPR certification. List provided to the scheduler to ensure that each shift has a certified CPR staff on at all times. Human Resource will begin tracking CPR status of all employees to ensure that we have a certified CPR individual on staff at all times. (completed ,[DATE] & [DATE]) * All 6 nursing units were audited to determine compliance with current policy: Face sheet for code status Advance Directive Sheet- resident and/or resident representative wishes related to CPR and Comfort Measures Physician order for [REDACTED].>DNR bracelets on residents that wish not to receive CPR Hearts above the door for residents that wish receive CPR This was done to ensure the safety of the resident while we implement the new policy/procedures. (completed [DATE]) * CPR-Cardio-Pulmonary Resuscitation Policy reviewed to include the requirements from DQA (Division of Quality Assurance) Memo ,[DATE] as well as updated process to ensure code status. The new procedure includes separate forms for both CPR (green form) and DNR (pink form) status. These forms will then be placed in the very front of the chart with a copy of the physician orders behind it. CPR- Policy and Procedure was reviewed with the Medical Director. Reviewed and revised Advanced Directive Guidelines form to reflect policy changes. All Certified Nursing Assistants and Nurses were trained on the facility's new CPR policies as of [DATE]. * Review of the Admission Agreement was reviewed and revised to reflect must current regulatory changes regarding Advanced Directives. Current Admission Agreement will be used by all new admissions beginning [DATE]th, 2017. A letter from the CEO explaining the changes in the admission agreement/policy will be sent to all residents/resident representatives indicating that they can review their current code status with their social worker. (completed ,[DATE] & [DATE]) * Social Services will review the code status electives at each interdisciplinary care conference and after

Based on record reviews and interviews, the facility failed to ensure that 1 of 2 Residents (Resident #1) who experienced a change in condition received the necessary care and services to attain his highest practicable physical well-being after demonstrating insufficient fluid and oral intake to maintain proper hydration and health. On 12/1/14 the facility initiated a UTI (Urinary Tract Infection) protocol because they suspected that Resident #1 may possibly have a UTI. The facility's protocol consists of placing the Resident on intake and output monitoring for 48 hours and to increase fluids beyond the daily amount to 240 mL of additional fluid four times daily. This is to be documented on the Resident's Medication Administration Record [REDACTED]. Review of the documentation of the UTI protocol indicates that the facility did not actually collect the intake and output information for the Resident and there is no indication that a systematic administration of the additional fluids was implemented to ensure the increased fluid intake. When Resident #1 continued to exhibit restlessness along with calling out during the night shift, the Nurse Practitioner increased the resident's [MEDICATION NAME] on 12/3/14 despite the fact that there had been no assessment to determine if the resident's behaviors were a manifestation of his depression Side effects can include drowsiness, weakness, and loss of appetite. Resident #1 experienced a continued decrease in fluid intake from 12/04/14 through 12/31/14. The medical record indicates Resident #1 became increasingly lethargic during this time and took fluids poorly. The facility did not recognize and assess the resident's change in condition and did not implement measures to increase fluid intake. On 12/22/14 Resident #1 was evaluated by a Gerontologist who indicated that "the patient's increased behaviors are likely related to [MEDICAL CONDITION] in the setting of fungal uti." "It is important to note that the also likely has dehydration that is playing a role (creatinine and BUN elevated)." The Gerontologist also indicated that Resident #1's [MEDICATION NAME] should be titrated back down to 25mg. This was not initiated until 12/29/14. The decrease in fluid intake was not reported to the dietitian, physician or the physician extender until 12/29/14. The Resident continued with no fluid or food intake and was transferred to the hospital via 911 on 12/31/14. The Hospital records indicate: the Resident presented moribund - comatose and obvious [MEDICAL CONDITION]. Following brief period of stabilization with IV fluids, he was intubated ...patient was transported to MICU. Per the ER report attempts were made to access the Resident's femoral vein or artery but were unsuccessful and could not be visualized with ultrasound, "which made us think he was very dehydrated." In addition, the ER notes that the Resident presented with AMS (altered mental status) and a serum sodium level of 173, which is an indicator of severe dehydration. The facility's failure to appropriately recognize and assess Resident #1's change in condition and to ensure that steps were taken to provide proper fluid intake created a situation of immediate jeopardy that started on 12/5/14 when Resident #1 demonstrated changes in behaviors that were treated with a dosage increase in his [MEDICATION NAME] without a thorough assessment and laboratory work indicated elevated lab values and the Resident was suspected of having a UTI that would have required staff to push fluids based upon facility policy. The facility's Administrator and Director of Nursing were notified of the determination of immediate jeopardy on 3/17/15 at approximately 2:30 pm. The facility removed the immediate jeopardy on 3/20/15 when the facility implemented their action plan. The deficient practice continues at a scope and severity (s/s) of an E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement their action plan. All residents at risk for dehydration, including seven sample residents, could be affected. Findings include; Resident #1 had been residing in the facility since June 2014. The Resident's [DIAGNOSES REDACTED]. The Resident was noted to be alert and oriented times one with poor short term memory, poor insight, and displayed agitation by yelling and screaming out. The Resident was admitted to the facility with a gastric feeding tube that was eventually removed as the Resident's food and fluid intake was adequate and meeting his nutritional needs as well as a steady weight of between 184-186 lbs. Per record review, on 12/03/14 the Resident started exhibiting restlessness along with calling out during the night shift. Nurse Practitioner (NP) -C ordered an increase in the Resident's medication ([MEDICATION NAME]) for depression from 25mg to 50mg a day as well as a UA with C&S (urinalysis, culture and sensitivity). According www.webmd.com common side effects to [MEDICATION NAME] include: Chronic Trouble Sleeping; Diarrhea; Dizziness; Drowsiness; Dry Mouth; Excessive Sweating; Feel Like Throwing Up; Feeling Weak; Gas; Head Pain; Involuntary Quivering; Loss of Appetite; Low Energy; Stomach Cramps; and Weight Loss. Per clinical record documentation review of the progress notes from 12/04/14, the following is noted; -12/04/14 at 03:21-"arouses from sleep, but is lethargic, fluids encouraged but is not drinking." -12/04/14 at 4:07-"couldn't even hold water glass himself, didn't seem to process what to do with the water, unusual for Resident as he usually will drink by himself." -12/04/14 at 12:25- The Resident's UA was identified by the Nurse Practitioner to be positive for an infection and the Resident was placed on antibiotics while awaiting the culture and sensitivity. -12/04/14 at 14:32- "very sleepy today, took fluids poorly, leaning to right side at times, slept through breakfast, spit out am meds, refused meals. The Resident's health care power of attorney "was informed." The remainder of the shift documentation shows, "refusing liquids, took only 160ccs of fluids with a lot of encouragement." -12/05/14 at 12:51- "appetite poor, did not take noon meds, ended up spitting out. Per documentation, the RN notified the Nurse Practitioner of the Resident's refusal to accept medications and lab work as the RN documented, "NP aware will wait for sensitivity." On this day the results of the BMP revealed the Resident had elevated red and white blood cells, a sodium level of 144 (reference range of 136-145), and elevated BUN of 28 (reference range of 6-23) per the facility laboratory services. An elevated BUN and high sodium level could suggest that the resident was becoming