Every finding on record at Madison Health and Rehabilitation Center

Based on observation, interview, and record review the facility did not Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 67 residents. Surveyor observed open food in the refrigerator, undated and unlabeled food in the freezer, staff food and beverages stored in the same cooler as resident food, ice accumulation in the freezer, and a freezer temperature of positive 8 degrees. Evidenced by: Facility policy, titled Food Safety Requirements, dated 3/26/25, includes the following, in part: Guideline: . Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definitions: . Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. Elements of the process include the following:. b. Storage of food in a manner that helps prevent deterioration or contamination of the food including from growth of microorganisms.Staff and residents shall follow facility policy regarding personal foods. c. Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable) discarded; and v. Keeping foods covered or in tight containers. Facility policy, titled, Food Storage: Cold Foods, dated 5/2014, with last revision date of 2/2023, includes the following, in part: Policy Statement: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with the guidelines of the FDA Food Code. Procedures:. 3. Freezer temperatures will be maintained at a temperature of 0 degrees F (Fahrenheit) or below. On 7/20/26 at 9:58 AM, Surveyor completed a kitchen tour with KAM E (Kitchen Account Manager) and observed uncovered peach cups in the walk-in cooler. KAM E indicated that those were going to be served today at lunch, and they should be covered. Surveyor observed an undated and unlabeled Ziploc bag that appeared to be spaghetti and sauce in the walk-in freezer. KAM E stated that it should be dated and indicated that he would throw that bag away. Surveyor observed that the outside freezer temperature fluctuated between positive 1 and 20 degrees. Surveyor observed a large amount of ice accumulation along the right-hand side of the walk-in freezer near the door, and also on the floor in front of the freezer door. KAM E indicated that the ice buildup has been happening a lot, and that he has to defrost the freezer weekly to make sure that the freezer door will close. Surveyor observed a bin on the bottom shelf of the kitchen deli cooler that was labeled Staff and had food and beverages that belonged to staff. On 7/20/26 at 1:23 PM, Surveyor observed the kitchen again with KAM E and asked if there was an internal thermometer for the freezer. KAM E showed Surveyor that the internal temperature of the walk-in freezer was registering as positive 8 degrees. KAM E indicated that the temperature should always be below zero for the freezer and indicated that the door doesn't always like to shut tight, and that they currently have a problem with the freezer buildup. Surveyor asked KAM E if he had told anyone in management or notified maintenance of the improper door seal or ice buildup. KAM E indicated that he had not, and that he wanted to defrost the freezer one more time and then he would let maintenance know. Surveyor observed the deli cooler again along with KAM E and noted a McDonald's drink cup on the top shelf, not in the bin labeled Staff on the bottom shelf. KAM E indicated that the refrigerator was used for deli items used to make the resident sandwiches, such as meat, lettuce, and mayonnaise. Surveyor asked KAM E if there could be a risk of cross contamination if there were staff food and beverages stored in the same refrigerator as resident food. KAM E stated that his district manager had told him it was okay to do this if the staff items were in a separate bin. On 7/22/26 at 9:28 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and shared her concerns about the food storage in the kitchen. NHA A stated that KAM E had made her aware of the food storage items that had been discussed. NHA A indicated that she informed KAM E that staff have their own refrigerator in the basement that they should be using, and that he should talk to MS G (Maintenance Supervisor) about the ice buildup in the walk-in freezer. NHA A indicated that the freezer temperature could be higher than zero degrees currently because the heat has been so bad and the door gets opened and closed frequently, letting hot air in, but she would check on that. The facility did not ensure that food was stored in a safe manner according to professional standards of food safety.

Based on observation, and interviews, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 4 of 6 shower rooms and 1 (R6) of 9 residents rooms reviewed for cleanliness of a total sample of 67 residents. R6 voiced concerns related to the cleanliness of their room. Surveyor observed brown smears on the floor, dirt and grime crusted in the corners, sticky floors, accumulated soap/shampoo scum on the wall, and overflowing waste baskets and linens carts in the shower rooms. Evidenced by: Facility Housekeeping Schedule indicates that public bath and shower rooms need to be deep cleaned on the weekends. The facility did not provide a policy and procedure related to how often they clean, what the cleaning entails, or who is responsible for the cleaning of the resident rooms or shower rooms. Example 1 R6 was admitted to the facility on [DATE]. Their most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/8/26 indicates R6's cognition is intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. On 7/20/26 at 5:05 PM, Surveyor observed debris on the floor of R6's room, accumulated grime in the corners of the bathroom, and a ring around the toilet bowl. FM L (Family Member) who was visiting R6 at the time of the observation indicated that she had cleaned the floor and dusted the cobwebs from R6's room herself yesterday, as it appeared the room had not been cleaned in some time. Example 2 On 7/20/26 at 10:32 AM, Surveyor observed the shower rooms along with LPN C (Licensed Practical Nurse). Surveyor observed accumulated soap/shampoo drips down the wall, an overflowing garbage can and overflowing linen cart, and a strong odor in the Cedar shower room. Surveyor observed brown smears on the floor and a strong odor in the [NAME] shower room. Surveyor observed accumulated hair, dust, and grime in the corners, and brown smears on the floor in the Pine shower room. Surveyor observed overflowing garbage and bagged linens on the floor, a dirty washcloth on the floor, and inadequate lighting in the Elm shower room. On 7/20/26 at 10:57 AM, Surveyor interviewed HK F (Housekeeper) who stated that the resident rooms are cleaned daily, but that someone else cleans the shower rooms. On 7/21/26 at 11:11 AM, Surveyor observed the shower rooms along with HS I (Housekeeping Supervisor) who stated that the housekeeping staff is responsible for cleaning the shower rooms, and that sometimes she does it herself. HS I indicated that the shower rooms are cleaned every other day. HS I stated that the Cedar shower room had been cleaned two days ago, that the [NAME] shower room had been cleaned yesterday, and that the Pine and Elm shower rooms were going to be cleaned today. HS I admitted that the shower rooms should be cleaned better. On 7/22/26 at 9:28 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and shared her concern about the cleanliness of the resident rooms and shower rooms. NHA A indicated that housekeeping is discussed every morning meeting, and she provides a list of rooms to clean and which shower rooms are to be cleaned each day. NHA A stated that the Cedar, Elm, Pine, and [NAME] shower rooms were probably getting overloaded with extra showers since the Aspen and Birch shower rooms were currently out of order. NHA A stated that the shower rooms could require more attention from housekeeping due to this. The facility did not ensure that each resident had a sanitary environment.

Based on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 residents (R6) observed with medications at bedside out of 9 sampled residents. R6 was observed to have medications left on her bedside table for her to take independently. R6 does not have an assessment for self-administration of medications indicating that she is safe to administer medications independently.This is evidenced by:The facility's policy Medication Administration, dated 4/9/25, includes: Medications are administer by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 18. Observe resident consumption of medication. The facility's policy Resident Self-Administration of Medication, dated 1/9/26, includes: A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 13. The care plan must reflect resident self-administration. R6 was admitted to the facility on [DATE]. R6's BIMS (Brief Interview for Mental Status), dated 5/8/26, has a score of 13, indicating R6 is cognitively intact. R6's physician orders, printed 7/22/26, include: Mirtazapine 7.5 mg Give 1 tablet by mouth one time a day every Tue, Thu, Sat for Major Depressive Disorder Of note, R6 does not have a physician's order to self-administer medications. R6's medical records do not include a Medication Self-Administration Assessment Form. R6's comprehensive care plan, printed 7/22/26, does not include anything regarding self-administration of medications. On 7/22/26 at 8:40 AM, Surveyor interviewed R6 in her room. Surveyor observed a white, oval pill on R6's bedside table. R6 indicated she was not sure what the medication was but thought it might be her Seroquel (Antipsychotic medication). On 7/22/26 at 8:46 AM, Surveyor interviewed RN O (Registered Nurse). RN O indicated she was R6's nurse. RN O indicated R6 is not able to self-administer medications. RN O stated we have to watch her take her medications. RN O indicated a resident has to have a physician's order to self-administer medications. RN O and surveyor went to R6's room to retrieve the medication left at bedside. RN O matched the pill to R6's medications and noted it to be R6's Mirtazapine. On 7/22/26 at 9:30 AM, Surveyor interviewed NP P (Nurse Practitioner). NP P indicated that R6 is not safe to self-administer medications and should be observed while taking medications. On 7/22/26 at 11:18 AM, Surveyor interviewed DON B (Director of Nursing) regarding R6. DON B indicated that medications should not be left at bedside. DON B indicated staff should be monitoring R6 when she is taking her medications.

Based on interview and record review, the facility did not ensure each resident's right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 of 3 residents reviewed for room changes (R8) out of a sample of 9. R8 was moved to another room without notice and without reason for the change.Findings includeThe facility's Resident Rights policy states, The resident has a right to be treated with respect and dignity, including:.The right to receive written notice, including the reason for the change, before the residence room or roommate in the facility is changed. The right to refuse to transfer to another room in the facility, if the purpose of the transfer is: To relocate a resident of a SNF from the distinct part of the institution that is a SNF to a part of the institution that is not a SNF .R8 was admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set), dated 6/23/26, includes a BIMS (Brief Interview for Mental Status) score of 14, indicating R8 is cognitively intact.On 6/26/26, the facility moved R8 from her room on one side of the building to the other side of the building.On 7/21/26 at 12:10 PM, Surveyor interviewed SW K (Social Worker) who indicated that she had followed up with R8 after the move but did not give any written notice or advance notice to R8 regarding her room change. SW K indicated that she verbally speaks with the residents but does not have any documentation that advance notice was given or an explanation as to why the room change was occurring.On 7/21/26 at 1:10 PM, Surveyor interviewed R8 who stated that she was not given any prior notice as to the room change. R8 stated that one day staff came into her room and just started packing up her stuff. R8 stated that she was given no reason as to why they were moving her.The facility was unable to provide any documentation regarding preparation or any written communication with R8 that she was being moved.On 7/22/26 at 9:30 AM, Surveyor interviewed NHA A (Nursing Home Administrator) who indicated that the facility does not provide any written notice to residents before changing rooms, but indicated that this needed to be done. NHA A stated that the facility actually has a document that clearly presents information to the resident regarding room changes and what reason they are being done, giving a reason for the move. However, NHA A stated this form was not currently being used. NHA A stated she would give SW K this document and, moving forward, written communication regarding room changes and the reason for those changes would be given and explained to residents.

Based on record review and interview, the facility did not complete the Preadmission Screening and Resident Review (PASARR) Level II when it was realized that a resident would reside in the facility for more than 30 days for 1 of 1 resident (R6) reviewed for PASARR out of 9 sampled residents. R6 resided in the facility for longer than 30 days and required a PASARR Level II screen, but the facility failed to complete the screening. This is evidenced by: The facility's policy, Resident Assessment - Coordination with PASARR Program, dated 1/9/26, includes: If a resident who was 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 I screening process and refer any resident who has or may have MD (Mental Disorder), ID (Intellectual Disability) or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. R6 was admitted to the facility on [DATE] with diagnoses including depression and post-traumatic stress disorder. R6's BIMS (Brief Interview for Mental Status), dated 5/8/26, has a score of 13, indicating R6 is cognitively intact. R6's Level I PASARR screen includes: Does the person have a major mental disorder? YESHas this person received psychotropic medication(s) to treat symptoms or behaviors of a major mental disorder? YESHospital discharge exemption - 30 days Maximum YES On 7/21/26 at 3:40 PM, Surveyor requested R6's Level II PASARR from SW K (Social Worker). SW K was unable to produce R6's Level II PASARR. On 7/22/26 at 1:39 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding R6's Level II PASARR. NHA A indicated R6's Level II PASARR should have been completed but had not been done.

Based on interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents and hazards for 1 of 1 residents (R6) reviewed for smoking out of 9 sampled residents. R6 was observed smoking in her room after she was deemed safe to have her smoking materials in her possession. R6 was not reassessed timely for safety after being observed smoking in her room. R6 was reassessed to be a supervised smoker and continued to have smoking materials in her possession without safety interventions being put in place. This is evidenced by: The facility's policy Resident Smoking, dated 12/1/23, includes: 1. Smoking is prohibited in all areas except the designated smoking areas. 4. Residents and resident representatives will be notified of this policy during the admission process and as needed. Residents who smoke will be further evaluated using the Smoking Evaluation: to determine supervision need and intervention. 9. If a resident who smokes experiences any decline in condition or cognition, he/she will be reevaluated for ability to smoke independently and/or to evaluate whether any additional safety measures are indicated. 10. All safe smoking measures will be documented on the care plan and communicated to all staff. 12. If a resident or resident representative does not abide by the smoking policy or care plan (e.g.,. smoking in non-smoking areas.) the plan of care may be revised to include additional safety measures. 13. Smoking materials of residents requiring supervision with smoking will be maintained by the facility staff. R6 was admitted to the facility on [DATE]. R6's BIMS (Brief Interview for Mental Status), dated 5/8/26, has a score of 13, indicating R6 is cognitively intact. R6's 5/6/26 Smoking Evaluation includes:8. Does resident need facility to store lighter and cigarettes? No9. Plan of care is used to assure resident is safe while smoking? Yes10. Has resident been educated on facility smoking procedures? Yes11. Is the resident a supervised or unsupervised smoker? Unsupervised R6's physician orders, printed on 7/22/26, include Resident Smokes: Resident assessed as a [sic] unsupervised smoker observe smoking safety, to include; no smoking materials on person if supervised smoker, no smoking within facility (only in designated smoking areas), no smoking while oxygen is present. Intervene immediately and notify management, every shift R6's comprehensive care plan, printed on 7/22/26, includes .uses smoking tobacco. R6 can smoke and/or use smokeless tobacco unsupervised. Date initiated 5/5/26. Revision on 5/8/26. On 5/17/26 at 12:02 PM, R6's progress note states: This writer went into resident's room for noon med pass and witnessed resident was smoking in the room. Resident was asked to turn the cigarette off, resident turned it off to the back of her soda can. Education was given to the resident of smoking policy andsafety [sic]. Resident apologized and told this writer that she would not do it again. On 5/18/26 at 2:07 PM, R6's progress note states Resident smoking in the room was notified to UM (Unit Manager) and Administrator. R6 went to the hospital on 5/28/26 and readmitted to the facility on [DATE]. R6's Admission/Readmission/Routine Head-to-toe Evaluation, dated 6/1/26, includes: 69. Smoking Evaluationi. Does resident need facility to store lighter and cigarettes? Yesj. Plan of care is used to assure resident is safe while smoking? Nok. Has the resident been educated on facility smoking procedures? [NAME]. Is the resident a supervised or unsupervised smoker? Supervised. Of note, R6's physician order and comprehensive care plan were not updated to reflect the change from an unsupervised smoker to a supervised smoker after this smoking evaluation was completed. On 7/21/26 at 3:40 PM, Surveyor interviewed SW K (Social Worker) regarding the process if a resident was found to be smoking in the facility. SW K indicated that the facility would complete a new smoking evaluation, and the facility would store the resident's smoking materials. SW K indicated that if a resident smokes in their room, they are not allowed to keep their smoking materials. On 7/22/26 at 10:53 AM, Surveyor interviewed LPN M (Licensed Practical Nurse). LPN M indicated residents are evaluated for their smoking ability as supervised or unsupervised based on the smoking evaluation. LPN M indicated the resident's care plan and physician orders should reflect the resident's smoking evaluation. LPN M indicated if a resident is considered to need supervision while smoking, the facility stores the residents' smoking materials. Surveyor and LPN M reviewed R6's most recent smoking evaluation. LPN M indicated that based on R6's 6/1/26 smoking evaluation, R6 would be considered a supervised smoker. LPN M indicated the facility has not been storing R6's smoking materials. LPN M indicated R6's physician orders and care plan should reflect R6's smoking evaluation. On 7/22/26 at 11:18 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated upon admission to the facility; all residents are screened for smoking. DON B indicated if a resident indicates they want to smoke while at the facility, a smoking evaluation is completed to determine if the resident is a supervised or unsupervised smoker. DON B indicated if a resident is observed doing something unsafe, a new smoking evaluation can be done. DON B indicated that if a resident is smoking in their room, that is considered unsafe smoking behavior. DON B indicated it is unsafe behavior to have access to cigarettes and a lighter after being found smoking in the facility. DON B indicated the facility attempted to store R6's smoking materials, but R6 refused. DON B indicated there are no new interventions or safety precautions put in place for R6's unsafe smoking behavior.

Based on observation, interview, and record review, the facility did not provide the necessary respiratory care and services 1 of 1 (R6) reviewed for CPAP (Continuous Positive Airway Pressure) usage out of 9 sampled residents.R6 stated she cannot use her CPAP machine because the mask was missing. This is evidenced by: The facility's policy Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy), dated 1/9/26, includes: It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice. CPAP, or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth. 3. The CPAP. device must be set up and maintained. 5. The facility will follow the manufacturer's instruction for use of the machine. 9. Replace equipment immediately when it is broken or malfunctions, or if visible soiling remains after cleaning. R6 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, morbid obesity, asthma, and obstructive sleep apnea. R6's BIMS (Brief Interview for Mental Status), dated 5/8/26, has a score of 13, indicating R6 is cognitively intact. R6's physician orders, printed on 7/22/26, include CPAP at night while sleeping or napping. for sleep apnea related to obstructive sleep apnea. R6's comprehensive care plan, printed on 7/22/26, includes .has altered respiratory status/difficulty breathing r/t (Related To) OSA (Obstructive Sleep Apnea), uses CPAP at noc (Night)On 7/22/26 at 8:35 AM, Surveyor and LPN M (Licensed Practical Nurse) interviewed R6. R6 indicated she has not had a mask for approximately one month for her CPAP machine. Surveyor and LPN M observed R6's CPAP machine with no mask. On 7/22/26 at 8:40 AM, Surveyor interviewed LPN M. LPN M indicated R6 should have a mask for her CPAP. LPN M indicated staff should have reported R6 does not have a mask so one could have been ordered. On 7/22/26 at 9:30 AM, Surveyor interviewed NP P (Nurse Practitioner). NP P indicated R6 should be wearing her CPAP as ordered. NP P indicated she expected staff to ensure R6 had a mask for her CPAP. On 7/22/26 at 11:18 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she was not aware R6 was not using her CPAP. DON B indicated she expected staff to ensure R6 had a mask for her CPAP. On 7/22/26 at 1:34 PM, Surveyor and NHA A (Nursing Home Administrator) interviewed R6. NHA A asked R6 if she uses her CPAP. R6 stated she is not able to use her CPAP because when staff were cleaning her room, they swept up the mask and threw it away. R6 indicated she had told a CNA (Certified Nursing Assistant) and a nurse. R6 indicated it has been about one month. R6 stated she would use her CPAP if it had a mask. NHA A indicated staff should have ordered a mask for R6 so she could use her CPAP machine.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for accidents. On 3/9/26, CNA C (Certified Nursing Assistant) was providing perineal care to R1. CNA C had R1 positioned on her left side which has paralysis from a stroke and toward the left side of the mattress versus the middle. Per NHA A (Nursing Home Administrator), CNA C turned to get more wipes and removed her hand from R1 for two (2) seconds. R1 fell from the bed onto the floor. R1's fall was unwitnessed as CNA C did not observe R1's fall from bed. R1 was not positioned toward CNA C for added stability nor did R1 have anything to hold onto with her right hand while positioned on her left side. On 3/10/26 an x-ray was obtained indicating No acute fracture or dislocation. On 3/11/26 R1 was sent to the emergency department. A computed tomography (CT) scan indicated a displaced fracture of greater trochanter of right femur (right hip).Evidenced by:The Facility's policy and procedure, Accidents and Supervision, reviewed 7/12/25, indicates, in part, as follows: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s) 2. Evaluating and analyzing hazard(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s) 4. Monitoring for effectiveness and modifying interventions when necessary. Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident. Fall refers to unintentionally coming to rest on the ground, floor or other lower level. Risk refers to any external factor, facility characteristics (e.g. staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident.A root cause analysis should be completed to determine: i. Specific interventions to keep the residents safe ii. Necessary supervision and monitoring of the resident Implementation of Interventions: .Providing training as needed.R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to the following: cerebrovascular disease (conditions affecting blood flow to the brain), hemiplegia and hemiparesis (a neurological condition causing paralysis or weakness on one side of the body) affecting the left side following cerebral infarction (stroke), vascular dementia (a decline in thinking skills resulting in memory loss, impaired decision making, and impaired safety awareness). cramp and spasm (muscle contraction commonly affecting calves, thighs or feet), muscle weakness, and contracture left hand,(a shortening of muscles causing rigid joint deformities and restricted movement. R1's Annual Minimum Data Set (MDS) dated [DATE] indicates R1 has a Brief Interview of Mental Status (BIMS) of a 7 out of 15, which indicates she is severely cognitively impaired. R1 has an Activated Power of Attorney for Health Care (APOAHC).R1's comprehensive Care Plan for Activities of Daily Living (ADLs): The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) activity intolerance, hemiplegia (left sided weakness), impaired balance, stroke, confusion. Goal: The resident will maintain current level of function through the review date. Interventions: May have side rails as an enabler, upper right (Date Initiated 12/11/25)Bed Mobility: R1 requires assistance by 1 staff to turn and reposition in bed and as necessary; (Revised 12/9/25)Contractures: R1 has contractures of the left hand. Apply carrot splint (used to treat hand contractures by separating fingers) as R1 allows. (Revised 12/9/25)Transfer: R1 requires assistance by 2 staff to move between surfaces via mechanical lift and as necessary. (Revised 12/9/25) R1's Fall report indicates the following: Fall Report: 3/9/25 5:30 AM Witnessed Fall without head injuryLevel of Consciousness: AlertMobility: Wheelchair boundMental Status: Baseline for individual; Oriented to placePredisposing environmental factors: OtherPredisposing physiological factors: Incontinent; Other; Weakness/FaintedOther information: was receiving care for large BM (bowel movement)On 3/9/26 at 5:53 AM, RN D (Registered Nurse) documented the following Progress Note: Resident (R1) was receiving incontinent cares from CNA C (Certified Nursing Assistant). R1 had a very large BM (bowel movement). CNA C was doing cares on R1 and reached back to get wipes and R1 slid out the left side of the bed. When writer (RN D) entered the room resident was on floor on left side of room. She was laying supine on her back with a pillow under her head. Writer spoke with R1 and did quick assessment and then assisted CNA's with getting R1 up with hoyer lift (full body lift). Provider notified via hucu (communication application). DON B (Director of Nursing) made aware of incident. Admin (Administration) also aware. Vitals 98.2 sats 94% bp 132/59.On 3/9/26 at 6:05 AM, RN D documented the following Progress Note: Pain Score: 0 Pain Evaluation Summary; R1 does not appear to be in pain, is at baseline. At normal functional level. On 3/9/26 at 6:13 AM RN D documented the following: Change in Condition: Falls Blood Pressure (BP): 132/52; Pulse (P): 71; RR (Respiration Rate): 18; Temperature (T): 98.2 Pulse Oximetry: 95%; Blood Glucose: 172Of note, RN D did not specifically document range of motion (ROM). RN D stated to Surveyor that she assessed R1's ROM and R1 was at baseline with no concerns noted. On 3/9/26 at 6:13 AM, RN D documented the following Progress Note: Called (name) R1's APOAHC and informed her of fall. All questions answered.On 3/9/26 at 12:08 PM, DON B documented the following Progress Note: LATE ENTRY IDT (Interdisciplinary Team Review) R1 had witnessed fall off of bed while resident [sic] was changing resident's brief, staff turned to grab additional wipes and resident rolled off of edge of left side of bed. Resident did hit head, provider and POA (Power of Attorney) notified of fall, facility protocol followed and neuros initiated. Neuros WNL (within normal limits), no apparent injury at time of falls.Immediate Intervention: Staff to utilize 2 assist for bed mobility/cares.Immediate Intervention appropriate: YesIDT (Interdisciplinary Team Review) Intervention: R1 is on a low air loss mattress that is no longer needed due to previous PI (pressure injury) being resolved, R1 could benefit from having a pressure reducing mattress in place of low air loss mattress, as well as a left side rail to assist with bed mobility and promote independents [sic]. PT/OT (Physical Therapy/Occupational Therapy) will evaluate R1.Goal: Prevent serious injury r/t (related to) fall On 3/10/26 at 6:38 AM, LPN F (Licensed Practical Nurse) documented the following Progress Note: CNA E reported that while she was changing R1 she heard a loud cracking sound come from R1's R (right) leg. LPN F could not see any protruding bones, but R1 stated that she was having a lot of pain in her R hip. Vitals signs are stable. LPN F notified the provider. Order was given to get an x-ray of R1's R hip. X-ray company was called and set up appointment for today.LPN F completed a Change in condition: Pain (uncontrolled). Blood Pressure: 141/70; Pulse: 73; Respirations: 18; Pulse Oximetry: 94%; Blood Glucose: 172Primary Care Provider Feedback: Obtain R (right)-hip x-ray R1's Radiology Report (x-ray) documents the following:Date of Service: 3/10/26Report Date: 3/11/26 7:16 AMResults: Mild joint space loss with subchondral sclerosis of the femoral acetabular joint consistent with osteoarthritis. *No acute fracture or dislocation.Conclusion: No acute osseous (bone) abnormality. Consider cross-sectional imaging correlation if there is a concern for a radiologically occult fracture (a broken bone that does not appear on initial x-rays but causes pain, swelling, and tenderness, often following a fall, repetitive stress, or due to weak bones.) On 3/11/26 at 5:37 PM, R1's Progress Notes document as follows: R1 sent nonemergent stretcher to hospital ER (emergency room)ER report documents the following diagnoses: Fall, initial encounter, Displaced fracture of greater trochanter of right femur, initial encounter for closed fractureCT Hip Right without Contrast: Result Date: 3/11/26Impression: 1. Mildly displaced (bone fragments have shifted) and slight comminuted fracture (broken bone with multiple pieces commonly caused by severe trauma) of the greater trochanter of the right femur.NHA A (Nursing Home Administrator) documented the following typed statement for CNA C. Writer, NHA A, met with DON B (Director of Nursing) and CNA C via phone to interview her related to a fall with fracture of a resident (R1's) right hip. CNA C stated that she came into the resident's room with incontinence supplies and placed them on the bedside table. CNA C said that she began to clean the resident. She (CNA C) stated that she placed her hand on the resident's hip and reached back to grab more products. While reaching for more product R1 slid to the other side of the bed and to the floor. CNA C stated that it happened very fast and that she did not have time to react. (It is important to note, CNA C did not sign this statement. In addition, the facility did not obtain a written statement from CNA C following R1's fall from bed. CNA C was the only staff member in the room when the fall occurred.)On 4/7/26 at 3:00 PM, Surveyor attempted to speak with R1. R1 declined to speak with Surveyor. On 4/7/26 at 3:15 PM and 4/8/26 at 4:00 PM, Surveyor spoke with CNA C. Surveyor asked CNA C to describe what occurred while assisting R1 with perineal care and the fall on 3/9/26. CNA C stated she was working the NOC (night) shift and doing her regular rounds. CNA C stated R1 was soiled and needed to be changed. CNA C stated she brought the needed supplies to R1's room with her. CNA C stated R1 had an XXL (extra extra large) bowel movement and it took longer to clean than normal. CNA C stated, R1 was positioned on her left side in bed and facing the wall with the window. CNA C stated she was standing behind R1. CNA C stated she had one (1) hand on R1 and was using her other hand to pull wipes out of the package. CNA C stated she did not see R1 fall as she was turned to grab more wipes and suddenly R1 rolled off the bed onto the floor (Note: Surveyor asked CNA C, which side of the bed did R1 roll off. CNA C stated the left side of the bed nearest the window. Surveyor asked CNA C, did R1 complain of any pain after the fall. CNA C stated, no, she did not. CNA C stated she immediately notified RN D (Registered Nurse). CNA C stated, RN D assessed R1, took vital signs, and asked her questions. CNA C stated, R1 was a 1 assist with perineal care and bed mobility. CNA C stated, my hand was never off her (R1) (prior to the fall). Surveyor asked CNA C, how was R1 positioned in the bed. CNA C stated, when she first walked in the room R1 was positioned in the middle of her bed. CNA C stated, R1 could have been closer to me and not on the edge of the bed. Surveyor asked CNA C, did the facility provide education to her as well as other staff following this incident. CNA C stated, yes. CNA C stated the facility provided education regarding making sure R1 (and all residents) are in the middle of the bed before starting cares, turning and repositioning residents, they did an evaluation for 2 assist, added 1 extra enabler bar (to the left side of R1's bed), and educated if staff notice that a resident is not able to stay positioned safely during cares to report this to the nurse. CNA C stated this has never happened with R1 prior to this. CNA E's typed statement documents as follows: I, CNA E, was repositioning R1 in her bed. I was turning R1 on to her left side with her help. I heard a cracking noise, R1 asked if I heard that and stated that her hip was in pain. I notified the nurse (LPN E) (Licensed Practical Nurse). CNA E signed the statement.On 4/7/26 at 4:00 PM, Surveyor spoke with CNA E. CNA E stated she was unable to talk at this time and would return Surveyor's call. CNA E has not returned Surveyor's call.LPN F's (Licensed Practical Nurse-Agency) typed statement documents as follows: NHA A interviewed LPN F about the nurses' note on the 10th that indicated CNA E heard a pop while providing incontinent care. LPN F stated that she conducted ROM (range of motion) and R1 had complaints of pain to her right hip area. MD (Medical Doctor) and POA (Power of Attorney) notified and initial x-ray was negative. CT (computed tomography) scan indicated a fracture to the right trochanter. LPN F signed the statement.On 4/7/26 at 4:02 PM, Surveyor spoke with LPN F (Agency). LPN F stated, CNA E notified her when CNA E was providing perineal care to R1 that she heard a crack or a pop. LPN F notified the provider who ordered an x-ray. The x-ray was completed that day. LPN F stated, R1 was in pain. R1 was provided with pain medication and monitored.On 4/8/26 at 2:45 PM, Surveyor spoke with CNA G. CNA G stated, she has worked at the facility for 31 years. CNA G is a consistent caregiver for R1. Surveyor asked CNA G, what R1's ability was with rolling and assisting during perineal care prior to her hip fracture. CNA G stated, R1 would just roll when you ask her to roll. CNA G stated, however, R1's level of cooperation depends on her mood. CNA G stated, if R1 is in a good mood she will help staff roll her with 1 hand using the enabler bar on R1's right side. CNA G stated, if R1 is in a bad mood she will not help staff roll her. CNA G stated, R1 has a short temper and gets upset easily. CNA G stated it is important to have everything ready (clarified supplies) before providing care to R1. CNA G stated, if staff are taking too long R1 gets upset. CNA G stated, it is not safe to walk away or turn away from R1 while providing perineal care. CNA G stated a left enabler was added to R1's bed following R1's fall out of bed. Surveyor asked CNA G, when providing perineal care to which side do you roll R1. CNA G stated, most of the time she will roll R1 on her left side so she is facing the window. CNA G stated, R1 can use her arm (right) to hold on if she has something to grab. CNA G stated, if R1 gets upset CNA G will tell her it is CNA G's fault and that will calm R1.On 4/8/26 at 3:20 PM, Surveyor spoke with DON B. Surveyor asked DON B to walk to R1's room with Surveyor. Surveyor asked DON B, which enabler bar did R1 have in place at the time of her fall from bed. DON B stated, R1 had a right enabler bar (clarify-R1's right side while she is lying in bed on her back) at the time of her fall. DON B stated, R1 would use the enabler bar to push herself up in bed. DON B stated a second enabler bar was added to the left side of R1's bed following R1's fall from bed. DON B stated the second grab bar was added so when R1 turns toward the left she has something to reach/grab onto with her right hand. DON B stated, prior to the fall with fracture R1 could use her right arm with the right enabler bar to turn on her side. DON B stated, R1 (and all residents) should be positioned in the middle of the bed. DON B added, staff should always be with that resident. DON B stated the facility educated staff regarding having supplies at bedside in reach. DON B stated, We determined that R1 was toward the left side of the bed not the center. Surveyor asked DON B, should CNA C (Certified Nursing Assistant) have positioned R1 in the center of the bed prior to starting perineal care. DON B stated, yes. DON B stated, we immediately did education with CNA C. Surveyor asked DON B, why is it important for R1 and other residents to be positioned in the center of the bed prior to starting perineal care. DON B stated, for safety it's important there's equal distance on either side of the bed. On 4/8/26 at 3:40 PM, Surveyors spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A to describe R1's fall from bed and actions taken by the facility. NHA A stated, RN D assessed R1's range of motion, R1's ROM was at baseline with no concerns noted. NHA A stated, the facility investigated how R1 fell. NHA A stated that the facility reviewed R1's care plan. NHA A stated, she interviewed CNA C about how R1 slid out of bed. NHA A stated, R1 had a low air loss mattress. NHA A stated, she has seen other residents (not at this facility) fall from a low air loss mattress and break both legs. NHA A stated, CNA C had had her hand on R1 and when CNA C turned to get more wipes her hand must have come off. NHA A stated, if R1 had something to hold she could have told CNA C she was slipping. NHA A stated, therapy worked with R1 regarding turning and repositioning following the fall from bed. NHA A added, the facility removed R1's low air loss mattress, notified R1's APOAHC (Activated Power of Attorney for Health Care), educated CNA C immediately and all staff. NHA A stated, she gave R1's APOAHC her personal phone number and had an in-person discussion with R1's APOAHC and another family member. NHA A stated, R1 knows about the fall but cannot elaborate. NHA A stated R1 had no complaints of pain after the fall and then started to have pain about 24 hours later. Surveyor asked NHA A, what is the root cause of R1's fall with fracture. NHA A stated, R1 was rolled to her weakened side (her left side with no movement following stroke), did not have anything to hold onto (no grab bar on left side of bed at the time of the fall), and CNA C was reaching behind her instead of having a hand on R1. Surveyor asked NHA A, if a resident is being repositioned in bed prior to perineal care where they should be positioned in the bed. NHA A stated, the middle of the bed and be secure - able to hold onto something. NHA A stated, if staff need to leave they should lower the bed to the lowest position and cover the resident for dignity. NHA A stated, R1 and CNA C needed education on securing R1's body. Surveyor asked NHA A, where was R1 positioned in the bed prior to CNA C providing perineal care. NHA A stated, she is not sure. NHA A stated, she is not aware R1 was positioned to the left side of the bed versus middle. NHA A stated, she thinks what occurred is when R1 was turned to her left side her legs may have gone off the bed and her body then follows. NHA A stated, I can't answer to that because I don't think that occurred. NHA A stated, she believes R1's weight was shifted and R1 fell off the low air loss mattress. NHA A stated, CNA C said she had her hand off R1 for two (2) seconds and it happened so fast. Surveyor asked NHA A, do you expect staff to be holding onto the resident at all times (secured). NHA A stated, yes. Surveyor asked NHA A, would you have expected staff to roll R1 toward them versus away to provide stability to R1 while in bed on her side. NHA A stated, yes.On 3/13/26 the facility educated twelve (12) staff members regarding Turning and RepositioningOn 4/3/26 the facility educated eighteen (18) staff members regarding the following:Preventing FallsMake sure you have products in front of youMake sure the resident is in the middle of the bedDo not turn away from residentHave the resident help and communicate with the resident to ensure they are comfortable Maintaining residents and staff's safety is a priority:Only leave the room when the bed is in the lowest position and your resident is safe from fallingUse the call light to ask for assistance if you need more products or forgot itemsNever leave resident in an unsafe positionIf the resident seems like they have had a physical decline complete a Stop and Watch The facility has 74 staff members and 58 agency staff that have worked over the past 30 days.As of 4/7/26 the facility has educated a total of 30 staff / agency staff with an education rate of approximately 22.7%. The facility failed to educate staff regarding positioning residents towards them while providing perineal care.CNA C rolled R1 away from CNA C, R1 was lying on her affected side, while cares were being provided resulting in R1 sustaining a fall due to sliding off the bed. R1 was noted to have increased pain and a fractured right femur on 3/11/26. On 4/9/26 The facility provided additional information for review.

Based on observation, staff interview, and record review the facility did not provide special assistive eating equipment for 1 of 3 sampled residents (R6) reviewed for assistive devices. The facility did not provide R6 with a built-up utensil (adaptive eating tools with thickened handles, designed for residents with limited gripping strength or hand tremors) as indicated per plan of care. Evidenced by: R6 was admitted with diagnoses of cerebral palsy (a neurological disorder affecting movement and muscle tone) and epilepsy (a chronic neurological disorder characterized by seizures causes by abnormal electrical activity in the brain). R6's meal ticket on 4/7/26 (breakfast) states in part, as follows: Built up utensils R6's comprehensive care plan documents as follows: Focus: R6 has nutritional problem or potential nutritional problem r/t (related to) multiple medical diagnoses including epilepsy (a chronic neurological disorder characterized by seizures causes by abnormal electrical activity in the brain).DM (diabetes mellitus), anxiety; need for therapeutic diet, and need for skilled nursing care, wt (weight) loss x 180 days at risk of malnutrition (Date Initiated: 3/18/26) Goal: R6 will maintain adequate nutritional status as evidenced by maintain weight. Interventions: Adaptive equipment: lipped plate, heavy weight built up silverware (Date Added: 4/6/26) On 4/7/26 at 8:30 AM, Surveyor observed R6 eating her breakfast. Surveyor observed regular silverware on R6's breakfast tray. R6 stated, she is supposed to receive built up utensils and when she asks staff for them, they do not listen to her. Surveyor observed R6's meal ticket on her tray indicated Built up utensils. Surveyor observed R6 eating Fruit Loops with a regular spoon. R6 stated that it is difficult for her to hold regular silverware. Surveyor observed R6 having difficulty eating with a regular spoon. On 4/7/26 at 8:48 AM, Surveyor spoke with CNA M (Certified Nursing Assistant). Surveyor asked CNA M if R6 should have built up utensils on her meal tray per her care plan. CNA M stated, yes. On 4/8/26 at 11:40 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if R6 is to have built up utensils during meals. DON B stated, yes. Surveyor asked DON B, do you expect staff to provide R6 with built up utensils per her meal card. DON B stated, yes.

Based on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect the census of 63. DA D (Dietary Aid) was observed stacking wet dishes without allowing them ample time to dry. Evidenced by: Facility policy entitled Warewashing, states in part: .All dishware, serviceware, and utensils will be cleaned and sanitized after each use. Procedures 1. The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware .4. All dishware will be air dried and properly stored. On 2/16/2026 at 1:03 PM, Surveyor observed dishwashing. Surveyor observed DA D (Dietary Aide) remove 10 glass plates, 9 metal plate warmers, and 5 bottom lids for the plate warming system, from the dishwashing rack while still wet from being washed. Surveyor observed DA D stack them on a black cart face up into a stack of plates, a stack of metal plates, and a stack of bottom lids. At 1:07 PM, DA D placed more wet plates, metal inserts and bottom lids on top of the current stacks on the black cart while still visibly wet. Surveyor asked DM E (Dietary Manager) if wet stacking was occurring. DM E indicated the items should be dry before putting them into the warmer. DA D started to bring the black cart with the wet stacked dishes out of the dishwashing room. DM E asked DA D what he was planning to do with the dishes. DA D indicated he was going to put the items into the plate warmer. (Of note, dishes were still visibly wet.) DA D was instructed by DM E to let the dishes dry before putting them into the heated plate warmers. DA D placed the glass plates, metal plate warmers, and lids onto a drying rack facing upside down, while still stacked together. Surveyor asked DM E how bacteria grow, DM E indicated bacteria can grow in water and heat. On 2/16/2026 at 1:57 PM, Surveyor asked KM F (Kitchen Manager) to separate the stacked plates to see if they were dry. KM F removed a section of glass plates that were previously wet stacked, and both surveyor and KM F noticed condensation was still visible on the plates. Surveyor asked KM F are the dishes able to dry by air flow when they are stacked, KM F stated No. KM F then began putting the plates in trays to air dry them. On 2/16/26 at 3:30 PM, KM F came to Surveyor and indicated DA D was newer and was not trained correctly. KM F indicated that wet stacking should not occur.

Based on interview and record review, the facility did not follow through on a recommendation from the Audiologist for hearing aides/amplification for a resident who expressed not being able to hear for 1 (R60) of 24 residents reviewed for hearing. R60 received an order for hearing aids, and this order was not fulfilled. This is evidenced by: Facility policy: Hearing and Vision Services, revised 3/2025 states in part: . Guideline: It is the guideline of the facility to ensure all residents have access to hearing services and receive adaptive equipment as indicated. R60 was admitted to the facility on [DATE] and has diagnoses that include Type II Diabetes Mellitus, Schizophrenia, and Major Depressive Disorder. R60's Minimum Data Set (MDS) assessment, dated 8/26/2025, indicated that resident has a BIMS (Brief Interview for Mental Status) of 14, which indicates the resident's cognition is intact. R60 does not have a care plan related to hearing loss. On 02/16/2026 at 3:26 PM Surveyor interviewed R60 during initial screening. R60 reported that a lady came here to test my hearing, said I needed hearing aides, but then never brought them to me. On 02/17/2026 at 2:32 PM during record review surveyor found that R60 had a Health Direct Audiology appt (appointment) on 9/10/25. Recommendations from this appt are as follows: Otoscopy Right Ear Non-Occluded. Audiological Right Ear Mild to Severe Sensorineural Hearing Loss Findings Left Ear Mild to Severe Sensorineural Hearing Loss Hearing Aid Recommendations: Binaural Make/Model: [NAME] Laboratories, Inc. /[NAME] Genesis Al 12 ITER Half [NAME] or Comparable Benefits of Amplification: Patient is eager for amplification to improve hearing in all situations. On 2/17/2026 at 3:08 PM Surveyor interviewed SW G (Social Worker). SW G reports that she has only been here three months, and she believes that NHA A was filling the role until the position was filled. Surveyor asked SW G what the process is after a resident sees Health Direct for Audiology. SW G reported that the audiologist sends a summary via email, to a group of people SW G, NHA A (Nursing Home Administrator), and DON B (Director of Nursing). If there are any follow-up orders, they should be placed and then they are seen every 90 days by the Audiologist. Surveyor asked SW G who gives the nurse the order to put into the system. SW G indicated that the forms come from Health Drive to SW G and then she is responsible for giving them to the RN (Registered Nurse) on the floor, and then they go to Medical Records. Surveyor asked SW G if the resident has orders to obtain a hearing aid what is the process you follow. SW G stated that nursing follows up with the order and SW follows up with the resident about getting the hearing aide. On 2/18/2026 at 9:07 AM Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked what the process was when a resident saw Health Drive. NHA A reports that if the resident has orders from the MD they will talk with the nurse on the floor. If there are no orders, the summary and recommendations, if any, will be emailed to SW G, DON B, and NHA A. NHA A stated that herself and DON B just started getting the emails. SW G will pull anything that needs to be addressed. When residents decide to follow recommendations (i.e.: hearing aide) then SW G is responsible for working with resident and get consent, discuss with family, and financial paperwork or prior authorization. NHA A stated that she knew this situation was about R60. NHA A stated that the recommendation was for amplification, which she said she provided to R60. Surveyor had NHA A look at R60's after visiting communication from Health Drive. Surveyor asked NHA A if she saw that the first recommendation was for [NAME] Genesis A1 12ITER Half [NAME] hearing aids. NHA A replied yes. NHA A reported that she will need to find out what happened to the order. On 2/18/2026 at 9:14 AM Surveyor asked R60 if anyone had ever brought her an amplification device. R60 stated I wish someone would bring me something so I can hear. A couple of weeks after I saw the Audiologist they (staff, doesn't remember who) were going to bring something down to me but they never did. On 2/18/2026 at 9:55 AM Surveyor interviewed NHA A. Surveyor asked when R60 had been given the amplifiers, as R60 stated she never received them. NHA A said she had just bought them last night and was going down to give R60 the amplifier today. On 2/19/2026 at 9:56 AM Surveyor interviewed NHA A. Surveyor asked if NHA A had any other information regarding R60. NHA A stated no. Surveyor asked NHA what the process should be when a resident sees Health Drive. NHA A stated that once the resident is seen, whatever provider is in the building should exit with SW G. Once Health Drive finishes the paperwork it is emailed to SW G, NHA A, and DON B and SW G is responsible for getting orders and giving to nursing. Once the order is in, the social worker needs to get consent from the POA and talk to the resident and lastly follow up to see if the resident received what was ordered. Surveyor asked NHA if she would expect that this process should be followed with all Health Direct orders. NHA replied yes.

Based on interview and record review, the facility did not ensure that: (i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; (ii) The resident or his or her representative acknowledges that he or she understands the agreement for 2 of 2 Residents (R2 and R72) reviewed for arbitration agreements. R2 indicated the arbitration agreement was not fully explained and he/she would not have signed if he/she knew there would no longer be the right to use the judicial system to resolve a dispute with the facility.R72 indicated the arbitration agreement was not fully explained and he/she would not have signed if he/she knew there would no longer be the right to use the judicial system to resolve a dispute with the facility.Evidenced by:The facility's Binding Arbitration Agreements policy, dated 12/12/24, states, in part: This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility. Definition: Arbitration is a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments. Arbitrator is an independent person or body officially appointed to settle a dispute. When explaining the arbitration agreement, the facility shall: .b. Explain to the resident and his or her representative in a form and manner that he or she understands. Example 1R2 was re-admitted to the facility on [DATE].R2's MDS (Minimum Data Set), dated 1/23/26, indicates a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident is cognitively intact.R2's Arbitration Agreement, signed and dated 1/22/26, states, in part: It is understood and agreed by facility and R2 that any legal dispute, controversy, demand, or claim, unless specifically excluded below, that arises out of or relates to the Resident admission Agreement or any service or health care provided by the Facility to the Resident shall be resolved exclusively by binding arbitration and not by a lawsuit or resort to judicial process.On 2/17/26 at 1:54 PM, Surveyor asked R2 about binding arbitration. R2 stated R2 did not recall any conversation with the facility about binding arbitration. Surveyor reviewed R2's signed Arbitration Agreement form with R2. R2 stated no, I wouldn't want that. Example 2R72 admitted to the facility on [DATE].R72's MDS (Minimum Data Set), dated 2/3/26, indicates a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident is cognitively intact.R72's Arbitration Agreement, signed and dated 2/5/26, states, in part: It is understood and agreed by facility and R72 that any legal dispute, controversy, demand, or claim, unless specifically excluded below, that arises out of or relates to the Resident admission Agreement or any service or health care provided by the Facility to the Resident shall be resolved exclusively by binding arbitration and not by a lawsuit or resort to judicial process.On 2/17/26 at 2:26 PM, Surveyor interviewed R72 and asked about binding arbitration. R72 stated, yes there was a form, if I wanted to have that option, that I could sign, and then I would be allowed to dispute something. I signed it just in case; you want to be allowed to do that, dispute something. Surveyor reviewed the agreement with R72 and explained that a dispute would be resolved using an appointed third party (arbitrator) and would not use the judicial system. R72 stated, I don't think it was explained to me like that. Surveyor asked if R72 had been given this explanation if R72 would have signed the form. R72 said no. On 2/17/2026 at 2:29 PM, Surveyor interviewed BOM C (Business Office Manager) and asked about the process for binding arbitration agreements. BOM C stated I go over it with admission documentation, let them know what it is, and that they have 30 days to change their mind. They don't need to sign if they don't wish. Surveyor asked how it is explained to the resident. BOM C stated if there is any type of dispute, it would be sitting down with lawyers and people involved (facility and resident/POA) to discuss if they can come to an agreement on what is happening before it goes on to the legal system. If they are unable to come to an agreement it would go to court. On 2/17/2026 at 2:36 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about binding arbitration. NHA A reviewed the form and stated by signing this they are asking them (the resident) to work with the facility and their arbitrators to come to some type of agreement. This form says they cannot use the legal system. I would expect that it would be explained that the legal system would not be an option. The resident should not sign something that they don't understand. Surveyor asked if staff should have a clear understanding of the document and be able to accurately explain it to a resident. NHA A stated yes.

Based on observation, interview, and record review the facility did not ensure that every resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (R4) of 6 sampled residents. R4 prefers staff to wear a mask when entering his room. Surveyor observed staff entering R4's room without a mask. Evidenced by: The facility's Resident Rights admission Document states, in part: . Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: . b. The right to participate in the development and implementation of his or her person-centered care plan, including but not limited to: 4. Respect and dignity.c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. 5. Self-determination.b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. R4 admitted to the facility on [DATE] and has diagnoses that include pneumonitis due to inhalation of food and vomit (inflammation of the lung tissue leading to symptoms like shortness of breath, dry cough, fatigue, and fever) and chronic kidney disease stage 3 (kidneys have moderate damage with a glomerular filtration rate between 30-59 mL/min where waste and extra fluid buildup causes fatigue, swelling, and potential issues like high blood pressure or anemia). R4's Minimum Data Set (MDS) Quarterly Assessment, dated 12/10/25, shows R4 has a Brief Interview of Mental Status (BIMS) score of 14 indicating R4 is cognitively intact. On 12/15/25 at 10:15AM, Surveyor observed a sign on R4's door stating, Please wear a mask when you enter. Surveyor observed a dry erase board on the railing next to door to R4's room stating, R4 wants staff to wear a mask to enter his room. On 12/15/25 at 10:20AM, Surveyor observed CNA D (certified nursing assistant) enter R4's room without a mask. CNA D did not ask R4 when entering R4's room if he would like her to have a mask on. On 12/15/25 at 10:26 AM, Surveyor interviewed CNA E outside of R4's room. Surveyor asked CNA E what the sign on the door and next to the door meant. CNA E indicated the signs were from COVID in the past and were R4's preference for staff to wear a mask at that time. Surveyor asked CNA E if staff follow the sign. CNA E indicated it does not bother R4 if staff go in without a mask. CNA E indicated staff just go in R4's room without a mask. On 12/15/25 at 10:35AM, Surveyor observed CNA E enter R4's room without a mask or without asking R4 if she could enter without a mask. On 12/15/25 at 10:40AM, Surveyor interviewed R4 and asked R4 about the sign on his door. R4 indicated it is his preference staff do not enter his room without a mask. Surveyor asked R4 when staff come in without a mask does it upset him. R4 indicated yes, it does a little bit. Surveyor asked R4 if he prefers staff do wear a mask and R4 indicated yes. On 12/15/25 at 2:52 PM, Surveyor interviewed DON B (director of nursing). Surveyor asked if she would expect residents' preferences and choices to be respected. DON B indicated yes. Surveyor asked if residents' preferences and choices should be care planned, and DON B indicated yes. Surveyor informed DON B of observation of R4's sign on the door and staff entering room without a mask. DON B indicated she had just become aware of the sign a week ago. DON B indicated R4 did inform her R4 would like staff to wear a mask when in his room. DON B indicated R4 was ok with some staff not wearing a mask. DON B indicated she would expect staff to ask R4 if it was ok to enter without a mask before entering his room. UM F (unit manager) indicated she would add it to care plan right away as it was not in there.

Based on observation, interview, and record review, the facility did not ensure that each resident has a safe, clean, comfortable and homelike environment for daily living for 1 of 6 sampled Residents (R2).Surveyor observed a commode in R2's room with a brown substance on the seat and arm.Findings Include:The facility policy, Safe and Homelike Environment, revised 7/1/25, indicates, in part: Guideline: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment.Definitions: . Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in completion of the activities of daily living.R2 was admitted on [DATE]. R2's most recent MDS (Minimum Data Set), dated 11/13/25, documents a BIMS (Brief Interview for Mental Status) of 00, indicating R2 is severely cognitively impaired. On 12/15/25 at 10:13AM, during general observations of the facility, Surveyors noted a commode in R2's room with a brown substance on the seat and the arm of the commode. On 12/15/25 at 11:20AM Surveyors noted the brown substance still present on R2's commode and interviewed LPN C (Licensed Practical Nurse) in R2's room regarding this. During the interview LPN C indicated that the commode was not clean and that she felt the brown substance was stool. LPN C indicated that R2 requires assistance to the commode and that whoever assisted him should have ensured the commode had been cleaned afterwards. LPN C indicated she would clean it.On 12/15/25 at 3:06 PM Surveyors interviewed DON B (Director of Nursing). During the interview DON B indicated she would expect staff to clean and empty the commode after resident use. Surveyors reviewed the above observation with DON B who indicated the commode should have been cleaned after use.

Based on interview and record review, the facility failed to ensure the results of all investigations of alleged violations were reported to the resident or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 2 Facility Reported Incidents reviewed.An initial Facility Reported Incident alleging possible misappropriation of property was submitted to the State Agency on 12/7/25. The facility submitted the results of their internal investigation to the State Agency on 12/15/25, which is outside of the required timeframe of 5 working days.This is evidenced by:The facility policy entitled Abuse, Neglect, and Exploitation with a review date of 5/25 states in part: .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.Reporting/Response.B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . On 12/7/25 at 3:30 PM, the facility was made aware of an allegation regarding R3 missing $160.00. The facility immediately started an investigation and submitted a report to the State Agency at 12/7/25 at 4:19 PM.On 12/15/25, Surveyor reviewed the facility's investigation regarding the misappropriation of money for R3. Surveyor noted the facility submitted the results of their internal investigation on 12/15/25. Surveyor noted this is 6 working/business days or 8 calendar days since the incident was initially reported. (12/12/25 would have been 5 working days since the incident was reported).On 12/15/25 at 3:45 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A when results of internal investigations from Facility Reported Incidents should be reported to the State Agency; NHA A stated 5 business days. NHA A added the results from this particular investigation were reported late due to waiting for a response from R3's daughter to see if she has the money. NHA A told Surveyor the investigation results should have been reported within 5 business days.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 72 of 72 residents. Surveyor observed left over food items not properly covered, labeled, or dated. Surveyor observed cleanliness concerns in main kitchen. Surveyor observed staff in kitchen not wearing beard restraints. Surveyor observed food being stored on the floor in the dry storage, walk in refrigerator, and walk in freezer. Surveyor observed staff touching the inside surface of a container used to hold food with their bare hands. Surveyor observed staff prepare food without using a recipe. This is evidenced by: The facility's policy Food Preparation Guidelines, dated 12/17/24, includes: The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. The facility's policy Date Marking for Food Safety, dated 5/26/24, includes: The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall consist of the day/date of opening, and the day/date the item must be consumed or discarded. The facility's policy Food Safety Requirements dated 5/26/24, includes: .keep foods/beverages in a clean, dry area off the floor. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its us-by date. Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. On 8/20/25 at 8:50 AM, Surveyor completed an initial tour of the kitchen with DM C (Dietary Manager). Surveyor observed the following: In the walk-in refrigerator: There were small bowls of prepared salad on a baking sheet on a storage rack. The lettuce was brown, and the salads were partially covered with parchment paper. The salads were not dated with a preparation date or use by date. There were 8 pitches of varying amounts of purple and pink liquid that were not dated with a preparation date or use by date. There was a crumpled up individual chocolate milk carton on the floor under the storage rack. There was food debris scattered on the floor. In the dry storage room: There were personal belongings on the floor and a box of personal belongings on the floor left from the previous dietary manager. There were boxes of snacks on the floor that included bags of chips and protein bars. There were pieces of paper and cardboard debris on the floor. In the walk-in freezer: There were empty boxes on the floor. There was packaging debris on the floor. There was food wrapped in plastic on the floor. Surveyor questioned DM C about the package of food on the floor. DM C picked up the package of food from the floor, stated the food inside was breadsticks and placed the package of breadsticks on the shelf, walked out of the freezer and shut the door. Surveyor asked DM C if he picked up the package of breadsticks and placed them on the shelf to later serve to the resident, DM C discarded the package of breadsticks. The main kitchen had food debris on the floor along with food wrappers. There were tops to individual butter packets on the floor. There were plastic bread ties on the floor. There was food spatter on the front surface of the stove and tray line. Broken eggshells were sitting on top of the flat top stove. During the initial tour of the kitchen, Surveyor interviewed DM C. DM C indicated the prepared salads should be properly covered and dated. DM C indicated the pitchers of fluids should be dated. DM C indicated food should not be stored on the floor and there should not be debris on the floor. DM C indicated the kitchen was not clean. On 8/20/25 at 11:36 AM, Surveyor observed the kitchen staff. Surveyor observed DM C, DA D (Dietary Aide), and DA F in the kitchen preparing the lunch meal. DM C, DA D, and DA F were not wearing beard restraints. On 8/20/25 at 12:12 PM, Surveyor interviewed DA D regarding his facial hair. DA D indicated he does have facial hair and should have been wearing a beard restraint and was not. DA D indicated he would put on a mask to cover his facial hair. On 8/21/25 at 8:16 AM, Surveyor observed DA D walk out of the kitchen, carrying a plate of food, without a beard restraint on. DA D walked back into the kitchen without donning a beard restraint. DA D walked back out of the kitchen wearing a mask. On 8/21/25 at 9:15 AM, Surveyor interviewed DM C regarding beard restraints. DM C indicated they started wearing masks after DA D was interviewed on 8/20/25 by the surveyor. DM C indicated the facility did not have beard restraints available and that is why the kitchen staff were wearing masks. On 8/21/25 at 2:30 PM, Surveyor went to the kitchen to observe the walk-in freezer. DA F answered the door, not wearing a beard restraint. DA F was observed walking across the kitchen and back again without a beard restraint. DA F indicated to surveyor he was not wearing a mask but should be. On 8/20/25 at 11:44 AM, Surveyor observed kitchen staff during the tray line process. DM C was obtaining the temperature of the foods on the tray line. DM C indicated the mashed potatoes were not at the right temperature and was going to correct them. DM C handed the metal container of mashed potatoes to DA U. DA U walked over to the coffee maker and dispensed an unmeasured amount of hot water into the mashed potatoes container. DA U carried the container to the prepping table and poured an unmeasured amount of potato flakes into the metal container of mashed potatoes. DA U whisked the potatoes and returned them to DM C. DM C rechecked the temperature of the mashed potatoes and the temperature still needed to be corrected. The kitchen staff placed the mashed potatoes into a pot on the stove to heat the mashed potatoes up. DM C went to get a new metal container and carried the new container to the tray line with his ungloved hand and was holding the container with his thumb on the inside of the container. On 8/25/25 at 2:10 PM, Surveyor interviewed DM C regarding recipe usage and safe handling of containers. DM C indicated DA U should have measured the water and potato flakes prior to adding them to the already prepared mashed potatoes. DM C indicated staff should only touch the outside of the containers or handles. DM C indicated he should not have placed his thumb inside the container for the mashed potatoes. On 8/21/25 at 3:11 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the observations made by surveyor in the kitchen. NHA A indicated the kitchen should be clean, food should not be stored on the floor, food should be covered and dated, staff should wear the appropriate facial hair restraints, recipes should be followed, and proper handling should be done of dishes. NHA A indicated the above observations were unacceptable and should not have happened.

Based on observation, interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 3 of 6 hallways. Surveyor observed 2 staff members incorrectly wearing PPE (Personal Protective Equipment) on the Covid-19 positive hallway. RN V (Registered Nurse) did not perform hand hygiene between glove changes. This is evidenced by: The facility's policy Personal Protective Equipment, dated 6/11/25, includes: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Personal protective equipment, or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infections agents. It includes gloves, gowns, face protection (facemasks, goggles, and face shields), and respiratory protection (respirators). All staff who have contact with residents and/or their environment must ear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. Respiratory protection: Select the size according to fit testing. Put on PPE in this order: gown, mask or respirator, goggle or face shield, then gloves. On 8/20/25, 8/21/25, 8/25/25, and 8/26/25, Surveyor observed the 100 hallway fire doors were closed and a sign was posted on both doors stating staff must wear a mask. On 8/20/25 at 9:00 AM, NHA A (Nursing Home Administrator) informed the surveyors the 100 hallway has Covid-19 positive residents. On 8/20/25 at 10:25 AM, Surveyor was on the 100 hallway and observed CNA I (Certified Nursing Assistant) entering a room. Surveyor observed CNA I wearing an N95 mask (a respirator) over a surgical mask. At 10:33 AM, Surveyor interviewed CNA I regarding PPE. CNA I indicated it was ok to wear an N95 mask over a surgical mask since he removed both masks upon exiting the room. On 8/20/25 at 2:17 PM, Surveyor was on the 100 hallway and observed CNA J in the hallway. CNA J was wearing an N95 mask over a surgical mask. Surveyor interviewed CNA J regarding PPE. CNA J indicated wearing an N95 mask over a surgical mask not correct and was not appropriate. On 8/25/25 at 10:36 AM, Surveyor interviewed DON B (Director of Nursing) regarding appropriate use of PPE. DON B indicated it is not the policy of the facility to wear an N95 mask over a surgical mask. DON B indicated wearing both masks at the same time is not a standard of practice. DON B indicated staff should not be wearing an N95 mask over a surgical mask. Example 2: Facility policy entitled ' Hand Hygiene,' states in part: all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR).additional considerations: a. the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. On 8/25/2025 at 12:25 PM Surveyor observed RN V (Registered Nurse) apply gloves, take out an insulin pen from the cart along with a new insulin cap needle. RN V then proceeded to go to R15's room with the insulin pen. RN V voiced to R15 that he's getting 2 units. RN V put the needle on R15's insulin pen, then removed her gloves. RN V did not use hand gel or wash her hands before putting on a new pair of gloves. RN V was observed dialing up 2 units and injecting the 2 units into R15's right arm. On 8/25/2025 at 12:33 PM Surveyor interviewed RN V (Registered Nurse) regarding Hand hygiene. RN V indicated she used gloves to prep her medications. Surveyor asked about Hand hygiene in between removing gloves, RN V indicated every time you remove your gloves. Surveyor asked RN V if she did hand hygiene between changing her gloves, RN V indicated I didn't touch anything. On 8/25/2025 at 3:02 PM Surveyor interviewed LPN T (Licensed Practical Nurse) regarding insulin pens and hand hygiene. Surveyor asked LPN T when it's appropriate to perform hand hygiene. LPN T indicated before you eat/drink, use the restroom, going from dirty to clean. Surveyor asked about hand hygiene with med pass. LPN T indicated before/after entering a room, after giving insulin, before/after using gloves, and before you leave a room and when you have visible soiled hands. Surveyor asked about gloves at med cart. LPN T indicated you shouldn't be wearing gloves at the med cart. Surveyor shared observation with LPN T and asked about Hand hygiene. LPN T indicated before discarding gloves and putting a new pair on. LPN T indicated anytime you discard gloves, you do hand hygiene. On 8/26/2025 at 1:49 PM, Surveyor interviewed DON B (Director of Nursing) regarding Hand hygiene. DON B indicated hand hygiene is to be performed after removing gloves and before doing anything else, staff should perform hand hygiene.

Number of residents sampled: 2Number of residents cited: 1Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 2 residents (R48) reviewed for self-administration of medications. Surveyor observed R48 to have a cup of medications left on her bedside table on her meal tray for her to take independently. R48 did not have an assessment for self-administration of medications and did not have an active physician's order. R48's care plan does not indicate R48 can self-administer medications. This is evidenced by: The facility's policy Resident Self-Administration of Medication dated 4/17/25, includes it is the guideline of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Each resident is offered the opportunity to self-administer medications during the routine assessment by licensed nurse and/or the facility's interdisciplinary team. The results of the licensed nurse and/or interdisciplinary team assessment are recorded using a Self-Administration of Medication Evaluation, which is placed in the resident's medical record. The care plan must reflect resident self-administration and storage arrangements for such medications. On 8/20/25, NHA A (Nursing Home Administrator) provided surveyors with a piece of paper indicating medication administration times. The facility's medication administration times were listed as:AM medication administration 7 AM - 10 AMNoon medication administration 11 AM - 1 PMPM medication administration 4 PM - 6 PMHS (Hours of Sleep) medication administration 7 PM - 10 PMEarly AM medication administration 4 AM - 6 AM R48's physician orders printed on 8/26/25 include:Acetaminophen 500 MG give 2 tables by mouth three times a day for pain.Protonix 40 MG give 1 tablet by mouth one time a day for heartburn.Sertraline 100 MG give 2 tablets by mouth one time a day for mood. R48 does not have an active order for self-administration of medication in her physician orders. R48's comprehensive care plan, printed on 8/26/25, does not include self-administration of medications. R48 does not have an evaluation for self-administration of medication in her electronic health record. On 8/20/25 at 11:30 AM, Surveyor entered R48's room. R48 was sitting in her chair with her bedside table in front of her. On her bedside table, R48 had her breakfast tray and a medication cup with 4 pills inside. R48 indicated these medications were from the morning medication pass. R48 stated she is slow at taking her medications and staff leave the cup of medications for her to take at her own pace. On 8/20/25 at 11:31 AM, Surveyor interviewed LPN H (Licensed Practical Nurse) regarding R48's medications. LPN H verified R48 had 1 Acetaminophen, 1 Protonix and 2 Sertraline pills in her medication cup on her bedside table. LPN H indicated these medications were scheduled for the AM medication administration time which is between 7 AM and 10 AM. LPN H reviewed R48's physician orders and indicated R48 does not have an active order for self-administration of medications. LPN H indicated R48 should have an active physician's order and an assessment to determine if R48 can safely self-administer medications. LPN H indicated R48 should not have her medications left at bedside to self-administer. On 8/25/25 at 2:11 PM, Surveyor interviewed DON B (Director of Nursing) regarding self-administration of medications. DON B indicated the following steps should be completed for a resident who wants to self-administer medications; a licensed nurse will evaluate the resident for safe self-administration of medication, document the evaluation in the resident's electronic health record, obtain a physician's order for the resident to self-administer medications, enter the order into the resident's medical record, and update the care plan. DON B indicated R48 does not have a self-administration of medication evaluation. DON B indicated R48 does not have an active physician's order for self-administration of medications. DON B indicated R48 should not have had medications left at bedside since she does not have an evaluation indicating R48 is safe to self-administer medications nor does R48 have an active physician order.

Based on interview and record review the facility failed to ensure that every resident had an Advance Directive, including Code Status (Do Not Resuscitate or Full Code (resuscitate)), this affected 1 of 21 residents (R58).R58 did not have a code status determination in her medical record.This is evidenced by:The Facilities Policy and Procedure entitled Resident's Rights Regarding Treatment and Advance Directives dated [DATE], documents in part: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care .R58 admitted to the facility [DATE], went out to the hospital [DATE] and re-admitted to the facility [DATE]. R58 has the following diagnoses: acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), heart failure, morbid (severe) obesity with alveolar hypoventilation (lungs are not adequately ventilating, leading to a buildup of carbon dioxide in the blood), obstructive sleep apnea (condition where sleep is interrupted by abnormal breathing), and dilated cardiomyopathy (heart becomes enlarged and can't pump blood effectively).Review of R58's EHR (Electronic Health Record) in banner on top of record, in the orders section, and in the miscellaneous section did not contain R58's code status.R58's Hospital Discharge summary dated [DATE] documents R58 is a full code.R58's Hospital Discharge summary dated [DATE] documents R58 is a full code.On [DATE] at 10:20 AM, Surveyor interviewed LPN P (Licensed Practical Nurse). Surveyor asked LPN P where you would look for a resident's code status, LPN P stated on their banner in EHR. Surveyor asked LPN P what would you do if you had a resident who was pulseless and nonbreathing and you could not see their code status, LPN P stated, That should not be a thing, but we would code them if we didn't know code status. Surveyor asked LPN P who does the code status paperwork with residents when they admit, LPN P said it should be the admitting RN (Registered Nurse) or whoever is doing their admission, could be the floor nurse. Surveyor asked LPN P should each resident have a code status on file in their record, LPN P replied yes.On [DATE] at 10:22 AM, Surveyor interviewed RN Q. Surveyor asked RN Q where would you look for a resident's code status, RN Q said in EHR (pointed to banner) or on the crash cart in binder. Surveyor asked RN Q what would you do if you had a resident who was pulseless and nonbreathing and you could not see their code status, RN Q said check for DNR (Do Not Resuscitate) bracelet (they wear them). Surveyor asked RN Q who does the code status paperwork with residents when they admit, RN Q replied the admission nurses. Surveyor asked RN Q should each resident have a code status on file in their record, RN Q stated absolutely.On [DATE] at 10:27 AM, Surveyor interviewed LPN R (Licensed Practical Nurse). Surveyor asked LPN R where you would look for a resident's code status, LPN R said EHR in the banner. Surveyor asked LPN R what would you do if you had a resident who was pulseless and nonbreathing and you could not see their code status, LPN R explained in the absence of code status paperwork, R58 would be treated like a full code. Surveyor asked LPN R who does the code status paperwork with residents when they admit, LPN R said she was not sure but thought likely the Admissions Nurse. Surveyor asked LPN R should each resident have a code status on file in their record, LPN R said yes.On [DATE] at 10:29 AM, Surveyor interviewed LPN S. Surveyor asked LPN S where you would look for a resident's code status, LPN S said in the EHR in the banner. Surveyor asked LPN S what would you do if you had a resident who was pulseless and nonbreathing and you could not see their code status, LPN S stated they would be a full code, and we would start CPR (cardiopulmonary resuscitation). Surveyor asked LPN S who does the code status paperwork with residents when they admit, LPN S replied the admission Nurse. Surveyor asked LPN S should each resident have a code status on file in their record, LPN S stated yes, they should.On [DATE] at 12:53 PM, Surveyor interviewed IUM T (Interim Unit Manager). Surveyor asked IUM T where you would look for a resident's code status, IUM T replied in the EHR under profile or in the banner. Surveyor asked IUM T what you would do if you had a resident who was pulseless and nonbreathing and you could not find their code status, IUM T stated we would start life saving measures, assume resident is a full code. Surveyor asked IUM T who does the code status paperwork with residents when they admit, IUM T said the Nurse on the hall. Surveyor asked IUM T if that would mean that Agency Nurses would also be responsible for completing this type of paperwork, IUM T stated sometimes the Agency staff do have to do them, there is an admission checklist, and the code status is right near the top and it is bolded. Surveyor asked IUM T should each resident have a code status on file in their record, IUM T stated yes.On [DATE] at 1:22 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B where would expect staff to look for a resident's code status, DON B explained it is in their orders, paperwork is uploaded into the miscellaneous tab, and in the banner in EHR. Surveyor asked DON B what would you expect staff to do if they had a resident who was pulseless and nonbreathing and they could not see their code status, DON B said quickly look in miscellaneous tab in EHR, resident is automatically a full code if no code status is documented. Surveyor asked DON B who does the code status paperwork with residents when they admit, DON B said the admitting nurse. Surveyor asked DON B would you expect each resident have a code status on file in their record, DON B stated yes.The facility provided Surveyor with a code status document for R58 that was dated [DATE].