dehydrated. -12/06/14 at 1:23-"taking fluids with encouragement today." -12/07/14 at 14:14- "Resident sleepy but easily aroused, appetite poor, taking fluids poorly, needs much encouragement to drink." -12/07/14 at 21:16-"taking fluids poorly." -12/08/14 at 6:14-"taking fluids poorly." On 12/08/14, the current antibiotic (Cipro) was discontinued and the Resident was placed on another ([MEDICATION NAME]). (Cross-reference F329) From 12/08/14 at 6:14am until 12/15/14, there is no further information documented regarding the Resident's fluid status. On 12/15/14 the Resident's behaviors were reviewed with the Nurse Practitioner and it was determined that a geriatric consultation would be done. There is no indication that the Resident's change in his level of arousal and ability to eat and drink was discussed or that consultation was sought regarding the Resident's intake status or change in ability to assist with eating and drinking. On 12/17/14, a meeting was held with the Resident's legal representatives, including the nursing staff, nurse practitioner, the medical doctor and social worker, but this meeting focused on the Resident's behaviors and did not address his weight or fluid intake. It was documented in the progress notes that the Resident's "weight was stable at 186 lbs." On 3/17/15 at approximately 10:00 am Surveyor # interviewed Social Worker (SW)-I regarding Resident #1's care conference. SW-I indicated that she did not recall any conversation or concern being discussed regarding the Resident's food and fluid intake. SW-I was asked about the reference in her documentation that the Resident's weight was stable. SW-I indicated that as far as she was aware, the Resident had not been weighed especially for the care conference meeting and that the weight she was referencing was from earlier in December. SW-I confirmed that it was referencing a historical weight. On 12/17/14 another UA was completed to determine if the Resident was cleared from the UTI from 12/4/14. Preliminary results came back and the Nurse Practitioner ordered the Resident to start Bactrim prior to receiving the culture and sensitivity result. -12/18/14 at 20:38-"Resident's skin warm/dry, very drowsy...drinking approx. 240cc's of water and total of 240cc's of cranberry juice." -12/19/14-"needs lots of encouragement to drink." On 12/19/14 the C&S (culture and sensitivity) returned from the Resident's UA and it was determined that he had a fungal infection so the Bactrim was discontinued and the Resident was started on Fluconazole. (Cross-reference F329) Again no discussion occurred regarding the Resident's intake status. -12/19/14-"needs lots of encouragement to drink." -12/20/14-13:38- "continues to yell and scream, not knowing what he wants...fluids taken poorly, appetite poor needs lots of encouragement." -12/20/14-18:52- "had few episodes of yelling out, continue on antibiotic for uti without signs and symptoms of adverse reactions, drinks 240cc's juice." -12/21/14 - 18:54- "History Diagnosis: [REDACTED]. Teaching method used: Discussion, Demonstration. Knowledge Level Verified: Needs more review. Interventions: Intake and Output monitoring, Urinary catheter in place, General Comfort Measures. Comments: General Renal and Urologic Comments = Continues on ABT without s/s of adverse reaction. Temp 97.5/oral. Offered 240 cc c. juice and drinks 100% with encouragement. This was documented despite the Resident having an assessed BIMs (Brief interview for Mental Status) of a 4. -12/22/14- 6:19-"taking fluids poorly." On 12/22/14 a Geriatric Consultation was completed the consult indicated: Diagnosis: [REDACTED]." "It is important to note that he also likely has dehydration that is playing a role (creatinine and BUN elevated)." Plan: 1. Treat UTI as you are doing and monitor. 2. He is already on [MEDICATION NAME] and [MEDICATION NAME] which he had been tolerating. 3. Consider titrating down [MEDICATION NAME] (as it is a newer med) if no improvement with treatment of [REDACTED]. Monitor for pain, constipation, [MEDICAL CONDITION], hunger, thirst. Surveyor noted that there was no follow up to this consultation until 12/29/14 when the nurse practitioner was contacted. -12/23/14-22:16-"day 4 no BM (bowel movement) Resident refused MOM (milk of magnesia). -12/27/14-20:49-"refused prn (as needed) laxative/cathartic for day 2 no BM." -12/28/14-"Resident unable to swallow medications, they just sat in mouth, writer held meds due to Resident unable to swallow, gave suppository due to 3 day no BM, continue to monitor." Per documentation, on 12/29/14, the health care power of attorney voiced concern over the Resident's eating habits to RN-E, who documented that the Resident was "only eating at most 0-25% of each meal. " RN-E notified NP-C. A dietary consultation was ordered as well as weekly weights, monitoring of meal percentages and I/O (intake and output). The Resident's medication [MEDICATION NAME] was decreased as well. The Resident was evaluated by RD-D (registered dietitian) on 12/29/14 at 3:58 pm and it was noted and documented that Resident #1 had lost weight of 12.4% over the last 30 days. The Resident was now at 163.1 lbs. a loss of 22.9 lbs. RD-D documented "significant decrease in po intake, he often refuses to eat, refuses hs snacks giving the [DIAGNOSES REDACTED]." The documented plan was to add magic cup, increase the Resident's protein with meals and increase calories. RD-D documented, "res. not likely to accept supplements due to refusing food and poor fluid intake, however, nursing to continue to offer food/fluids." This evaluation offered no information or plan to address the Resident's fluid needs. The Resident's fluid intake continues to be poor as evident on 12/30/14 2:50 pm "no oral intake, slept all day, was not able to get any meds in, took few sips of liquids from sister. " At 8 pm, "Resident in bed, remains responsive to tactile stimuli, skin warm/dry, not able to give additional fluids or magic cup, Resident did not eat any of his meal and took in less than 25% intake....output 50ml this shift. No mention of the Resident's total fluid intake. On 12/31/14 at 7:54 am, "vitals were difficult to obtain this morning, upon assessment, labored, swallow breathing noted, respirations 40-50's, oxygen applied at 4 l/m, radial pulses faint 86." "Unresponsive to verbal stimuli, responsive to painful stimuli, diaphoretic, unable to obtain a temp, full code. Documentation states that NP-C was aware and orders given to "send the Resident to the ER for eval and treat as necessary, 911 called." The Resident's power of attorney for health was informed of Resident's condition and transfer to the hospital. The electronic Intake and Output record shows no entries for resident intake on December 7, 10, 12, 13, 14, 15, 16, 17, 18, 19, 23, 24, 25, 26, and 27. Progress notes address resident intake only on: 12/07/14 - "taking fluids poorly"; 12/18/14 - RN-G notes at 8:38 p.m. that the resident did drink approx. 240 cccs of water and total of 240 ccs of cranberry juice and 1/4 of soup with assistance and encouragement; and 12/19/14 - "needs lots of encouragement to drink". There are 13 days prior to 12/31/14 on which no fluid intake is documented. Surveyor also reviewed the Resident's care plan on 03/04/15 and noted no evidence that the potential for dehydration had been addressed with approaches and measurable interventions. Review of Resident #1's nutritional care plans indicate that they had not been revised since 6/2014 even with Resident #1's removal of a feeding tube 10/21/14. Per discussion with Resident #1's family member-L and review of submitted e-mail documentation between Resident #1's family members and RN-E; Resident #1's family members had raised concerns about Resident #1's status throughout December that should have been addressed by the facility. Per interview with Nurse Practitioner (NP) -C on 03/04/15 at 2:40 p.m., NP-C stated that the lab work completed on the Resident on 12/05/14 did not show dehydration when asked by Surveyor. On 03/05/15 at 3:05 p.m. NP-C was interviewed again and Resident's intake and output flow sheet were shared and NP-C she was asked if she had been aware of the Resident's poor intake as it related to fluids, of which NP-C stated, "No she was not aware until now." NP-C stated, "Told only of general condition on the 31st, that's when I told them to send him out." On 3/17/15 at approximately 10:50 am NP-C again confirmed that nursing staff had not reported concerns regarding the Resident's eating and drinking that went back to earlier in the month until 12/29/14. Per telephone interview with RD-D on 03/04/15 