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 2 of 3 residents reviewed (R53 and R85). R53 began smoking at the facility and was not assessed to be a safe, independent smoker once the facility was aware R53 began smoking. R85 was assessed to be at risk for falls. The facility did not assure that the care plan interventions were in place for R85. Evidenced by: The facility's policy titled Resident Smoking dated 12/15/23 states in part .6. Residents who smoke will be further evaluated using the Smoking Evaluation to determine supervision need and intervention.10. All safe smoking measures will be documented on the care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on the care plan.15. Documentation to support decision making will be included in the medical record, including but not limited to: .b. Evaluation of relevant functional and cognitive factors affecting ability to smoke safely. Example 1 R53 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that include type 2 diabetes, alcoholic cirrhosis (chronic liver damage), anxiety disorder, and depression. R53's most recent MDS (Minimum Data Set) dated 7/20/25 states that R53 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R53 is cognitively intact. On 8/20/25, the Survey team entered the facility and requested a list of smokers. R53 was on the list. R53's admission assessment and provider notes indicate that R53 has a history of smoking but was not actively smoking at that time. R53 had a Smoking Evaluation completed on 8/20/25 at 9:48 AM stating in part .Safe to smoke unsupervised. R53's care plan dated 8/20/25 states in part .Focus: The resident is a smoker. Goal: The resident will be free from complications r/t (related to) smoking independently through the next review date. Interventions: Smoking evaluations will be completed quarterly, annually, and with sig. (significant) change in condition. The resident can smoke independently. It is important to note that R53's smoking evaluation and care plan was completed after the Survey team entered the facility. On 8/20/25 at 2:05 PM, Surveyor observed R53 smoking in the designated smoking area. On 8/21/25 at 2:16 PM, Surveyor interviewed R53. Surveyor asked R53 how long she had been smoking, R53 stated since she was a teenager. Surveyor asked R53 if she had been smoking at the facility since she was admitted , R53 stated yes. On 8/21/25 at 2:23 PM, Surveyor interviewed CNA K (Certified Nursing Assistant). Surveyor asked CNA K if R53 has been smoking since admission to the facility, CNA K stated that R53 did not smoke when they were admitted to the facility but has been smoking for about a week or so. On 8/21/25 at 2:49 PM, Surveyor interviewed RN L (Registered Nurse). Surveyor asked RN L when did R53 start smoking at the facility, RN L stated the R53 made a new friend at the facility and has been smoking for about 2 weeks. Surveyor asked RN L if anyone at the facility completed a smoking assessment prior to R53 being allowed to smoke, RN L stated no. Surveyor asked RN L if an assessment should have been completed before a resident starts smoking at the facility, RN L stated yes. On 8/25/25 at 3:35 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when a smoking evaluation should be completed, DON B stated on admission or as soon as they are identified as a smoker. Surveyor asked DON B if a smoking evaluation should be completed prior to a resident smoking at the facility, DON B stated that they were not aware that R53 was smoking due to her taking herself outside and that she would expect that if staff were aware of R53 smoking, they should have completed the evaluation. Surveyor asked DON B if R53 should have a care plan for smoking, DON B stated yes. Example 2 R85 was admitted to the facility on [DATE] with diagnoses of cerebral infarction(stroke), moderate protein-calorie malnutrition, contracture R knee, contracture L knee, and chronic pain syndrome. The facility policy, titled Fall Prevention Program, dated 10/8/2024, states in part: . 6. High Risk Protocols: .8. Each resident's risk factors, and environmental hazards will be evaluated when developing the residents comprehensive plan of care.a. Interventions will be monitored for effectiveness b. The plan of care will be revised as needed.9. When the resident experiences a fall, the facility will: .e. Review the residents care plan and update as indicated.h. Monitor residents' condition and response to interventions as per standard of practice. R85's Minimum Data Set (MDS) assessment, dated 3/7/25, indicated that R85's Brief Interview of Mental Status (BIMS) score was a 13. This indicates R85 is cognitively intact. R85's care plan with a revision date of 8/21/25, states in part: .R85 is at risk for falls r/t (related to) hx (history) of fall and decreased mobility, and contractures. Intervention dated 3/8/25: Provide resident with a wider mattress to allow for more space to be comfortably repositioned. R85's CNA (Certified Nursing Assistant) Kardex with a date of 8/25/25, states in part: .Accident-Fall Risk. Use pillows for positioning and supporting residents back. On 8/21/25 at 7:48 AM Surveyor entered R85's room and observed R85 in a standard size bed with pressure relief mattress and bolster overlay. Bolsters on the top half of the bed were laid flat, not upright. Surveyor interviewed R85 who stated that he was supposed to get a bigger bed a long time ago but had not gotten it yet. He said when he goes to roll over the bed is too small, and he gets too close to the edge and falls out. He doesn't know why he doesn't have a bigger bed; R85 said he has asked but no one tells him. On 8/25/25 at10:22 AM Surveyor observed R85 in a standard size bed with air mattress and bolsters, which is an overlay that fits on the bed like a sheet. The overlay was not hooked to the upper and lower right side of the mattress making the bolsters on top and bottom of bed fall out flat, which would be ineffective to prevent R85 from rolling out of bed. On 8/25/25 at 3:12 PM Surveyor interviewed CNA M (Certified Nursing Assistant). Surveyor asked if R85 had ever been in a larger bed than he has now. CNA M replied I believe it has always been the same bed. On 8/25/25 at 4:10 PM Surveyor interviewed MD N (Maintenance Director). Surveyor asked if R85 had ever had a different bed than he has now. MD N stated I think it has always been a standard bed. If a bigger bed came into the facility I would know about it, and I don't remember seeing a larger bed. On 8/26/25 at 9:50 AM Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R85 had ever had a larger bed. DON B replied that he may have had a bigger bed when he was up front (the rehab rooms). DON B stated she would have to ask maintenance if they know. DON B also stated that hospice had gotten him a new bed so the old one could have been bigger. Surveyor showed DON B R85's care plan intervention dated 3/8/25, which stated, Provide resident with a wider mattress to allow for more space to be comfortably repositioned. Surveyor asked DON B who is responsible for updating the care plans for new interventions and review of current interventions. DON B replied everyone is, the interdisciplinary team can update a care plan. Usually, the transcriber will do it. It's a team effort. Surveyor asked DON B would you expect fall interventions on the care plan to be utilized. DON B stated yes. Surveyor asked DON B should all interventions on the care plan be current. DON B replied yes or at least applicable. On 8/25/25 at 10:35 AM Surveyor was in R85's room with RN H (Registered Nurse). Surveyor observed R85 in standard size bed, bolster overlay was lying on the top of the bed, only hooked with strap around the bed frame and corners not pulled over the mattress. Surveyor asked RN H what the bolsters on the bed were used for. RN H replied fall prevention. Surveyor asked RN H if the bolsters were on the bed correctly. RN H stated I have no idea how they go on the bed I just know they are helping him not to fall. Surveyor asked RN H if the bolsters would be effective to prevent R85 from falling at this time. RN H replied it looks fine to me. It is just for fall prevention. On 8/25/25 at 10:37 AM Surveyor was in R85's room with CNA K (Certified Nursing Assistant) Surveyor showed CNA K the overlay on R85's bed and asked how the overlay fit onto the bed. CNA K responded that there are straps that go under the bed to keep it on the bed. Surveyor asked CNA K if the overlay fit on the bed like a sheet. CNA K replied yes. Surveyor showed CNA K the end of the bed and part of the sheet that should go over the edge of the bed. Surveyor asked CNA K if she would expect the overlay, the way it is now, to be effective. CNA K responded I guess it would. On 8/26/25 at 10:05 AM Surveyor interviewed DON B (Director of Nursing). Surveyor and DON B went down to R85's room. Surveyor observed R85 in bed lying on his left side close to the edge of the bed. The bolsters on the top part of the bed were down flat. Surveyor asked DON B if the bolsters on R85's bed would be effective the way they are currently. (Observed bolsters in a flat position vs upright, overlay was not completely attached to the bed.) R85 stated no. DON B attempted to pull the bolster upright but R85 was lying on part of the bolster, and she was unable to move it. DON B stated that it seemed like the overlay was not the right size for the bed and was going to have maintenance come and look at it right away. Surveyor asked DON B why the bolsters were not on R85's care plan or CNA Kardex. DON replied that hospice has a company come in and bring the equipment and they may not know when they come. DON B stated that R85 just got the bolsters put on his bed. Surveyor asked DON B when they were put on the bed. DON B stated she would find out. DON B returned later and stated 7/16/25. On 8/26/25 at 10:38 AM Surveyor called RN O (Hospice nurse). Surveyor asked when the bolster overlay was delivered for R85. RN O stated 7/16/25. R85 has had 4 falls since 3/8/25 care plan intervention to provide larger mattress to allow for more space to be comfortably repositioned. On 7/16/25 hospice provided a bolster overlay for fall prevention. Staff were not educated in proper use of the bolsters to effectively prevent R85 from rolling out of bed. Care plan and CNA Kardex did not have an intervention on use of the bolsters.

Based on observation, interview, and record review, the facility failed to ensure other alternatives were tried prior to installing/utilizing side rails. The facility failed to have a system in place to assess for risk of entrapment between the mattress and side rail and failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 3 (R2, R424, and R9) of 3 supplemental residents and 8 (R61, R20, R65, R25, R17, R423, R6, and R24) of 21 sampled residents reviewed for bed rails. The facility failed to ensure a system was in place regarding the use of bed rails/enabler bars prior to surveyors entering the facility. The facility failed to ensure alternatives were tried prior to installing side rails/enabler bars, failed to provide assessments, failed to provide risks and benefits, failed to obtain informed consent, and failed to identify and recognize side rails with the use of an air mattress increase the risk for entrapment. This created a finding of immediate jeopardy that began on 3/5/25. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 3/12/25 at 5:10 PM. The immediate jeopardy was removed on 3/25/25. However, the deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan and as evidenced by the following. Evidenced by The facility policy, Proper Use of Bed Rails, dated 5/24, states, in part; .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Definitions: Bed Rails .Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars .Policy Explanation and Compliance Guidelines: Resident Assessment .1. As part of the resident's comprehensive assessment, the following components will be considered .a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Size and weight c. Sleep habits d. Medications e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility l. Risk of falling .Informed Consent .Appropriate Alternatives .Installation and Maintenance of Bed Rails .c. Observing ongoing precautions such as following manufacturer's equipment alerts and recalls and increasing resident supervision, especially with the use of air-filled mattresses or therapeutic air-filled beds that may present a different entrapment risk than rail entrapment .Ongoing Monitoring and Supervision .d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails . According to the Food and Drug Administration (FDA), The FDA recommends the following actions to prevent deaths and injuries from entrapment and falls from adult portable bed rails: . When installing and using bed rails: Confirm that the age, size, and weight of the person using the bed rails are appropriate for the bed rails used. Install bed rails using the manufacturer's instructions to ensure a proper fit. Ensure that the safety strap or bed rail retention system is permanently attached to the rail and secured to the bed frame according to the manufacturer's instructions. Regularly inspect the mattress and bed rails for gaps and areas of possible entrapment. Regardless of mattress width, length, and depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a patient's head or body. Use caution when using bed rails with a soft mattress as this may increase risk of entrapment between the mattress and bed rail. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or waterbed. Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time. When in doubt, call the manufacturer of the bed rails for assistance. https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-consumers-and-caregivers-about-adult-portable-bed-rails On 3/12/25 at 8:33 AM, DON B indicated the facility identified a concern with side rail system during facility mock survey at the end of February. Surveyor asked for the date of mock survey. DON B indicated DON B didn't know offhand, but it was done some time in February. DON B indicated the facility was going to complete audit and remove side rails on the day the survey team entered the building on 3/5/25 but got busy with survey. DON B indicated she understands what it looks like, but that was the date the facility was going to work on side rails. Surveyor asked about resident progress notes from 3/7/25 and if the facility started working on assessments and removing the side rails on 3/7/25. DON B indicated 3/7/25 was the date many side rails were removed. DON B indicated there was not a process in place for side rails/half rails/transfer bars. There was nothing in place prior to 3/7/25 and this is why the facility has the plan to correct. DON B indicated there were no assessments completed prior to 3/7/25. DON B indicated NHA A has the plan from facility mock survey in February. DON B provided surveyor documentation of the assessments that will be completed moving forward. DON B indicated moving forward assessment will be completed prior to installing side rails. Surveyor reviewed documentation DON B provided. Effective 3/7/25 facility implemented Transfer Bar Use Assessment Form. Form states, in part; .complete this form as you go through the decision making process of determining whether a transfer bar is appropriate for a particular resident height .weight .Reason Transfer Bar is being considered .Benefits to using the transfer bar .Evaluation of potential risks of using transfer bar(s) .other areas of potential risk .mobility and transfer assessment .interdisciplinary team recommendations/therapy or nursing .transfer bar informed consent for use .potential risks and negative outcomes. The facility also now utilizes a form titled Transfer Bar/Mattress Safety Assessment. Maintenance completes this form .reason for assessment .type of bed .type of mattress gap assessment .general safety assessment . On 3/12/25 at 11:05 AM, Surveyors requested any additional assessments, documentation, and manufacturer's recommendations for side rails. NHA A and DON B indicated there are no assessments or documentation prior to 3/7/25. NHA A indicated the facility does not utilize true side rails, but rather grab bars. NHA A indicated they identified a concern with the system during facility mock survey and the plan was to correct the system. NHA A indicated the system was corrected on 3/7/25 when they removed side rail bars and completed assessments for residents who were identified appropriate for side rails. Surveyor reviewed facility Plan of Correction from facility mock survey, states, in part; .Dates: February 4th, 5th, and February 11th 2025 .F700 Bed rails .The facility failed to assess the risk for entrapment for residents within the facility. Majority of bed with bed rails and no evaluation . On 3/12/25 at 1:31 PM, MD Q (Maintenance Director) indicated prior to 3/7/25, he did not complete any kind of measurements or assessments of side rails. MD Q indicated on 3/7/25 the facility removed side rails and completed assessments for residents who have side rails currently. MD Q indicated prior to 3/7/25 the facility would leave side rails on the beds when residents would discharge, and they would be left on bed for next resident. MD Q indicated he now documents his measurements on the assessment form. MD Q is not aware of anything he should be mindful of when installing side rails to beds with air mattresses. On 3/12/25 at 2:01 PM, PTA R (Physical Therapy Assistant) indicated she helped complete side rail assessments for two residents on 3/7/25. PTA R indicated she was not aware of any system or assessment in place prior to 3/7/25 for side rails. PTA R indicated the Transfer Bar Use Assessment Form includes risks and benefits of side rails and alternatives are offered/discussed before using a side rail now. PTA R indicated all residents who have side rail bars should now have assessments and measurements. On 3/11/25 at 9:00 AM, LPN P (Licensed Practical Nurse) indicated she did not realize the concern with side rails and the risk for entrapment. LPN P indicated on 3/7/25 the facility took off many resident side rails and now there is an assessment that must be completed prior to installing side rails. LPN P indicated there was not an assessment or a process prior to 3/7/25. Surveyors completed sweep of facility on 3/12/25 at 10:00 AM for side rails. Surveyors identified 11 residents who are utilizing air mattresses with side rails. Example 1 R61 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, stroke, anxiety disorder, and other seizures. R61's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/5/25, indicates R61 has a Brief Interview for Mental Status (BIMS) score of 04 indicating R61 is severely cognitively impaired. R61 has an activated power of attorney. R61's Comprehensive Care Plan, states, in part; .Bed Mobility .The resident is totally dependent on 1 staff for repositioning and turning in bed .Transferring .The resident is totally dependent on 2 staff for transferring via hoyer .Resident is Fall Risk . On 3/6/25, Surveyor observed R61 lying in bed. R61 was observed to have an air mattress with side rails. It is important to note, there is no documentation for R61 of risks and benefits, alternatives tried, measurements, assessments, or signed consents for the use of side rails. On 3/11/25 at 8:04 AM, DON B indicated R61 does not have any assessments or documentation for side rails because R61 no longer has side rails. DON B indicated R61's side rails were taken off on 3/7/25. On 3/12/25 at 12:29 PM, POA O (Power of Attorney) indicated R61 has always had side rails on air mattress bed while residing at facility. POA O indicated POA O never signed a consent or had a discussion with facility on risks and benefits. POA O indicated he was told a long bar could be considered a restraint, but not the side rails that are currently being used. Example 2 R20 was admitted to the facility on [DATE] with diagnoses including obesity, abnormalities of gait and mobility, lack of coordination, repeated falls, and unspecified open wound. R20's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/5/25 indicates R20 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R20 is cognitively intact. R20 is own person. R20's Comprehensive Care Plan, states, in part; .Bed Mobility Assist of 1 with turning side to side and sitting up laying down in bed. Assist of 2 with boost up in bed . On 3/6/25 Surveyor observed R20 to have air mattress with side rails. It is important to note, there is no documentation for R20 of risks and benefits, alternatives tried, measurements, assessments, or signed consents for the use of side rails. On 3/11/25 at 8:04 AM, DON B indicated R61 does not have any assessments or documentation for side rails because R61 no longer has side rails. DON B indicated R61's side rails were taken off on 3/7/25. 30992 Example 3 R65 was admitted to the facility 11/4/24 with diagnoses including, but not limited to, the following: cerebral infarction (stroke), contractures bilateral knees (when muscles, tendons, joints tighten or shorten causing a deformity), reduced mobility (inability to move freely), osteoarthritis (degenerative disease that worsens over time causing pain and stiffness) of knee. R65's most recent Minimum Data Set (MDS) dated [DATE] documents, a score of 13 on his Brief Interview of Mental Status (BIMS), which indicates R65 is cognitively intact. R65 is his own person. R65's comprehensive care plan states, in part, as follows: Focus area: (Date Initiated: 11/4/24; Date Revised: 3/9/25) The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) CVA (cerebrovascular accident); Goal: The resident will improve current level of function in ADL's (Activities of Daily Living) through the review date. Interventions: The resident requires hoyer transfer by (2) staff with bathing/showering 2 times a week and as necessary. Bed Mobility: The resident requires assist by (1) staff to turn and reposition in bed as necessary. Resident is able to reposition independently from side to side but needs reminders from staff and assistance at times. Contractures: Provide skin care to keep clean and prevent skin breakdown. Keep knee extended as much as resident can tolerate, no pain, while in bed. Use a pillow in between knees. Transfer: The resident requires dependent assist/hoyer by (2) staff to move between surfaces. It is important to note, R65 has a history of falls from bed. On 2/11/25, R65's Physician Orders document an air mattress was put in place. On 3/11/2025 at 5:28 AM, R65's Progress Notes document the following: Change of Condition (Res had fall from bed last night) Resident found down in room at 2:45 AM; no injuries noted and resident denies pain and injury. Per resident I slipped out of bed, help me get up. Resident assessed for injuries, neurological exam completed, and VS (vital signs) obtained. Resident assisted back to bed with the assist of two staff; care ongoing. Note, R65's fall from bed puts him at increased risk of entrapment. On 3/12/25 at 10:45 AM, Surveyor observed R65 to have bilateral enabler bars with an air mattress. Surveyor observed a gap in between mattress and enabler bars of approximately one (1) inch. On 3/12/25 at 11:00 AM, Surveyor spoke with R65. R65 stated his air mattress was put in place just a couple of days ago when he returned from the hospital on 3/7/25. Surveyor asked R65, did the facility go over a consent form with you regarding using enabler bars with an air mattress. R65 stated, no. Surveyor asked R65, did the facility discuss the risks and benefits of using enabler bars with an air mattress. R65 stated, no. Surveyor asked R65, did the facility attempt alternatives prior to installing the bilateral enabler bars. R65 stated, no. Surveyor asked R65, have you ever become stuck (entrapped) in between an enabler bar and mattress. R65 stated, no. On 3/12/25 at 1:30 PM, Surveyor spoke with MD Q (Maintenance Director). Surveyor asked MD Q if he has done any assessments for R65's air mattress being used with bilateral enabler bars. MD Q stated, no. MD Q stated, if assessments are done he takes a couple measurements. MD Q added, he measures from the bottom of the mattress to the bottom of the siderail and the inside top of the mattress to the siderail with the resident in bed. MD Q stated this is a new process started 3/7/25. Surveyor asked MD Q, when was R65's air mattress put in place. MD Q stated, he knows the facility swapped his air mattress to a larger size. MD Q stated, R65 had a 36 or 38 air mattress and now he has a 42 mattress that was put in place a few days ago. MD Q stated, R65 had an air mattress in place prior to 3/7/25. MD Q stated he was going to check for the original work order. Surveyor asked Maintenance Q if he has measured gaps between the air mattress and enabler bars. MD Q stated, no. Surveyor asked MD Q, when you measure what are looking for? MD Q stated, pinch points or large enough gaps. Surveyor asked MD Q, what size of a gap is acceptable. MD Q stated, he's not sure and will look it up. MD Q stated, the Transfer Bar use Assessment Form was just started on 3/7/25. MD Q stated, there's no Transfer Bar use Assessment for R65. Surveyor asked MD Q, what's the process started 5/7/25. MD Q stated, stated, he uses a tape measure to measure gaps. Note, no additional information was provided to Surveyor. On 3/12/25 at 2:00 PM, Surveyor spoke with PTA R (Physical Therapy Assistant). Surveyor asked PTA R, have other alternatives been attempted prior to installing the air mattress with bilateral enabler bars. PTA R stated, no. Surveyor asked PTA R, does R65 require assistance to turn and reposition in bed. PTA R stated, yes. PTA R stated, R65 can use an enabler bar to assist staff with turning and repositioning, however, he does need assistance with turning and repositioning. PTA R added, R65 uses the bilateral enabler bars to help staff, we want to encourage as much help as the residents can give to keep up their muscles and strength. Surveyor asked PTA R, given R65's bilateral knee contractures and falls from bed would you consider him at high risk for entrapment. PTA R stated, she has not seen him in a little bit. PTA R added, R65 had good movement with his upper body and arms, however, he doesn't tolerate any stretching at all, it's very painful for him. PTA R stated. she is unable to answer that question. PTA R stated, the facility just started a new process for assessing residents with air mattresses and side rails/enabler bars on 3/7/25. PTA R stated, she has not done any assessments for R65. It is important to note, there is no documentation for R65 of risks and benefits, alternatives tried, measurements, assessments, or signed consents for the use of side rails. R65 stated she had never signed any consent to use enabler bars with an air mattress, educated regarding the risk and benefits and alternatives attempted. 36253 Example 4 R25 was admitted to the facility on [DATE]. On 3/5/25 at 11:21 AM, Surveyor observed R25 in her bed. She was lying on an air mattress with attached circulating pump and partial bedrails on either side of the bed. Facility maintenance documentation shows this air mattress was put into place on 2/18/25. Surveyor attempted to interview R25, but she was unable to answer any questions. A progress note dated 3/7/25 at 4:38 PM states, IDT (Interdisciplinary Team) review of resident need for t-bars per facility policy. Bars removed from resident bed and resident provided with education on safety/risk of use of t-bars. It should be noted that R25 discharged from the facility to the hospital on 3/6/25. On 3/12/25 at 1:00 PM, Surveyor requested any evaluations, assessments and risks and benefits for R25 and the use of the partial side rails before 3/5/24 when Surveyors were in the facility. The facility was unable to provide this requested documentation. 42038 Example 5 R17 was admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of anus, type 2 diabetes mellitus, and neuropathy. R17's MDS dated [DATE], section O states that R17 is on hospice care. R17's MDS states that R17 has a BIMS of 13 out of 15, indicating that R17 is cognitively intact. R17's MDS also states that he requires 1 assist to turn and reposition in bed. On 3/12/25 at 1:46 PM, Surveyor interviewed R17 and noted that R17 has 1/4 side rails to each side of his bed and is on an air mattress. Surveyor asked R17 if he uses the side rails on his bed, R17 reported that he brought the right one from home and uses it to help himself sit on the edge of the bed. R17 reported that he doesn't like the left one because it moves too much, but he uses it when he rolls on his side. Surveyor asked R17 if facility staff discussed the risks and benefits of using side rails with him, R17 reported that they had talked to him recently. Surveyor asked if he had given consent for the side rails, R17 stated that he did last week. It is important to note that R17's Transfer Bar/ Mattress Safety Assessment, Transfer Bar Use Assessment Form, and Transfer Bar Informed Consent for Use were completed on 3/7/25. Example 6 R2 was admitted to the facility on [DATE] with diagnoses that include spastic diplegic cerebral palsy (neurological disorder that affects movement and causes overly toned muscles), rheumatoid arthritis, neuropathy (nerve damage that usually occurs in feet and hands), and paraplegia (loss of motor and sensory function of the lower half of the body). R2's most recent MDS dated [DATE] states that R2 has a BIMS of 14 out of 15, indicating the R2 is cognitively intact. The MDS states that R2 requires substantial/ maximal assistance for bed mobility. On 3/12/25 at 1:50PM, Surveyor interviewed R2. Surveyor noted that R2 is laying on an air mattress and has enabler bars. Surveyor asked R2 how long she has had the enabler bars, R2 stated that she wasn't sure. R2 reported that it is hard for her to turn in bed without them. R2 reported to Surveyor that they took one of the rails off and that the nurse agreed with her that she needed both rails. Surveyor asked R2 if the facility she was assessed for the use of the bed rails, R2 stated that she was last week. Surveyor asked if the facility discussed the risks and benefits of using the rails with her, R2 reported that they did last week. Surveyor asked if she gave consent for the rails, R2 stated yes, last week. It is important to note that R2's Transfer Bar/ Mattress Safety Assessment, Transfer Bar Use Assessment Form, and Transfer Bar Informed Consent for Use were completed on 3/7/25. 49434 Example 7 R423 was admitted to the facility on [DATE] with diagnoses that include, in part: cerebrovascular accident (stroke), nontraumatic chronic subdural hemorrhage (brain bleed between the brain and the outer layer of the membrane around the brain), and dementia. R423's Admission Minimum Data Set, with Assessment Reference Date of 2/19/25, states that R423 has a Brief Interview for Mental Status (BIMS) of 7 out of 15, indicating that R423 is severely cognitively impaired. Section GG states R423 has impairment on one side of her upper extremities and utilizes a walker and wheelchair for mobility. GG0170 indicates R423 is dependent (meaning helper does all the effort) on staff for all mobility including rolling left and right, moving from sitting to lying and lying to sitting, moving from siting to standing, transferring between the bed and a chair, transferring to a toilet, transferring to a tub or shower, and walking 10 feet. R423's Comprehensive Care Plan states, in part: . The resident has an interpretation need . Resident's preferred language is: Hmong .The resident is at risk for falls, accidents and incidents r/t (related to) CVA[sic], Dementia, and Alzheimer's . Language board provided to the resident to facilitate communication . Nursing to keep resident within sight during time resident is in W/C (wheelchair) if CNA (Certified Nursing Assistant) is busy . Room change to facilitate closer observation . SS (Social Services) to conference with family concerning resident specific preferences r/t (related to) sitting on the floor, sleeping on the floor, environment . A progress note, dated 3/1/25, indicates the R423 was found sitting on the floor with blankets wrapped around her and the resident had been trying to get out of bed several times. A progress note, dated 3/1/25 at 5:43 PM, indicates R423 continues to have neurological checks completed related to her recent unwitnessed fall. The note also indicates the resident continues to self-transfer on this shift and had been found getting up from her wheelchair and attempting to ambulate. A progress note, dated 3/2/25 at 11:34 PM, indicates R423 continues to have neurological checks completed related to her unwitnessed fall. The note also indicates R423 was experiencing agitation on the PM shift and was given PRN (as needed) Haldol (antipsychotic). However, R423 continued to be restless, attempting self-transfers, and the facility initiated 1 to 1 monitoring on this shift. A progress note, dated 3/3/25 at 9:57 PM, indicates R423 continues on neurological checks related to her recent fall and that the resident remains on 1 to 1 monitoring on this shift due to impulsivity and her attempts to transfer independently. On 3/5/25 at 10:15 AM, Surveyor observed R423 lying in her bed. R423's bed was in the low position with a floor mat on the floor. Surveyor noted that R423 had an air mattress on her bed with grab bars installed on both sides. On 3/5/25 at 3:10 PM, Surveyor observed R423's bed with the air mattress and grab bars still in place. On 3/10/25 at 4:20 PM, Surveyor observed R423's bed had an air mattress installed with dial set to 120 and grab bars attached. On 3/12/25 at 10:30 AM, Surveyor observed R423's bed still had the air mattress on her bed with the grab bars installed. Surveyor notes the gap between the mattress and the grab bar is large enough for the Surveyor to fit their arm in between the mattress and the grab bar. (Of note: No evidence was found, and no evidence could be provided regarding a bed rail evaluation for R423. Surveyor also found no evidence of risks and benefits being provided to R423's activated healthcare power of attorney or evidence that alternatives to the grab bars were attempted prior to their installation). Example 8 R424 was admitted on [DATE] with diagnoses that include, in part: acute infarction of the spinal cord (stoke occurring within the spinal cord instead of the brain), transient ischemic attack (stroke that completely resolves within 24 hours), and quadriplegia (from of paralysis affecting all four limbs and torso). R424's Admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 2/19/25, states that R424 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating that R424 is cognitively intact. Section GG states R424 has impairment in both of her upper extremities and one side of her lower extremities along with an electric wheelchair for mobility. GG0170 indicates R424 requires partial/moderate assistance with rolling left and right. GG0170 also indicates R424 is dependent (meaning helper does all the effort) on staff for most mobility including moving from sitting to lying and lying to sitting, moving from siting to standing, transferring between the bed and a chair, transferring to a toilet, and transferring to a tub or shower. On 3/12/25, Surveyor was provided with a document titled, Transfer Bar Use Assessment Form. This form indicates R424 requested a transfer bar for safety and for mobility/transferring assistance. Potential risks and benefits are indicated to be discussed with the resident along with the completion of a mobility transfer assessment. Therapy evaluation is indicated to be conducted by physical therapy. Transfer bars are indicated to be recommended for the left and right side of R424's bed. PTA R signed this form on 3/7/25. (Of note: This form does note make any statements or references to safety in regard to using a transfer bar with an air mattress). On 3/12/25, Surveyor was provided with a document titled, Transfer Bar Informed Consent for Use. This document states, in part: .It is the policy of this facility to use transfer bar only after an individualized resident assessment evaluation and care planning by an interdisciplinary team, determine it is beneficial and appropriate for use to treat the resident's medical symptoms, assist the resident in attaining or maintaining the highest possible physical and psychosocial wellbeing and after attempts of using alternatives have proven inadequate or inappropriate . One question asked on this form states: Alternatives attempted that failed to meet resident needs: is marked n/a. Another question asked on this form states: Alternatives considered but not attempted because they were considered inappropriate: is marked lack of transfer bars. This document indicates recommendation of left and right transfer bars with R424's initials and signatures indicating they voluntarily consent to the use of transfer bars and is dated 3/7/25. This documented is signed by PTA R on 3/7/25. (Of note: This form does note make any statements or references to safety in regard to using a transfer bar with an air mattress). On 3/12/25, Surveyor was provided with a document titled, Transfer Bar/Mattress Safety Assessment. R424'S name and room number are indicated at the top of the assessment; however, the date of assessment, resident height, and resident weight is blank. The section that states, Reason for Assessment: has nothing checked. The section titled, Device Information includes the following information, type of bed: Standard, type of mattress: Air Mattress, and type of device: Transfer bar. The section titled, Gap Assessment, states, in part: The gap between the mattress and the lowermost portion of the bed rail can be no greater than 2.5 inches or 1.75 for this resident. The gap between the inside surface of the bed rails and the mattress can be no greater than 4.5 inches or 3 1/8 for this resident . Each zone listed in this section is marked, Pass. The section titled, General Safety Assessment has not been completed. The signature line states, Signature and Title, which is signed but illegible and it appears that no title was provided. This document is dated 3/7/25. 50285 Example 9 R6 was admitted to the facility on [DATE] with diagnoses that include, in part, Alzheimer's disease, age related osteoporosis with current pathological fracture, unspecified dementia with agitation, depression, and adult failure to thrive. R6's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/17/25, indicates R6 has a Brief Interview for Mental Status (BIMS) score of 5 indicating R6 is severely cognitively impaired. R6 has an activated power of attorney. R6's Comprehensive Care Plan, states, in part; .Bed Mobility: The resident requires partial assistance by 1 staff to turn and reposition in bed as necessary . 1 assist, uses bilateral hand rails to improve independence. 2 assist prn . Transfer: The resident requires max assistance of 1 to move between surfaces at a stand pivot level. R6 was assessed on 11/16/24 as a moderate risk for falls. On 3/5/25 at 3:55 PM, Surveyor observed R6 lying in bed. R6 was observed to have an air mattress with side rails. It is important to note, there is no documentation for R6 of risks and benefits, alternatives tried, measurements, assessments, or signed consents for the use of side rails. On 3/11/25 at 8:04 AM, DON B indicated R6 does not have any assessments or documentation for side rails because R6 no longer has side rails. DON B indicated R6's side rails were taken off on 3/7/25. On 3/13/25 at 11:24 AM, Surveyor interviewed POA EE (Power of Attorney). POA EE stated she had never signed a consent or been provided education on the risks and benefits of the use of side rails. Example 10 R24 was admitted to the facility on [DATE] with diagnoses that include, in part, Type 2 diabetes mellitus, depression, dependence on renal dialysis, acquired absence of left leg below knee, end stage renal disease, and insomnia. R24's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 2/2/25 indicates R24 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R24 is cognitively intact. R24 is her own person. R24's Comprehensive Care Plan, states, in part: Bed Mobility: The resident requires assistance by 2 staff to turn and reposition in bed . Transfer: The resident is dependent upon staff assist of 2 and Hoyer lift . Skin integrity: Pressure redistribution mattress. R24 was assessed on 1/13/25 as a moderate risk for falls. On 3/5/25 at 10:31 AM,

Based on observation, interview and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 3 of 3 residents reviewed for pressure injuries (R25, R65, and R61). R25 is being cited at severity level 4 (Immediate Jeopardy). R65, is being cited at severity level 3 (actual harm) and R61 is being cited at level 2 (potential for more than minimal harm). R25 was at risk for developing pressure injuries related to immobility and history of poor nutrition. The facility failed to implement aggressive pressure injury interventions; failed to implement orders timely; failed to provide risk and benefits despite knowledge of R25 refusing repositioning. Surveyors observed R25's treatment to not be in accordance with orders and facility staff did not wear the appropriate PPE (Personal Protective Equipment). R25 developed an in-house unstageable pressure injury on her sacrum on 2/8/25 and required transfer to the hospital on 3/6/25 where R25's sacrum wound was assessed as stage IV and infected. Facility failure to ensure R25 received care consistent with professional standards of practice to prevent pressure injuries from developing or deteriorating, created a finding of immediate jeopardy that began on 3/7/25. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 3/12/25 at 5:12 PM. The immediate jeopardy was removed on 3/13/25. However, the deficient practice continues at a scope/severity of G (actual harm/isolated) as the facility continues to implement its action plan and as evidenced by the following. R65 was at risk for pressure injury (PI) development. On 2/11/25 NP C (Nurse Practitioner) ordered Apply skin prep to R (right) foot two times a day for blanchable redness with intact skin. NP C assessed R65 on 2/17/25 noting no lesion on exposed skin. On 3/3/25 during a routine visit, NP C discovered R65 has an Unstageable PI to the right later heel. NP C stated, she always checks R65's heels for any signs of PI's as he is at high risk for PI's due to his positioning. R65 is continually in a fetal position on his left or right side due to bilateral knee contractures. NP C stated, the facility did not notify her or any provider regarding this Unstageable PI. NP C stated, R65 will not allow for frequent repositioning; he needs pillow placement and offloading. The facility staff did not implement appropriate offloading interventions until after the PI was discovered. Despite facility staff applying skin prep to the PI twice daily, nursing staff did not identify the Unstageable PI, assess and measure the PI, and notify the provider. R65 stated staff were not turning and repositioning him every 2 hours and have not provided risks and benefits regarding not repositioning at least every 2 hours. Surveyor observed R65's PI uncovered and open to air. CNA G (Certified Nursing Assistant) stated she noted R65's dressing was off approximately 1.5 hours prior to Surveyor's observation and did not notify the nurse. Surveyor observed R61 laying on specialized air mattress with 3 layers of sheets and chux pad under R61. R61 is at risk for pressure injuries. Findings include The facility's policy, titled Pressure Injury Prevention and Management states, in part: *The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. *Licensed nurses will conduct a pressure injury risk evaluation, using the Braden, on all residents upon admission/re-admission, weekly for four weeks, then quarterly or whenever the resident's condition changes significantly. *The Braden will be used in conjunction with other risk factors not captured by the risk evaluation tool. Examples of risk factors include, but are not limited to: Impaired/decreased mobility and decreased functional ability, comorbid conditions, resident refusal of some aspects of care and treatment cognitive impairment, exposure of skin to urinary and fecal incontinence, and malnutrition. *Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. *After completing a thorough assessment evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. *Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment *Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i.) Redistribute pressure (such as positioning, protecting and/or offloading heels, etc.); ii.) minimize exposure to moisture and keep skin clean; iii.) Provide appropriate, pressure-redistributing, support surfaces; iv.) Provide non-irritating surfaces; and v.) Maintain or improve nutrition and hydration status, where feasible *Interventions will be documented in the care plan and communicated to all relevant staff. *Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: i.) Changes in resident's degree of risk for developing a pressure injury, ii.) New onset or recurrent pressure injury development iii.) Lack of progression towards healing iv.) Resident non-compliance and v.) Changes in the resident's goals and preferences comma such as end of life or in accordance with his/her rights. According to National Pressure Injury Advisory Panel (NPIAP) <https://npiap.com/page/PressureInjuryStages> Definitions of staging state: Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Example 1 R25 was admitted to the facility on [DATE], from the hospital and has diagnoses that include Type II Diabetes, pulmonary embolism (blood clot in the lungs), seizure disorder, severe protein calorie malnutrition and coronary artery disease status post single-vessel CABG (Coronary Artery Bypass Graft; to improve blood flow to the heart by bypassing narrowed or blocked arteries). Her hospital discharge paperwork indicates she had been in the hospital from 9/2/24 to 10/25/24 in part due to septic shock and infection of the post CABG sternal wound. Her admission Minimum Data Set (MDS), dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, indicating R25 was cognitively intact. The functional abilities section of this MDS (section GG) also indicated R25 was independent rolling side to side, sitting to lying, lying to sitting and sitting to standing. Additionally, this MDS indicated R25 needed supervision with chair to bed transfers, could walk 10 feet with supervision, and could walk 50 feet with maximal assistance. R25's care plan states, Focus: the resident has actual impairment of the chest related to infection of surgical site after CABG (initiated 2/1/25). Goal: the resident will maintain or develop clean and intact skin by the review date. Interventions: assist to turn and/or reposition every 2-3 hours (initiated 10/26/24), pressure reduction mattress (initiated 10/26/24), monitor skin during cares, report to nurse any changes (initiated 10/26/24). Additionally, R25's care plan states, Precaution: Enhanced barrier precaution related to impaired skin integrity. Goal: resident will remain free from infection or infectious concerns through review date. Interventions: follow enhanced barrier precaution protocol when coming in contact with resident (initiated: 11/12/24). R25's nutrition care plan states, Focus: The resident has nutritional problem or potential nutritional problem related to .severe malnutrition, history of morbid obesity status post gastric bypass .severe protein calorie malnutrition (dated 10/27/24). Goal: The resident will maintain adequate nutritional status as evidenced by maintaining weight with no significant adverse triggers, no signs or symptoms of malnutrition .Interventions: Administer medications as ordered .honor food preferences .I cannot have a PEG (Percutaneous endoscopic gastrostomy/feeding tube) placed given my previous bypass surgical procedure history .I desire to not have additional portions or nutritional supplements at this time. I am willing to try prostat supplement at this time (dated 2/7/25) On 11/26/24, R25 was sent to the hospital due to confusion and aphasia. She was found to have a late acute to subacute ischemic infarction. Additionally, her sternal wound was growing MSSA (Methicillin-susceptible Staphylococcus aureus, a type of bacterial infection) and Pseudomonas (bacteria). R25 remained at the hospital until 12/30/25 at which point she was admitted back to the facility to a different room. A facility skin check on 1/14/25 states R25 has redness around coccyx, dry and fragile, irritation/redness. On 1/14/25, the facility conducted a Braden (scale for predicting pressure sore risk) on R25 which resulted in a score of 15, indicating R25 was at risk for pressure injury development. Facility occupational therapy documentation, dated 1/17/25, indicates R25 had become totally dependent on staff, requiring maximum assistance for toileting, mobility and transfers during ADLs (activities of daily living). Additionally, a physical therapy note, dated 1/17/25 states, Discussed with patient and IDT (Interdisciplinary Team) patient participation in therapy, goals, and plan of care. Educated patient on performing activities including bed mobility, at end of bed, and attempting transfers with therapy team. Patient showed fair-poor understanding and continued to decline out of bed or end of bed acts during discussion and for therapy this date. R25 was sent back to the hospital on 1/19/25 due to hypotension R25 returned to the facility on [DATE] with additional diagnoses of metabolic encephalopathy and continued protein calorie malnutrition. On 1/31/25, the facility began monitoring for signs and symptoms of malnutrition such as emaciation, muscle wasting, noticeable fat loss, fluid accumulations such as edema or ascites, nausea or vomiting, constipation or diarrhea, new wounds or worsening of wounds, infection. This was monitored 3 times daily. As part of the re-admission assessment, the facility noted that R25 did not have any additional wounds other than her known abdominal and chest wounds (from admission on 10/25/24). The facility conducted a Braden assessment on 2/2/25 with a resulting score of 11. On 2/8/24, the facility identified an open area on R25's coccyx and noted the wound to be an unstageable pressure injury, 5 cm x 4 cm (L x W) with 20% slough 80% eschar. Of note, this pressure injury was not added to R25's care plan, nor were any additional interventions added to her care plan to specifically address her coccyx wound. A note by NP C (Nurse Practitioner), dated 2/10/25 states, Pressure ulcer of sacral region, stage 3. New wound noted by nursing to coccyx with evaluation today. 100% slough. Treatment orders provided to floor nurse including Medihoney to wound bed followed by alginate and bordered foam to be changed 3x/week and as needed. Offloading mattress to be ordered. Prostat nutritional supplement 30 ml each day for wound healing was ordered and tracked for R25 beginning 2/11/25. R25 had refused all supplements, extra portions and additional protein in meals to this point. A 2/3/25 nutritional note states, in part, She (R25) doesn't want greasy food or spaghetti. Her food preferences/intakes vary pending on the day. She is aware of alternative menu, declines wanting a weekly menu. She doesn't want any nutritional supplement anymore (previously had Juven but she had it too much, other supplements not desired). No desire having additional portions with meals. She does want apple/grape juice as preference. Her son will bring food for her (mostly restaurant food) almost daily. Pudding/Jello/water in her room as preference .independent with meal setup assistance. On 2/17/25, R25's coccyx wound measured 5cm x 4cm, noted as an unstageable with slough and eschar. Further assessment notes by NP C state, Patient seen today resting in bed appearing comfortable. DON (Director of Nursing) present doing wound care today. Surgical wound assessed and overall appears cleaner with no further eschar to wound edges. Coccyx wound had already been changed at time of my visit and not visualized today. Patient without any fevers or chills. Appetite poor however improved from previous. R25 tested positive for COVID on 2/22/25. On 2/25/25, the wound is assessed as 7 cm x 3 cm, unstageable with 50% slough, 50% eschar. Further details of this assessment state, Consultation with NP this date regarding concerns with wound decline. Peri-wound is red and resident has increased pain. Measurements are larger. Continues to be unstageable. NP ordered labs and change in treatment order and will see resident on Monday 3/3 for further evaluation. Resident provided education on importance of repositioning. Resident states she cannot lay on her side due to her chest wounds. Worked with resident to position with pillow wedging to relieve some pressure on bottom. Resident also re-educated on need for optimal nutrition to support wound healing and resident verbally understood. On 3/3/25, the facility assessed R25's coccyx wound to be 9 cm x 8.8 cm with 50% slough 50% eschar and described as a suspected deep tissue. Further notes on the assessment state, Resident signed on with hospice with intent of better pain control. Medical Director has been alerted of wound and the unavoidable nature of issue. New wound orders given by NP. Resident is unable to fully perform turning and repositioning d/t (due to) nature of additional wounds on body. A note by NP C, dated 3/3/25 at 8:45 AM states, Pressure ulcer of sacral region, unstageable. Worsening pressure ulcer to coccyx now unstageable. There is significant amount of drainage and patient with significant pain. She continues on offloading mattress. Very poor nutrition nutritional status with high risk for nonhealing of multiple wounds. Treatment nurse to continue weekly wound assessment with treatment plan as directed. Orders given today for Dakin's dampened gauze packing followed by dry dressing. Hospice discussed today with informational meeting to be set by social worker. In addition, a facility progress note details an order by NP C on 3/3/25 at 11:42 AM, stating, NP ordered wound culture for resident to be completed. Writer contacted Simple Labs in regards to having a supply of wound culture swabs sent .Simple Labs informed writer that they could take up to 2 days to be delivered, but that the order was placed. Wound culture to be collected upon arrival of swabs. No further actions to note. Resident started hospice on 3/4/25. On 3/5/25 A note by MD PP (Medical Doctor), who is also the facility's Medical Director, states, It appears that the patient has developed a Candida ulcer in the sacrum. Had sudden onset and this is an unavoidable ulcer secondary to her chest wounds and inability to maintain nutritional status as well. She has very poor oral intake along with the fact that she is not a candidate for a PEG tube due to her chest wounds and she cannot also have positional change associated to offload secondary to her chest wounds. She has very low albumin and prealbumin. Repositioning is not effective due to her chest wounds. She has now signed onto hospice as well. Her wound is unavoidable. According to the State Operations Manual to determine unadvoidable would show the facility did the following: Conducted an accurate and comprehensive assessment including evaluating the resident ' s clinical condition and risk factors for the concern being investigated; Based on information gathered through resident assessments, with resident/representative input, developed a person centered care plan, defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; Implemented the care plan, and monitored resident responses to the interventions; and Provided ongoing review and revision of the care plan and interventions as necessary. If the facility has not done one or more of the above bulleted items, this would be considered avoidable. It should be noted R25 was at risk for PI development and despite the facility discovering an unstageable PI, R25's reluctance to reposition, the facility did implement or revise R25's care plan to ensure robust care plan interventions were implemented to prevent further decline in R25's skin/PI. It should be noted that the facility addresses resident repositioning in their Electronic Health Record (EHR). For R25, facility staff documented repositioning daily in 2025 as follows: 1/1: 3x 1/2: 3x 1/3: 2x 1/4: 2x 1/5: 3x with one refusal 1/6: 2x 1/7: 3x 1/8: 2x 1/9: 3x 1/10: 3x 1/11: 3x 1/12: 2x 1/13: 2x 1/14: 3x 1/15: 2x 1/16: 2x 1/17: 1x 1/18: 3x 1/19/25 through 1/31: Hospital 2/1: 2x 2/2: 4x 2/3: 2x 2/4: 2x 2/5: 3x 2/6: 2x 2/7: 3x 2/8: 3x 2/9: 2x 2/11: 3x with 1 refusal 2/12: 2x 2/14: 3x 2/15: 1x 2/16: 2x 2/17: 2x 2/18: 2x 2/19: 4x 2/20: 1x 2/21: 2x 2/22: 2x 2/23: 2x 2/24: 2x 2/25: 2x 2/26: 2x 2/28: 5x with 5 resident refusals 3/1: 3x with 1 resident refusal 3/2: 7x with 3 resident refusals 3/3: 6x 3/5: 4x 3/6: 5x No repositioning or refusals were documented for 2/13, 2/27, and 3/4. On 3/5/25 at 11:20 AM, Surveyor observed R25 in her bed. Surveyor attempted to ask R25 questions to which R25 responded with inaudible and incoherent answers and words. The head of R25's bed was up and it appeared that she could move very little. On 3/6/25 at 9:56 AM, Surveyor observed wound care on R25. R25 had the following wound care orders: Wound care: Coccyx wound Cleanse with wound cleanser; pat dry; apply dakins [sic](1/4 strength) moistened gauze; apply hydralock dressing; apply ABD; secure with tape. Every day shift for wound care to coccyx. It is important to note that R25 is on EBP (Enhanced Barrier Precautions), requiring staff to wear gloves, gown, and mask while performing cares. RN F (Registered Nurse) and CNA G (Certified Nursing Assistant) entered R25's room without performing hand hygiene and without wearing a gown. RN F removed the old mepilex dressing that was saturated with purulent and bloody drainage. RN F then cleansed the wound with wound cleanser. Surveyor observed R25's wound. The wound was slightly larger than a golf ball and was deep. The wound had a large flap of slough hanging from it. The wound bed was mostly slough covered (approximately 75%) with necrotic tissue (approximately 25%). The peri wound was bright red. RN F changed her gloves and did not perform hand hygiene. RN F applied the Dakin's-soaked gauze, skin prep applied to peri- wound, hydralock applied, and covered with a mepilex. RN F changed her gloves, but did not perform hand hygiene and began incontinence care, as R25 was incontinent of stool. RN F changed her gloves, but did not perform hand hygiene and performed catheter care on R25. Surveyor observed that R25 was on an air mattress and had several layers underneath her. Prior to wound care R25 had a fitted sheet, a draw sheet, and an incontinence brief. After wound care, R25 had a fitted sheet, a folded blanket, and an incontinence brief. R25 was calling out in pain throughout the entire wound care. RN F reported that R25 was premedicated, but did not stop wound care at any time. On 3/6/25 at 10:28 AM, Surveyor interviewed CNA G. Surveyor asked CNA G what type of PPE (Personal Protective Equipment) should be worn in a room that has EBP, CNA G reported that they should wear a gown, gloves, and a mask. Surveyor asked CNA G if she should have been wearing a gown during wound care, CNA G stated yes. On 3/6/25 at 10:28 AM, Surveyor interviewed RN F. Surveyor asked RN F what PPE should be worn in a room with EBP, RN F stated gloves and mask, but that she wasn't sure about a gown. RN F and Surveyor reviewed the EBP sign on R25's door. Surveyor asked RN F if she should have had a gown on, RN F stated yes. Surveyor asked RN F if she had any missed opportunities for hand hygiene, RN F stated yes, she should have performed hand hygiene before starting wound care. Surveyor asked RN F if she should have performed hand hygiene after taking off soiled gloves and before applying clean gloves, RN F stated yes. Surveyor asked RN F if R25's order was for an ABD pad, RN F stated yes and she should have applied an ABD pad to the wound. A progress note dated 3/6/25 at 2:23 PM states, Per resident and family request, resident is being sent to emergency room for pain management and evaluation. Documentation from the hospital, dated 3/7/25 notes R25's wound as a Sacral stage 4 infected pressure injury with [NAME] purulence, odor and extensive undermining from 7-11 o'clock (deepest 8cm). The documentation states, Staff aware of 50ml of [NAME] purulence milked from left lateral and superior wound bed. Unable to completely irradiate related to pain, thus stopped wound manipulation with goals of comfort. This documentation did not refer to or mention the wound as being a [NAME]-type ulcer. On 3/10/25 at 11:42 AM, Surveyor interviewed NP C (Nurse Practitioner) who indicated that typically when she makes an order for an air mattress, it likely means that the resident had the standard mattress and not an air mattress at that time. When asked about the delay in getting the wound culture, NP C indicated that she was not concerned about it and did not think it was going to reveal anything and indicated lab supplies were not always readily available for such wound cultures. Additionally, NP C stated that she was questioning whether R25's wound was a Kennedy ulcer. When asked when she began questioning this, NP C stated it would have been in one of her notes. When asked if it was her 3/3/25 note, NP C stated, Yes. On 3/10/25 at 1:41 PM, Surveyor interviewed IP D (Infection Preventionist), who is an LPN (Licensed Practical Nurse) and the facility's wound care nurse. IP D stated that the redness that was noted on R25's coccyx on 1/14/25 cleared up and was not noted after that date. IP D stated that R25 cannot turn on her side due to her sternal surgical wound. R25 also stated that the facility spoke with MD PP (Medical Doctor) regarding R25's pressure injury and asked for the doctor to note the wound as unavoidable. IP D stated that R25 could be offloaded with the help of pillows but could not go beyond approximately 45 degrees when on her side due to pain, but this would offload the wound some and provide some relief. IP D indicated that R25 was able to pull herself over with the sidebars on her bed and wedge pillows under herself. IP D indicated that he had witnessed R25 doing it herself, but couldn't recall the last time he visualized this. IP D indicated it was the around the first week of March that R25 started losing the ability to reposition herself, but also stated that after R25's first hospital stay (return 12/30/24), she became completely bed bound. IP D indicated that he was not aware if nurses or CNAs were checking in on R25 and documenting repositioning. IP D also indicated that R25 was on an air mattress when she first came to the facility on [DATE]. When asked why NP C would order an air mattress if she already had one, IP D stated he was not sure, but could speak with maintenance regarding the placement of all mattresses in the facility. Additionally, IP D stated that his note on the 3/3/25 assessment of R25's wound as suspected deep tissue injury was a mistake and it should have read unstageable. Of note, facility orders show an order for low loss air mattress Frequent repositioning, dated 10/26/24. The facility was unable to provide further detail of this or if an air mattress was in place at this time. On 3/11/25 at 9:50 AM, Surveyor requested, from maintenance, any records relating to R25 and air mattress placement. Maintenance provided Surveyors with a work order, dated 2/18/25, which reads, Resident needs air mattress, resident room-[number]. This was requested by SSA X (Social Services Assistant). This was the only record provided to Surveyors. No other work orders or mattress orders/placements were provided. On 3/11/25 at 10:00 AM, Surveyor interviewed SSA X who stated that he had put in the work order for an air mattress on 2/18/25 because he believed R25 was on an inappropriate mattress. When asked if that meant she was on the standard mattress issued to all residents upon admission, SSA X stated, I don't believe she was on an air mattress, which is why we put the work order in. It should be noted that documentation issued to Surveyors indicates the facility's standard mattress (Proex pressure redistribution mattress) is listed as effective through state 2 wound therapy. Surveyor again interviewed IP D on 3/11/25 at 10:10 AM. When Surveyor described the work order, IP D stated that when R25 went to the hospital back in December 2024, she had stated that she did not want to come back, so her room was given to another resident. IP D suggested that when R25 came back to the facility, she was placed in another room, which only had the facility's standard mattress and would make sense that NP C would have to create another order for an air mattress on 2/10/25. Additionally, IP D indicated that the wound culture that NP C ordered on 3/3/25 and gathered on 3/6/25 was discarded by hospice as R25 was discharged from their care when she went to the hospital. Facility census records show R25 was originally in room [number]. When she was discharged to the hospital on 11/26/24 and returned on 12/30/24, she was returned to room [different room number] where she remained until her most recent hospital stay, beginning on 3/6/25. On 3/11/25 at 2:32 PM, Surveyor interviewed MD PP who stated that he looked at R25's wound on 3/5/25 but does not remember what it looked like or when it started, but that it was a Kennedy ulcer. MD PP indicated that the problem with R25 is that she could not be repositioned. It should be noted MD PP did not clasify this PI as a Kennedy terminal ulcer (KTU) on 3/5/25. On 3/12/25 at 11:29 AM Surveyor interviewed CNA II who stated that R25 needed a lot of help with repositioning but that she refused most times this was offered. CNA II stated that staff were to ask her every 2 hours to be repositioned. CNA II stated they would use pillows underneath both sides of R25 and her knees and they would chart when she refused repositioning. On 3/12/25 at 11:58 AM, Surveyor interviewed CNA S who stated that R25 was unable to reposition herself and needed staff to reposition her side to side every 2 hours. CNA S stated that R25 would refuse and would use her call light later to then request repositioning. CNA S stated that R25 always refused to get out of bed but he could get her to reposition in bed when she refused by explaining to her the reasons she needed to be repositioned and that they didn't want the wound on her bottom to get worse. CNA S also stated that when R25 would refuse, he would let the nurse know so she could document the refusal. On 3/12/25 at 12:55 PM, RN U stated that R25 was not good at repositioning herself. RN U stated she does not recall if R25 was on a repositioning program or was to be repositioned regularly. On 3/12/25 2:13 PM Surveyor interviewed DON B (Director of Nursing) who indicated that that the nursing standard for repositioning a resident with a wound like R25's is every 2 hours. DON B stated that it is her expectation is that staff would be repositioning R25 every 2 hours, documenting refusals or letting the charge nurse know so that they can document the refusal. DON B stated that staff had attempted to use pillows to wedge R25 off her bottom but that she would pull the pillows out. DON B stated that she had not given R25 any risks and benefits regarding her repositioning in relation to the sacrum wound. DON B stated that the facility did not put the air mattress into place for R25 when it was ordered and although there was a delay, that delay did not cause any harm to R25. Additionally, DON B indicated that the wound culture ordered on 3/3/25 was not expected to be gathered for 2-3 days due to waiting on supplies from the lab they use. When asked if this process could have been expedited another way, DON B indicated that it's the same issue everywhere with supplies. R25 was admitted with a history of wound infection and malnutrition. R25 began to decline after multiple hospital stays. R25 was admitted with orders for an air mattress. After returning to a different room from a hospital stay on 12/30/24, R25 was without the air mattress. An unstageable pressure injury was discovered on R25's coccyx on 2/8/25. Orders were placed again for an air mattress on 2/10/25, which was not put into place until 2/18/25. The facility did not care plan any additional measures for R25 when her coccyx wound appeared and facility staff were not consistently repositioning R25, as was expected by DON B and R25's care plan. Staff stated R25 would refuse repositioning, but this was documented only 11 times between 1/1/25 and her exit from the facility on 3/6/25. R25's wound deteriorated from 2/8/25 until she was sent to the hospital on 3/6/25. Hospital documentation details the wound had progressed to a stage 4 and was infected. A wound culture that was ordered on 3/3/25 was not gathered until 3/6/25. Facility staff was observed on 3/6/25 performing wound care incorrectly and without the required PPE. The failure to ensure R25 received care consistent with professional standards of practice to prevent pressure injuries from developing or deteriorating led to serious harm for R25, which created a finding of Immediate Jeopardy. The facility removed the jeopardy on 3/13/25 when it completed the following: ~If R25 returns to facility, the following actions will be taken by Director of Nursing and/or Designee upon return: *Care Plan review to ensure robust and individualized interventions are in place and appropriate for residents' current condition, will be reviewed for changes if applicable *Review documentation in resident's medical record as it relates to turn and repositioning by staff for opportunity, updates to PCC (EMR) Tasks / POC charting to reflect current documentation needs *Upon resident's return, the need for a Risk vs. Benefit discussion will be evaluated based on residents' condition and completed if applicable at time of readmission For all other residents on 3/13/2025: ~Skin Evaluations completed on active in-house residents by Director of Nursing and/or Designee on 3/12/2025 with no additional significant results. ~Braden Risk Evaluations completed and reviewed on active in-house residents by the Director of Nursing and/or Nursing Managem [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 3 of 20 sampled residents (R41, R73 & R37). R41 and R73 are being cited at severity level 3 (actual harm) R37 is being cited at severity level 2 (potential for more than minimal harm). R41 has diagnoses of congestive heart failure and protein calorie malnutrition. The facility failed to complete a RN assessment and monitor R41 for complications of her congestive heart failure (CHF) and protein calorie malnutrition. R41 was receiving a diuretic (a medication to remove excess fluid from the body via the kidneys) related to her CHF the facility failed to asses R41's weight response inlight of diuretic therapy. The facility failed to weigh the resident according to physician order, notify the physician of weight loss or gain of 3 lbs. in a day or 5 lbs. in a week. R41 had a weight loss of 13.2 lbs from 12/30/24-1/4/25 (6 days), and a weight gain of 4 lbs. from 1/4/25-1/5/25 (one day). R41 was ultimately hospitalized for acute exacerbation of her congestive heart failure on 2/22/25, requiring IV (intravenous) diuresis (removal of excess fluid within the body). R73 was taking an anticoagulant medication. The facility failed to adequately monitor R73's anticoagulant medication side effects and complete an RN assessment when bleeding occurred. R73 experienced a nose bleed that was unable to be stopped, had a drop in blood pressure, and was not sent to the emergency department until the next morning. This ultimately resulted in R73 being admitted to the hospital on 2/9/25, requiring 1 unit of blood and intravenous vitamin K to improve R73's ability to clot. Facility staff were not following physician orders for wound care treatment for R37. This is evidenced by: The facility policy entitled, Weight Monitoring, dated 11/1/23, states, in part: Policy: 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. Compliance Guidelines: . Siginficant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem . 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the exten possible: a. Identified causes of impaired nutritional status b. Reflect the resident' spersonal goals and preferences c. idnentify resident-specific interventions d. time frame and parameters for monitoring e. Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or new causes of nutrition-related problems are identified f. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate . 5. A weight monitoring schedule will be developed upon admission for all residents: . c. Residents with weight loss- monitor weight weekly d. If clinically indicated - monitor weight daily . 6. Weight Analysis: The newly recorded weight should be compared to the previous recorded weight 7. Documentation. a. The physician should be informed of a significant change in weight and may order nutritional interventions . c. Meal consumption information should be recorded and may be referenced by the interdisciplinary team as needed . e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. f. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate . The facility policy entitled, Hydration (Food/Fluid) Monitoring, dated 10/30/24, states, in part: Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Definitions: Sufficient fluid means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake) and maintain health . Compliance Guidelines: . 2. Identification/assessment: . *It is recommended that doctor's orders are obtained for fluid intake amounts, where renal or cardiac distress exists and excess fluids may be contraindicated . 4. Care plan implementation: The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: i. Offer the resident a variety of fluids during and between meals. ii. Provide assistance with drinking. iii. Ensure beverages are available and within reach. iv. Evaluate resident's medications that may place the resident at risk for dehydration. v. Offer alternative fluids such as broths, popsicles, gelatin, and ice cream. vi. Address underlying causes of dehydration or fluid imbalance. vii. 5. Monitoring/revision: a. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. b. The resident will be monitored for signs and symptoms of dehydration . c. The resident will be monitored for signs and symptoms of fluid overload: i. peripheral edema (noticeable swelling in the legs and arms) . iv. Shortness of breath, cough, presence of rales (fine, high pitched lung sounds indicating fluid in the lungs) such as in pleural effusion (excess fluid build up around the lungs) of CHF (congestive heart failure)) . d. The resident will be monitored for signs and symptoms of electrolyte imbalance: i. irregular or fast heart rate ii. Unexplained fatigue or lethargy . vii. Confusion . e. The resident will be monitored for conditions that may increase fluid needs: . v. New cardiac medication or diuretic f. The resident will be monitored for complications associated with interventions . h. The physician will be notified of: i. Signs and symptoms of dehydration, fluid overload, electrolyte imbalance, or conditions that may increase fluid needs. ii. Lack of improvement toward goals. iii. Any complications associated with interventions. 6. Documentation: a. Record observations pertinent to the resident's hydration status in the nurses' notes. b. Record beverage intake in designated locations (meal intake records, MAR (Medication Administration Record) as indicated). c. Record output in designated locations (MAR or output record) . f. Document assessments in designated locations . The facility policy entitled, Notification of changes, dated 8/27/24, states, in part: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Changes of condition require an evaluation, using the SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note Evaluation) ensure proper documentation and notification has been made. Definitions: . Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction) . The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: .3. Circumstances that require a need to alter treatment. This may include: a. New Treatment. b. Discontinuation of current treatment due to: i. adverse consequences . iii. Exacerbation of a chronic condition. Interact, a Change of Condition standard of practice, Version 4.0 tool states in part: Weight gain - report immediately 3 pounds in 3 days or 5 pounds in 7 days with heart failure, chronic renal failure, or other volume overload state. Example 1 R41 was admitted to the facility on [DATE], with diagnoses that include: congestive heart failure (inadequate heart beats causing poor circulation and fluid buildup into the lungs), protein calorie malnutrition, atrial fibrillation, myocardial infarction (heart attack), deficiency of B group vitamins, dementia, malignant neoplasm of skin (skin cancer), and hypertension (high blood pressure). R41's Admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 3/3/25, states that R41 has a Brief Interview for Mental Status (BIMS) of 7 out of 15, indicating that R41 is severely cognitively impaired. Section GG indicates R41 requires setup or clean-up assistance to eat. Section K indicates R41 does not have a swallowing disorder, had a height of 59 inches on admission, and weighed 68 lbs. as of most recent weight from the date of assessment. Nutritional approaches on admission and while a resident is indicated to be a mechanically altered diet. Section L indicates R41 has no dental concerns. R41's Comprehensive Care Plan, states, in part: Focus: The resident has dehydration or potential fluid deficit r/t (related to) HF (Heart Failure), poor appetite. Created date: 12/24/24. Goals: The resident will drink/take in a minimum of (SPECIFY)cc's each 24-hour period. Start Date: 1/24/25. (Of note: The care plan does not specify how much fluid R41 should be consuming). The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Created date: 12/23/24. Interventions: Ensure The resident has access to (SPECIFY: nectar thick liquids, no ice.y fluids i.e. cold water, thickened apple sauce) whenever possible. Start date: 3/6/25. (Of note: this intervention started after Survey entrance). Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities. Start date: 1/24/2025. Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Focus: The resident has nutritional problem or potential nutritional problem r/t (related to) noted dementia, protein-cal (protein calorie) malnutrition, afib (atrial fibrillation), CHF (Congestive Heart Failure), B vit def (Vitamin B deficiency), malignant skin (Skin cancer), multiple fx L/R leg (multiple fractures of left and right leg), HTN (hypertension), HLD (hyperlipidemia), osteoporosis, dysphagia, NSTEMI (Non-ST Elevation Myocardial Infarction (Heart Attack)). Created date: 12/24/24. Malnourished.Involuntary wt (weight) loss r/t decreased appetite/recent hospitalization AEB (as evidenced by) >5% wt loss x 1 mo (month); Swallowing difficulty r/t dysphagia dx AEB pureed texture, NTL (nectar thick liquids). Goals: The resident will maintain adequate nutritional status as evidenced by gradual wt gain, no s/sx of malnutrition, and consuming at least 75% of at least 2 meals daily through review date. Monitor/record/report to MD PRN (as needed) s/sx (signs/symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Created date: 12/24/24. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Created date: 12/24/24. Obtain weights per MD order/facility protocol. Created date: 12/24/24. Provide and serve diet as ordered; 2000ml FR (1080ml dietary). Created date: 12/24/24. Monitor intake and record q (every) meal. Created date: 12/24/24. RD (Registered Dietician) to evaluate and make diet change recommendations PRN. Created date: 12/24/24. On 12/23/24 R41 weighed 85lbs. R41's Weight Physician Orders state, in part: Obtain weight upon admission, then weekly for four weeks, then monthly every evening shift for baseline weight for 1 day weight and every day shift every Mon (Monday) for weight for 4 weeks weight and every day shift every 1 month(s) starting on the 1st for 7 day(s) for monthly weights. Start date: 12/24/24. End date: 1/20/25. R41's Medication Physician Orders state, in part: Lasix Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for edema until 12/25/24 23:59 (11:59 PM) and Give 1 tablet by mouth one time a day for edema until 12/27/24 23:59. Start date: 12/25/24. End date: 12/26/24. On 12/26/24 R41 weighed 87lbs A Medical Practitioner Note indicates the following. Date of service was 12/26/24. In the hospital, ENT (Ear, Nose and Throat) recommended a soft diet for six weeks and speech therapy recommended soft and bite-sized solids. Liquid consistency was discussed between hospital staff and FM LL (Family Member), R41's activated healthcare power of attorney, and thin liquids were initiated which R41 tolerated well. R41 was admitted for rehab in the presence of multiple medical comorbidities leading to a functional decline. R41 was admitted to the facility for skilled nursing and rehab. The assessment and plan indicate R41 was admitted for subacute rehabilitation and in the section marked CHF the note states: Monitor fluid input and output, mobility, maintenance with physical therapy, diuretics as needed, clinical and lab monitoring. Monitor further symptoms such as edema, weight gain, and shortness of breath. Physician orders: Chlorthalidone Oral Tablet (Chlorthalidone). Give 12.5 mg (milligrams) by mouth one time a day for HTN (hypertension), BLE (bilateral lower extremity) edema (swelling). Start date: 12/27/24. End date: 1/20/25. Start daily weights. Call if change of #3 (3 pounds) in 1 day or #5 (5 pounds) in a week. One time a day for HTN (hypertension). Start date: 12/27/24. End date: 1/20/25. Of note: R41's weight was not recorded or monitored according to physician orders on 12/27/24. On 12/28/24 R41 weighed 86.4 lbs On 12/29/24 R41 weighed 86 lbs On 12/30/24, R41 weighed 86 lbs. On 12/31/24, R41 weighed 83.9 lbs On 1/1/25, R41 weighed 77 lbs. Of note: This is a 6.9 pound loss in 1 day and a 9lb weight loss in 2 days. There is no evidence the facility notified the physician of this loss per physician orders or completed a cardiorespiratory assessment for R41. On 1/2/25, R41 weighed 75.8 lbs. On 1/3/25, R41 Weighed 73.4 lbs On 1/4/25, R41 Weighed 72.8 lbs Of note: Between 12/30/24 and 1/4/25, R41 lost 13.2 lbs in 5 days. R41 was receiving diuretic therapy at this time however there is no evidence the facility assessed R41's intake versus output, addressed the increased weight loss with the physician/nurse practitioner per physician orders, or assessed R41's cardiorespiratoty status. On 3/12/25 at 9:15 AM, Surveyor interviewed NP HH (Nurse Practitioner). Surveyor asked NP HH about the weight loss from 12/30/24 to 1/4/25 and what she would expect facility staff to do. NP HH indicates she would expect staff to reweigh and assess R41, then notify a provider. Surveyor asked NP HH what interventions she could have put in place to stop, or slow R41's weight loss. NP HH indicated she was not the NP to see her on 12/26 but she may have considered adjusting the diuretic order and using a consistent scale and consistent weight method. On 1/5/25, R41 weighed 78.6 lbs Of Note: This is a 5.8 lbs weight gain in a day. There is no evidence the facility assessed R41's intake versus output, addressed the increased weight loss with the physician/nurse practitioner per physician orders, or assessed R41's cardiorespiratoty. On 1/6/25, R41 weighed 77.4 lbs On 1/7/25, R41 weighed 78.0 lbs On 1/8/25, R41 weighed 77.8 lbs On 1/9/25, R41 weighed 76.4 lbs On 1/10/25, there is no weight recorded for R41. On 1/11/25, R41 weighed 76.0 lbs On 1/20/25, R41 was discharged from the hospital back to the facility. On 1/20/25, R41's Clinical Transfer Report for R41's hospital admission. R41 was admitted to the hospital with diagnosis of hemorrhagic shock due to a GI (Gastrointestinal) bleed related to taking Xarelto (anticoagulant), elevated troponin (enzyme released by the heart muscle when it is damaged), and atrial fibrillation (irregular heart rhythm). In the hospital, R41's NT-proBNP (B-type natriuretic peptide: a protein released by your heart when it is working harder to pump blood), resulted on 1/20/25, shows a value of 35,000, indicating an exacerbation of congestive heart failure. (Of note: The normal value for this test for stable heart failure is less than 450). Patient instructions state, in part: Reduce SODIUM in your diet to 2000 mg or less every day . Weigh yourself first thing every morning and write it down .CALL YOUR PROVIDER IF your weight goes up 5 pounds in a week OR your weight goes up 2 pounds from one day to the next; if you have increased shortness of breath; you have feet, ankle or abdominal swelling . Of Note: These patient instructions were not added to R41's physician orders or clarified by the facility. Weigh yourself first thing every morning and write it down. CALL YOUR PROVIDER IF your weight goes up 5 pounds in a week OR your weight goes up 2 pounds from one day to the next; if you have increased shortness of breath; you have feet, ankle or abdominal swelling . On 1/20/25, R41 weighed 72.8 On 1/21/25, R41 weighed 68.6 On 1/22/25, R41 weighed 68.3 There are no weights recorded for 1/23 or 1/24/25 On 1/25/25, R41 weighed 72.8 There are no weights recorded for 1/26, 1/27, 1/28 and 1/29/25 On 1/30/25, R41 weighed 70.8 On 1/31/25, R41 weighed 68.6 There are no weights recorded for 2/1, 2/2 and 2/3. On 2/4/25, R41 weighed 73.0 On 2/5/25, R41 weighed 73.2 On 2/6/25, R41 weighed 74.0 R41's Physician Orders state, in part: Monitor weight 3x weekly MWF (Monday Wednesday Friday) one time a day every Mon, Wed, Fri for weight monitoring. Start date: 2/7/25. End date: 2/14/25. Of note: R41's weight was not recorded or monitored according to physician orders on 2/7/25, 2/10/25, 2/14/25, On 2/11/25, R41 weighed 73.0 On 2/12/25, R41 weighed 73.8 On 2/17/25, R41 weighed 73.4 On 2/18/25, R41 weighed 74.4 On 2/19/25, R41 weighed 74.0 On 2/22/25 at 9:00 AM, a Nurses Note is written, that states: Resident had a witnessed fall in the back common area with head injury. Nose, mouth bleeding, bump above right eye, having leg pain. POA (Power of Attorney) and DON (Director of Nursing) notified. Waiting for on call NP (Nurse Practitioner) to call back. 911 was called and EMTs (Emergency Medical Technicians) took her to [Hospital Name]. On 2/22/25 at 1:25 PM, a Nurses Note is written that states: Writer called [Hospital Name] to get report of resident from fall this morning. Resident does not have any acute injuries from fall, but O2 (Oxygen) sats (saturation) are running low, in the 80's (Normally 94-99) and they are continuing to monitor the resident. Nurse from [Hospital Name] will call back . On 2/22/25, R41 was admitted to the hospital with diagnosis of Acute Respiratory Failure with Hypoxia due to Acute Exacerbation of Chronic HFpEF (Heart failure with Preserved Ejection Fraction- Heart Failure without loss of cardiac output) and a fall. R41's Hospital Discharge Packet states, in part: . Hospital Course: Patient received some IV (intravenous) diuresis in ED (emergency department). Creatinine (waste product of muscle metabolism filtered out of blood by kidneys) up-trended without meeting criteria for AKI (Acute Kidney Injury/kidneys not functioning properly), but this improved with conversion to PO (by mouth) diuretic .on 2/26 thoracentesis (Procedure utilizing needle to remove fluid from the space around the lungs) performed with 950 mL removed and subsequent resolution of O2 need. Nutritional Assessment: Is this patient clinically malnourished?: Yes. Context of Malnutrition: Chronic Illness. Severe Malnutrition: Yes. Underweight, BMI <18.5: Yes. Weight Loss: >7.5% in 3 months. Body Fat: Severe Depletion. Muscle Mass: Severe Depletion . R41's Physician Orders state, in part: Torsemide Oral Tablet 20 MG (Torsemide) Give 1 tablet by mouth one time a day for heart failure related to unspecified diastolic (congestive) heart failure. Start date: 2/27/25. End date: 3/5/25. 2000ml Fluid Restriction every day shift for Fluid restriction Dietary = 840ml (breakfast & lunch) Nursing = 340ml AND every evening shift for Fluid restriction Dietary = 240ml (dinner) Nursing = 340ml AND every night shift for Fluid restriction Nursing 240ml AND every night shift for Fluid restriction. Add total fluid consumed for the day and record. Start date: 2/28/25. Active order. Obtain weight daily. Have weight completed in the morning before breakfast one time a day for Heart Failure. Alert NP/MD if weight gain is >3 lbs. a day or >5 lbs in a week. Start date: 2/28/25. End date: 3/5/25. Of note: R41's weight was not recorded or monitored according to physician orders on 3/2/25. 3/4/25: 66.8 lbs. 3/5/25: 67.4 lbs. Of note: R41's weight was not recorded or monitored according to physician orders on 3/7/25, 3/8/25, and 3/9/25. R41's Physician Orders state, in part: ~Torsemide Oral Tablet 10 MG (Torsemide) Give 10 mg by mouth one time a day for fluid overload. Start date: 3/7/25. Active order. (Diuretic medication). ~Encourage fluids; 120 mL TID (three times a day) c (with) medication pass three times a day for hydration. Start date: 3/10/2025. Order Pending Confirmation. ~Obtain Weight daily. Have weight completed in the morning before breakfast. One time a day every Mon, Wed, Fri for Heart Failure. Update NP on 3/12/25. Start date: 3/7/2025. Active order. On 3/11/25 at 8:10 AM, Surveyor interviewed LPN JJ. Surveyor asked LPN JJ if she is familiar with R41's hall. LPN JJ indicates she always works the day shift on this hallway. Surveyor asked LPN JJ to describe R41's fluid intake. LPN JJ indicates R41 has poor fluid intake, is currently on a fluid restriction, but staff do try to help her hit her max for fluid intake. Surveyor asked LPN JJ if R41 is getting enough fluids. LPN JJ indicates she is not. On 3/11/25 at 8:24 AM, Surveyor interviewed CNA II. Surveyor asked CNA II if she is familiar with R41's hall. CNA II indicates she frequently works her hall. asked CNA II to describe R41's fluid intake. CNA II indicates that R41 needs to be encouraged to drink and that she tries to go into R41's room as often as she can to encourage her to drink. Surveyor asked CNA II if she thinks R41 drinks enough fluids. CNA II indicates R41 does not get enough fluids. On 3/12/25 at 5:20 PM, Surveyor interviewed DON B (Director of Nursing). Prior to starting this interview, Surveyor asked DON B if she would like to conduct this interview in her office, so she had access to a computer. DON B declined. Surveyor asked DON B what some of the interventions are they have put in place to prevent R41's weight loss. DON B indicates she does not have everyone's care plan memorized but is aware she is losing weight. Surveyor asked DON B about R41's 13.2 lbs. weight loss from 12/30/24 to 1/4/25, and what she would expect staff to do. DON B indicates she would expect staff to always reweigh the resident to confirm the weight, conduct an assessment, and notify the physician. Surveyor asked DON B about R41's weight gain from 1/4/25 to 1/5/25 and what she would expect staff to do. DON B indicates she would expect staff to follow physician orders for provider notification, reweigh the resident, assess the resident, and then notify the provider if ordered. R41 had orders for daily weights - these were not completed as ordered and R41 had weights outside of MD parameters requiring immediate MD notification. R41 continued to lose weight without providing appropriate interventions to help her gain weight as was her goal. On 2/22/25, she was admitted to the hospital for acute exacerbation of her heart failure after initially being transported to the emergency room after a fall. The facility failed to complete a comprehensive system assessment in a resident with a known history of CHF and respiratory failure. The facility failed to notify the physician of changing weights. The facility failed to implement interventions to increase R41's food and fluid intake. R41 was sent to the hospital and found to have an acute exacerbation of CHF requiring aggressive diuresis, thoracentesis, and medical intervention. Example 2 R73 was admitted to the facility on [DATE] with diagnoses that include, in part: other complication of kidney transplant, chronic obstructive pulmonary disease (lung disease causing damage to lung tissue and difficulty breathing), peripheral arterial disease (Poor blood circulation in the lower arms and legs) type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema (Diabetes causing vision loss), heart failure, cerebral infarction (stroke), hypertension (high blood pressure) and moderate protein-calorie malnutrition. R73's Physician Orders state, in part: Eliquis (Blood thinner) Oral Tablet 5 MG (Milligrams) (Apixaban) Give 1 tablet by mouth two times a day for Pulmonary Embolism (Blood clot in lungs). Start date: 12/24/24. Active Order. R73's Comprehensive Care Plan does not contain any monitoring for adverse events of anticoagulant medication. R73's Medication Administration Record (MAR) indicates R73 received her dose of Eliquis twice a day from 12/25/24 through 2/8/25 as ordered by the physician, except when R73 was hospitalized . Blood pressure and heart rate monitoring were completed with each dose. (Of note: R73's Medication Administration Record and Treatment Administration Record )TAR) contain no documentation related to monitoring the signs and symptoms of anticoagulant (blood thinners) adverse events). On 2/8/25 at 7:31 AM, R73's blood pressure was assessed alongside her anticoagulant administration according to physician order. R73's blood pressure was 84/56. No further assessment was completed for R73, and the physician was not notified of R73's low blood pressure. On 2/8/25 at 7:04 PM, R73's blood pressure was assessed alongside her anticoagulant administration according to physician order. R73's blood pressure was 89/43. No further assessment was completed for R73, and the physician was not notified of R73's low blood pressure. On 2/9/25 at 1:35 AM, a Nurses Note is written by LPN TT (Licensed Practical Nurse) that states: patient reports having a nosebleed. Nose was assessed and nosebleed stopped by patient applying pressure with paper towel PRN (as needed) nasal spray was given to moisturize nostrils. Patient is being monitored for nose bleeds. On 2/9/25 at 2:58 AM, a Nurses Note is written by LPN UU that states, in part: At approximately 2315 (11:15 PM), the resident activated the call light requesting loperamide (antidiarrhea medication), stating she had been asking for it all night. Thirty minutes later, the call light was used again, and the resident requested creams for her shoulders and feet. Another 30 minutes later, the resident activated the call light again, requesting nasal spray due to a slight bloody nose . The nasal spray was administered, and the bleeding stopped. However, 30 minutes later, the resident activated the call light again for nasal spray, as it appeared she had been picking at her nose .Patient is frequently rounded on by nurses and assistive staff. On 2/9/25 at 9:55 AM, a SBAR Communication Evaluation is written by LPN VV that states, in part: Situation: Patient has a nose bleed. Reported to this nurse by NOC (Night Shift) nurse that nose had been bleeding all night. Patient is on blood thinners. Resident is in facility for post-acute care .Notifications: Provider: 2/9/25 at 7:28 AM. (Of note: Provider notification made around 7 hours after initial nose bleed began and around 24 hours after initial low blood pressure). On 2/9/25 at 10:57 AM, a document titled, ED (Emergency Department) Transfer Summary was completed by an outside hospital registered nurse. This document states, in part: .History of the present illness: [ED Nurse Name], RN: Patient presents to the ED via EMS (Emergency Medical Services) from [Facility Name] SNF (Skilled Nursing Facility) for Bloody Nose. Pt (Patient) bloody nose started last night sometime, denies hitting her head or falling. Pt is on anticoagulants. Pt arrives with nose clamp applied; no active bleeding observed when clamp removed by RMD (Resident Medical Doctor) at bedside upon arrival. Pt also reports several months of diarrhea, cough, and chills. Pt reports she is at SNF for rehab (rehabilitation) for L (left) foot pain . EMS reports pt is normally hypertensive (High blood pressure) at baseline, 108/55. All other VSS (Vital Signs Stable) . (Of note: R73's blood pressure on arrival to the emergency department was 95/57 with a pulse of 104). Summary (events, concerns, course of treatment): Nose stopped bleeding after self-removing clamp. Intermittent nose dripping due to patient blowing nose/picking nose . Small amount of black/bloody stool noted on brief change. Lab results were significant for a Hemoglobin (Protein that carries oxygen in red blood cells) of 7.1 (Normal is 11.7-13.8 gm/dL) and Hematocrit (Amount of red blood cells compared to the total blood cell count) of 23 (Normal is 36-48%). On 2/9/25 at 3:13 PM, a document titled, History and Physical - [Hospital Name] General Medicine Service is signed by an outside hospital physician. This document states, in part: HPI (History of Present Illness) [Resident Name] . admitted for epistaxis (nose bleed) and melena (blood in stool) concerning for potential GI (gastrointestinal) bleed . The epistaxis began spontaneously on the[sic] evening of 2/8 and reports having clots. No history of epistaxis. The patient is on apixaban for chronic, severe PAD (peripheral arterial disease). She had a nose clamp applied by EMS and when removed in the ED there was no active bleeding appreciated. There has been a small amount of intermittent nose bleeding that occurs when the patient blows/picks nose. During care in the ED, she was noted to have a small amount of black/bloody stool and had a stool guaiac completed which was positive for blood. She was noted to have a hemoglobin of 7.1 so the patient was given 1u (unit) of PRBCs (Packed Red Blood Cells) in the ED. She has some unspecified diffuse epigastric pain to palpation . No previous report of blood or black stools. No use of NSAIDs (non-steroidal anti-inflammatory medications, which can cause GI bleeds) . Feels fatigued . This document notes an INR (International Normalized Ratio/lab checks blood clotting time) lab of 2.2 (Normal is between 0.8 and 1.2) on 2/9/25 at 10:12 AM. The section of this document titled Assessment & Plan states, in part: . #Epistaxis #Anemia . -Holding anticoagulation, consider resuming tomorrow -IV (intravenous) vitamin K (vitamin that is essential for normal blood clotting) for INR 2.2, suspect related to malnutrition CKD/ESRD (Chronic Kidney Disease/End Stage Renal Disease) . #C/f (Clinical features) GI bleed #Melena #Unspecified epigastric abdominal pain #Hx of colon cancer .Favor epistaxis as cause for melena, however, given GI history, vague abdominal pain, and recent seemingly worsening fatigue and generalized malaise. -GI consulted -Holding anticoagulation, consider resuming tomorrow . On 2/9/25 at 8:27 AM, a Gastroenterology Inpatient Consultation note is written by an outside hospital physician. This note states, in part: Pt was in her normal state of