at 11:10 a.m., the Resident had been removed from the nutritional list after being stable and the removal of his gastric feeding tube in October. RN-D indicated that she was made aware of the Resident's poor intake by RN-E. When questioned if there was ever any discussion with the health care power of attorney regarding artificial nutrition again including intravenous and RD-D indicated that she did not bring it up. On 03/09/15 Surveyor interviewed RD-D per telephone at 11:21 a.m. and RD-D acknowledged when questioned that she was not aware of that the intake and output daily average flow sheet showed "days" in which the Resident is documented for 0 intake. On 3/17/15 Surveyor # interviewed RN - M and N who both indicated that Resident #1 was eating and drinking less and that they thought it was due to his disease process. Licensed Practical Nurse (LPN)-O was also interviewed on this date and indicated that she remembered the Resident starting to not eat and that she was the one to send him out on the 31st because she could not get vitals. During the review of the care provided to Resident #1 while in the facility, the facility provided Surveyor # with a "snapshot" that they had documented regarding Resident #1 and a timeline of events. Upon Review of this document it is noted that RN-E and SW-I document that the family was very concerned about his eating habits since behaviors started. The document indicates that weights seemed stable according to Optimus but did obtain a weight on 12/29/14 and he lost 22 lbs. since the beginning of December. A dietary consult was ordered and supplements were added on 12/30/14. We are also weighing him every week and monitoring his meal percentages closely (he is on the 24 hour board). Review of the facility's 24 hour board shows for Resident #1 that he was on the board on 12/1/14-12/4/14 for UTI protocol, 12/5/14-12/7/14 for positive UA then he was off the board until 12/12/14-12/14/14 when he is placed back on the board not for fluid/eating concerns but for a rash on his legs. He is off the board until 12/18/14-12/21/14 when he is back on for a UTI. He is not on the board again until 12/25/14 when it indicates he is out on a pass. He does not go back on the board until 12/29/14 where it indicates he is being monitored for decreased appetite and refusal of medications. On 12/30/14 the board indicates to include meal percentages on 12/31/14 the Resident was transported out to the hospital on day shift after having no oral intake as documented on the 24 hour boards for 12/29/14, 12/30/14 and day shift on 12/31/14. Review of the facility provided time line indicates inaccuracies in its details based upon investigation - the timeline does indicate that on 12/17/14 that they discussed appetite and how it has decreased and that the Resident's weight has been stable and appetite depended on his mood. Resident #1 was transferred to the hospital via 911 on 12/31/14. The Hospital records indicate: the Resident presented moribund - comatose and obvious [MEDICAL CONDITION]. Following brief period of stabilization with IV fluids, he was intubated ...patient was transported to MICU. The ED (emergency department) critical care note indicates that the physician personally spent 120 minutes performing these lifesaving critical interventions: respiratory and neurologic failure due to these clinical conditions: pneumonia, UTI, [MEDICAL CONDITION] with respiratory and neurologic failure. Per the ED report attempts were made to access the Resident's femoral vein or artery but were unsuccessful and could not be visualized with ultrasound, "which made us think he was very dehydrated." In addition, the ED notes that the Resident presented with AMS (altered mental status) and a serum sodium level of 173, which is an indicator of severe dehydration. According to Medscape (www.medscape.com/view article/ 8 <http://www.medscape.com/view article/ 8>) Dehydration in Geriatrics from Geriatrics and Aging 2007:10(9) 590-596: Dehydration is a common and serious condition in older adults. Mortality of patients with dehydration is high if not treated adequately....In the older adult dehydration often causes atypical symptoms such as confusion, constipation or falls....Body weight proved to be the most responsive to changes in hydration....Patients consuming less than 50% of meals are at high risk for dehydration. The facility's failure to recognize the changes in condition experience by Resident #1 to include changes in behaviors, the Resident's intake and activity level and level of assistance needed to carry out activities of daily living including eating and drinking created a situation of immediate jeopardy that started on 12/5/14. The facility removed the immediate jeopardy on 3/20/15 when the facility implemented the following: 1. The facility reviewed and reassessed all Residents presently on the 24 hour board to ensure that their change in condition was appropriately recognized and addressed. The facility initiated I&O (intake and output) on Residents where indicated by policy. 2. The facility reviewed their policies and procedures regarding their UTI protocol. 3. The facility implemented revised I&O forms, hydration checklists, mood and behavior monitoring flow sheets. 4. The facility implemented retraining for staff on UTI protocol, I&O monitoring, behavior monitoring and assessment, etc. 5. The facility established review processes to monitor nursing response to changes in conditions and behavioral changes. Following the implementation of their action plan, the deficient practice continues at a scope and severity of an "E" (potential for harm that is not immediate jeopardy/pattern).

Based on interviews and record reviews, the facility failed to immediately inform and consult with 1 of 1 resident's (Resident #1) physician regarding a significant change in the condition when Resident #1 began to demonstrate insufficient fluid and oral intake. Resident #1 experienced a decrease in fluid intake and poor appetite from 12/04/14 through 12/31/14. The decrease in fluid intake oral intake was not reported to the dietitian, physician or the physician extender (APNP-advanced practice nurse practitioner) until 12/29/14. The advanced practice nurse practitioner was notified on 12/29/14 that the resident was not eating and ordered a dietary consult. The resident was then evaluated by the dietitian who documented the resident's "significant decrease in po intake, often refuses to eat, refuses HS snacks. The dietitian added magic cup everyday for extra calories and protein. The resident was transferred to the hospital via 911 on 12/31/14 and admitted per ER (emergency room ). Per the ER record, the resident "appears dehydrated, acute distress...dry mucous membranes." The resident had to be intubated for [MEDICAL CONDITION] and impending [MEDICAL CONDITION] per the ER report. The resident also under went ventilator management and the placement of a central line (IV line in the chest) for the administration of fluids. Per the ER report attempts were made to access the resident's femoral vein or artery but were unsuccessful and could not be visualized with ultrasound, "which made us think he was very dehydrated." In addition, the ER notes that the resident presented with AMS (altered mental status) and a serum sodium level of 173, which is an indicator of severe dehydration. Failure to notify the physician of Resident #1's change in condition of insufficient fluid and food intake resulted in harm to the resident. Findings include; Resident #1 had been residing in the facility since 06/14. The resident's [DIAGNOSES REDACTED]. The resident was noted to be alert and oriented times one with poor short term memory, poor insight, and displayed agitation by yelling and screaming out. The resident was admitted to the facility with a gastric feeding tube that was eventually removed on October of 2014 as the resident's food and fluid intake was adequate and meeting his nutritional needs as well as a steady weight of between 184-186 lbs. Per record review, on 12/03/14 the resident started exhibiting restlessness along with calling out during the night shift. Nurse Practitioner (NP) -C ordered an increase in the resident's medication ([MEDICATION NAME]) for depression from 25 mg to 50 mg a day as well as a UA with C&S (urinalysis, culture and sensitivity). It was also noted that the resident's indwelling catheter was changed the day of 12/03/14 as well and staff were documenting "resident drinking cranberry juice with encouragement." Per clinical record documentation of the progress notes from 12/04/14, the following was