Based on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. R223 had a multi-drug resistant organism (MDRO) in her urine. R32, R44, and R47 later tested postived for the same MDRO. Hand hygiene was not performed per standards of practice for (R25 and R74). Residents (R223, R32, R44, & R47) are being cited at severity level 3 (actual harm), and (R25 and R74) are being cited at severity level 2 (potential for more than minimal harm). R223 had extended-spectrum beta-lactamase (ESBL) a MDRO, in R223's urine. ESBL is spread easily through hands and surfaces. The facility failed to ensure R223 was placed in proper transmission-based precautions. R32, R44, & R47 also tested positive after R223 was diagnosed with ESBL. Three of the residents resided on the same hall. Facility had no evidence precautions were put into place for R223, R32, R44, & R47 with confirmed ESBL. Staff did not complete hand hygiene according to Standards of Practice during cares for R25 & R74. Staff did not handle soiled linens appropriately. During R74's bed bath, staff threw dirty, soiled clothing and linens on the floor. Staff did not complete hand hygiene for residents prior to eating. Facility did not provide evidence the infection control policies get reviewed annually. This is evidenced by: The facility policy titled, Infection Prevention and Control Program, dated 10/4/23, states in part: POLICY: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases . 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as a leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility . 4. Standard Precautions: . b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE . 5. Isolation Protocol (Transmission- Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC (Centers for Disease Control) guidelines. b. Residents on transmission-based precautions should be placed into a private/single room if available/appropriate, or are cohorted with residents with the same pathogen, or share a room with a roommate with limited risk factors, in accordance with national standards . 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection . e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room . 16. Staff Education: a. All staff receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. b. All staff shall demonstrate competence in relevant infection control practices . 18. Annual Review: a. The facility will conduct an annual review of the infection prevention and control program, including associated programs and policies and procedures . The facility policy titled, Infection Outbreak Response and Investigation, dated 12/23/22, states, in part: . Policy: The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections. Definitions: Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time . Policy Explanation and Compliance Guidelines: 1. Prompt recognition of outbreak: a. Changes in condition and/or signs and symptoms of infection will be reported according to procedures for infection reporting. b. The following triggers shall prompt an investigation as to whether an outbreak exist: . ii. A sudden cluster of infections on a unit or during a short period of time (i.e. three or more cases) . 2. Implementation of infection control measures: . c. Standard precautions will be emphasized. Transmission-based precautions will be implemented as indicated for the particular organism. d. Staff will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures. This includes special environmental infection control measures that are warranted based on the organism and current CDC guidelines . The facility policy titled, Handwashing/Hand Hygiene, dated 9/21, states, in part: . Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . c. Before and after direct contact with residents; . e. Before performing any non-surgical invasive procedures; . h. Before handling clean or soiled dressings, gauze pads, etc. i. Before moving from a contaminated body site to a clean body site during resident care; j. After contact with a resident's intact skin; k. After contact with blood or bodily fluids; l. After handling used dressings, contaminated equipment, etc.; m. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; n. After removing gloves; . 9. The use of gloves does not replace hand washing/hand hygiene . According to <https://www.cdc.gov/esbl-producing-enterobacterales/about/index.html> Extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales are resistant to common antibiotics and may require complex treatments. Infections caused by ESBL-producing Enterobacterales can occur both in and outside of healthcare settings. Good hand hygiene and infection prevention practices can help reduce infection risk. Enterobacterales are a group of bacteria that cause infections in healthcare settings and communities. Some species are also a normal part of the human gut. Some Enterobacterales produce enzymes called extended-spectrum beta-lactamases (ESBLs). Extended-spectrum beta-lactamases (ESBLs) break down certain antibiotics, making some infections caused by ESBL-producing Enterobacterales difficult to treat. ESBL-producing Enterobacterales infections occur in healthcare settings like hospitals and nursing homes. These infections may also occur in healthy people. ESBL-producing Enterobacterales can spread from person to person through dirty hands and surfaces. Reducing the risk healthcare workers should: Wash their hands often with soap and water or using alcohol-based hand sanitizer. Wash their hands after using the bathroom and before eating or preparing food. Remind people (including healthcare staff) to clean their hands before touching the patient or handling medical devices. Healthcare providers should always follow core infection control practices to reduce the risk of spreading these germs to patients. Treatment and recovery: ESBL-producing Enterobacterales infections are resistant to many prescribed antibiotics, such as penicillin's and cephalosporins. These infections might require hospitalization and intravenous (IV) antibiotics. According to <https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html> Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) How to implement personal protective equipment (PPE) use in nursing homes to prevent spread of multi-drug resistant organisms (MDROs). Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status; infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. Example 1 R223 admitted to the facility on [DATE] and has diagnoses that include chronic kidney disease stage 3 (kidneys have mild to moderate damage, meaning they're less effective at filtering waste and fluid from your blood) and malignant neoplasm (cancerous tumor) of right kidney. R223 had a urinalysis (UA) and culture and sensitivity (C&S) on 1/1/25, which showed R223 was positive for a urinary tract infection (UTI). R223's culture showed 1) Escherichia coli (bacteria that causes UTIs) >100,000 COL/ML (colony forming units in milliliter of urine) and 2) Proteus mirabilis ESBL (Gram negative bacterium that causes variety of infections including UTIs.) (ESBL-extended-spectrum beta-lactamase- an enzyme produced by certain bacteria that makes them resistant to many commonly used antibiotics, making it harder to treat) producing Proteus mirabilis are resistant to several antibiotics) >10,000- 50,000 COL/ML. Result phoned, read back, and faxed/electronically transmitted . Positive for ESBL. This organism is an extended-spectrum beta-lactamase producer. These organisms may not clinically respond to treatment with cephalosporins, extended-spectrum penicillin or aztreonam. Isolation precautions may be required. Facility's surveillance list for residents for month of January 2025 shows: R223- Onset Date- 1/11/25. Site- GU (GENITOURINARY) SYSTEM. Symptoms- trouble urinating and burning. Diagnostics/Results- UTI. Type of isolation- N/A (NOT APPLICABLE). Treatment & Intervention- Ceftriaxone Sodium Injection solution reconstituted 1 gram. HAI (healthcare acquired infection) /CAI (community acquired infection)- HAI. Completion Well Date- 1/14/25. *Note: Per CDC guidelines Enhanced Barrier Precautions (use of gloves and gown during high contact resident care) recommended. Example 2 R32 admitted to the facility on [DATE] and has diagnoses that include chronic kidney disease stage 3 and metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance). R32 had a UA and C&S on 2/3/25, which showed R32 was positive for a UTI. R32's urine culture showed 1) Citrobacter freundii complex-ESBL (gram negative bacteria that can cause various infections, including a UTI). 50,000-100,000 COL/ML. Positive for ESBL. This organism is an extended-spectrum beta-lactamase producer. These organisms may not clinically respond to treatment with cephalosporins, extended-spectrum penicillin or aztreonam. Isolation precautions may be required. 2) Enterococcus faecium (a gram-negative bacterium, is resistant to many standard therapies, including antibiotics) -10,000-50,000 COL/ML. Facility's surveillance list for residents for month of February 2025 shows: R32 (100 hallway)- Onset Date- 2/5/25. Site- GU. Symptoms- Multiple organisms noted in UA: ESBL (50,000- 100,000) and Enterococcus faecium (10,000-50,000COL/ML) Burning with urination, public tenderness, foul smelling urine, darkened discolored urine. Diagnostics/Results- UTI. Type of isolation- N/A. Treatment & Intervention- Macrobid Oral Capsule 100mg (milligrams). HAI/CAI- HAI. Completion Well Date- 2/9/25. *Note: Per CDC guidelines Enhanced Barrier Precautions (use of gloves and gown during high contact resident care) recommended. Example 3 R44 admitted to the facility on [DATE] and has diagnoses that include neuromuscular dysfunction of bladder (a condition where bladder control is lost due to damage to the nerves resulting in difficulties with urination) and hemiplegia (severe weakness/complete paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left dominant side. R44 had an UA and C&S on 2/18/24, which showed R44 was positive for a UTI. R44's urine culture showed Proteus vulgaris-ESBL (a rod-shaped, gram-negative bacterium that can cause urinary tract and wound infections) 50,000-100,000 COL/ML. Positive for ESBL. This organism is an extended-spectrum beta-lactamase producer. These organisms may not clinically respond to treatment with cephalosporins, extended-spectrum penicillin or aztreonam. Isolation precautions may be required. Please refer to your infection control policy. Result phoned, read back, and faxed/electronically transmitted to . Facility's surveillance list for residents for month of February 2025 shows: R44 (Hallway 100)- Onset Date- 2/20/25. Site- GU. Symptoms- ESBL Culture results= 50,000 through 100,000 col/ml. NP (Nurse Practitioner) informed-wants to keep medication active for resident. Diagnostics/Results- UTI. Type of isolation- N/A. Treatment & Intervention- Cefpodoxime Proxetil Oral Tablet 100 mg. HAI/CAI- HAI. Completion Well Date-2/27/25. *Note: Per CDC guidelines Enhanced Barrier Precautions (use of gloves and gown during high contact resident care) recommended. Example 4 R47 was admitted to the facility on [DATE] and has diagnoses that include end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) and dependence on renal dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so). R47 had an UA and C&S on 2/17/25 that showed R47 was positive for an UTI. R47's urine culture showed Klebsiella oxytoca-ESBL (a gram-negative, rod-shaped bacteria that can cause a range of infections, from mild diarrhea to life-threatening bacteremia and meningitis). Positive for ESBL. This organism is an extended-spectrum beta-lactamase producer. These organisms may not clinically respond to treatment with cephalosporins< extended-spectrum penicillin or aztreonam. Isolation precautions may be required. Please refer to your infection control policy. Result phoned, read back, and faxed/electronically transmitted to . Facility's surveillance list for residents for month of February 2025 shows: R47 (Hallway 100)- Onset Date- 2/22/25. Site- GU. Symptoms- Klebsiella Oxytoca 50,000=100,000 COL/ML (Positive for ESBL). Confusion, pubic pain. Diagnostics/Results- ESBL-UTI. Type of isolation- N/A. Treatment & Intervention- Cipro Oral Tablet 500 mg. Give after dialysis. HAI/CAI- HAI. Completion Well Date- 2/27/25. *Note: Per CDC guidelines Enhanced Barrier Precautions (use of gloves and gown during high contact resident care) recommended. On 3/10/25 at 10:01 AM, Surveyor interviewed CNA Y (Certified Nursing Assistant) and asked if CNA Y had received any education on PPE, handwashing, and precautions. CNA Y indicated staff received education on handwashing and PPE for norovirus outbreak. Surveyor asked if CNA Y was aware of any residents with MDRO's and what care requirements would include for these residents. CNA Y stated she was not aware of residents with MDROs or what precautions would be required for these residents. On 3/10/25 at 10:14 AM, Surveyor interviewed CNA Z who indicated education on PPE and handwashing was received only in orientation. Surveyor asked if CNA Z was aware of any residents with MDRO's and what care requirements would include for these residents. CNA Z stated she was not aware of residents with MDROs or what precautions would be required for these residents. On 3/10/25 at 10:20 AM, Surveyor interviewed LPN AA (Licensed Practical Nurse) who indicated education on PPE may have been a few months back, but she could not remember. Surveyor asked LPN AA if she was aware of residents on MDRO's LPN AA stated she was not aware of residents with MDROs, LPN AA stated a resident with an MDRO would require transmission-based precautions. On 3/11/25 at 12:02 PM, Surveyor interviewed IP D (Infection Preventionist) regarding R223's ESBL infection. Surveyor asked IP D when the facility received R223's lab results indicating R223 had ESBL in the urine what did facility do? IP D indicated MDRO Precautions would have been put into place for R223. Surveyor showed IP D the facility line list under type of isolation the line list indicates isolation precautions were documented as N/A. IP D indicated he does not know why he put N/A in there, he thought he had put precautions into place but can't remember for sure. Surveyor asked if any staff training was provided at that time. IP D indicated staff get trained at orientation on PPE (Protective Personal Equipment), hand washing and on peri cares. IP D indicated precaution signs would be placed as needed and if staff have any questions they are to come to me. Surveyor asked if there are any other times staff should receive education on infection prevention and IP D indicated if there were concerns with infection control and if failure to use infection prevention measures. Surveyor asked IP D if any education would be provided to staff with an outbreak and IP D indicated yes, on what the outbreak was and the necessities for the outbreak. Surveyor asked what is meant by necessities and IP D indicated for COVID outbreak- the PPE and hand washing, and for GI (gastrointestinal) outbreak and respiratory would be same ballpark and to keep everyone as safe as possible. Surveyor asked about R32, R44, and R47's lab results showing positive for ESBL. IP D referred Surveyor to DON B (Director of Nursing). On 3/12/25 at 9:03 AM, Surveyor interviewed DON B. Surveyor requested March 2025 line list. DON B indicated she would get Surveyor a copy. Surveyor asked DON B regarding R223's ESBL infection. Surveyor asked DON B when the facility received R223's lab results indicating R223 had ESBL in the urine what did facility do? DON B indicated she will have to get back to Surveyor. Surveyor asked DON B about R32, R44, and R47's positive ESBL, what precautions were put into place, what cleaning and disinfecting went into effect, and if education was provided to staff on hand washing, PPE, ESBL/precautions. DON B indicated she will get back to Surveyor. Surveyor asked if poor hand hygiene or lack of PPE use could contribute to the spread of ESBL and DON B indicated yes. On 3/12/25 at 5:44 PM, Surveyor interviewed DON B and asked if there were concerns after R223 had an ESBL infection. DON B indicated yes this would be a concern. DON B indicated the facility tracks MDROs by line lists and mapping of symptoms. Surveyor asked DON B would you expect the positive cases of ESBL on the 100 hallway within the month of February to be recognized as a concern. DON B indicated it should have been recognized. Surveyor asked DON B if she would expect education to be provided to staff on MDROs, hand hygiene and precautions to be put into place. DON B indicated yes, and she would have to check with the educator to see if education was provided. DON B indicated it is a concern to have multiple cases of MDROs on the same hallway. The concern would be the spread to others and of course the concern of antibiotic resistance. Surveyor asked DON B would you expect the IP to follow outbreaks and DON B indicated yes. On 3/12/25 at 5:56 PM, Surveyor interviewed IP D. IP D indicated he would expect education to be provided to staff regarding ESBL, hand washing, peri cares and PPE/precautions. IP D indicated having 4 positive cases of ESBL within a short period of time in the facility is concerning with possible spread of a MDRO. IP D indicated he would expect residents with ESBL to be on precautions and he cannot pinpoint if the R223, R32, R44, & R47 residents were put on precautions and if so what for. IP D indicated he has no documentation to show the residents were on precautions. On 3/17/25 at 8:27 AM, Surveyor interviewed NP C (Nurse Practitioner) and asked NP C if she was aware of multiple cases of ESBL in the facility starting in January 2025 and in the month of February 2025. NP C indicated she would have to go back and look, at this time NP C indicated she does not know. Surveyor asked NP C if this were something she would want to be notified of and NP C indicated yes, if it were her patients. Surveyor asked NP C in her opinion how would this be a concern for the facility. NP C indicated they would want to know why this is occurring and see if their infection control practices need to be changed. Surveyor asked NP C how she would expect the facility to address multiple cases of ESBL in the facility. NP C indicated by making sure with the cases of ESBL precautions are being met and review who has been taking care of those residents. I would expect the facility to follow the proper precautions which would include gown and gloves and the standard precautions for ESBL. Example 5 R25 admitted to the facility on [DATE] and has diagnoses that include Diabetes Mellitus (a disease that result in too much sugar in the blood). R25's Quarterly Minimum Data Set (MDS) Assessment, dated 2/4/25, shows R25 has a Brief Interview of Mental Status (BIMS) score of 14 indicating R25 is cognitively intact. On 3/6/25 at 9:56 AM, Surveyor observed wound care on R25 with CNA G (Certified Nursing Assistant) and RN F (Registered Nurse). It is important to note that R25 is on EBP (Enhanced Barrier Precautions), requiring staff to wear gloves, gown, and mask while performing cares. RN F (Registered Nurse) and CNA G entered R25's room without performing hand hygiene and without wearing a gown. RN F removed the old Mepilex dressing that was saturated with purulent and bloody drainage. RN F then cleansed the wound with wound cleanser. RN F changed her gloves and did not perform hand hygiene. RN F applied the Dakin's-soaked gauze, skin prep applied to peri- wound, Hydralock applied, and covered with a Mepilex. RN F changed her gloves, but did not perform hand hygiene and began incontinence care, as R25 was incontinent of stool. RN F changed her gloves, but did not perform hand hygiene and performed catheter care on R25. On 3/6/25 at 10:28 AM, Surveyor interviewed CNA G. Surveyor asked CNA G what type of PPE (Personal Protective Equipment) should be worn in a room that has EBP, CNA G reported that they should wear a gown, gloves, and a mask. Surveyor asked CNA G if she should have been wearing a gown during wound care, CNA G stated yes. On 3/6/25 at 10:28 AM, Surveyor interviewed RN F. Surveyor asked RN F what PPE should be worn in a room with EBP, RN F stated gloves and mask, but that she wasn't sure about a gown. RN F and Surveyor reviewed the EBP sign on R25's door. Surveyor asked RN F if she should have had a gown on, RN F stated yes. Surveyor asked RN F if she had any missed opportunities for hand hygiene, RN F stated yes, she should have performed hand hygiene before starting wound care. Surveyor asked RN F if she should have performed hand hygiene after taking off soiled gloves and before applying clean gloves, RN F stated yes. Example 6 R74 admitted to the facility on [DATE] and has diagnoses that include cerebral infarction (also known as an ischemic stroke, a condition where blood flow to the brain is interrupted, causing brain cells to die) and unspecified symptoms and signs involving cognitive functions and awareness. R74's Quarterly MDS Assessment, dated 1/25/25, section C shows no BIMS score recorded, indicating R74's cognitive status was not assessed or deemed not applicable during the assessment period. On 3/11/25 at 9:42 AM, Surveyor observed CNA M give R74 a bed bath. CNA M did not change gloves and perform hand hygiene after washing R74's peri area and then reaching into clean rinse basin for wash cloth to rinse R74's peri area. CNA M removed gloves during bed bath and reached into her pocket for her phone and accessed Google Translate to ask R74 what she was saying without performing hand hygiene. CNA M then applied new gloves without hand hygiene and continued with bed bath. CNA M threw a soiled brief and gown on R74's floor along with the used washcloths and towels. CNA M kept same soiled gloves on and began dressing R74. During this time, CNA M grabbed the bed remote, grabbed R74's slippers out from under the bed, opened R74's door and grabbed the EZ stand from out in the hallway, picked up the soiled brief, the gown and used washcloths from bed bath off the floor and threw to another area on the floor to get the EZ stand up to the bed. CNA M then transferred R74 into the wheelchair and adjusted R74's clothing once in wheelchair with the same dirty gloves on. CNA M opened R74's drawer and grabbed R74's brush and ponytail holder and brushed R74's hair and put her hair in a ponytail with same dirty gloves on. CNA M transferred R74 halfway down the hallway and then stopped at a hand sanitizer mounted on wall, removed gloves and used hand sanitizer, then continued to take R74 to lounge area. On 3/11/25 at 10:16 AM, Surveyor interviewed CNA M and asked if there were missed hand hygiene opportunities during R74's bed bath. CNA M indicated after peri care, when she went in and out of room, and before taking R74 down the hallway. CNA M indicated gloves and hand hygiene should have been done 4 to 5 times during bed bath but R74 was rushing her. CNA M indicated hand hygiene should have been performed before brushing R74's hair and before grabbing bed remote, EZ stand and wheelchair. Surveyor asked CNA M if it is appropriate to throw dirty laundry on the floor and CNA M indicated that is what they do here. CNA M indicated it is not appropriate, but the facility does not have bins in the rooms to place laundry in. Surveyor asked CNA M if she received any education on PPE, precautions or hand washing. CNA M indicated no. On 3/12/25 at 9:03 AM, Surveyor interviewed DON B (Director of Nursing) and asked if dirty clothes, used wash clothes and towels and soiled briefs should be thrown on the floor while performing a bed bath. DON B indicated no. DON B indicated the facility has special containers the dirty clothes go in on each unit. Surveyor asked what staff should do with dirty clothing and linens etc. during care and DON B indicated staff should put dirty linens and clothing in a plastic bag. Surveyor informed DON B of observation of CNA M with missed hand hygiene opportunities during bed bath and dirty clothing and linens being thrown on R74's floor. DON B indicated that is not appropriate. DON B indicated she would have expected hand hygiene any time gloves get changed, after peri cares, before leaving room, before handling bed remote, wheelchair, EZ stand and resident. Example 7 The facility did not provide evidence the infection control policies get reviewed annually. -Infection Outbreak Response and Investigation- dated 12/23/22. -Management of Respiratory Syncytial Virus (RSV)- dated 12/1/22. -COVID-19 Vaccination- 5/16/23. -Influenza Vaccination- 8/30/23. -Pneumococcal Vaccine- 8/30/23. -Antibiotic Stewardship Program- 10/4/23. -Infection Control Surveillance-10/4/23. -Hand washing- 9/21. Surveyor asked IP D and DON B for evidence polices were reviewed annually. No evidence was brought to Surveyor. On 3/10/25 at 1:30 PM, Surveyor interviewed IP D and asked how often Infection Control Policies are to be reviewed. IP D indicated the DON B and NHA A (Nursing Home Administrator) review them yearly. Surveyor asked IP D if there is evidence of this and IP D indicated he would have to check with DON B. On 3/12/25 at 9:03 AM, Surveyor asked DON B if there were evidence the Infection Control Policies were reviewed annually. DON B indicated she would see if there were a sheet signed for annual review. 50285 Example 8 On 3/6/25 at 8:04 AM, Surveyor observed CNA GG (Certified Nursing Assistant) passing hall trays on [NAME] Hallway. No hand hygiene was being offered to residents before eating. On 3/6/25 at 9:18 AM, Surveyor interviewed CNA GG and asked when it was appropriate to complete hand hygiene. CNA GG stated that she performs hand hygiene before and after completing cares with the resident. Surveyor asked CNA GG if hand hygiene should be offered to the residents before eating. CNA GG stated yes. Surveyor asked CNA GG if she had offered the residents hand hygiene before she gave them their meal trays. CNA GG stated that she had not because there was no hand sanitizer available. Example 9 On 3/11/25 at 7:40 AM, Surveyor observed CNA M passing hall trays on [NAME] Hallway. No hand hygiene was being offered to residents before eating. On 3/11/25 at 8:35 AM, Surveyor interviewed CNA M and asked when it was appropriate to complete hand hygiene. CNA M stated she performs hand hygiene when her hands are visibly soiled and when providing cares to residents. Surveyor asked CNA M if hand hygiene should be performed before eating. CNA M stated yes. Surveyor asked CNA M if she had offered the residents hand hygiene before giving them their meal trays. CNA M stated she had not. On 3/12/25 at 8:47 AM, Surveyor interviewed DON B (Director of Nursing) and asked if she expected that staff offer hand hygiene to the residents before eating. DON B replied that yes, that was her expectation.

Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R3) reviewed for wandering and elopement potential. R3 eloped from the facility on 7/6/24 and the facility did not know his whereabouts for approximately seven (7) hours. Facility staff let R3 out of the building but did not know who he was or ensure he was monitored for safety. Police contact was made and a community silver alert was issued due to R3's unknown whereabouts. The facility's failure to provide adequate supervision to R3 and ensure adequate supervision created a finding of Immediate Jeopardy that began on 7/6/24. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 8/21/24 at 3:30 PM. The Immediate Jeopardy was removed on 7/12/24; however, the deficient practice continues at a severeity/scope level of D (potential for harm/isolated) as the facility implements its removal plan. Findings include: The facility's Elopements and Wandering Residents policy states: *The facility is equipped with door locks and alarms to help avoid elopements. *Alarms are not a replacement for necessary supervision. Staff are to be vigilant and respond to alarms in a timely manner. *The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Additionally, this policy adds the following under Monitoring and managing residents at risk for elopement or unsafe wandering: *Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. *The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. *Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. *Adequate supervision will be provided to help prevent accidents or elopements. *Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. *The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. The policy states the following under Procedure for Locating Missing Resident: *Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code) *The designated facility staff will look for the resident. *If the resident is not located in the building or on the grounds, administrator or designee will notify the Police Department and serve as the designated liaison between the facility and the Police Department. The administrator or designee should also notify the company's corporate office. *Director of nursing or designee shall notify the physician and family member or legal representative. *Police will be given a description and information about the resident; include any photos. *All parties will be notified of the outcome once the resident is located. *Appropriate reporting requirements to the state survey agency shall be conducted. Note: this policy does not state how the facility will monitor or supervise any resident who is not at risk for elopement or wandering. R3 was admitted to the facility from the hospital on 6/21/24 and had diagnoses that included pulmonary embolism, anoxic brain injury, and type 2 diabetes. His most recent Minimum Data Set (MDS) dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 10, indicating R3 was moderately cognitively impaired. R3's hospital discharge note states, in part: Patient developed mild confusion and impulsivity leading to one witnessed fall without head trauma or other injury. He briefly required video monitor for safety. Speech cognition evaluation completed and raised concern for cognitive impairment. Geriatrics specialty service was consulted for capacity evaluation and patients POA (Power of Attorney) was activated. A facility document titled, Head to Toe Assessment, conducted by the facility on 6/21/24 indicates R3 was a low risk for elopement due to: *No verbalization to leave the facility *No predisposing diseases such as dementia, Alzheimer's disease, major depression, mental illness, expressive language deficits, substance abuse dependence, or end of life *R3 is alert and oriented *No history of elopement *Not on any narcotic, antipsychotic, antidepressant, or anti-anxiety/hypnotic medications It should be noted despite not having Alzheimer's or Dementia, R3 is moderately cognitively impaired, with an Anoxic Brain Injury and has an activated POA. A therapy discharge note for R3, with a discharge date of [DATE], indicates R3 had met his goal of walking 150 ft with his walker with contact guard assistance only. Of note, the facility employs cameras in common areas in the facility, including some hallways and on both sides of the facility's main entrance. This main entrance is locked from the inside at all times and a code must be used to exit. The facility documented the following event that occurred on Saturday, 7/6/24: At 12:45 PM it was noticed by a CNA (Certified Nursing Assistant) that resident (R3) was not in his room and was not located elsewhere in the building. Staff acted appropriately. A Code [NAME] (Alerts staff a resident is missing) was called at 12:45 PM according to policy/procedure. Building was searched inside and immediate outside vicinity with no results. Administrator was called at 1:14 PM. Administrator directed facility to call police. Police issued a silver alert at 1:20 PM. Additional details of facility report and investigation: *The facility attempted multiple times to contact R3's cell phone, with no success *Cameras were reviewed and R3 was observed leaving the building at 12:05 PM, dressed and with proper footwear *Police went to R3's home and noted his car in the driveway. Police left and then returned a short time later and R3's car was gone. *R3's POA called the facility and stated R3 was at home. *Silver Alert was ended just after midnight (7/7/24), though resident did not return to facility On 8/20/24 at 11:10 AM, POA G (Power of Attorney) stated that she had heard from the facility around noon on 7/6/24 that the facility could not find R3. POA G also stated that she was able to get in touch with R3 at around 6:30 PM on 7/6/24 in which R3 stated that he was at his residence at which point POA G contacted the facility. POA G stated that when she asked R3 how he had gotten home, he stated that a guy picked him up and took him home. POA G stated that R3 would not tell her, despite repeated requests, who the guy was. Additionally, POA G stated that in a subsequent conversation with R3, he told POA G that a girl with a bus had picked him up. POA G stated she did not believe it was the city bus, but R3 still has not revealed a name or details regarding the ride home. On 8/20/24 at 2:30 PM, MR E (Medical Records) stated to Surveyor that she was the manager on duty on 7/6/24 and after the Code [NAME] (Missing Resident) was announced, she contacted administration and then the police. The police arrived and asked questions of nurses and she gave the police officer the address of R3, and then the officer left. MR E was not able to access video footage for the officer but stated that later, along with DON B (Director of Nursing), she viewed camera footage after staff were unable to locate R3. MR E stated that R3 could be seen on video footage in his wheelchair at 12:00 PM. MR E stated R3's phone could be seen lighting up and R3 answered the phone. MR E stated that R3 then propelled himself to his room and he could be seen moments later exiting his room with his walker. MR E stated that R3 is then seen at 12:05 PM near the front door at which time CNA F can be seen typing in the code of the front door and R3 walks out. On 8/20/24 at 1:36 PM, PO H (Police Officer) stated to Surveyor that he was dispatched to the facility at 2:02 PM on 7/6/24 and the call came into the police department at that time. PO H stated that when he arrived at the facility (time unknown), the facility staff had trouble accessing video footage, so he was unable to view the footage. PO H stated he left the facility at 2:30 PM. PO H stated that he arrived at R3's residence, approximately 3 miles from the facility, at 3:30 PM. PO H stated that when he arrived at R3's residence, he noticed his car parked there. He knocked on his door and got no response. He then left and returned a short time later and noticed R3's car was no longer parked at the residence. (It should be noted the discrepancy in time from when the Police Officer states he was dispatched and when the facility states they notified the Police Department.) On 8/20/24 at 4:15 PM, CNA I stated that she had let R3 out of the building on 7/5/24 around lunch time to get some fresh air. According to CNA I, R3 visited outside with two friends, one female and one male, and then CNA I later let R3 back into the building with no problems. CNA I stated that she overheard one of the visitors state that they would be back but did not think it meant anything at the time or if it would be that day. On 8/20/24 at 3:15 PM, CNA F stated that she let R3 out of the facility on 7/6/24 by punching in the code on the door. CNA F stated that R3 walked to the door with his walker and she did not know if he was a resident or not and R3 stated that he just wanted to go out and get some fresh air. CNA F stated that she then opened the door for R3. CNA F also stated that she had put a tray in R3's room for breakfast earlier in the day when he was not in his room, and when she came to pick it up, the food had been eaten. Then for lunch, R3 was not in his room again and CNA F stated that she thought he was just out of his room and he would return, like breakfast, and eat his lunch meal, but when she came to pick the tray up, it looked as if it had not been touched, so she alerted fell ow staff at which point the facility began to look for R3. Additionally, CNA F stated that she had actually seen R3 earlier in the day, but he was in his wheelchair. CNA F stated that he looked completely different when she let R3 out and actually did not know that it was him (R3) until DON B (Director of Nursing) called her later in the evening and told her (CNA F) that she had let R3 out of the building. CNA F stated that she then put it together and remembered that she had seen R3 earlier in the day. CNA F stated that she did not come back and check on R3 as she was unsure if he was even a resident. CNA F stated that this was her first shift at the facility. It should be noted that CNA F is a new employee and the facility schedule indicates CNA F was in training on 7/6/24. It should be noted CNA F did not verify if R3 was a resident and did not verify if R3 was a resident who could independently leave the facility without supervision. The following should also be noted: *According to NHA A (Nursing Home Administrator) and POA G, R3 did not keep his car at the facility *No facility staff, including MR E, CNA I, POA G, RN J (Registered Nurse), PTA K (Physical Therapist Assistant), OT L (Occupational Therapist), CNA M, CNA N, and LPN O (Licensed Practical Nurse), had seen or heard any indication that R3 was going to leave the facility. *The facility does not require visitors to sign in and there was no record of R3 signing out on 7/6/24. On 8/21/24 at 12:03 PM, Surveyor walked around the facility to see if there was a nearby bus stop. Surveyor was unable to find a nearby bus stop within a few walking blocks. Surveyor called [NAME] City Metro and spoke with an employee. MCM D ([NAME] City Metro) indicated the nearest bus stop to the Nursing Home would be over by the Kwik Trip which would be route D1. MCM D indicated that this bus stop is the Milwaukee/[NAME] which would run the route over to Milwaukee/[NAME]. MCM D indicated this stop would be the closest to the residential address for R3. MCM D indicated that the individual would need to then walk about 13 minutes to the location of the address provided. (Surveyor provided R3's destination.) Of note: per Google maps, R3's home address is three (3) miles from the nursing home, which would be a 6-minute car ride, 24-minute transit (bus) ride, or a 48 minute walk to walk to R3's home. To get to the Milwaukee/[NAME] bus stop, R3 would have needed to cross Milwaukee Street, which has a high traffic volume. Once R3 arrived at the final bus stop, R3 would have needed to cross over East [NAME] Avenue, which also has a very high traffic volume. It should be noted it is not clear to the facility, Surveyor, or POA G how R3 arrived at his home. On 8/21/24 at 1:18 PM, Surveyor interviewed VPCS C (Vice President of Clinical Services) regarding the root cause analysis of R3's leaving the facility grounds unsupervised. VPCS C indicated the root cause was CNA F did not check with the nurse if R3 could go outside independently or if R3 needed supervison. VPCS C indicated that CNA F also thought R3 was just going to sit outside. R3 left the facility grounds, without facility staff knowledge, without adequate supervision and was found almost seven hours later, three miles away at his home. R3 did not tell staff he was leaving the facility nor did the facility ensure R3 had adequate supervision to prevent R3 from leaving the facility unsupervised. The facility's failure to ensure facility staff knew who R3 was and that he had adequate supervision when outside of the building created a reasonable likelihood of serious harm which led to a finding of Immediate Jeopardy. The Immediate Jeopardy was removed on 7/12/24 when the facility began implementing the following: ~Resident (R3) no longer resides at the facility. However, many efforts were made by facility to encourage resident to return, including involvement with POA. Resident desired to discharge to prior residence and refused to return. ~On 7/6/24 the following was initiated: *Code [NAME] immediately initiated *POA notified *Staff called R3 multiple times beginning at 1:00pm and texted at 5:30pm and 7:55pm resident and explained risks resident was taking by not returning, however no answer to either voicemails or texts *Staff notified law enforcement at 1:20pm after inability to locate or connect with resident, Silver Alert initiated, and police completed a wellness check at his residence. *Provider updated 1:15pm *Staff interviews initiated at 12:45pm *DON came to facility at 1:45pm and also drove around the neighborhood searching for the resident. *Ad Hoc QA (Risk Event Call) held with Governing Body and Facility Leadership X3 to discuss root cause of event and next steps held on 7/6/24 at 3:56pm, 4:58pm and 7:11pm. New CNA not familiar with who resident was, assisted him out the front door mistaking him for a visitor. Resident had set up plan in advance and pre-arranged a friend waiting for him to pick him up. (Of note, this was never confirmed that R3 had a prearranged ride, it is unclear how R3 arrived at his residence. What is known is R3 left the facility grounds without supervision and was found almost 7 hours later, 3 miles away at his home.) ~New Elopement Risk Assessments were conducted on all residents, and care plans reviewed on in-house residents by 7/11/24 by Director of Nursing and/or Designee ~Education on Elopement/Wander Policy initiated by Director of Nursing to center staff immediately on 7/6/24 after root cause completed. Education included: Elopements & Wandering Residents Policy, Elopement Care Planning, Elopement Tips (to include how to identify potential elopement risks), and Elopement Door Alarm Procedures-when door alarm sounds, staff are to investigate and intervene if necessary. ~On 7/6/24, DON B began education that staff are to go to nurse to find out if resident is able to go out of facility on their own. ~Post-Tests also included to measure understanding of education. ~On 8/21/24, IDT (Interdisciplinary Team) members conducted an audit to confirm education completed around verbal discussion including, asking nurse before allowing residents outside, if unable to verbalize education was complete, education immediately provided. Re-education was validated prior to next scheduled shift. ~Elopement Drill conducted on 7/12/24 by Maintenance Director. ~Elopement Binders reviewed and updated by DON and/or Designee by 7/12/24 ~Facility conducted an Ad-Hoc QAPI with QAPI Committee on 07/12/2024 to discuss root cause and implementation of above steps. ~DON and/or Designee to audit employee knowledge with use of questionnaire around elopement and notification of nurse prior to allowing unfamiliar resident/visitor out of facility, starting 8/22/24. Audits conducted weekly for 4 weeks, monthly for 2 months. Audits will be discussed during the IDT (interdisciplinary team) QAPI monthly meetings. ~Maintenance Director/Designee will conduct elopement drills weekly for 4 weeks, monthly for 2 months on various shifts at various times.

Based on observation, interviews, and record review, the facility did not ensure that residents had the right to receive visitors of their choosing at the time of their choosing for 1 of 19 residents (R5) reviewed for visitation rights. This resulted in R5 experiencing depression, financial hardship, and disinterest in participating in activities of daily living (ADLs). R5's husband is limited by the facility to visiting between the hours of 8:00 AM to 4:30 PM, regardless of the resident's wishes. Findings include: The facility policy, entitled Resident Right to Access and Visitation, undated, states: Policy: It is the policy of this facility to support and facilitate the resident's right to receive visitors of their choosing, at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of other residents . The policy also states, 1. The facility will provide immediate access to a resident by immediate family and other relatives of the resident . Resident's family members are not subject to visiting hour limitations or other restrictions not imposed by the resident, with the exception of reasonable clinical and safety restrictions, placed by the facility according to CDC (Centers for Disease Control) guidelines, and/or local health department recommendations. R5 was admitted to the facility on [DATE], and has diagnoses that include: multiple sclerosis (degenerative disorder causing nerve damage which leads to paralysis, vision loss, fatigue, and mood disturbance) , sickle cell disorder with acute chest syndrome (red blood cells become crescent-shaped causing severe pain with occlusion of arteries and veins around the lungs), idiopathic aseptic necrosis of right femur (death of bone tissue related to loss of blood supply), idiopathic aseptic necrosis of left femur, and other chronic pain. R5 has a Brief Interview of Mental Status (BIMS) of 15, indicating that she is cognitively intact. R5's Care Plan indicates activity interventions of R5 activity preferences: visits from husband, TV, shopping, resting, smoking, snacking, socializing with other residents, smartphone games, bingo . Allow private time for her and husband. These interventions were initiated on 12/11/23 and maintained following a revision on 3/15/24. R5 has an additional care plan focus of The resident is at risk for mood impairment r/t (related to) decline in capabilities r/t dx (diagnosis) of MS (multiple sclerosis). Goal: The resident will verbalize improved well-being by next review date. Intervention: Monitor/document/report PRN (as needed) any risk for harm to self: . This focus was initiated on 12/2/23 and maintained through a revision on 5/15/24, with a target date of 8/15/24. The Facility also created a typed document that is untitled to restrict R5's visitation hours. The document is dated 1/3/24. This document states, Witnesses have reported seeing the resident's significant other utilizing resources that are meant for the resident, and resident alone. It has been determined that R5's progress to health and wellness is being compromised by the presence of the significant other. This document specifies that starting 1/4/24, the husband's visitation was restricted to business hours of 8:00 AM to 4:30 PM. The document also states, If the significant other is seen on the premises, he will be asked to leave. If this is unsuccessful, we will be required to contact[sic] law enforcement. Emergency shelter address and contact information also included. This document was signed by SW D (Social Worker). R5 and her husband did not sign the document. Of note: No evidence provided as to how the facility made the determination that R5's progress to health and wellness was being compromised by the presence of her husband. On 6/18/24 at 10:07 AM, Surveyor interviewed R5. Surveyor asked R5 if her visitors have ever been restricted. R5 indicates that the facility is currently restricting her husband's visitation hours and has been since January of this year. Facility staff have told R5 and her husband that the husband can only visit between the hours of 8:00 AM and 4:30 PM. R5 denies ever receiving a valid reason to why this restriction was put in place. R5 also states that the facility tried to get her to sign a contract agreeing to this visitation restriction which both the resident and her husband refused to sign because they did not agree to the conditions imposed by the facility. The contract itself was initiated by a prior administrator, and when R5 approached NHA A (Nursing Home Administrator) to remove these restrictions, as it was R5's wish to visit with her husband outside of these hours and that the contract was never signed, NHA A advised the resident that it didn't matter that R5 and her husband didn't sign the contract, the restriction would remain in place. Surveyor asked R5 why the restriction was initially implemented. R5 states that staff observed her husband lying in her bed several months ago and claimed that her husband was trying to live here. R5 explains that her husband worked the night shift at the time, and the resident did not use her bed as she remained in her electric wheelchair by choice. They were watching a movie together when her husband fell asleep after working all night. Surveyor asked if her husband currently has a residence of his own. R5 reports that her husband has his own residence and has since before she was admitted to the facility, as they had separated several months prior to her admission to the facility and were living separately before her admission. R5 also indicates that her husband is currently caring for their 8-year-old child at the husband's personal residence. R5 states that recently, the facility has started calling the police when they see her husband on facility grounds after 4:30 PM, without a prior verbal warning as the contract she did not sign states. Surveyor asked if police ever charged her husband with any crime. R5 indicated that police took no other action then to just ask her husband to leave, which he complied. On 6/19/24 at 8:43 AM, Surveyor interviewed CNA I (Certified Nursing Assistant). Surveyor asked CNA I if she is familiar with R5's husband. CNA I indicated that she is familiar with him. Surveyor asked CNA I if she has ever had any issues or negative interactions with R5's husband. CNA I indicates that she has never had any issues or seen R5's husband act in an aggressive manner towards other residents or staff. On 6/19/24 at 8:55 AM, Surveyor interviewed LPN G (Licensed Practical Nurse). Surveyor asked LPN G if she is familiar with R5's husband. LPN G indicated that she is familiar with him. Surveyor asked LPN G if she has ever had any issues or negative interactions with R5's husband. LPN G indicates that she has never experienced any negative interaction towards herself. However, several months ago, she witnessed an incident between R5, R5's husband, and SWA J (Social Worker Assistant), in which the husband was yelling at SWA J which included vulgar language. LPN G does not know what the argument was about. LPN G did not witness any physical aggression at that time and has not witnessed or experienced any incidents since that time. Of note: This is the only clinical staff member who witnessed aggression from R5's husband that Surveyor was able to interview. On 6/19/24 at 9:29 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked about R5's husband when DON B indicated that the husband was another problem. Surveyor asked DON B if the facility was restricting the husband's visiting hours. DON B indicates that they are restricting his visiting hours. Surveyor asked why the husband's visiting hours are restricted. DON B indicates that he is scary, intimidating, swears, raises his voice to herself, staff, and other residents. DON B indicates that it doesn't matter what the facility rules are, he will just pull his car into the driveway and basically tailgate in the driveway. Surveyor asked if DON B was aware of how these restrictions started as DON B was not employed by this facility when the restrictions were initiated. DON B indicates that through discussions with the previous administration, R5's husband was eating R5's meals and sleeping in her bed. DON B indicates that at that time, the facility believed the husband to be homeless. DON B reiterates that she is intimidated by R5's husband. On 6/19/24 at 10:43 AM, Surveyor interviewed R18. R18 has a BIMS of 15, indicating she is cognitively intact, and was admitted to the facility three years ago. R18 resides in a room across the hall from R5's room. Surveyor asked R18 if she ever has had any issues with a visitor in the building. R18 indicates that she has never had any problem with a visitor. Surveyor asked R18 if she has ever heard any loud arguments, disturbances, or been intimidated by a visitor from the facility. R18 reports that she has never been intimidated or disturbed by a visitor within the facility. R18 indicates that she would report the incident if she had been bothered by a visitor. Of note: No residents that Surveyor was able to interview reported any issues with a visitor in the facility. On 6/19/24 at 1:57 PM, Surveyor interviewed R5. Surveyor asked R5 if she could remain in the building to visit with her husband. R5 states that she can visit with her husband anywhere on the property from 8:30 AM to 4:30 PM, but after that she must visit with him off the property. R5 indicates that they usually visit on the bridge which Surveyor notes to be a public pedestrian bridge adjacent to the property. Surveyor asked R5 if she has ever been completely denied access to her husband, which R5 indicates that she has not. Surveyor asked R5 if the visitor hour restriction on her husband limits her ability to visit with her child. R5 indicates that it does, since her daughter is only in Wisconsin for the summer, and since it is not safe for her child to be outside in the extreme heat, she has not been able to visit with her daughter as much as she wants. Surveyor asked R5 how not being able to visit with her husband and daughter at the times of her choosing has affected her. R5 reports to Surveyor that she fights hard every day and that she is in a constant state of depression. Surveyor asked R5 if she could describe what she means by fights hard every day. R5 paused for a moment, shook her head, looked away, and was visibly tearful. Surveyor asked R5 if there was anything else she was willing to share about what she was experiencing. R5 describes not being able to focus on anything going on outside of the facility because she is constantly worried about and missing her family. R5 also describes financial hardship as her husband lost his job because he was taking so much time off work trying to visit with her before 4:30 PM when his visiting hours ended. R5's husband is also spending more money on gas trying to facilitate visits with R5's daughter while she is residing locally over the summer. On 6/19/24 at 2:15 PM, Surveyor interviewed CNA H. Surveyor asked CNA H if she was familiar with R5's husband. CNA H states that she is familiar with R5's husband. Surveyor asked CNA H if she has ever experienced R5's husband acting aggressively or had any problems with him. CNA H reports that she has never had any problems with him. CNA H also states, I think it is just wrong what they are doing to her and her husband. They don't restrict any other visitors here. CNA H also believes they are hurting R5 by not letting her husband visit. On 6/19/24 at 2:30 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if the facility has a visitation policy. NHA A indicates that the facility does have a visitation policy and Surveyor was provided the policy upon request. Surveyor asked NHA A if the facility restricts any visitors. NHA A indicates the facility only restricts visitation hours for R5's husband. Surveyor asked NHA A if there was anything restricting R5's husband's visitation besides the imposed hour restriction. NHA A reports that there are no additional restrictions and that R5's husband is allowed to utilize the entire property when visiting R5. NHA A indicates that the visitation hour restriction was in place prior to his employment with the facility but he has not seen any indication that the restriction should be lifted. Surveyor asked NHA A to describe the reason for the continuation of the visitor restriction. NHA A indicates that R5's husband has cursed at staff, used derogatory language against staff, flipped me off from his car window, and used derogatory language towards DON B. Surveyor asked NHA A if other residents were around during these incidents. NHA A indicates that he does not recall if residents were around or not. Surveyor asked NHA A if he believes that R5's husband is a threat to staff safety. NHA A states absolutely. NHA A states that R5's husband is scary, and that facility staff are worried about going to their car at night. NHA A reports that the week R5 was in the hospital was a relief to him because he didn't have to worry about his safety walking to his car at night. NHA A also indicates that, in his perspective, R5's husband is physically intimidating and reports the tailgating incident that DON B reported in her interview. Surveyor asked NHA A if he believes there is a threat to resident safety, since his staff feel threatened. NHA A states yes, there is a threat to resident safety and that if NHA A's mother resided at the facility, he would be concerned for her safety with R5's husband around. Surveyor asked NHA A, since he believed there is a threat to resident safety, if any self-reports were made regarding incidents occurring with R5's husband. NHA A indicates that the facility has not made any self-reports because no reportable incidents have occurred yet, but that the facility has contacted the police several times for R5's husband being on the property after 4:30 PM. Surveyor asked NHA A if any residents had approached him personally regarding R5's husband or his behavior. NHA A indicated that no residents had reported anything to him personally but was unsure if anything had been reported to other staff members. Surveyor asked NHA A if the facility had received any police reports from the facility calling the police on R5's husband. NHA A indicates they have not received any police reports. NHA A also made a statement to Surveyor that NHA A believes that if the facility were to lift the visitor restriction, the facility would turn into a 24-hour bed and breakfast for R5's family members. Of note: No grievances or self-reports were provided to Surveyor that accused R5's husband of resident mistreatment. The facility's unreasonable visitation restriction of R5's husband has caused R5 pyschosocial harm as evidenced by R5 has voicing constant depression, feeling hopeless, and can not focus on other things as she is worried and misses her family.

Based on observation, interviews, and record review, facility staff did not ensure that each resident who required pain management received such services according to the comprehensive person-centered care plan and the resident's goals and preferences for 2 of 19 residents (R6 and R5) reviewed for pain management. R6 asked for her as needed pain medication and did not receive it for almost 22 hours resulting in emotional distress, agitation, becoming physically hostile, and throwing objects. R5 was experiencing breakthrough pain at an 8 out of 10. R5 consistently takes her as needed (PRN) Hydromorphone every 4 hours for breakthrough pain. The facility ran out of R5's hydromorphone and R5 went several hours without her PRN medication which resulted in increased verbalizations of pain and uncontrolled pain. R5's progress notes indicate that this facility ran out of R5's medications twice in the span of four days. R5's care plan does not include any non-pharmacological interventions. Evidenced by: The facility policy, entitled Pain Management, dated 10/1/23, states: Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the policy states: In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will . c. manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the residents' goals and preferences. In the section titled, Pain Management and Treatment facility policy states, non-pharmacological interventions will include but are not limited to . a. environmental comfort measures . cognitive/behavioral interventions (e.g., Music, relaxation techniques, activities, diversions, spiritual and comfort support .) .Opioids will be prescribed and dosed in accordance with current professional standards of practice and manufactures' guidelines . Of note: This policy does not indicate the procedure for ordering additional pain medication from the pharmacy when a resident's supply runs low or how to obtain or access additional stores of pain medication if a medication runs out. Example 1 R6 admitted to the facility on [DATE] with the following diagnoses: bipolar disorder, generalized anxiety disorder, fibromyalgia, non-displaced fracture of olecranon process without intraarticular extension of unspecified ulna (fracture within the elbow), and an abscessed tooth with inflammatory conditions of the jaws. R6's Hospital Discharge, dated 4/29/24, include: . Date of admission: 4/21/24 . Date of discharge: 4/29/24 . history of myoepithelial carcinoma of parotid gland, status post parotidectomy in 2020, Hypertension, chronic back pain and jaw, bipolar, Attention Deficit Hyper Activity disorder, generalized anxiety disorder . who is being admitted with weakness, falls gait instability, hyponatremia, and anemia . Patient complained of dry mouth related to prior cancer . Patient takes 6 oxycodone per day, lorazepam up to 3 per day . Patient complained of elbow pain since one of her falls . Chronic pain- fibromyalgia . generalized debility: She did fall and have an olecranon fracture which is going to be followed up the week after discharge with orthopedic clinic . Myoepithelial carcinoma of parotid gland status post parotidectomy 2020: Osteoradionecrosis of temporal bone . CT (CAT Scan/Medical Imaging) of facial bones with contrast: 4/24/24 result date: impression Periapical lucency again identified adjacent to the left first mandibular molar tooth. A periapical abscess is suspected . XR Panorex (x-ray): 4/23/24 result date: impression: large cavity in the left first mandibular molar, probably associated with root abscess . XR elbow right . : 4/21/24 result date: . Nonoperative olecranon fracture: splint provided by orthopedics along with sling . Discharge Medications: . lorazepam 0.5MG (milligrams) Take one tablet by mouth every 8 hours as needed for Anxiety or Agitation . Oxycodone Immediate Release 5MG Take one tablet by mouth every 6 hours as needed . Lorazepam 0.5MG Take one tablet three times a day as needed for Anxiety . Oxycodone Immediate Release 5MG Take one tablet by mouth every 4 hours as needed for Pain: do not exceed 6 tablets per day, must last 28 days . R6's Physician Orders, 4/29/24-5/31/24, include: start date 4/29/24 Lorazepam Oral Tablet 0.5MG Give 1 tablet by mouth every 8 hours as needed for agitation/anxiety . start date 4/30/24 Lorazepam Oral Tablet 0.5MG Give 1 tablet by mouth every 8 hours as needed for agitation/anxiety for 13 days .start date 4/29/24 Oxycodone HCI Oral Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for pain . start date 4/30/24 Oxycodone HCI Oral Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for pain for 13 days . R6's Pain Evaluation, dated 4/29/24, includes: Have you had pain or hurting any time in the last 5 days? Yes . Pain frequency: Frequently . Numerical Rating Scale: 6 . Pain Goal: 3 . Verbal depicter scale: Moderate . where is pain located: back . How long have you had it? Chronic . Describe pain: aching . What alleviates pain: medications and rest . Pain effect sleep? Occasionally. Pain interferes with therapy activities. Occasionally . Pain interferes with day-to-day activities? Occasionally . R6's Nurse Notes, include: 4/29/2024 9:29 PM Clinical Summary: resident arrived via emergency medical services . resident alert and oriented x3 able to make needs known resident is one assist . states she is able to use a cane . resident able to transfer with standby assist . gait mildly unsteady when standing/pivot, has a splint to right upper extremity with limited range of motion . has 0 skin issues. 4/29/2024 9:30 PM Resident complains regarding medication and anxiety appears heightened because of this. Resident given emotional support, encouragement; continues with complaint. Pharmacy has been called with voice mail entered . wide, noticeable change in mood with resident going from calm, pleasant and cooperative to angry with outbursts and insults. Soft cast is intact to right upper extremity . Unsteady gait is noted. Resident is here to participate in an individualized program of physical rehabilitation . She plans to return home. 4/29/2024 11:15 PM Encountered resident at bedside during initial room rounds. She is alert, awake and oriented with noted anxiety. Resident asking about her medications. All medication orders have been sent to pharmacy to be dispensed. This is a new admission arriving from hospital earlier this evening. Resident has soft cast to right upper extremity, secondary to hospitalization , fall, and fracture. Review of available records indicate hospital course started in emergency room with patient complaining of weakness, confusion, and falls. 4/30/2024 12:50 AM Resident scheduled to resume course of oral antibiotic therapy secondary to infected abscesses within oral cavity. She denies pain to mouth, neck, or jaw. She is afebrile at 98.2 oral measurement. Will be further observed for s/s (signs/symptoms) uncontrolled infection with interventions as indicated. 4/30/2024 2:15 AM An individual, unknown to writer, presents in doorway of nurses station yells out I want to know who the hell is taking care of my sister. This individual appears to be a thin, female of approximately 5'9 (tall) with long blonde hair who comes to be known as the sister of this resident. Expresses concern regarding medications and other care issues for this resident. General information provided and she is asked multiple times to cease / control angry presentation, she was instructed to leave nursing office. Writer continued with efforts to secure access to (facility's contingency box) system. This person exited workstation and was in resident's room approximately 15 mins. After which time she returned to nursing station, again with an agitated angry presentation, stated I did not want to have my sister in this ghetto place and what you're doing just prove me (explicit language) right. Again, instruction is given to refrain from yelling and swearing at which time she turned and traveled down hallway, turned, and began shouting . This person exited the unit and proceeded to exit the building. Observed resident at bedside, reassured resident of continued efforts to secure ordered (medication) but not prescribed narcotics. Resident appears anxious, there is no observable, nonverbal signs, and symptoms of severe pain. Assisted to position of comfort. 4/30/2024 4:45 AM Resident's family member identified herself as resident's sister, returned to facility asking for an update on resident's pain and anxiety .controlled narcotic medications. Writer informed her that facility medical director has been called . Provided education on the process and immediate options available to include Emergency Services assessment and transport to emergency room for immediate intervention . Writer responded to loud commotion in hall, came to know this family member was yelling and swearing at staff . who was clearly providing stand by physical assist and personal care as needed. Family dismissive, continuing to swear while assuming aggressive posturing. Sister . expresses regret about losing it, she is instructed on policy prohibiting aggressive behavior. 4/30/2024 8:11 AM Personal Care Provider and Physician Assistant's numbers incorrect in the electronic health record system. Correct number listed on resident profile. Voicemail left .Voicemail says not normal business hours . Will attempt call-back after 9:00 AM. (It is important to note at least 11 hours after admission the facility just realized they are not using the correct phone number for R6's Personal Care Provider/MD or R6's Physician Assistant.) 4/30/2024 8:38 AM Resident in emotional distress, becomes more agitated with any discussion or answer to questions in general, resident becomes physically hostile throwing items in room-unable to obtain consents or review admission paperwork. Immunizations in hospital records. (It is important to note the documented state of R6 and that there is no numeric pain rating with this note.) 4/30/2024 9:52 AM Physician's office called back-they are calling pharmacy directly to give narcotic prescriptions and okay' d psych consult. 4/30/2024 6:48 PM Yesterday, 4/29/24 after resident being discharged from hospital and admitting to facility, narcotic (written) prescriptions were not sent to facility's pharmacy. The Physician's office returned the call today and sent prescriptions to the pharmacy for as needed medications Lorazepam and Oxycodone. However, upon follow-up, the medications have not arrived at the facility at this time due to the prescriptions now being sent to the wrong pharmacy. (It is important to note R6's Nurse Notes do not include any pain monitoring using the numeric scale the facility used for R6's pain risk evaluation, dated 4/29/24. It is unknown if R6's pain was at, under, or above her pain goal of 3 throughout this review period.) R6's Medication Administration Record (MAR), 4/29-5/31, includes: 4/30/2024 7:13 AM Oxycodone HCI Oral Tablet 5 MG . Given . 5/7/24 3:00 PM Lorazepam 0.5MG . Given (It is important to note R6's MAR does not include any pain monitoring using the numeric scale the facility used during R6's pain risk evaluation, on 4/29/24. It is also important to note R6 went without prescribed as needed Oxycodone and as needed Lorazepam for over 22 hours when she has a history of taking 6 Oxycodone a day and 3 lorazepam a day.) R6 Grievance Form, dated 4/30/24, includes, in part: . Resident did not receive controlled substance medication . R6 was concerned that they did not receive their controlled substance medications . Resident's physician sent medications to the wrong pharmacy . On 6/18/24 at 3:58 PM, NP L (Nurse Practitioner) stated, Getting medications on admission has been an issue in this facility. On 6/19/24 at 12:31 PM, LPN G (Licensed Practical Nurse) indicated the facility pharmacy is hard to work with and cause issues with acquiring medications. LPN G indicated it is the responsibility of the facility's floor nurse to fax orders to the facility's pharmacy when there is a new admission. LPN G indicated the facility's Medical Director has the ability to write emergency orders. On 6/19/24 at 12:40 PM, LPN M (Licensed Practical Nurse) indicated there has been delays getting medications from the pharmacy with new admissions. LPN M indicated the hospital will fax the medication orders and hand-written prescriptions to the pharmacy and then the floor nurse will also fax the orders when the resident arrives in the facility. LPN M indicated the hospital sent R6's medication orders and handwritten prescriptions to the wrong pharmacy. Then when the facility staff sent R6's orders to the facility's pharmacy they did not have the handwritten prescriptions for her narcotics and would not give facility staff a code to obtain them from the contingency box. LPN M indicated the facility staff tried to call R6's MD throughout the first day to get the handwritten prescriptions to the correct pharmacy, but they were using an incorrect phone number until 8:00 AM the following day. LPN M indicated R6 was showing signs of being in distress and agitated by raising her voice, throwing objects, using foul language, and verbalizing pain/discomfort. Surveyor asked if the facility offered to send R6 to the emergency department, LPN M indicated she thinks they did. Surveyor asked if the facility's Medical Doctor was notified to see if he would give an emergency written prescription for the controlled narcotics. LPN M indicated she was unsure. LPN M indicated R6 was asking for her as needed oxycodone and did not receive it for over 22 hours. LPN M indicated the facility received access to R6's oxycodone and lorazepam at the same time, but R6 did not request to have her as needed lorazepam until 5/7/24. LPN M indicated she was unsure if non-pharmaceutical interventions were attempted with R6 during this time. (It is important to note there is one time where emergency services were brought up to R6's sister, but there is no evidence of R6 being offered to go to the emergency room . The facility did not provide evidence of the facility's Medical Director being notified and asked to write an emergency order for the controlled narcotics.) On 6/19/24 at 12:56 PM, DON B (Director of Nursing) indicated the facility pharmacy would not give the facility a code to access oxycodone or lorazepam from the facility's contingency stock box, because they did not have the handwritten prescriptions. DON B indicated the facility's Medical Director does have the ability to write emergency prescriptions and she is unaware if the Medical Director was asked to do this or not. DON B indicated the delay in obtaining R6's medications was caused by the hospital sending the order and handwritten prescriptions to the wrong pharmacy, the facility staff not using the correct contact information for R6's Medical Doctor, and the staff not consulting with the facility's Medical Director. DON B indicated the pharmacy is not always timely with filling orders and keeping medications stocked in the contingency box. DON B indicated R6's distress was caused by waiting for so long for her pain medication. DON B indicated staff should have recorded if they offered R6 to go to the emergency room . 49434 Example 2 R5 was admitted to the facility on [DATE], and has diagnoses that include: multiple sclerosis (degenerative disorder causing nerve damage which leads to paralysis, vision loss, fatigue, and mood disturbance) , sickle cell disorder with acute chest syndrome (red blood cells become crescent-shaped causing severe pain with occlusion of arteries and veins around the lungs), idiopathic aseptic necrosis of right femur (death of bone tissue related to loss of blood supply), idiopathic aseptic necrosis of left femur, and other chronic pain. R7's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/7/24 includes a Brief Interview of Mental Status (BIMS) of 15, indicating that she is cognitively intact. The MDS also indicates R5 is not receiving non-medication pain interventions and that her pain frequently interferes with her day-to-day activities and sleep. R5's Pain Assessment, dated 5/28/24 at 17:13 indicates the resident had a pain level of 8 out of 10 and verbally described the pain as very severe, horrible at the time of assessment. The assessment indicates that R5 has a pain goal of 2 out of 10. R5 indicates that her pain is constant, generalized all over her body, and occurs due to several chronic medical conditions. This assessment indicates that her pain occasionally affects her sleep and almost constantly interferes with her day-to-day activities. Medications ordered for the resident to treat her pain are listed as morphine and hydromorphone. R5's Care Plan, dated 5/29/24, with a target date of 8/15/24, states, The resident has an alteration in musculoskeletal status r/t (related to) dx (diagnosis) of MS (multiple sclerosis). Goal: The resident will remain free of injuries or complications related to MS by review date. Interventions: Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness. Monitor for fatigue. Plan activities during optimal times when pain and stiffness abated . An additional care plan focus initiated 4/17/24 and revised on 5/15/24 with a target date of 6/26/24, states, The resident is on pain medication r/t (related to) disease process sickle cell/(crisis). Goal: The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions: Administer ANALGESIC (pain relief) mediations as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift) . R5's care plan also has a focus initiated 12/2/23 and revised on 5/15/24 with a target date of 5/31/24, states, The resident has chronic pain r/t MS. Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function . Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Provide the resident with reassurance that pain is time limited. Encourage (SPECIFY: resident, NAME, me) to try different pain-relieving methods i.e., positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. The resident is able to: (SPECIFY: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain). The resident prefers to have pain controlled by: Dilaudid prn (administer as needed). R5's Physician Orders, active as of 6/18/24, include: Acetaminophen (Tylenol) Oral Tablet 500 MG (milligram), Give 2 tablet by mouth every 5 hours as needed for Pain. Take 2 tablets by mouth every 6 hours as needed. Start date: 5/28/24. Baclofen (muscle relaxer) Oral Tablet 10 MG, Give 1 tablet by mouth four times a day for Muscle Spasticity. Start date: 5/28/24. Baclofen (muscle relaxer) Oral Tablet 5 MG. Give 1 tablet by mouth every 8 hours as needed for Muscle Spasticity 1 tab PO every 8 hours as needed. Start date: 5/28/24. Gabapentin (relieves nerve pain) Oral Capsule 300 MG. Give 2 capsule by mouth every 4 hours as needed for Pain. Start date: 5/28/24. Hydromorphone (Dilaudid, Opioid pain medication) HCl Oral Tablet 4 MG. Give 2 tablet by mouth every 4 hours as needed for Pain. Take 2-3 tabs by mouth every 4 hours as needed. Start date: 5/28/24. Morphine (Opioid) Sulfate ER Oral Tablet Extended Release 15 MG (Morphine Sulfate). Give 1 tablet by mouth one time a day for Chronic Pain. Start date: 5/30/24. Morphine (Opioid) Sulfate ER Oral Tablet Extended Release 30 MG (Morphine Sulfate). Give 1 tablet by mouth two times a day for Chronic Pain. Start date: 5/30/24. Zanaflex Oral Tablet 4 MG (Tizanidine HCl, muscle relaxer). Give 1 tablet by mouth six times a day for MUSCLE SPASM. Start date: 6/1/24. Order to hold medication for sedation. Four times a day. Start date: 6/6/24. On 6/14/24 at 11:50 PM, a Progress Note indicates, in part, Resident presents to nursing station seat[sic] in electric wheelchair, requesting PRN narcotic for c/o(complaint) pain. Upon attempt to administer discovered floor supply to be depleted. Resident observed with s/s (signs and symptoms) of anxiety re: (regarding) when new supply can be obtained. Reassured resident contact will be pursued to establish refill delivery or subsequent orders. Resident with continued questioning. Inquiry as to present pain, resident states It's eight .Resident declines emergency room intervention. Call placed to pharmacy, message left .Nsng (nursing) observation is inconsistent with mod-high pain level . Of note: Individuals with chronic pain often do not display typical pain responses to high levels of pain. They may not exhibit outward displays of emotion similar to those with acute pain. Several articles have been written on this topic including, Over-Rating Pain is Overrated: A Fundamental Self-Other Bias in Pain Reporting Behavior from the Journal of Pain, DOI: https://doi.org/10.1016/j.jpain.2022.06.002 R5's Medication Administration Record (MAR), from June 2024, includes, in part: 6/14/24: 7:29 AM- Hydromorphone 4 MG x3 tablets administered for Pain .Pain Rating: 7/10 1:43 PM- Hydromorphone 4 MG x3 tablets administered for Pain .Pain Rating: 6/10 7:30 PM- Hydromorphone 4 MG x3 tablets administered for Pain .Pain Rating: 5/10 Of note, 6/14/24 shows R5 consistently takes PRN Hydromorphone every 6 hours. 6/15/24: 1:27 AM- Baclofen 5 MG x1 tablet administered for Muscle Spasticity 2:28 AM- Gabapentin 300 MG x2 capsule administered for Pain .Pain Rating: Not documented. 4:01 PM- Hydromorphone 4 MG x3 tablets administered for Pain .Pain Rating: 10/10 On 6/15/24 at 3:31 AM, a Progress Note indicates, Spoke with [Pharmacy] pharmacy technician regarding depletion of Hydromorphone. States additional supply is available on existing order; RPh (pharmacist) contacted for authorization, #30 tablets to be sent on STAT (Immediate) delivery basis. Resident is presently outside facility; Will advise when she returns; Will report to oncoming RN in AM. On 6/15/24 at 6:30 AM, a Progress Note indicates, Resident remains off unit. Reported and discussed with oncoming, RN (Registered Nurse), reported to unit manager, PRN narcotic delivery remains pending. R5's MAR from June 2024, includes, in part: 6/16/24: 8:33 AM- Hydromorphone 4 MG x3 tablets administered for Pain .Pain Rating: 9/10 12:56 PM- Hydromorphone 4 MG x2 tablets administered for Pain .Pain Rating: 8/10 8:09 PM- Hydromorphone 4 MG x3 tablets administered for Pain .Pain Rating: 8/10 11:30 PM- Hydromorphone 4 MG x3 tablets administered for Pain .Pain Rating: 8/10 6/17/24: 8:55 AM- Hydromorphone 4 MG x3 tablets administered for Pain .Pain Rating: 3/10 1:18 PM- Hydromorphone 4 MG x2 tablets administered for Pain .Pain Rating: 8/10 6:42 PM- Hydromorphone 4 MG x3 tablets administered for Pain .Pain Rating: 6/10 Note R5's consistent use of the PRN Hydromorphone. 6/18/24: 2:00 AM- Baclofen 5 MG administered for Muscle Spasticity 2:45 AM- Hydromorphone 4 MG x2 tablets administered for Pain .Pain Rating: 6/10 12:36 PM- Gabapentin 300 MG x2 capsule administered for Pain .Pain Rating: Not documented. 12:38 PM- Baclofen 5 MG administered for Muscle Spasticity Of note: R5 receives a dose of hydromorphone on 6/18 at 2:45 AM and the facility again runs out of her PRN pain medication. Of note: No Tylenol or tizanidine administered or marked refused and no medications were held for sedation. Gabapentin and Baclofen were only administered when R5 was out of her Hydromorphone. From 6/14/24 through 6/15/24 for a period of 16 hours and on 6/18/24 for a period of 10 hours, patient went without her pain relief ordered by her physician and indicated on her care plan and pain assessment. It is also important to note muscle relaxers are not prescribed to treat sickle cell pain. On 6/18/24 at 10:07 AM, Surveyor interviewed R5. R5 stated, This is the second time they let me run out of pain meds. R5 states that she takes PRN (as needed) pain medicine every 4 hours and that in the past when the facility has run out of her medication, she has needed to be admitted to the hospital for pain control. R5 reports that the last time she ran out of her medicine was on Friday (6/14/24) and that she is out of her medication again today (6/18/24). During Surveyor interview with R5, LPN P (Licensed Practical Nurse) entered the room to administer the resident's morning medications. Without prompting, LPN P stated that the facility was out of R5's pain medication and that a call has been placed to pharmacy for a STAT (immediate) order. R5 was visibly upset at this information but took the rest of the medications handed to her at this time. On 6/18/24 at 3:01 PM, Surveyor interviewed LPN P. Surveyor asked LPN P if she asked R5 if she would like to receive her hydromorphone. LPN P indicates that R5 told her that she wanted her pain medication and LPN P told her that she would let her know when it comes in from the pharmacy. LPN P indicates that she did give R5 prn Baclofen and Gabapentin. Surveyor asked if R5 came up any additional times to request pain medication. LPN P states that she did not. Surveyor asked what the process is for refilling prescriptions. LPN P states that the pill packs indicate when the supply is running low, and she calls pharmacy to reorder when she sees that indicator on the pill pack. LPN P indicated she called the pharmacy last night about the same prescription, but it was after hours, and she had to leave a message. LPN P indicates she has called again today regarding the prescription, as well as the Nurse Practitioner. Surveyor asked LPN P if there was any of the hydromorphone in the facility's contingency supply. LPN P states she was told that there was no hydromorphone in contingency, and if there was, she would not have access as agency staff do not have access to the contingency supply. Surveyor asked if LPN P would expect non-pharmacological interventions to be on the care plan. LPN P states she would expect non-pharmacological interventions to be on the care plan. Surveyor asked LPN P if she is aware of R5's acceptable pain level according to her most recent pain assessment. LPN P states she is not aware of R5's acceptable pain level. On 6/18/24 at 3:14 PM, Surveyor interviewed R5. R5 reports that she has still not received her PRN pain medication. Over the course of the interview, Surveyor observed several non-verbal indicators of pain including grimacing, wincing, staccato speech (speaking in 2-3-word sentences), holding her breath, intermittent repositioning, and audible cracking of joints as the resident attempted to reposition. Surveyor asked the resident to describe how her uncontrolled pain has been affecting her, and R5 reported that because of her history of sickle cell and multiple sclerosis, breakthrough pain often causes exacerbations of these disorders. R5 reports that she believes she is starting to experience an exacerbation of her multiple sclerosis as her legs were starting to go numb which has happened in the past. On 6/18/24 at 3:54 PM, Surveyor interviewed NP L (Nurse Practitioner). Surveyor asked if she was contacted over the weekend regarding R5's hydromorphone prescription. NP L indicates that she does not work nights or weekends but when she checked her phone today (6/18/24) she had received a voice message at some point regarding the prescription. Surveyor asked NP L what her expectation was of nursing staff if a resident was to run out of a prescription. NP L indicates that during the weekday she can be contacted, otherwise they can use contingency medications, and if that is empty, she would expect them to call the on-call physician. Surveyor asked NP L if R5 requires complex pain management. NP L indicates that R5 does have a complex pain management strategy due to her multiple chronic pain diagnoses that all play into each other. NP L indicates that she has recommended R5 see pain specialists as further support for her pain management. On 6/18/24 at 4:41 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she was aware that R5 ran out of her hydromorphone on 6/14/24 and 6/18/24. DON B indicates she was not aware. Surveyor asked DON B what her expectation would be for nursing staff if a resident's medication ran out. DON B states nursing staff need to call the pharmacy, and if they are unable to obtain additional medication, they need to call the physician. DON B would also expect these steps to be taken before the medication runs out. DON B reports to Surveyor that R5 has severe, chronic pain with associated behaviors that is not manageable. Surveyor asks DON B if she would expect the care plan to reflect the non-pharmacological interventions identified in the pain assessment. DON B states that non-pharmacological interventions should be in the care plan. On 6/18/24 at 5:01 PM, a Progress Note indicates, NP sent prescription of Dilaudid 6 tablets to [Pharmacy] for STAT, prescription picked up and delivered to Facility at this time. R5 was admitted with diagnoses including multiple sclerosis and sickle cell with acute chest syndrome. R5 had severe, breakthrough pain and the facility did not provide R5 with her prescribed and care planned pain medication or provide non-pharmacological pain management causing exacerbation in symptoms of her chronic conditions.