noted; -12/04/14 03:21-"arouses from sleep, but is lethargic, fluids encouraged but is not drinking." -12/04/14 4:07- "couldn't even hold water glass himself, didn't seem to process what to do with the water, unusual for resident as he usually will drink by himself." -12/04/14 12:25 The resident's UA was identified to be positive for an infection and the resident was placed on antibiotics while awaiting the culture and sensitivity. There was also a BMP (basic metabolic panel) ordered -12/04/14 14:32- "very sleepy today, took fluids poorly, leaning to right side at times, slept through breakfast, spit out am meds, refused meals. The resident's health care power of attorney "was informed." The remainder of the shift documentation shows, "refusing liquids, took only 160ccs of fluids with a lot of encouragement." -12/05/14- 5:49- "has not been taking fluids." -12/05/14-12:51- "appetite poor, did not take noon meds, ended up spitting out. Per documentation, RN-E notified NP-C of the resident's refusal to accept medications and lab work as RN-E documented,"NP aware will wait for sensitivity." It was also noted on this day the results of the BMP revealed the resident had elevated red and white blood cells, a sodium level 144 (reference range of 136-145), and elevated BUN of 28 (reference range of 6-23) per the facility laboratory services. -12/06/14-1:23-"taking fluids with encouragement today." -12/07/14-4:30-"fluids encouraged." -12/07/14-14:14- "resident sleepy but easily aroused, appetite poor, taking fluids poorly, needs much encouragement to drink." -12/07/14-21:16-"taking fluids poorly." -12/08/14-6:14-"taking fluids poorly." On 12/08/14, the current antibiotic (Cipro) was discontinued and the resident was placed on another ([MEDICATION NAME]). Per clinical documentation, the health care power of attorney was notified. From 12/08/14 at 6:14 there is no further information documented regarding the resident fluid status. On 12/15/14 the resident's behaviors were reviewed with NP-C and that a geriatric consultation would be done. There was no indication that Resident #1's status regarding food or fluid intake was reviewed or consulted on during this review. On 12/17/14, a meeting was held with the resident's legal representatives, including NP-C, RN-E and MD-F (medical doctor). Per documentation, the discussion surrounded the resident's behaviors of calling and yelling out, confusion, dementia and Parkinson. It was also documented in the progress notes that the residents "weight was stable at 186 lbs. On 3/17/15 at approximately 10:00 am Surveyor # interviewed Social Worker (SW)-I regarding Resident #1's care conference. SW-I indicated that she did not recall any conversation or concern being discussed regarding the Resident's food and fluid intake. SW-I was asked about the reference in her documentation that the Resident's weight was stable. SW-I indicated that as far as she was aware, the Resident had not been weigh specially for the care conference meeting and that the weight she was referencing was from earlier in December. SW-I confirmed that it was referencing a historical weight. SW-I was asked if there was specific review or discussion regarding Resident #1's fluid intake or eating and SW-I indicated no, just that his weight was stable. The focus was on his behaviors. On 12/17/14 another UA was completed to determine if the Resident was cleared from the UTI from 12/4/14. Preliminary results came back and the Nurse Practitioner ordered the Resident to start Bactrim prior to receiving the culture and sensitivity result. -12/18/14 at 20:38-"Resident's skin warm/dry, very drowsy...drinking approx. 240cc's of water and total of 240cc's of cranberry juice." -12/19/14-"needs lots of encouragement to drink." On 12/19/14 the C&S (culture and sensitivity) returned from the Resident's UA and it was determined that he had a fungal infection so the Bactrim was discontinued and the Resident was started on Fluconazole. (Cross-reference F329) Again no discussion occurred regarding the Resident's intake status. -12/19/14-"needs lots of encouragement to drink." -12/20/14-13:38- "continues to yell and scream, not knowing what he wants...fluids taken poorly, appetite poor needs lots of encouragement." -12/20/14-18:52- "had few episodes of yelling out, continue on antibiotic for uti without signs and symptoms of adverse reactions, drinks 240cc's juice." -12/21/14 - 18:54- "History Diagnosis: [REDACTED]. Teaching method used: Discussion, Demonstration. Knowledge Level Verified: Needs more review. Interventions: Intake and Output monitoring, Urinary catheter in place, General Comfort Measures. Comments: General Renal and Urologic Comments = Continues on ABT without s/s of adverse reaction. Temp 97.5/oral. Offered 240 cc c. juice and drinks 100% with encouragement. This was documented despite the Resident having an assessed BIMs (Brief interview for Mental Status) of a 4. -12/22/14- 6:19-"taking fluids poorly." On 12/22/14 a Geriatric Consultation was completed the consult indicated: Diagnosis: [REDACTED]." "It is important to note that the also likely has dehydration that is playing a role (creatinine and BUN elevated)." Plan: 1. Treat UTI as you are doing and monitor. 2. He is already on [MEDICATION NAME] and [MEDICATION NAME] which he had been tolerating. 3. Consider titrating down [MEDICATION NAME] (as it is a newer med) if no improvement with treatment of [REDACTED]. Monitor for pain, constipation, [MEDICAL CONDITION], hunger, thirst. Surveyor noted that there was no follow up to this consultation until 12/29/14 when the nurse practitioner was contacted. -12/23/14-22:16-"day 4 no BM (bowel movement) resident refused MOM (milk of magnesia). -12/27/14-20:49-"refused prn (as needed) laxative/cathartic for day 2 no BM." -12/28/14-"resident unable to swallow medications, they just sat in mouth, writer held meds due to resident unable to swallow, gave suppository due to 3 day no BM, continue to monitor." Per documentation, on 12/29/14, the health care power of attorney voiced concern over the resident's eating habits to RN-E, who documented that the resident was "only eating at most 0-25% of each meal. RN-E notified NP-C. A dietary consultation was ordered as well as weekly weights, monitoring of meal percentages and I/O (intake and output). The resident's medication [MEDICATION NAME] was decreased as well at this time despite recommendations to consider titrating the [MEDICATION NAME] by the Geriatric consultant on 12/22/14. The resident was evaluated by RD-D (registered dietitian) on 12/29/14 at 15:58 and it was noted and documented that Resident #1 had lost weight of 12.4% over the last 30 days. The resident was now at 163.1 lbs. a loss of 22.9 lbs. RD-D documented "significant decrease in po intake, he often refuses to eat, refuses hs snacks giving the [DIAGNOSES REDACTED]." The documented plan was to add magic cup, increase the residents protein with meals and increase calories. RD-D documented, "res. not likely to accept supplements due to refusing food and poor fluid intake, however, nursing to continue to offer food/fluids." This evaluation offered no information or plan to address the resident's fluid needs. The resident's fluid intake continues to be poor as evident on 12/30/14 14:50 "no oral intake, slept all day, was not able to get any meds in, took few sips of liquids from sister. At 20:00 (8 pm), "resident in bed, remains responsive to tactile stimuli, skin warm/dry, not able to give additional fluids or magic cup, resident did not eat any of his meal and took in less than 25% intake....out put 50ml this shift. No mention of the residents intake. There is no indication that the physician was consulted with. On 12/31/14 at 7:54a.m., "vitals were difficult to obtain this morning, upon assessment, labored, swallow breathing noted, respirations 40-50's, oxygen applied at 4 l/m, radial pulses faint 86." "Unresponsive to verbal stimuli, responsive to painful stimuli, diaphoretic, unable to obtain a temp, full code. Documentation states that NP-C was aware and orders given to "send the resident to the ER for eval and treat as necessary, 911 called." The residents power of attorney for health was informed of residents condition and transfer to the hospital. The electronic Intake and Output record shows no entries for resident intake on December 7, 10, 12, 13, 14, 15, 16, 17, 18, 19, 23, 24, 25, 26, and 27. Progress notes address resident intake only on: 12/07/14 - "taking fluids poorly'; 12/18/14 - RN-G noted at 8:38 p.m. that the resident did drink approx. 240 cccs of water and total of 240 ccs of cranberry juice and 1/4 of soup with assistance and encouragement; and 12/19/14 - "needs lots of encouragement to drink". There are 13 days prior to 12/31/14 on which no fluid intake is documented. Surveyor also reviewed the resident's care plan on 03/04/15 and noted no evidence that the potential for dehydration had been addressed with approaches and measurable interventions. On 03/05/15 at 3:05 p.m. NP-C was interviewed again and Resident's intake and output flowsheet were shared and NP-C she was asked if she had been aware of the Resident's poor intake as it related to fluids, of which NP-C stated, "no she was not aware until now." NP-C stated, "told only of general condition on the 31st, that's when I told them to send him out." Per telephone interview with RD-D on 03/04/15 at 11:10 a.m., the resident had been removed from the nutritional list after being stable and the removal of his gastric feeding tube in October. RN-D indicated that she was made aware of the resident poor intake by RN-E. When questioned if there was ever any discussion with the health care power of attorney regarding artificial nutrition again including intravenous and RD-D indicated that she did not bring it up. On 03/09/15 Surveyor interviewed RD-D per telephone at 11:21 a.m. and RD-D acknowledged when questioned that she was not aware of that the intake and output daily average flowsheet showed "days" in which the resident is documented for 0 intake. It was also noted per the clinical record that on 12/22/14 the resident was evaluated in the facility by the geriatric consultant MD-H who documented "patients increased behaviors are likely related to [MEDICAL CONDITION] in the setting of fungal uti." "It is important to note that he also likely has dehydration that is playing a role (creatinine and BUN elevated). NP-C was interviewed again on 03/17/15 at 10:50 a.m. at which time Surveyor # inquired as to the content of a 12/17/14 meeting with the family and legal representative of Resident #1 NP-C, MD-F, RN-E and SW-I (social worker). NP-C acknowledged that the content of the meeting surrounded a discussion of the resident's "behavior", we didn't necessarily pinpoint on that" when questioned regarding the resident's fluid intake and appetite. NP-C stated that she "did not see MD-H's report until after the fact." NP-C acknowledged that she became aware of Resident #1's poor intake on 12/29/14 when "contacted at home." It was noted that also on this same date per documentation in the progress notes, "sister's very concerned related to Resident #1 eating habits." It was at that time that the dietary consult was ordered by NP-C as well as the decrease in the medication [MEDICATION NAME]. RN-E was also interviewed again per telephone on 03/17/15 at 1:00 p.m. RN-E acknowledged that Resident #1 had a geriatric consult on 12/22/14 but also acknowledged that she "does not recall reading the information that the resident "likely has dehydration." It was also noted that there was no evidence of a discussion with the legal representative regarding alternatives to providing the resident with the services that he needed to improve his fluid and appetite; Resident #1 had a code status of full code.

Based on observation, interview, and record review the Facility did not ensure that 3 of 30 sampled Residents received the necessary care and services to attain or maintain their highest practicable physical, mental and psychosocial well being. * Resident #11 was observed to be screaming out "Oh God, Oh God, Mama Mama" during cares. Staff interview and documentation from Resident #11's physician indicates this behavior is worse during her tub bath and that it is torture for her. The Facility has not tried to determine when Resident #11's cries out and screams what unmet need is not being met. When Resident #11 cries out and screams is Resident #11 in pain, is she anxious, or does Resident #11 scream when staff touch her feet because she is experiencing diabetic [MEDICAL CONDITION]? * An order to change the treatment to Resident #12 left lower leg was not transcribed. Resident #12 received the incorrect treatment to her left lower leg from 8/6/13 through 9/13/13. * Resident #4 had a change in her bowel continence. Resident #4's change in bowel incontinence was not comprehensively assessed in order to establish an individualized plan of care with interventions provided in order for Resident #4 to achieve or maintain bowel continence. Findings include: 1. Surveyor # reviewed Resident #11's medical record from 9/24/13 to 9/30/13. Resident #11 [DIAGNOSES REDACTED]. Resident #11's power of attorney was activated on 8/26/09. Resident #11's medications includes extra strength [MEDICATION NAME] 1000 mg every six hours, [MEDICATION NAME] 9.5 mg/24 hours one patch daily, Aspirin 81 mg daily, [MEDICATION NAME] 10 mg twice daily, [MEDICATION NAME] 75 mg before bath on Friday, and [MEDICATION NAME] HCL 5 mg every three hours as needed. The ADL (activity of daily living) care plan dated 3/9/12 includes approaches dated 3/9/12 of "I depend on you give me medication at least an hour before my bath to help me calm down for bath," "I depend on you to give me prn (as needed) pain medication at least an hour before getting my bath" and "I need help with washing and bathing. I scream when I feel the water. It helps to allow me time to get used to the water." Dated 9/10/13 an approach documents, "Family prefers to give a whole body tub bath than a no rinse sponge bath." The physician progress notes [REDACTED]. Some paranoia that people want to hurt her. Not in best interest to taper [MEDICATION NAME]." "Clearly unhappy. Poor insight to cares. Occ. (occasional) joking PRN [MEDICATION NAME] good. Joking with her usually breaks cycle. Son doesn't want more meds and I'm not sure they'd help anyway." Nurse's note dated 5/11/13 documents, "Pain perceived as: Ache. Pain has affected the following areas: Mood, sleep patterns, energy level. Observation: Resident verbalizes pain. Resident describes pain as: Ache. Pain is affecting the following areas: Change in behavior. Topics: Administration of PO (by mouth) medication. Comments: General Pain Comments = resident c/o (complained of) leg pain." Nurse's note dated 5/15/13 documents, "When doing cares resident noted yelling even before staff would begin. Staff would speak in a calm voice and tell her before hand what she would be doing and go slow. This is the most effective way with resident and yelling ceased." Nurse's note dated 5/22/13 documents, "Becomes angry and upset with any cares or treatments. Staff calmly explains the cares or treatments and when the cares or treatment are over then resident calm." Nurse's note dated 5/23/13 documents, "Call out in pain during all cares. Pain is non-specific and generalized all over. Can be resistant to cares. Uses a landing strip by bed for extra safety device. Transfers with extensive assist and EZ stand but refuses to strap legs d/t (due to) sensitivity. Is on a turning/repositioning program of every 2 hours while in bed. Positioning requires extensive assist of 1." Nurse's note dated 5/24/13 documents, "Resident yells out when cares are being done. Staff is able to ease resident's anxiety by telling her what is going to be done before hand and distracting her." A Physician telephone order dated 5/24/13 documents, "[MEDICATION NAME] 50 mg 1 tab PO 1 hour prior to bath on Fridays." Nurse's note dated 5/24/13 documents, "New order written for [MEDICATION NAME] 50 mg (milligrams) one tab PO one hour prior to bath on Friday. Writer called POA (power of attorney) and left message to return call to facility." Social service note dated 5/29/13 documents, "She becomes very anxious and upset with even anticipating cares, esp. (especially) bath and [MEDICATION NAME] was recently ordered to be given prior to her bath by PMD (private medical doctor)." Nurse's note dated 5/30/13 documents, "Pain assessment interview should be conducted, Resident has had pain or hurt in the last 5 days, Resident unable to answer how much of the time experienced pain or hurting over the last 5 days, resident unable to answer whether over the past 5 days, pain has made it hard to sleep at night, Resident unable to answer whether over the past 5 days, resident has limited day-to-day activities because of pain. Resident constantly calls out in pain during cares and any movement. She can be resistant to cares due to pain. Pain seems to be generalized." The quarterly MDS (minimum data set) signed as completed on 6/1/13 has a summary score of 7 for brief interview for mental status. A score of 7 indicates severe impairment. [MEDICAL