Based on observation, interview, and record review, the facility failed to ensure 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 for 1 (R1) of 3 residents reviewed for pressure ulcers (PU). R1 was a risk for PU development. The facility failed to implement aggressive interventions to prevent PU development. R1 developed a stage 2 PU which worsened to an unstageable PU. The facility failed to ensure R1 had aggressive offloading, failed to complete all physician ordered treatments, and failed to ensure physician prescribed offloading orders were followed. This is evidenced by: The facility policy entitled, Pressure Injury Prevention and Management undated, states in part: . Definitions: 'Pressure Ulcer/Injury' refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device . Policy . 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Evaluation of Pressure Injury Risk . b. The tool will be used in conjunction with other risk factors not captured by the risk evaluation tool. Examples of risk factors include but are not limited to i. Impaired/decreased mobility and decreased functional ability; ii. Co-morbid conditions . iv. Impaired diffuse or localized blood flow . vi. Cognitive impairment; vii. Exposure of skin to urinary and fecal incontinence . 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factor identified in the risk assessment, skin assessment, and any pressure injury assessment. c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces . f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting . According to the National Pressure Ulcer Advisory Panel (NPUAP)'s Pressure Ulcer Prevention and Treatment Clinical Practice Guidelines, published in 2019, page 27: .Once individuals are identified as being at risk of pressure ulcer development, a prevention program should be developed that aims to minimize the impact of those variables. Page 25 under Repositioning the Individual with Existing Pressure Ulcers in a Chair, section 3: If sitting in a chair is necessary for individuals with pressure ulcers on a sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less . While sitting is important for overall health, every effort should be made to avoid or minimize pressure on the ulcer . Section 5: Modify sitting time schedules and re-evaluate the seating surface and the individual's posture if the ulcer worsens or fails to improve. Page 34 under, Repositioning Technique subsection 3.2: Avoid subjecting the skin to pressure .This statement is based on expert opinion. Pressure ulcers occur because of sustained mechanical loading .Therefore, in order to prevent pressure ulcers, the skin should not be exposed to pressure . R1 was admitted to the facility on [DATE] and has the following diagnoses: cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it that can cause parts of the brain to die off due to lack of oxygen), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, weakness, neuromuscular dysfunction of bladder (lacks bladder control due to brain, spinal cord, or nerve problems), malignant neoplasm of prostate (cancer in the prostate), secondary malignant neoplasm of bone, unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decision, and solve problems), mild, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys), personal history of urinary tract infections, parkinsonism (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and the principal diagnosis of cord compression (external compression of the spinal cord causing neurological symptoms of causes that can include spinal trauma, degenerative disease, an abscess, or a tumor). R1's Minimum Data Set (MDS) admission assessment on 10/13/23 indicates R1 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition. R1's cognitive impairment is he sometimes understands and sometimes is understood. R1's Functional Assessment of toileting, chair/bed-to-chair and sit to stand is dependent upon human assistance to do all the effort. R1's personal hygiene assessment is substantial with maximal assistance that the human assistance does more than half the effort. R1's bladder and bowel assessment indicate he is always incontinent of bowel and bladder. R1's risk for pressure ulcer assessment (M0150) indicates resident is at risk for developing pressure ulcer and does not have one or more unhealed pressure ulcers at stage 1 or higher (M0210). R1's Braden Scale (an evidenced-based tool that predicts the risk for developing a pressure injury), on 10/7/23 was a 14 (moderate risk) On 12/11/23 the Braden scale was a 12 (high risk). R1's Skin plan of care initiated 11/10/23 and revised on 11/13/23 states in part; Focus: I may have a potential or actual impairment to skin integrity due to my in ability to move as related to my left side weakness due to my diagnosis of stroke. Goal: I will be free of skin breakdown throughout this review period. Interventions: 10/7/23 Educate resident/family/caregivers of causative factors and measures. Encourage good nutrition and hydration in order to promote healthier skin. 10/6/23 Pressure relieving boots while in bed. 10/8/23 Staff to offload boney prominences. Staff to reposition every two hours. Upon admission R1 had a Panacea foam pressure redistribution support surface. The manufacturers guidance for the Panacea mattress states in part; mattresses are one part of an overall care plan to prevent and treat decubitis ulcers. A complete clinical assessment of each resident should be performed before selecting any therapeutic support surface. R1's Nursing Progress Notes dated 10/6/23 documented at 3:33 PM state, in part: . resident admitted to facility Transferred from transport cot to bed with 3-person assist . Skin intact to shoulders, coccyx, and heels. Bordered foam dressing intact to coccyx. Incontinent brief in place . (It is important to note, resident had preventative measures of a pressure injury from the application of a border foam applied by the discharging facility.) R1's Admission Skin assessment dated [DATE] documented at 5:51 PM state, in part: .Skin integrity . Site 23) Coccyx - Red, speckled and blancheable. 31) Right buttock - Red blancheable area . R1's physician orders state in part: weekly skin check by licensed nurse on shower day. R1's physician orders dated 10/9/23 state in part: house supplement two times a day for failure to thrive (FTT), 4 ounces twice a day start date 10/9/23. 10/15/23 at 1:45 PM, Initial Wound Assessment (1 of 3) Date wound was identified: 10/15/23. Where was the wound acquired? Acquired after admission to the facility Wound Description: 31) Right buttock Type: Pressure Wound Measurements: Length 4.2cm (centimeters), Width 2.7cm, Depth 0cm Stage: 2 Percentage: 100% epithelization Exudate: None . 10/15/23 at 1:45 PM, Initial Wound Assessment (2 of 3) Date wound was identified: 10/15/23. Wound Description: 31) left buttock Type: Pressure Wound Measurements: Length 1.0cm, Width 0.9cm, Depth 0cm Stage: 2 Percentage: 100% epithelization Exudate: None . 10/15/23 at 7:26 PM, Initial Wound Assessment (3of 3) Date wound was identified: 10/15/23. Where was the wound acquired? Acquired after admission to facility. Wound Description: 23) Coccyx Type: Pressure Wound Measurements: Length 5.1cm, Width 3.2cm, Depth 0.6cm Stage: 2 Percentage: 100% epithelization Exudate: None . R1's Nursing Orders states: Reposition resident Q2H (every 2 hours) as tolerated every shift. Start date, 10/15/23. Staff to clean left/right buttocks with soap and water pat dry and apply bordered foam wound dressing with soft silicone adhesive and silver QD (every day) every day shift. Start date, 10/16/23. R1's physician orders states: Update MD 10/16/23 with wounds to coccyx left/right buttock and for additional tx (treatment) orders if needed. R1's Physician Orders states: Medihoney Wound/Burn Dressing External Gel (wound Dressings) Apply to Sacrum extend RT (right) buttocks topically every day shift for Treatment order. Start date, 10/17/23. Prostat supplement give 30ml for wound healing one time a day. Start date, 10/19/23. 10/23/23 at 1:45 PM, Weekly Wound Assessment Type: Pressure Wound Description: Coccyx/R buttock Wound Measurements: Length 8.0cm, Width 3.5cm, Depth 0.1cm Stage: Unstageable Percentage: 20% slough, 80% epithelization Exudate: small amount of serosanguineous Wound Progress: Stable/No change . 10/30/23 at 12:04 PM, Weekly Wound Assessment Type: Pressure Wound Description: Sacrum to RT (right) buttock Wound Measurements: Length 7.5cm, Width 6.0cm, Depth Undetermined Stage: 2 Percentage: 10% granulation, 40% slough, 50% epithelization Exudate: moderate serosanguineous Wound Progress: Deteriorated/Declined Comments: Wound has extended from coccyx through bilateral buttocks . 11/7/23 at 7:01 PM, Weekly Wound Assessment Type: Pressure Wound Description: Coccyx/Rt-Lt (right to left) buttock. Wound Measurements: Length 6.8cc, Width 4.3cm, Depth Undetermined Stage: Unstageable Percentage: 30% granulation, 60% slough, 10% epithelization Exudate: moderate serosanguineous Wound Progress: Deteriorated/Declined Comments: .This wound declined while resident was in the hospital . (Note: R1 was hospitalized from 11/4/23-11/7/23) R1's Physician Orders states: Up to chair max three times a day, max 1 hour at a time. Must reposition in chair every 30 minutes while up. Start date, 11/7/2023. Offloading cushion in wheelchair. Start date, 11/7/23. Therapeutic Air Mattress: Complete visual inspection for proper inflation . Start date, 11/7/23. Bilateral Buttocks Wound Care: . Wash wound with antimicrobial soap (i.e., Dial soap) and water using a washcloth, rinse completely and pat dry with clean wash cloth or towel. Apply Medihoney to open wounds. Cover with ABD (abdominal) pad. Dressing Changes to be done daily and PRN (as needed) if soiled every day shift for Wound Care. Start date, 11/8/23. R1 received the Proactive Aire 2000/3000 mattress after stage 2 PU development, and it has the following manufacturer's recommendations: .combines dual therapies of low air loss and alternating pressure in one unit . is designed to treat pressure ulcers . for deep immersion and excellent pressure redistribution . On 1/4/24 at 2:30 PM, Surveyor interviewed Maintenance Director G. Surveyor asked Maintenance Director G when the pulsating mattress was in place and he provided the work orders which did not document a mattress installation. Maintenance Director G further indicated that he does not usually do a work order, he installs them when he is asked, and the facility has the pulsating mattresses on hand. 11/13/23 at 11:55 AM, Weekly Wound Assessment Type: Pressure Wound Description: Coccyx/Rt-Lt buttock Wound Measurements: Length 6.8cm, Width 4.3cm, Depth Undetermined Stage: Unstageable Percentage: 30% granulation, 60% slough, 10% epithelization Exudate: moderate serosanguineous Wound Progress: Stable/No change . (It is important to note this assessment was signed the same day surveyors entered on 1/4/24. The wound measurements and percentages are identical on 11/7/23 and 11/13/23.) 11/20/23 at 3:17 PM, Weekly Wound Assessment Type: Pressure Wound Description: Coccyx/Rt-Lt buttock Wound Measurements: Length 7.5cm, Width 2.4cm, Depth Undetermined Stage: Unstageable Percentage: 60% slough, 30% epithelization Exudate: moderate serosanguineous Wound Progress: Improved . 11/27/23 at 3:45 PM, Weekly Wound Assessment Type: Pressure Wound Description: Coccyx/Rt-Lt buttock Wound Measurements: Length 4.0cm, Width 2.4 cm, Depth Undetermined Stage: Unstageable Percentage: 100% slough Exudate: moderate serosanguineous . R1's wound clinic visit notes dated 11/29/23 state, in part: .present to the clinic today for evaluation and treatment of stage 3 sacral wound due to poor offloading . Our team was consulted for inpatient wound cares . Assessment/Plan . Stage 3 sacral decubitus ulcer complicated by limited mobility and sensation to the area that started October 2023 . There is improvement in the periwound breakdown, but the main wound is larger which I attribute to the natural evolvement of his pressure injury, plus not great offloading. There is thick yellow devitalized tissue that I debrided today, but adherent slough still remains . Offloading: the patient is up in his wheelchair a good amount of the day . wife wants to do whatever she can to help him heal, so agrees to try a more aggressive offloading knowing he will need to be on his sides in bed more often . Wound cares will be as followed: Up to chair max three times a day, max 1 hours at a time. Must reposition in chair every 30 minutes while up. Must be seated on pressure offloading cushion (waffle or roho) when up in chair, must be on a pulsate mattress, turn side to side every two hours . Diagnoses for this visit include 1. Pressure injury of sacral region, stage 3, 2. Sloughing a wound . Measurements documented at this appointment, . 4.2cm x 2.6cm x 1.3cm . Wound bed: open full thickness wound with yellow devitalized tissue with pale on granular tissue to wound edges. Hyperemia surrounding with slight periwound breakdown . Surrounding tissue: dry, intact, no erythema or warmth, some signs of continued pressure . R1's Physician Orders states: Coccyx Wound Care: . Apply Medihoney to wound base, followed by calcium alginate. Cover with border foam . Start date, 11/29/23. Must be on pulsate mattress every shift. Start date, 11/29/23. Must be seated on pressure offloading cushion (waffle or roho) when up in chair every shift. Start date, 11/29/23. R1's Treatment Administration Record (TAR) indicates Sacral Wound Care on 12/2/23, 12/3/23, and 12/7/23 are empty boxes without documentation of wound care services being provided. 12/4/23 at 12:55 PM, Weekly Wound Assessment Type: Pressure Wound Description: Coccyx/Rt buttock Wound Measurements: Length 3.2cm, Width 82.4cm [error value], Depth Undetermined Stage: Unstageable Percentage: 100% slough Exudate: moderate serosanguineous . 12/11/23 at 12:08 PM, Weekly Wound Assessment Type: Pressure Wound Description: Pressure/RT Buttocks Wound Measurements: Length 3.4cm, Width 3cm, Depth Undetermined Stage: Unstageable Percentage: 100% slough Exudate: moderate serosanguineous Comments: IDT (interdisciplinary team) met to discuss wound. Area to Coccyx/Right buttocks has declined as it is larger. Continues with 100% slough. New area noted by the rectum. Wound NP (Nurse Practitioner) seen and classified as area of trauma and order for zinc oxide paste to be applied . R1's wound clinic visit notes dated 12/14/23 state, in part: .Offloading: Up in his wheelchair around 3 hours straight per day, spends the rest of the day in bed, using pillows to help offload and reposition patient, does not always get repositioned every 2 hours per wife . Wound cares: . Will change wound cares to Dakins packing with dressing changes once daily and as needed if soiled . Offloading: We discussed the importance of offloading with wound healing. Patient is doing a much better job with offloading over the past 2 weeks. Encouraged patient and his wife to continue with aggressive offloading if they would like this wound to improve . Diagnosis: 1. Pressure injury of sacral region, stage 3 . Measurements documented at this appointment, . 3.5cm x 2.9cm x 0.4 cm . Wound bed: open full thickness ulcer with adherent yellow devitalized tissue starting to thin out with minimal areas of red granular tissue underneath, moderate serous drainage, no odor, no bone exposure . R1's physician orders Sacral Wound Care: . Apply skin barrier prep to periwound. Lightly moistened gauze with half strength Dakin's solution. Wring out excess moisture-should be damp not soaking wet with fluid every day shift for Wound care . Start date 12/15/23. 12/18/23 at 2:42 PM, Weekly Wound Assessment Type: Pressure Wound Description: Coccyx/RT Buttocks Wound Measurements: Length 3.4cm, Width 2.4cm, Depth Undetermined Stage: Unstageable Percentage: 90% slough Exudate: moderate serosanguineous . 12/25/23 at 6:21 AM, Weekly Wound Assessment Type: Pressure Wound Description: Coccyx/RT Buttocks Wound Measurements: Length 3.4cm, Width 2.4cm, Depth Undetermined Stage: (no documentation of the stage) Percentage: 90% slough Exudate: serosanguineous (no amount of drainage is documented) . 1/1/24 at 9:17 AM, Weekly Wound Assessment Type: Pressure Wound Description: coccyx/RT Buttocks Wound Measurements: Length 3.4cm, Width 2.4cm, Depth Undetermined Stage: (no documentation of the stage) Percentage: 90% slough Exudate: serosanguineous (no amount of drainage is documented) . (It is important to note this assessment was signed the same day surveyors entered on 1/4/24. The wound measurements and the percentages are identical documentation of the previous 3 weeks of assessments. The wound continued to be documented as unstageable with an undetermined depth that is not congruent with the wound care clinic's assessments.) On 1/4/24 at 9:21 AM, Surveyor observed R1 sitting in his wheelchair in his room. On 1/4/24 at 10:56 AM, Surveyor interviewed FV C (Family Visitor). FV C reported he has been in R1's room since 10:00 AM and that R1 was put in his bed at 10:45 AM. (Note: R1 was observed being up in his wheelchair for at least 1 hour and 40 minutes.) On 1/4/24 at 1:01 PM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D how often R1 is repositioned? She indicated R1 gets repositioned every 2 hours in bed and R1 can only be in his chair for an hour. CNA D further indicated that R1 was up for almost 2 hours and she was late getting him back into bed because she had 2 showers to complete. On 1/4/24 at 1:45 PM, Surveyor interviewed RR E (Resident Representative). RR E indicated to Surveyor that they don't reposition R1 and that she has reminded the staff for dressing changes when it was not provided. On 1/4/24 at 3:44 PM, Surveyor interviewed LPN H (Licensed Practical Nurse). LPN H indicated R1 is repositioned every 2 hours. Surveyor asked LPN H how she would know if someone were at risk for pressure injury? She indicated if the resident was bedridden, or chair ridden and would also look at the Braden scale to see if resident is at high risk. LPN H then looked up R1's most recent Braden scale and stated it was a 12 and that means R1 is at high risk for pressure injury. LPN H indicated the interventions for R1 would be to reposition every 2 hours, wound care is daily, and if the dressing comes off, she will change it. Surveyor asked LPN H if a wound is unstageable, can you see the wound bed to stage the wound? She indicated no, because one cannot see the wound bed because it is covered in dead tissue. On 1/4/24 at 3:51 PM, Surveyor interviewed CNA I. Surveyor asked CNA I if R1 had a wound when he was admitted ? She indicated she did not believe so and if he did, he would have been repositioned every 2 hours. On 1/4/24 at 3:59 PM, Surveyor interviewed DON B (Director of Nursing) and RCS F (Regional Clinical Specialist) jointly. Surveyor asked DON B if R1 was at risk for pressure injury when he was admitted ? She indicated yes and R1 had a protective dressing on his coccyx from the hospital. DON B further indicated R1's Braden scale was 14 on admission and he had a red blancheable area on the right buttock and red speckled area on his coccyx. Surveyor asked DON B what was implemented knowing this information of R1 being at risk. She indicated an air mattress on 10/16 was put into place. Surveyor asked DON B if any aggressive measures were put into place right upon admission? DON B indicated the CNAs were repositioning from the date of admission and anybody in a wheelchair would have a cushion in the wheelchair as a standard of care. Surveyor asked DON B if these interventions were evaluated. She indicated yes with weekly skin checks with showering. Surveyor asked DON B for any documentation supporting the interventions were evaluated. She indicated another Braden was done on 10/7/23 that was a score of 14 and then we started documenting on 10/15/23 of the initial skin impairment. This initial skin impairment was on a Sunday, so the team looked at R1 on 10/16/23. Surveyor asked DON B why the interventions were not in the care plan until 10/16/23? She indicated the standard of care and repositioning was in the tasks for the CNAs and was not reinstated in the care plan. Surveyor asked DON B what the standard of care would be? She indicated anyone that is not ambulatory or mobile on their own and that R1 is not independent with bed mobility. DON B further indicated that R1 has a history of fecal incontinence, so the staff is repositioning and checking R1. Surveyor asked DON B if they continue to monitor R1's interventions? She indicated yes with the weekly skin assessments, and it is done by nurses and CNAs. Surveyor asked DON B the meaning of an empty box when looking at the MAR/TAR (Medication Administration Record/Treatment Administration Record). She indicated it is implied that it is not completed unless there is a code for a refusal. Surveyor asked DON B if R1 has any missed dressing changes? She reviewed the MAR/TAR and reported 12/2/23, 12/3/23, and 12/7/23. DON B further indicated that she has gone through the progress notes and reported that she did not have clear documentation for the omissions of the dressing changes. Surveyor asked DON B if the physician orders should be followed? She indicated yes, and the dressing change is ordered daily. Surveyor asked DON B if a wound is unstageable, can the wound be staged? She indicated no because one cannot see the wound bed. RCS F indicated that they could measure the depth if the wound is unstageable and was able to document a depth because she can see a depth. RCS F further indicated that she performs the dressing changes when she makes the rounds with the NP and is certified in wound care. Surveyor discussed the observation of R1 sitting in his chair for one hour and 40 minutes and the interview from the CNA stating R1 was in his chair for almost 2 hours. Surveyor asked DON B if R1 should have the physician order followed to not be in his chair for more than one hour, she indicated yes.