CONDITION] is checked. Verbal other behavior and refuses care is checked. Resident #11 is frequently incontinent of bowel and bladder, does not ambulate and requires extensive assistance with two+ person physical assist for transfers & bed mobility. For pain management yes is checked for on a scheduled pain medication regimen, received prn pain medications, and received non-medication interventions for pain. Pain is described as moderate. Nurse's note dated 6/5/13 documents, "When cares and tx (treatment) done resident yells out and becomes angry. As soon as cares and tx done resident relaxed and calm. Resident counts out loud with prompt from staff during transfers and it helps her to focus and not yell out as much. Given verbal cues with all tx and cares so she is aware of what will be done and what is being done." A Physician order [REDACTED]. Report on result to me." A physician progress notes [REDACTED]. Chief concern is her trouble on bath day. She screams throughout the bath upsetting, resident, staff and clearly feeling she's being tortured. I have attended in the past nursing baths and despite every effort to reassure and be gentle she shrieks when touched. [MEDICATION NAME] 50 mg no effect. Will try increase premedicate." "Dementia- agitation with cares is very distressing to pt. (patient) & staff see above." Nurse's note dated 6/7/13 documents, "up arrow (Increase) [MEDICATION NAME] to 100 mg 60-90 minutes prior to bath every Friday, report. Physician-MM in at 0915 am to see resident for review. NOR (new order received) made." Nurse's note dated 6/7/13 documents, "POA aware of increase in [MEDICATION NAME] to 100 mg every Friday prior to bath, consent signed and faxed over." Nurses note dated 6/12/13 documents, "Resident is yelling during ADL (activity of daily living) rounds. Staff shares with her before ADL's what she is going to do & resident says ok. When staff begins ADL resident begins to yell. Staff stops & talk with resident to ease her anxiety. Reapproaches and talks during the entire time of ADL which is helpful & soothing to resident. Will allow resident to help assist but resident will decline. Resident says thank you." Nurse's note dated 6/12/13 documents, "YELLING AND SCREAMING." A Physician order [REDACTED]. before bath. Report result to PMD." A physician progress notes [REDACTED]. Unable to take bath d/t (due to) lethargy, leaning far down in w/c (wheelchair)." Nurse's note dated 6/14/13 documents, "lethargy post receiving [MEDICATION NAME] 100 mg this AM, Other orders obtained = Decrease [MEDICATION NAME] to 75 mg PO 60-90 mins. (minutes) before bath on Friday." Nurse's note dated 6/14/13 documents, "Severity of pain = 8/10. Pain related to chronic process: [MEDICAL CONDITION]." Nurse's note dated 6/20/13 documents, "Can be verbally aggressive towards staff. Shouts out a lot in pain and can refuse cares at times." The pain interview conducted on 6/28/13 answers "no" to the question any pain or hurting at any time in the last 5 days. Nurse's note dated 7/1/13 documents, "Yells with each tx. or cares and when care or tx done she is calm." Nurse's note dated 7/3/13 documents, "with every care, tx or med she starts yelling and becomes angry but staff lets her know what is going to happen and let her count while transfers are being done and once tx, care, med over she is calm and smiles." Nurse's note dated 7/15/13 documents, "with each med and tx and care yells out and when done is calm and thankful." The pain interview conducted on 7/18/13 answers "yes" to the question any pain or hurting at any time in the last 5 days. The verbal pain rating scale documents, "very severe, horrible." Nurse's note dated 7/19/13 documents, "with every adl, change of position, med or tx yells out loudly, after done calm and states thank you." Nurse's note dated 7/23/13 documents, "Resident yelling out, using profanity, verbally aggressive with staff during adl rounds. CNA able to redirect resident and decrease behavior by talking addressing her concerns etc. Resident does not like for peri care to be done, but will participate and direct staff in how to do the care for her, which also helps decrease her yelling out with profanity and verbal aggression. Staff does reapproach when required. Medical intervention was not required." Nurse's note dated 7/23/13 documents, "yelling and screaming." Nurse's note dated 7/24/13 documents, "screaming and yelling out during cares." The pain interview conducted on 8/1/13 answers "yes" to the question any pain or hurting at any time in the last 5 days. The verbal pain rating scale documents "very severe, horrible." Nurse's note dated 8/22/13 documents, "PRN (as needed) given for increased agitation with anxiety." Nurse's note dated 8/23/13 documents, "Resident laying in bed. Alert and yelling out during cares. Denies pain when questioned. 1:1 given." A physician progress notes [REDACTED]. Denies any pain." Nurse's note dated 8/25/13 documents, "Resident slept well, no complaints of pain or discomfort, scheduled Tylenol has been effective for pain management, however, resident refused 0600 (6:00 a.m.) dose. States "No I don't want that, get out of here now." Hostile and yells out during cares, loud and disruptive which is usual behavior. Remains incontinent of bladder. Will attempt to reapproach 0600 Tylenol." Nurse's note dated 8/25/13 documents, "yelling out in pain" Nurse's note dated 8/26/13 documents, "Severity of pain = 9/10. General pain comments = Moaning and yelling out in pain." The pain interview conducted on 8/28/13 answers "yes" to the question any pain or hurting at any time in the last 5 days. The verbal pain rating scale documents "severe." Social Service note dated 8/28/13 documents, "Care conference was held with Family care case manager and nurse. Resident #11's status is the same as prior to hospitalization . She remains oriented to self and surroundings and will make needs known. She is forgetful and occasionally confused however remembers that she was in the hospital and that she had back pain. She states that the back pain is resolved however she continues to be extremely fearful of any staff intervention that requires her to be touched." Nurse's note dated 8/29/13 documents, "Resident sleeping well during the night, scheduled Tylenol as been effective for pain management. Resident remains angry and hostile during cares, yells out and is very loud and disruptive. No complaints of dysuria. Sleeping well @ (at) this time." The pain interview conducted on 8/29/13 answers "yes" to the question any pain or hurting at any time in the last 5 days. The verbal pain rating scale documents "very severe, horrible." The significant change MDS signed as completed on 9/4/13 has a summary score of 5 for brief interview for mental status. A score of 5 indicates severe impairment. [MEDICAL CONDITION] is checked. Verbal behavior is checked. Resident #11 is frequently incontinent of bowel and bladder, does not ambulate and requires extensive assistance with two+ person physical assist for transfers & bed mobility. For pain management yes is checked for on a scheduled pain medication regimen, received prn pain medications, and received non-medication interventions for pain. Pain is described as very severe, horrible. The behavior symptoms CAA (care area assessment) dated 9/3/13 documents under comments, "Resident #11 does not enjoy being touched and can become very anxious resulting in screaming and yelling, esp. (especially) during weekly bath. PMD has ordered use of medication prior to bath each week." The pain CAA dated 9/4/13 documents under comments, "Resident #11 recently diagnosed with [REDACTED]. She does have hx (history) of oversensitivity to touch. Will proceed to care plan." The pain interview conducted on 9/5/13 answers "no" to the question any pain or hurting at any time in the last 5 days. Nurse's note dated 9/10/13 documents, "Resident was screaming, when checked her in her room, c/o (complained of) pain to R (right) foot. Screams even bare touching R foot, stated pain at the bottom of foot. Attempted to put pillow under foot and did not help either, requested to take pillow off." Nurse's note dated 9/11/13 documents, "Writer noted on first ADL rounds resident was yelling, using profanity, calling out, threatening, and being verbally abusive to CNA. Writer in room and listed as CNA was explaining to resident what was going to be done. Resident wanted to stay in her incontinent chuck. CNA was doing everything right and even reproached the resident. Writer intervened as a distraction, and give scheduled medication, which gave enough time for resident to calm down and allow cares to be completed." Nurse's note dated 9/12/13 documents, "Resident refused 0600 ES Acet. 1000 mg po at three different intervals. Would not give any reason as to why except that she didn't want to take it. Upon another reapproach resident stated that "I will slap an' hur(t) you if you even try to give dat' to me!" (with a thick accent). Resident yelling, cursing and refusing. Documented as such." The pain interview conducted on 9/12/13 answers "yes" to the question any pain or hurting at any time in the last 5 days. The verbal pain rating scale documents "very severe, horrible." The pain interview conducted on 9/19/13 answers "no" to the question any pain or hurting at any time in the last 5 days. Nurse's note dated 9/23/13 documents, "Resident refused to lie down this afternoon. Resident yelling in dining room at both meals, as well as in room during early morning cares. Resident yelling "Oh God, Oh God!" and Mama, Mama!" Calm reassurance/redirection was somewhat effective. Resident refused insulin at lunch time on first and second attempt, but allowed writer to administer insulin on third/final attempt." On 9/25/13 at 9:16 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-AA wheel Resident #11 into her room and then leave Resident #11's room. Surveyor # could hear Resident #11 yelling from down the hallway. Surveyor # observed that CNA-AA then went back into Resident #11's room to speak with the Resident. Surveyor # noted after a couple of minutes Resident #11 was not yelling out. On 9/25/13 at 10:57 a.m., Surveyor # observed CNA (Certified Nursing Assistant)-N and CNA-AA in Resident #11's room. CNA-N informed Resident #11 that they were going to check and change her. CNA-N placed an EZ stand lift in front of Resident #11. CNA-AA placed a sling around Resident #11. While CNA-AA was placing the sling, Resident #11 was yelling out "Oh God, Oh God, Oh God, Oh God." CNA-N lowered Resident #11's pants, unfastened the incontinence product and Resident #11 was wheeled into the bathroom and lowered onto the toilet. CNA-N informed Resident #11 that they were going to let her sit for awhile. CNA-N and CNA-AA removed their gloves and washed their hands. Resident #11 started yelling "Oh God, Oh God, Oh God, Oh God." At 11:05 a.m. Resident #11 was raised off the toilet. CNA-N washed Resident #11's perineal area, removed her gloves, washed her hands, and placed gloves on. CNA-N washed Resident #11's rectal area and buttocks. While CNA-N was washing Resident #11, Resident #11 was yelling out "Oh God, Oh God, Mama, Mama." CNA-AA applied butt past on Resident #11's buttocks. CNA-N and CNA-AA removed their gloves, washed their hands, and placed new gloves on. CNA-N and CNA-AA placed an incontinence product on. Resident #11 was yelling out while staff was placing on the incontinence product and pulling up her pants, "Oh God, Oh God, Oh God." Surveyor # noted Resident #11 yelled out while staff was taking care of Resident #11 but after she was placed in her wheelchair she did not yell out. On 9/25/13 at 11:11 a.m., Surveyor # asked CNA-N if Resident #11 usually yells out like Surveyor # observed. CNA-N informed Surveyor # that she does but she really yells out especially when she gets a bath. CNA-N explained that staff would come in to make sure the Resident was alright because she yells so loud. CNA-N informed Surveyor # that staff upstairs could hear Resident #11 yelling. On 9/26/13 at 8:07 a.m., Surveyor # observed morning cares for Resident #11 with CNA-NN and CNA-OO. CNA-NN removed the sheets from Resident #11. After the sheets were removed Resident #11 yelled out "Oh God, Oh God." CNA-NN asked Resident #11 what was the matter. CNA-NN informed Resident #11 that she was going to take her socks off. Resident #11 stated leave my socks. CNA-NN placed Resident #11's pants on. While CNA-NN was putting on Resident #11's pants, Resident #11 was yelling out "Oh God, Oh God, Oh God." CNA-NN informed Resident #11 that she was going to sit her up and that she needed Resident #11 to help her. CNA-NN was attempting to sit Resident #11 up in bed, Resident #11 was yelling out "Oh God, Oh God." CNA-NN told Resident #11 that she was almost there. Resident #11 told CNA-NN "just be quiet, my legs are hurting, oh my legs." CNA-NN asked Resident #11 if she needed something for pain. Resident #11 replied "no." CNA-NN informed Resident #11 going to keep sitting you up. Resident #11 replied "Just be quiet, shut your mouth." Resident #11 stated "ow, ow." CNA-NN asked what was wrong. Resident #11 replied "nothing just be quiet and do what you have to." At 8:13 a.m. RN (Registered Nurse)-PP opened the door stating that she heard Resident #11 and wanted to make sure everything was alright. CNA-NN gave Resident #11 a wash cloth to wash her own face. CNA-NN then asked Resident #11 if she could raise her right arm. Resident #11 stated "this arm hurts." CNA-OO stated that they will let the nurse know. CNA-NN washed Resident #11's right arm. While her arm was being washed, Resident #11 yelled out "Oh God, Oh God." CNA-OO informed CNA-NN that she was going to tell the nurse. CNA-NN washed Resident #11's left arm. Surveyor # noted that Resident #11 did not yell out. CNA-NN asked Resident #11 if she could lean forward to put on her bra and shirt. CNA-NN leaned Resident #11 forward. Resident #11 began to yell out "Oh God, Oh God." CNA-OO asked Resident #11 if she was in pain. Resident #11 stated "no." CNA-OO asked Resident #11 why she was yelling and screaming. Resident #11 is yelling out "Help me, help me, Oh God." CNA-NN and CNA-OO placed a purple sweater on Resident #11. Resident #11 wasn't yelling when staff started to place the sweater on but then started yelling "Oh God, Oh God." CNA-NN and CNA-OO sat Resident #11 on the edge of the bed and place an EZ stand in front of her. Staff placed sling around Resident #11. Resident #11 was yelling out "Oh God, Oh God, Mama, Mama." At 8:22 a.m. RN-PP opened the door stating she was going to give Resident #11 a pain pill. CNA-NN informed Resident #11 that they were going to lay her back in bed. While laying Resident #11 back in bed and covering her with a sheet Resident #11 was yelling out "Oh God, Oh God, Oh God." At 8:22 a.m. RN-PP attempted to give Resident #11 pain medication which Resident #11 refused. On 9/26/13 at 8:37 a.m., Surveyor # asked Resident #11 when staff was getting her up this morning did her legs hurt. Resident #11 replied "no, they talk so loud and that bothers me." Surveyor # asked if her right arm hurts her. Resident #11 replied "that hurts." Surveyor # asked Resident #11 why she didn't take her pain medication when the nurse offered it to her. Resident #11 informed Surveyor # that she didn't want to take it, that they talk loud and that bothers her. Nurse's note dated 9/26/13 documents, "Resident refused AM meds, cares, and 0700 (7:00 a.m.) glucose check. Offered x 3. Resident seemed more agitated when reproached, yelling "Get lost, Get lost, Get lost!" Resident provided calm reassurance but was not helpful. Resident c/o pain per CNA but when writer approached with Oxy 5 mg po IR, resident refused. Resident denied pain. Resident ate breakfast in bed. Appetite 100%, Resident more calm after breakfast. Resident allowed writer to perform 1100 (11:00 a.m.) glucose check and tolerated well. Resident allowed CNA's to perform cares in afternoon but refused to have upper clothing changed will continue to monitor." Nurse's note dated 9/26/13 documents, "Resident continues on behavior monitoring for refusing cares and medication. Resident took medications and insulin. Occasional yelling out with cares. 1:1 given and redirection. Will continue to monitor." On 9/26/13 at 11:01 a.m., Surveyor # met with RN (Registered Nurse) Manager-M to discuss Resident #11. Surveyor # inquired if a bath is so traumatic to Resident #11 has the Facility tried other methods. RN Manger-M informed Surveyor # that it has always been a challenge to give Resident #11 a shower or bath. Resident #11 used to get a shower when she was in the rehab unit and when she moved over to this unit she didn't like the shower head and would really scream. RN Manager-M indicated that she spoke with Resident #11's POA to ask if they could give Resident #11 a no rinse bath but he prefers that Resident #11 be washed up in the tub. Surveyor # inquired when Resident #11 moved over to this unit. RN Manager-M replied a little over a year ago. Surveyor # asked RN Manager-M if they ever tried the no rinse bath. RN Manager-M indicated maybe a couple times when Resident #11 was receiving the showers before the tub bath. Surveyor # inquired why [MEDICATION NAME] 50 mg was ordered. RN Manager-M informed Surveyor # that even with the tub baths Resident #11 would be screaming out. Surveyor # inquire why the [MEDICATION NAME] was increased to 100 mg. RN Manager-M informed Surveyor # that the 50 mg was not effective so it was increased to 100 mg but that was too much as Resident #11 was lethargic. The [MEDICATION NAME] was decreased to 75 mg but she still screams during her baths. Surveyor # inquired about pain medications. RN Manager-M informed Surveyor # that Resident #11 is on scheduled Tylenol extra strength four times a day. Surveyor # inquired about a scheduled narcotic. RN Manager-M informed Surveyor # that Resident #11's POA does not want any narcotics scheduled but that she does have a prn [MEDICATION NAME] for break through pain. Surveyor # inquired if Resident #11 has seen a psychiatrist to help determine if the screaming out is behavior versus pain. RN Manager-M informed Surveyor # that Resident #11's POA has declined and its her primary physician that does the reviews. On 9/26/13 at 3:30 p.m., Surveyor # spoke with Resident #11's POA (power of attorney) via the telephone to inquire if the Facility has spoken with him regarding Resident #11 screaming during her baths and cares, if the Facility has spoken to him about trying a bed bath or other method, different pain medications and whether he as been spoken to regarding Resident #11 being seen by a psychiatrist. The POA informed Surveyor # that Resident #11 has been like this for a while and he doesn't know if she is in pain or just screaming out. The POA informed Surveyor # that he wants Resident #11 to have a tub bath as he wants Resident #11 clean and feels this is the only way have her clean. The POA informed Surveyor # that Resident #11 has had pressure sores in the past and is incontinent. Also he wants Resident #11's hair to be clean. The POA informed Surveyor # that the Facility is giving Resident #11 medication prior to the bath so she is not combative or hitting staff. The POA thought the Facility had brought up a bed bath in the past but could not recall when. When Surveyor # asked the POA if Facility staff spoke with him about scheduling a narcotic pain medication, the POA informed Surveyor # that he didn't think so. When Surveyor # asked about if the Facility staff had spoken to him about Resident #11 seeing a psychiatrist, the POA informed Surveyor # that prior to Resident #11 being admitted to an assisted living facility they had a number of tests done with a psychologist, an Alzheimer's expert and that's when they found out that Resident #11 has Alzheimer's and dementia. Resident #11's POA informed Surveyor # that he is very comfortable with Physician-MM and if he were to speak to him about different recommendations then he would be willing to go along with them. The POA informed Surveyor # that he heard that they might be having a meeting tomorrow. On 9/26/13 at 12:47 p.m., Surveyor # with Surveyor # spoke with SW (Social Worker)-CC regarding Resident #11. SW-CC informed Surveyor # that she has worked with Resident #11 and her POA for about three years and that Resident #11 lived on the rehab unit. SW-CC indicated that she thinks Resident #11 anticipates people are going to do cares and does not want to be touched. SW-CC informed Surveyor # that they tried no rinse bath in the past but was not sure when. SW-CC stated that it is very important to Resident #11's POA that Resident #11 have a bath. SW-CC informed Surveyor # that she feels that they are often between a rock and a hard place. Surveyor # inquired if SW-CC has spoken with Resident #11's POA about seeing a psychiatrist. SW-CC replied that if she did it was a long time ago and not that she could recall. SW-CC informed Surveyor # that Resident #11's POA is very exact in who he will speak with. SW-CC stated that she had called Resident #11's POA about setting up an appointment, he refused to speak to her stating he would speak with RN Manager-M even though she is the one that calls for transportation. Surveyor # asked SW-CC if Resident #11's POA was asked to come in to talk about Resident #11's behavior with her baths. SW-CC informed Surveyor # that he is invited to the care conferences but he hasn't been coming. SW-CC informed Surveyor # that Resident #11's POA doesn't want to deal with them but if the Physician-MM takes the lead that might work. Nurse's note dated 9/27/13 documents, "Resident refused Tylenol @ (at) 2400 & 0600 (midnight and 6:00 a.m.). Yelling out and very hostile, cursing during cares. Resident states "get out and leave me alone." On 9/27/13 at 6:59 a.m. Surveyor # observed CNA-N and RN-BB transfer Resident #11 from bed into her wheelchair using an EZ stand lift. CNA-N placed a sling around Resident #11, attached the sling to the lift and asked Resident #11 if she was ready. While Resident #11 was being lifted off the bed, Resident #11 was yelling out "ow, ow, Mama, Mama." While Resident #11 was yelling out, CNA-N told Resident #11 lets count. Resident #11 responded back "ya, you count." CNA-N then washed Resident #11's perineal area. While CNA-N was providing continence care, Resident #11 was yelling out. CNA-N suggested Resident #11 count. Resident #11 stated "just be quiet, I'm better off if you're quiet, oh mama mama, oh god oh god." An incontinence product was placed on Resident #11 and Resident #11 was lowered into her wheelchair. On 9/27/13 at 8:11 a.m. Surveyor # heard RN-BB inform Resident #11 that she was going to give her a pain pill. After RN-BB administered Resident #11 her medication, Surveyor # asked RN-BB what pain medication she gave Resident #11. RN-BB replied, "[MEDICATION NAME] 5 mg." Surveyor # asked RN-BB if Resident #11 usually gets this medication in the morning. RN-BB replied "no" and then explained that earlier when Resident #11 was leaning over she asked Resident #11 if she was in pain and Resident #11 indicated that she had back pain. Surveyor # inquired if Resident #11 received [MEDICATION NAME] this morning. RN-BB informed Surveyor # that Resident #11 did received [MEDICATION NAME] as today was her bath day. On 9/27/13 at 8:54 a.m. Surveyor # entered Resident #11's room. CNA-N and CNA-11 attaching the sling to the sit to stand lift. Surveyor # asked if they were putting Resident #11 back to bed. CNA-N replied "yes" and explained that Resident #11 won't sit up. While transferring Resident #11 back into bed, Resident #11 was yelling out "oh god, oh god, oh mama." On 9/27/13 at 9:05 a.m. Surveyor # met with Physician-MM regarding Resident #11. Physician-MM informed Surveyor # that he has been following Resident #11 for three years but has known Resident #11 for about twenty years. Physician-MM informed Surveyor # that in 2010 and 2011 he has tried different pain and antianxiety medications for Resident #11 and that he doesn't think seeing a psychiatrist would be a good idea as he doesn't want Resident #11 on any antipsychotic medications. Physician-MM informed Surveyor # that he has heard Resident #11 screaming twenty times or more in the past year during baths or when her toe nails are being cut. Physician-MM stated that Resident #11 can go from screaming to joking. Physician-MM informed Surveyor # that Resident #11 has a frozen shoulder which she used to come to his office for an injection and that he thinks a colleague of his came six to eight months ago to give her an injection. On 9/27/13 at 10:27 a.m. CNA-N informed Surveyor # that she was going to give Resident #11 a bed bath. CNA-N explained that she isn't able to give Resident #11 a tub bath as Resident #11 won't sit up and it wouldn't be safe. Surveyor # then observed CNA-N and CNA-AA provide Resident #11 with a bed bath. Surveyor # noted that during the bed bath Resident #11 was yelling out "oh god, oh god, mama, mama." Surveyor # noted that when staff touched Resident #11's feet, Resident #11 screamed louder than what she usually did. Surveyor # noted that although Resident #11 received [MEDICATION NAME] 75 mg (milligrams) she continued to scream out. On 9/27/13 at 10:54 a.m., Surveyor # asked CNA-N when she gives Resident #11 a tub bath is there another staff member in the room with her. CNA-N replied "yes" and explained that Resident #11 yells out so she doesn't want anyone to think that she is doing something wrong to Resident #11 and she is also lifted with an EZ stand. Nurse's note dated 9/27/13 documents, "Resident refused early am cares this shift, CNA reapproached resident about 15 to 30 minutes later and resident was yelling and swearing at writer. Resident