Based on observation, interview, and record review, the facility did not ensure all residents who smoke did so safely for 4 of 4 (R4, R6, R7, and R8) residents reviewed. R4's Smoking Assessment and Care Plan indicated they required supervision while smoking and that all smoking material should be stored by the facility. R4 uses oxygen. On 12/8/23, R4 was allowed to keep their smoking materials in their possession. Staff observed R4 smoking in their room. Staff observed R4's oxygen running, with the nasal cannula sitting on the bedside table thereby enriching the room with oxygen. R4 admitted to Surveyor that she had smoking materials on her person prior to being deemed safe to smoke independently. This created an unsafe environment for R4 as well as other residents of the building as a fire could have started much easier with the oxygen enriched air in the room. The facility's failure to implement safety and accident prevention measures for residents that are assessed to be supervised smokers created a finding of immediate jeopardy that began on 12/8/23. The Nursing Home Administrator (NHA A) was notified of the immediate jeopardy on 12/15/23 at 10:15 AM. The immediate jeopardy was removed by the facility on 12/15/23. The deficient practice continues at a scope and severity of a E (potential for harm/pattern) related to the following examples: R6, R7, and R8 were all determined to be supervised smokers. Their Smoking Evaluations all indicate that the facility is to store their smoking materials. Observations and interviews found that staff do not store R6's, R7's, or R8's smoking materials. They are allowed to keep their own smoking materials. Evidenced by: The facility's Resident Smoking policy, reviewed 12/01/23, includes, in part, the following: 4. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS (Minimum Data Set) assessment process. 5. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. 11. If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures. 12. Smoking material of residents requiring supervision with smoking will be maintained by nursing staff. Per The National Fire Protection Association (NFPA) 2016 *Oxygen saturates fabric covered furniture, clothing, hair and bedding, making it easier for a fire to start and spread. *Smoking materials is the leading heat source resulting in medical oxygen related fires, injuries and deaths. *Smoking and Medical Oxygen - Never smoke and never allow anyone to smoke where medical oxygen is used. Medical oxygen can cause materials to ignite more easily and make fires burn at a faster rate than normal. It can make an existing fire burn faster and hotter. The facility's Supervised Smoking Times, which was provided to State Agency on 12/13/23, indicates, in part, the following residents must be supervised while smoking: R4, R6, R7, and R8. Example 1: R4 was admitted to the facility on [DATE], hospitalized on [DATE] and readmitted on [DATE]. R4's diagnoses include, in part: chronic sacral decubitus ulcer, heart failure, and tobacco use disorder. R4's History and Physical from the hospital, dated 10/18/23, includes, in part the following: Social History: Decades long history of tobacco smoking approximately 10 cigarettes per day. Rare alcohol. History of marijuana smoking. R4's most recent full Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/27/23, indicates, in part, the following: R4 is cognitively intact, is independent with indoor mobility with a walker, and does not have current tobacco use. R4's Smoking Evaluation, dated 11/24/23 includes, in part, the following: a. Does the resident smoke? Yes b. Does the resident have cognitive loss? No c. Does the resident have a visual deficit? No d. Does the resident have a dexterity problem? No e. How often does the resident smoke per day? 10+ f. What time of day does the resident like to smoke? a. Morning, b. Afternoon, c. Evening, d. Nights g. Can resident light own cigarette? Yes h. Does the resident need adaptive equipment or assistance? None of the above i. Does the resident need facility to store lighter and cigarettes? No j. Plan of care is used to assure resident is safe while smoking? Yes k. Has the resident been educated on smoking procedure? Yes 1. Smoking Care Plan (It is important to note the following are all check marked.) Focus: I enjoy smoking as evident by my history of smoking. Goal: I will have no problems with breathing throughout this review period. Intervention: Instruct resident about the facility policy on smoking: locations, times, safety concerns. Intervention: The resident can smoke UNSUPERVISED. Intervention: The resident requires SUPERVISION while smoking. l. Have the risks of continued smoking been explained? Yes m. Does the resident express desire to quit smoking? Yes n. Has the resident ever tried to quit smoking before? No o. Has the resident requested a physician order for assistance to quit smoking? No p. Additional Notes On Smoking Cessation: Vaping to assist w (with) not smoking. The Smoking Care Plan section of the Smoking Evaluation indicates that R4 can smoke unsupervised but also that R4 requires supervision while smoking. Surveyor noted this and reviewed R4's care plan. R4's Care Plan Focus: I enjoy smoking as evident by my history of smoking. The resident is a smoker. Date Initiated: 10/27/23 I enjoy smoking as evident by my history of smoking. Date Initiated: 11/24/23 Revision on: 11/24/23 Interventions: Instruct resident about the facility policy on smoking: locations, times, safety concerns (10/27/23). Staff to monitor for residents safety during smoke breaks. (10/27/23) The resident requires SUPERVISION while smoking. (10/27/23) Based on the documentation in the care plan as well as the Smoking Evaluation, R4 required supervision while smoking and, according to the facility's smoking policy, should have had their smoking materials stored by the facility. R4's Progress Notes include, in part, the following: 12/8/23, 05:32 (AM). Type Nurses Notes. Note Text: Resident was observed smoking in bedroom with oxygen machine running, no O2 (oxygen) being worn but NC (nasal cannula) sitting at bedside. Asked resident to please allow us to hold her cigarettes and lighter and she can have the cigarettes when she goes to the designated smoking area. Resident stated she is not to the point to have to be monitored. Resident was educated and handed over cigarettes and lighter. Items placed at nursing station. Informed nursing management. The facility's investigation, dated 12/8/23, into R4's incident of smoking in her room includes, in part, the following: Incident Location: Resident's Room Incident Description Nursing Description: At approximately 0530 (AM): Resident was observed smoking in bedroom with oxygen machine running, no O2 NC (nasal cannula) being worn but NC sitting at bedside. Resident Description: smoking in my room. Immediate Action Taken Description: Asked resident to please allow us to hold her cigarettes and lighter and she can have the cigarettes when she goes to the designated smoking area. Resident stated she isn't to the point to have to be monitored. Resident was educated and handed over cigarettes and lighter. Items placed at nursing station. Injuries Observed at Time of Incident Injury Type: No injuries observed at time of incident Level of Pain: Level of Consciousness: Alert Mobility: Ambulatory without assistance Mental Status: Oriented to Place, Oriented to Time, Oriented to Person, Oriented to Situation Predisposing Physiological Factors: Recent Illness, Weakness/Fainted Predisposing Situation Factors: Ambulating without Assist Notes: 12/8/23 IDT (Interdisciplinary Team) met and reviewed smoking event. Resident medical diagnoses include: stage 4 sacral pressure ulcer, type 2 diabetes, viral hepatitis, health [sic] failure, chronic kidney disease - stage 3, spinal stenosis. Recent hospitalization for influenza with return to facility on 11/24/23. Last BIMS (Brief Interview for Mental Status): 15 (cognitively intact). Resident protected from initial harm with removal of smoking materials. 1:1 observation with progression to 15 minute safety checks initiated. Education provided for safety. Event discussed with (R4's Managed Care Organization), Ombudsman and DHS RFOD (Department of Health Services Regional Field Operations Director). Root cause for decision to smoke in the room determined as resident's physical location long distance from safe smoking area. Available room options reviewed, resident agreed to change rooms to be on the hallway in which the smoking access door is located. Resident smoking evaluation completed. Frequent safety checks completed through weekend. Care conference held with Case Managers on Monday, December 11th. Resident to continue with supervision with smoking at this time. On 12/13/23, 11:05 AM, R4 was observed lying in her bed with an oxygen concentrator on and a nasal cannula in her nose to deliver oxygen. Surveyor interviewed R4. Surveyor asked R4 if she ever smoked in her room. R4 stated she got caught a few days ago smoking in her room and staff took her cigarettes and lighter away at that time. Surveyor asked R4 if she was able to go outside and smoke currently. R4 replied that she could ask for her cigarettes and lighter and go outside with staff. On 12/14/23 at 7:53 AM, R4 asked to speak with Surveyor. R4 stated the Social Worker came into my room yesterday and told me I was independent again with smoking. R4 stated she was told she was going to get her cigarettes and lighter back today, 12/14/23. On 12/14/23 at 8:25 AM, Surveyor observed R4 outside smoking in the smoking area with staff. On 12/14/23 at 8:30 AM, R4 asked to speak with Surveyor. R4 told Surveyor she does not want to be told when she can go outside to smoke. R4 asked Surveyor when she was going to get her cigarettes and lighter back. Surveyor directed R4 to speak with DON B (Director of Nursing). R4 stated she did not have any more cigarettes and needed more. Surveyor asked if she had her cigarettes or if the staff were holding them for her. R4 stated she had a few in her room but had smoked them. Surveyor asked R4 if staff were aware she had the cigarettes in her room. R4 stated she had told staff but could not remember who. Surveyor asked R4 if she had a lighter. R4 refused to answer. 12/14/23, 10:30 (AM). Type Nurses Notes. Note Text: Consulted with Medical Director regarding resident's medical diagnoses, recent hospitalization , plans to discharge from facility within the near future. Reviewed details of smoking event within the facility last week and the compliance. Smoking assessment re-evaluated and independence with smoking determined at this time. On 12/14/23 at 1:25 PM, Surveyor interviewed LPN E (Licensed Practical Nurse) about R4 smoking in her room. LPN E stated on 12/8/23 she went into R4's room to change her dressing and saw smoke in R4's room. LPN E stated R4's oxygen concentrator was running and R4's nasal cannula was sitting next to her on the bed. LPN E asked R4 if she was smoking in her room. R4 stated she did have a cigarette, and showed LPN E the cigarette butt which was in her pack of cigarettes. LPN E asked R4 for her cigarettes and lighter and explained to R4 the safety concerns of smoking with oxygen and R4 could not smoke inside the facility. LPN E informed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) that R4 was smoking in her room. LPN E stated she smelled smoke before, a day or two before, coming from R4's room. LPN E stated she informed NHA A and DON B and brought NHA A to the hallway outside R4's room to witness the smoke smell herself. On 12/14/23 at 12:25 PM, Surveyor interviewed DON B. Surveyor asked DON B if she had knowledge that R4 had smoked in her room. DON B stated she was aware that R4 had smoked in her room with the oxygen concentrator running and after this R4 allowed the facility to hold her cigarettes and lighter. DON B stated after R4 was found smoking in her room, she was supervised while smoking and was moved closer to the smoking area after the incident to make it easier for R4 to get to the smoking area. Surveyor asked DON B if R4 was a supervised smoker. DON B stated R4 was a supervised smoker when she was first admitted , however on 11/24/23, R4 was re-assessed and found that she did not require supervision to smoke any longer. DON B stated on 12/14/23 in the morning she had reassessed R4 and found her to be independent and able to have her smoking materials after she was watched for a week and that R4 stated she understood the smoking policy. On 12/14/23 at 2:05 PM, Surveyor interviewed NHA A and DON B. Surveyor asked NHA A if she had knowledge that R4 had smoked in her room. NHA A stated she was aware that R4 had smoked in her room with the oxygen concentrator running. Surveyor asked NHA A and DON B if they were aware that R4's Smoking Evaluation, dated 11/24/23, indicated that R4 could smoke unsupervised and that R4 required supervision while smoking. NHA A stated the assessment was ambiguous. Surveyor asked NHA A and DON B if they were aware that on 12/8/23 R1's smoking care plan intervention, dated 10/7/23, stated R4 required supervision while smoking. NHA A stated the care plan is based on the assessment and should have been clearer. Surveyor asked NHA A and DON B how the staff would know whether R4 was a supervised smoker or could smoke independently. NHA A stated staff would review the care plan. NHA A stated the policy was followed and supervised smokers can keep their cigarette and lighters if it is assessed and care planned. Surveyor asked NHA A and DON B if the facility policy stated smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. NHA A stated the policy was followed, each resident's care plan is individualized and residents who are supervised smokers can keep their cigarettes and lighters if their assessment shows they will be safe. NHA A stated the policy should be made clearer to individualize this. Surveyor's review of the care plan did not indicate that R4 could keep smoking materials in their own possession. The facility's failure to implement safety and accident prevention measures for residents who smoke created a reasonable likelihood that serious harm could occur. This led to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 12/15/23 when it implemented the following: 1. Smoking Evaluations and Care Plans were updated for all resident who wish to smoke. 2. Assured all residents who require supervision while smoking have their smoking materials stored by facility staff. 3. No Smoking signs placed outside of resident room. 4. Reeducation of residents on the facility's Smoking Policy. 5. All staff reeducated prior to the beginning of their next scheduled shift, on the facility's Smoking Policy with a post-test. 6. DON will audit all actions weekly for 6 weeks with reports to the QM Committee to determine if additional action is required. The following examples are cited at a scope/severity of E (Potential for more than minimal harm that is not immediate jeopardy/Pattern). Example 2: R6 was admitted [DATE]. R6's diagnoses include stroke with hemiplegia and diabetes. R6's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/23 indicates R6 is cognitively intact, uses tobacco and has upper extremity impairment on one side. R6's Smoking Evaluation, dated 12/12/23, includes, in part, the following: 1. Does the resident have cognitive loss? Yes 2. Does the resident have a visual deficit? No 3. Does the resident have a dexterity problem? Yes 4. How often does the resident smoke per day? 2-5 5. What time of day does the resident like to smoke? a. Morning, b. Afternoon, c. Evenings, d. Nights 6. Can resident light own cigarette? No 7. Does the resident need adaptive equipment or assistance? Supervision 8. Does the resident need facility to store lighter and cigarettes? Yes 9. Plan of care is used to assure resident is safe while smoking? Yes 10. Has the resident been educated on smoking procedures? Yes R6's Care Plan Focus: The resident is a supervised smoker, Date Initiated: 11/21/23, Revision on: 12/13/23 Interventions: Instruct resident about the facility policy on smoking, locations, times, safety concerns. Date Initiated: 11/21/23 The resident requires SUPERVISION while smoking. Date Initiated: 11/21/23 The resident requires SUPERVISION while smoking. Needs assistance lighting cigarette. Date Initiated: 11/21/23, Revision on: 12/13/23 The resident's smoking supplies are stored (SPECIFY). Date Initiated: 11/21/23 The resident's smoking supplies are stored by the facility. Date Initiated: 11/21/23 Revision Date: 12/13/23 On 12/13/23 at 3:15 PM, Surveyor observed R6 sitting in his wheelchair in his room. Surveyor interviewed R6. Surveyor asked R6 if he smoked. R6 stated yes. Surveyor asked R6 where his cigarettes and lighter are kept. R6 stated he had his cigarettes, R6 showed Surveyor a pack of 6 cigarettes. R6 stated his lighter was somewhere in the room but he did not know where. Example 3: R7 was admitted on [DATE]. R7's diagnoses include chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. R7's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/23 indicates R7 is cognitively intact and uses oxygen. The question of tobacco use is not answered. R7's Smoking Evaluation, dated 11/7/23, includes, in part, the following: 1. Does the resident have cognitive loss? No 2. Does the resident have a visual deficit? No 3. Does the resident have a dexterity problem? No 4. How often does the resident smoke per day? 5-10 5. What time of day does the resident like to smoke? a. Morning, b. Afternoon, c. Evenings, d. Nights 6. Can resident light own cigarette? Yes 7. Does the resident need adaptive equipment? Supervision 8. Does the resident need facility to store lighter and cigarettes? Yes 9. Plan of care is used to assure resident is safe while smoking? Yes 10. Has the resident been educated on smoking procedure? No selection is marked R7's Care Plan Focus: The resident is a smoker. Date Initiated: 11/10/23 The resident is a supervised smoker, Date Initiated: 11/10/23, Revision on: 12/13/23 Interventions: Instruct resident about the facility policy on smoking locations, times, safety concerns. Date Initiated: 11/10/23 The resident can smoke UNSUPERVISED. Date Initiated: 11/10/23 The resident can smoke with SUPERVISION due to resident continuing to not take O2 (oxygen) off prior to oxygen which is unsafe and could potentially lead to harm or death. Date Initiated: 11/10/23 Revision on: 11/20/23 The resident can smoke with SUPERVISION due to resident continuing to not take O2 (oxygen) off prior to oxygen which is unsafe and could potentially lead to harm or death. Date Initiated: 11/10/23 Revision on: 11/28/23 The resident can smoke with SUPERVISION due to resident continuing to forget to take O2 (oxygen) off prior to smoking which is unsafe and could potentially lead to harm or death. Date Initiated: 11/10/23 Revision on: 12/13/23 The resident's smoking supplies are stored by herself. Date Initiated: 11/10/23 Revision on: 12/13/23 Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Date Initiated: 12/13/23 Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 12/13/23 R7's Progress Notes include, in part, the following: 12/9/23, 08:42 (AM), Late Entry Note Text: Resident educated about not going outside unsupervised as she is taking her portable O2 (oxygen) tank outside as well. (R7) was reminded we are not able to light her 3 wick candle in room at bedside. (R7) was educated about not smoking in room with O2 portable tank and concentrator both running. 12/11/23, 09:44 (AM), Note Text: Resident was observed out front of facility with portable O2 at side. Resident was educated on smoking with O2 and supervised smoke times. Resident has been educated several times over the weekend by this writer and resident states understanding ad (sic) still continues to go outside unsupervised with O2. On 12/13/23 at 4:25 PM, Surveyor observed R7 sitting in her wheelchair in her room. R7 had a small oxygen concentrator on her wheelchair and an oxygen concentrator in her room. R7 was being administered oxygen via a nasal cannula. Surveyor asked R7 if she smoked. R7 stated yes, she does smoke. Surveyor asked R7 where her cigarettes and lighter are stored. R7 stated she keeps her own cigarettes and lighter, showing them to Surveyor. Example 4: R8 was admitted on [DATE]. R8's diagnoses include stroke with hemiplegia and chronic obstructive pulmonary disease. R8's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/23 indicates R8 is cognitively intact and the question of tobacco use is not answered. R8's Smoking Evaluation, dated 11/25/23 includes, in part, the following: 1. Does the resident smoke? Yes 2. Does the resident have cognitive loss? No 3. Does the resident have a visual deficit? No 4. Does the resident have a dexterity problem? No 5. How often does the resident smoke per day? 2-5 6. What time of day does the resident like to smoke? a. Morning, b. Afternoon, c. Evening, d. Nights 7. Can resident light own cigarette? No 8. Does the resident need adaptive equipment or assistance? One-on-one 9. Does the resident need facility to store lighter and cigarettes? Yes 10. Plan of care is used to assure resident is safe while smoking? Yes 11. Has the resident been educated on smoking procedure? Yes Smoking Care Plan (It is important to note the following are all check marked.) Focus: The resident is a smoker. Goal: The resident will not suffer from unsafe smoking practices through the review date. Intervention: Instruct resident about the facility policy on smoking: locations, times, safety concerns. Intervention: The resident requires SUPERVISION while smoking. Intervention: The resident's smoking supplies are stored (SPECIFY). R8's Care Plan Focus: The resident is a smoker, Date Initiated: 10/18/23 The resident is a supervised smoker. Date Initiated: 10/18/23 Revision on: 12/13/23 Interventions: Instruct resident about the facility policy on smoking locations, times, safety concerns. Date Initiated 10/18/23 The resident requires SUPERVISION while smoking. Date Initiated: 10/18/23 The resident's smoking supplies are maintained by her, Date Initiated: 10/18/23 The resident requires SUPERVISION while smoking. Needs assistance entering/exiting facility. Date Initiated 10/18/23 Revision on 12/13/23 Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. 12/13/23 On 12/14/23 at 11:00 AM, Surveyor observed R8 outside smoking supervised. R8 had her cigarettes and lighter in her purse. On 12/14/23 at 11:00 AM, Surveyor observed DM C (Dietary Manager) supervising residents outside smoking. On 12/14/23 at 11:15 AM, Surveyor interviewed DM C. Surveyor asked DM C if he supervises the smokers. DM C stated he supervises smokers when needed. Surveyor asked DM C if the facility stores any of the residents smoking materials. DM C stated yes. Surveyor asked DM C if the facility stores R6's, R7's, or R8's smoking materials. DM C stated no, they keep their own smoking materials. On 12/14/23 at 11:25 AM, Surveyor interviewed AD F (Activity Director). Surveyor asked AD F if he supervises the smokers. AD F stated he supervises smokers on a regular basis. Surveyor asked AD F if the facility stores any of the residents' smoking materials. AD F stated yes. Surveyor asked AD F if the facility stores R6's, R7's, or R8's smoking materials. AD F stated no, they keep their own smoking materials. On 12/14/23 at 5:20 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the facility should follow the smoking policy as it relates to storing of smoking materials. DON B declined to comment.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PI) from worsening for 1 of 3 resident reviewed for PIs, out of a sample of 16 residents (R4). The facility did not ensure interventions were in place to prevent the PI from developing or worsening. R4 had a pressure injury on the heel that had closed and then redeveloped on 1/27/23. R4's pressure injury to the heel worsened and became an Unstageable PI on 4/25/23. The facility failed to complete weekly skin assessments and did not follow care plan interventions. This is evidenced by: The facility's policy, Pressure Injury Prevention Guidelines, implemented 2/2023, states in part . Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: 1. Individualized interventions will address specific factors identified in the resident's risk assessment (e.g., nutritional deficit, staging, wound characteristics). 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 5. Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel flotation devices, cushions, mattresses). 7. Interventions will be documented in the care plan and communicated to all relevant staff. 8. Compliance with interventions will be documented in the medical record. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. 3. Apply heel suspension devices according to the manufacturer's instructions. b. For stage 3, 4, unstageable, or deep tissue injury: Place foot and leg into a heel suspension boot that elevates the heel from the surface of the bed, completely offloading the pressure injury. Check the skin each shift and prn for signs of redness or skin breakdown related to the boot. The facility's policy, Skin Evaluation, implemented 02/2023, states, in part . Policy: It is out policy to perform a full body skin evaluation as part of our systematic approach to pressure injury prevention and management. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin evaluation will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The evaluation may also be performed after a change of condition or after any newly identified pressure injury. 6. Documentation of skin evaluation b. Document observations (e.g., skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Documents if resident refused assessment and why. f. Document other information as indicated or appropriate. The facility's policy, Wound Treatment Management, implemented 02/2023, states, in part . Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. The facility's policy, Pressure Injury Preventions and Management, implemented 2/2023, states, in part . The facility shall establish and utilize a systematic approach for pressure injury preventions and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Evaluation of Pressure Injury Risk. a. Licensed nurses will conduct a pressure injury risk evaluation, using the Braden, on all residents upon admission/re-admission, weekly x (times) four weeks, then quarterly or whenever the resident's condition changes significantly. d. Assessments of pressure injuries; will be performed by a licensed nurse and documented. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS (Minimum Data Set). 4. Interventions for Prevention and to Promote Healing f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting. 5. Monitoring a. The RN (registered nurse) Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. b. The attending physician will be notified of ii. The progression towards healing, or lack of healing, of any pressure injuries weekly. According to the National Pressure Injury Advisory Panel an Unstageable Pressure Injury is defined as, Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. According to the National Pressure Injury Advisory Panel a Deep Tissue Pressure Injury is defined as, Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood filled [NAME]. R4 was admitted to the facility on [DATE] with diagnoses including . Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, nontraumatic intracranial hemorrhage, reduced mobility, muscle weakness, and acute kidney failure. R4's last 3 Braden Scores are as follows . Braden completed on 7/11/22, shows a score of 16, indicating R4 is at moderate risk for PI development. Braden completed on 7/18/22, shows a score of 16, indicating R4 is at moderate risk for PI development. Braden completed on 4/03/23, shows a score of 11, indicating R4 is at high risk for PI development. Note: Per Hospice Notes R4's pressure injury reopened on 1/27/23 and a new Braden assessment was not completed until 4/3/23. R4's Comprehensive Care Plan, initiated 9/9/22, revised 4/26/23, states in part . Focus: Resident has Impaired Skin Integrity: Right heel pressure injury non-stageable and right foot 2nd toe callous. Interventions: Keep Mepilex on coccyx to prevent potential wound, initiated 3/8/23; measure area weekly, initiated 9/9/22; monitor for s/sx (signs and symptoms) of infection, initiated 9/9/22; monitor for s/sx (signs and symptoms) of worsening skin tissue, initiated 9/9/22; monitor pain and offer PRN (as needed) analgesic as ordered, initiated 9/9/22; treatment as ordered, initiated 9/9/22; update MD (medical doctor) with changes in wound status and PRN, initiated 9/9/22. R4's Comprehensive are Plan, initiated 11/04/21, revised, states in part . Focus: Skin Integrity: At Risk / and/or Potential for complications with impaired skin integrity and/or pressure r/t (related to) DM (diabetes mellitus) and decreased mobility, initiated 11/13/21, revised 5/2/23. Interventions: Air mattress settings are based on weight. Setting is at 185# (pounds). Check function of air mattress every shift, initiated 6/9/22, revised 6/20/22; heel boots on at all times, resident will kick off heel boots or refuse them at times, initiated 2/22/22; meds (medications)/labs/tx's (treatments) as ordered, initiated 11/13/21. R4's Comprehensive are Plan, initiated 11/4/21, revised 11/13/21 states in part . Focus: At Risk and/or Potential for Complications with Deficit's with ADL's (Activities of Daily Living) r/t current medical Recent Non-ST Elevation MI (myocardial infarction), severe bicuspid valve stenosis. Interventions: Bed Mobility - assist 1, pillow to left side when in bed. Bilateral side bars on bed to improve independence with bed mobility, initiated 11/04/21, revised 6/22; Transfer - 2 assist with Hoyer, initiated 11/4/21, revised 1/19/22. R4's most recent Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview of Mental Status (BIMS) of 8, indicating R4 has moderate cognitive deficits. In R4's most recent MDS, section G0110 indicates extensive assist of one staff is needed with bed mobility, transfers, hygiene, and dressing. R4 is dependent of one staff member for toileting. R4 is always continent of bowel and bladder. M0150 - At Risk for Pressure Injury. Yes. M0210 - Unhealed Pressure Injury. Yes. M0300 - Stage 2. M1200 - Skin and Ulcer Treatments: Pressure reducing device for bed; Pressure reducing device for chair; Nutrition or hydration intervention to manage skin problems; pressure ulcer care; applications of dressing to feet (with or without topical medications). R4's Physician's Orders stated in part . Blue boots it [sic] bilateral heels at all times every shift for wound. Start Date: 2/8/23. R4's Certified Nursing Assistant (CNA) Care sheet states in part . Heel boots at all times; mattress extender at the end of the bed. (Note: The facility did not have pressure relieving boots in place prior to 2/22/22 and R4 was at risk for PI's.) (Note: Per interview with NP D (Nurse Practitioner) and Hospice notes R4's pressure injury (PI) on right heel reopened on 1/27/23. The facility was unable to provide Surveyor with any of the NP's notes or documentation for the last 3 months as requested.) (Note: The 3/6/23 Wound Evaluation is the first documentation of R4's wound being evaluated since it opened on 1/27/23.) (It is important to note that PI was initially discovered on 1/27/23 but the facility did not complete an assessment of the area until 3/6/23. Interventions to prevent and/or heal pressure injuries were observed not in place during this Survey.) R4's Weekly Skin Impairment and Wound Evaluation -V 1, dated 3/6/23 at 20:14 (8:14 PM), states in part . A. Assessment Date: 3/6/23. 2. Wound Description: Site: Right Heel. Type: Pressure. Length: 2.5. Width: 1.6. Depth: 0. Stage: (blank). Are abnormalities noted to wound edges/peri-wound? 2. No. 5. Exudate Amount: 2. Scant. 5a. Check all tat [sic] apply: 1. Serous. 6. Is wound/exudate odorous? 2. No. C. Wound Progress: 1. Onset Date of Treatment: 3/6/23. 1a. Check all treatments that apply: 3. Turning and repositioning; 4. Positioning/splinting device. E. Wound Pain: 1. Is pain associated with the wound? 2. No. F. Other: 1. Other comments/recommendations: tan fibrin attached to wound edges, scant drainage. Pressure boots on. Signed by: NHA A. Signed Date: 5/4/23. R4's Weekly Skin Impairment and Wound Evaluation -V 1, dated 4/4/23 at 09:32 (9:32 AM), states in part . A. Assessment Date: 4/4/23. Type of wound: Pressure. 2. Wound Description: Site: Right Heel. Type: Pressure. Length: 2. Width: 1.5. Depth: 0.1. Stage: III 4j. Predisposing Factors: 8. Other. 4k. If other, please describe boney prominence. 5. Exudate Amount: 2. Small. 5. Wound Progress: 2. Stable/No Change. Onset Date of Treatment: 1/14/22. 1a. Check all treatments that apply: 1. Bed pressure reduction/redistribution mattress. 2. Chair pressure reduction/redistribution cushion. 3. Turning and repositioning; 5. Wound treatment/application of dressing. Current level of pain: Hurts a Little More. 3. Pain Management Plan: c/o (complains of) pain when sock and heel padding is removed. R4's Weekly Skin Impairment and Wound Evaluation -V 1, dated 4/11/23 at 18:46 (6:46 PM), states in part . Assessment Date: 4/11/23. Type of wound: Pressure. 2. Wound Description: Site: Right Heel. Length: 1.5. Width: 2. Depth: 0.1. Stage: III. Predisposing Factors: 3. Erythema. 5. Exudate Amount: 2. Scant. 5. Wound Progress: 2. Improved. 1a. Check all treatments that apply: 1. Bed pressure reduction/redistribution mattress. 2. Chair pressure reduction/redistribution cushion. 3. Turning and repositioning; 5. Wound treatment/application of dressing. E. Wound Pain: 1. Is pain associated with the wound? 2. No. 3. Pain Management Plan: offer PRN analgesia as indicated. F. Other: 1. Other comments/recommendations: (blank). Pressure boots on. R4's Weekly Skin Impairment and Wound Evaluation -V 1, dated 4/25/23 at 15:37 (3:37 PM), states in part . A. Assessment Date: 4/25/23. B. Wound Description: Pressure. 2. Wound Description: Site: Right Heel. Type: Pressure. Length: 1.0 cm (centimeters). Width: 1.5 cm. Depth: UND (undetermined). Stage: Unstageable. 4. Are abnormalities noted to wound edges/peri-wound? 2. No. 5. Exudate Amount: 2. Small. 6. Has the physician been notified of no change or deterioration over the past 2 weeks? 1. Yes. 5. Wound Progress: 3. Deteriorated/declined. Onset Date of Treatment: 3/17/23. 1a. Check all treatments that apply: 1. Bed pressure reduction/redistribution mattress. 2. Chair pressure reduction/redistribution cushion. 3. Turning and repositioning; 5. Wound treatment/application of dressing. 8. Other. 1b. If other, please describe heel boot. E. Wound Pain: 1. Is pain associated with the wound? 1. Yes. 2. Current level of pain. Hurts a little more. 3. Pain Management Plan: Pre medicated prior to dressing change. F. Other: 1. Other comments/recommendations: Area to heel is a NS (non-stageable) pressure injury with slough covering. Facility has identified as stage II (2) on last assessment, so this is a decline. Area to toe remains stable callous. Receives 4oz (ounces) house supplement with med pass and mighty shake to help facilitate wound healing. (Note: Weekly Skin Assessments were not completed between 3/6/23 and 4/4/23, between 4/11/23 and 4/25/23, and between 4/25/23 and 5/3/23.) (Note: The PI to the right heel was not staged on first documented skin assessment on 3/6/23. Wound was first staged on 4/4/23 at a stage 3.) (Note: There is no documentation to indicate the NP or MD were notified of R4's wound decline on 4/25/23.) R4's Physician's Orders include . - Weekly Skin Check: Complete weekly skin assessment under assessment tab, report any abnormal findings to PCP (primary care provider) every day shift every Thu (Thursday) for skin monitoring. Start Date: 9/29/22. - Pain Evaluation 0=no pain 1-3=mild pain 4-6=moderate pain 7-10=severe pain every shift, document pain level 1-10. State Date: 5/02/23. - R4 to be premedicated 1 hour PRIOR to (RIGHT heel) wound care with Morphine 7.5mg (milligrams) AND Lorazepam 0.5mg (Note: both medications are available under PRN (As needed) medications) every shift for pain management. Start Date: 4/2/23. - Nsg (Nursing) Order: Wound care to heel is daily, please enter a note about having done it. Every day and evening shift for wound care. Start Date: 3/16/23. - Blue boots it [sic] bilateral feet at all times every shift for wound. Start Date: 2/8/22. - Evaluate pain Every Shift using Numerical or Visual Analog pain scale every shift for Pain Management. Start Date: 11/03/21. - 1. Cleanse w (with) soap and water or wound cleanser, pat dry; 2. Apply medihoney to slough; 3. Skin prep peri- wound; 4. Cover w bordered gauze or mepilex; 5. Change daily and prn everyday shift for wound care also PRN if soiled. Start Date: 3/16/23. - Air Mattress setting is based on weight. Setting is at 185. Check function of air mattress every shift. Every shift. Start Date: 6/9/22. - House supplement three times a day 4 ounces to be given with med pass. Start Date: 9/12/22. - Mighty Shake two times a day for supplement. Start Date: 10/6/22. Physician Orders for Wound Care are as follows: Wound Care Order: On 2/17/23 at 8:17 AM, Wound care to R heel: 1. Cleanse with soap and water or wound cleanser; pat dry. 2. Apply medihoney to slough on wound. 3. Apply skin prep to peri wound. 4. Cover with bordered gauze or mepilex. 5. Change daily and PRN. To be completed by facility nurse; Hospice nurse will complete once weekly on Thursdays. R4's Treatment Administration Record (TAR) for the months of February, March, April and May, state in part . 1. Cleanse w soap and water or wound cleanser, pat dry. 2. Apply Medihoney to slough. 3. Skin prep peri-wound. 4. Cover w bordered gauze or mepilex. 5. Change daily and prn. One time a day for wound care tx to right heel daily on pm shift and prn. Start Date: 3/16/23. Wound care Treatments reviewed for February, March, April, and May indicate wound care was not signed out as completed on the following dates with the following reasons if indicated . 2/05/23 2/15/23 2/20/23 3/17/23 - Refused 3/18/23 3/21/23 - Refused 3/22/23 - Refused 3/25/23 3/26/23 3/27/23 - Refused 3/31/23 - Refused 4/03/23 - Refused 4/09/23 4/10/23 4/11/23 - Refused 4/19/23 - See Nurses Note: Completed on day shift by this nurse. 4/23/23 - See Nurses Note: Nurses Note dated, 4/23/23 at 17:11 (5:11 PM), states in part . Dressing change to be done by PM nurse this day. Nurses Note dated, 4/23/23 at 18:54 (6:54 PM), states in part . Dressing change completed by AM nurse. Charting to be completed by AM nurse. (Note: Notes from 4/23/23 indicate PM shift to complete dressing change and another indicates dressing change was completed on AM shift. There is no documentation to indicate the dressing change was completed on either shift.) 4/25/23 - See Nurses Note Nurses Note dated, 4/25/23 at 15:23 (3:23 PM), states in part . AM nurse completed wound care. Note not completed by this writer. (Note: Note from 4/25/23 nurse indicates she did not complete the wound treatment. There is no documentation by the any nurse indicating that the treatment was completed by on 4/25/23.) 4/29/23 - See Nurses Note Nurses Note dated, 4/29/23 at 17:17 (5:17 PM), states in part . completed by am nurse. Nurses Note dated, 4/29/23 at 21:01 (9:01 PM), states in part . completed on am. Nurses Note dated, 4/29/23 at 22:15 (10:15 PM), states in part . completed on AM shift. (Note: Nurses notes from 4/29/23 indicate that the AM nurse completed the treatment, there is no documentation or indication the treatment was completed by the AM nurse.) Nurses Note dated 3/29/23 15:12 (3:12 PM) states, Writer updated the POA that the Resident had been refusing his wound care related to pain and his refusal to get OOB (out of bed) at all. NP (Nurse Practitioner) also updated, and a request was made to pre-medicate for wound care. Resident has been angrier with people tending to me [sic], appears more despondent. Nurses Note dated, 4/2/23 at 15:34 (3:34 PM) states in part . Received order from NP [name] to start morphine 15mg: Take 0.5-tab (7.5mg) PO (by mouth) one-time daily PRN (to be given daily, 1 hour PRIOR TO right heel WOUND CARE). Also, R4 is to be premedicated 1 hour PRIOR to (RIGHT heel) wound care with Morphine 7.5mg AND Lorazepam 0.5mg (Note: both medications are available under PRN medications). Avoid pressure with medical devices. Orders to be placed in [electronic charting system name] and faxed to pharmacy. Nurses Note dated 4/17/23 at 14:48 (2:48 PM), states, The resident refused all treatments today. Writer did call the residents POA at 1445 (2:45 PM) and informed him. Writer did explain that writer being new and not knowing the resident's routine may have affected residents' refusal. Writer expressed using a different strategy tomorrow. The resident is currently laying in his bed awake showing no signs of pain or distress. Note placed in 24-hour report. Nurses Note dated 4/17/23 at 15:01 (3:01 PM), states, NP notified, and writer was instructed to ask oncoming shift to attempt dressing changes with resident. Oncoming nurses notified. Hospice Note dated 4/6/23 at 10:57 AM, states in part . Wound 1/27/23 Pressure Injury Heel Right. Wound Assessment: Bleeding; Moist; Painful; Slough; Tan (100% slough, scant). Drainage Description: Purulent; Serosanguineous; Tan. Wound Length 2 cm. Wound Width: 1.6 cm. Hospice Note dated 4/13/23 at 11:34 AM, states in part . Wound 1/27/23 Pressure Injury Heel Right. Wound Assessment: Moist; Painful; Pink; Slough. Drainage Amount: Small. Drainage Description: Serous; Tan. Wound Length 1.5 cm. Wound Width: 1.5 cm. Hospice Note dated 4/20/23 at 11:30 AM, states in part . Wound 1/27/23 Pressure Injury Heel Right. Wound Assessment: Moist; Painful; Pink; Tan. Drainage Amount: Small. Drainage Description: Tan. Wound Length 1.5 cm. Wound Width: 1.3 cm. Hospice Note dated 4/27/23 at 11:49 AM, states in part . Wound 1/27/23 Pressure Injury Heel Right. Wound Assessment: Fragile/Friable; Granulation tissue; Moist; Pink; Slough. Drainage Amount: Small. Drainage Description: Serous; Tan. Wound Length 1.3 cm. Wound Width: 0.8 cm. On 5/3/23 at 8:42 AM, Surveyor observed RN E (Registered Nurse) complete wound care for R4. Upon entering R4's room, he was noted to being lying in bed supine with heels directly on the bed, no boots on as ordered. RN E washed hands and then gloves applied. RN E removed old dressing from wound, area cleansed with 4x4's, and patted dry with 4x4's. Skin prep applied to peri-wound. RN E placed Medihoney on gloved finger and applied it to the wound bed. RN E removed gloves, sanitized hands, and applied new gloves prior to putting on new Mepilex dressing to wound. Following R4's treatment, RN E did not put R4's heel protector boots on him. (Note: R4 did not have heel protector boots on when Surveyor entered room to observe wound care with RN E. RN E did not put heel protector boots on R4 following the treatment or prior to leaving R4's room.) On 5/3/23 at 9:03 AM following wound care, Surveyor interviewed RN E. Surveyor asked RN E if she had time for a few questions. Surveyor asked RN E if R4 was premedicated prior to R4's treatment, RN E stated, R4 did complain of pain during the treatment when the old dressing was removed, and the area was cleansed. Surveyor asked RN E if she should have removed gloves, washed hands, and applied new gloves when going from dirty to clean. RN E stated, I guess I was a step too late. On 5/3/23 at 11:40 AM, R4 was noted to be in the dining room in his wheelchair. Heel protectors were not on at that time. On 5/3/23 at 12:06 PM, Surveyor interviewed IDON B (Interim Director of Nursing). Surveyor asked IDON B when doing wound care when would it be expected staff remove gloves and perform hand hygiene. IDON B stated, Hands should be washed when going from dirty to clean. On 5/4/23 at 9:20 AM, Surveyor entered R4's room to see Hospice RN F just finishing wound care. Surveyor asked Hospice RN F how R4 tolerated his wound care. Hospice RN F stated, He was not happy with wound care today. I had talked with the nurse on duty and asked that the resident be pre medicated but it did not appear as if he was. On 5/4/23 at 9:28 AM, Surveyor spoke with NP D (Nurse Practitioner). Surveyor asked NP about R4's wound on the right heel. NP D stated, From the notes I have, this area was an area that had previously healed and then reopened on 1/27/23. On 5/4/23 at 1:57 PM, Surveyor interviewed CNA G (Certified Nursing Assistant). Surveyor asked CNA G if R4 should have heel protector boots on. CNA G stated, R4 is supposed to have the big heel protector boots on but hospice hasn't been putting them on him. The Hospice CNA told me about the sleeves with padding on the heel were better protection. Surveyor asked CNA G if R4's care plan states he should have the big heel protector boots on. CNA G stated, Yes. On 5/4/23 at 1:59 PM, Surveyor interviewed CNA H. Surveyor asked CNA H if R4 should be wearing heel protector boots. CNA H stated, He is supposed to have those on. I haven't seen anyone put them on him, but it is something that he probably needs. On 5/4/23 at 2:00 PM, Surveyor observed R4 in bed watching television without heel protector boots on. On 5/4/23 at 2:07 PM, Surveyor interviewed IDON B. Surveyor asked IDON B if R4 should be wearing heel protector boots as indicated on his care plan. IDON B stated, He doesn't have them on? I will take care of that right now. On 5/04/23 at 2:15 PM, Surveyor interviewed LPN T (Licensed Practical Nurse). Surveyor asked LPN T if R4 should be wearing heel protector boots. LPN T stated, Aren't they on? I will get them on him right now. R4 was at risk for PI's. R4 did not have wound care assessments completed weekly per standard of practice, treatments were not completed as ordered, observation of poor hand hygiene during wound care, and three separate observations were made of R4's heels not being offloaded. R4's heel worsened from a stage III to an unstageable PI. The facility completed an Ad Hoc QAPI Meeting on 4/25/23 for PI's which included wound rounds, notifications, skin assessments, and Braden's. During this survey, current non-compliance was identified.

Based on observation, interview, and record review, the facility failed to have sufficient and competent staffing to ensure resident safety and attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being. This has the potential to affect all 71 residents. The facility failed to ensure sufficient and competent staffing. On [DATE] a student nurse was left in the building for 1 1/2 hours without a licensed nurse in the building. In addition there was no dietary staff in the building. The Director of Nursing (DON) has worked numerous shifts on the floor as a floor nurse and is unable to fulfill the duties of a Director of Nurses. The building is almost entirely staffed with agency staff, and they have not received training on emergency procedures or daily operations. Agency staff and new facility hires report receiving no training prior to working the floor. Multiple staff report they were not oriented on how to respond to emergency procedures. The facility had multiple days with insufficient or no dietary staff in the building. The Nursing Home Administrator (NHA), Social Worker, Activity Director and Maintenance Director have cooked and worked in dietary with no dietary training. Facility failure to have sufficient staff with appropriate competencies to ensure resident safety and to attain/maintain each resident's highest practicable well-being, which created a finding of immediate jeopardy that began on [DATE]. NHA A was notified of the immediate jeopardy on [DATE] at 11:40 AM. The immediate jeopardy was removed on [DATE] and continues at a level severity/scope of F (Potential for harm/Widespread) as the facility continues to implement its removal plan. Findings include: The Division of Quality Assurance/Bureau of Nursing Home Resident Care received a complaint alleging that on [DATE] the facility did not have a licensed nurse in the building for over an hour and alleging general staffing concerns. On [DATE] at 8:30 AM Surveyor observed Agency Licensed Practical Nurse I (LPN) complete medication pass on Elm wing. On [DATE] at 10:36 AM Surveyor observed Agency Licensed Practical Nurse I (LPN) continue medication pass on Elm wing. On [DATE] at 10:45 AM Surveyor observed Agency Licensed Practical Nurse I (LPN) start medication pass on Elm wing. On [DATE] at 2:15 PM Surveyor interviewed Agency LPN I regarding facility staffing. LPN I stated she has worked at the facility on and off since June of 2021. LPN I stated the staffing at the facility is horrible. LPN I stated she is responsible for medication pass and treatments for 2 halls. Medication pass is always late and first medication pass goes right into second medication pass. There is really no system to ensure medications are accurately spaced out, and it is scary sometimes. On [DATE] at 10:45 AM, Surveyor spoke to Agency Certified Nursing Assistant H (CNA) regarding staffing. CNA H stated she is an agency CNA and has worked at the facility for about 3 weeks. CNA H stated the facility is short staffed almost every day. When CNA H stated on [DATE] there were no licensed nurses in the facility. The night nurses left, leaving a Student Nurse here alone. That same day there was no dietary staff in the kitchen, so Student Nurse T was trying to find nurses and dietary help. She had to pull CNAs to work in the kitchen so residents would be fed. CNA H stated Director of Nursing (DON) B finally came in to help pass medications. Surveyor asked if she knew about what time DON B arrived. CNA H stated she thought it was about 7:30ish. Surveyor asked CNA H if there were any resident concerns during the time frame the facility did not have a nurse in the building such as a fall, change of condition (COC), or residents requesting pain medication. CNA H stated not that she was aware of. Surveyor asked CNA H what the CNA to resident ratio is on most days. CNA H stated she has only worked day shift and there is one CNA per hall, 1 CNA to 10 -14 residents and 1 nurse to two halls so 1 nurse to 20 - 28 residents or so. Surveyor asked CNA H if there are things she cannot complete. CNA H stated Willow Hall is very busy. The residents have dementia, and this is not a safe situation for 1 staff to be on the hall. CNA H stated she can complete activities of daily living (ADLs). Surveyor asked CNA H how she transfers residents if the plan of care states two assist. CNA H stated this can be difficult; the CNA has to leave the hall to find someone to help and it's difficult to find help at times so the resident ends up waiting. On [DATE] at 3:00 PM Surveyor interviewed Agency LPN K regarding orientation to the facility. LPN K stated today was her second day at the facility. LPN K stated she did not receive orientation per se as she is agency. Surveyor asked LPN K if she knew the facility policy and procedure for emergency procedures such as a fire, CPR, elopement, or change of condition (COC). LPN K stated she asked other nurses where the crash cart was located and stated she would look at the Point Click Care (PCC- electronic health record) for a resident's code status. She was not aware of what to do in the event of a fire, knew residents wore a wander guard bracelet but was unsure of which residents were an elopement risk. LPN K stated the nurse practitioners (NP) follow the residents and she would place a call to the NP if a resident had a COC. LPN K stated orientation could be better. On [DATE] at 3:10 PM Surveyor interviewed Agency LPN L regarding orientation to the facility. LPN L stated there is no orientation; a nurse must orient themselves and ask questions. LPN L stated he has worked at the facility for about a month. LPN L stated you ask questions like show me where the crash cart is, where do you locate code status, who is an elopement risk and is there a wander guard system, how do I know who is at risk, what to do when you have a resident with a COC? As an agency nurse I am responsible to ask these questions, or you will not know. The first day I was here every nurse in the building was agency we had to teach and orient each other on how to navigate through the day. It was utter chaos. On [DATE] at 3:15 PM Surveyor interviewed Agency LPN M regarding orientation to the facility. LPN M stated she has worked at the facility less than a year but has been a nurse for over [AGE] years. LPN M stated she did not receive orientation but that it was self-directed in that she had to ask the critical questions such as how one would know if someone is a full code, what to do in the event of an emergency such as a fire, elopement, or poor weather. I had to ask questions to where items such as the crash cart were located. As a nurse I know to call the physician if there is a COC. If I do not know something I can contact the Director of Nursing (DON). On [DATE] at 3:30 PM Surveyor interviewed Agency LPN N regarding orientation to the facility. LPN N stated she did not receive orientation to the facility. LPN N stated she asked questions and staff assisted her to find things such as the crash cart. LPN N stated she knew code status was a concern for her and so she asked questions and found out she could locate the residents' code status on the dashboard of PCC. On [DATE] at 12:55 PM Surveyor interviewed Human Resources J (HR) regarding facility onboarding for new employees and agency staff. HR J stated if the facility has a long-term contract with the agency staff the facility requests the agency staff come in a couple hours early to get a general overview of the facility and walk with CNAs to find things such as supplies etc. HR J stated if the agency staff is someone who will come day to day they come in before their shift and get the computer log in and begin work. Surveyor asked HR J if agency staff receive orientation on emergency procedures such as a fire, elopement, CPR, policies, and procedures for resident change of condition etc. HR J stated, No they do not. Surveyor asked if there is a system to ensure staff who are scheduled are CPR certified. HR J stated, No. Surveyor asked HR J what the process is for onboarding new facility hires. HR J stated they go through facility orientation paperwork and watch videos on the computer. Surveyor asked if this includes emergency procedures. HR J stated, Yes. When Surveyor asked if there has been a time this has not occurred lately due to staffing issues, HR J stated, I'm sure there has. On [DATE] at 9:20 AM Surveyor spoke to Resident (R) 1 regarding staffing. R1 has a Brief Interview of Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. R1 stated the staffing is poor. R1 stated the meals are always late and cold due to lack of staffing. The facility is constantly short-staffed causing medications to be late including receiving his medication late. R1 stated he does not always receive personal care timely or get repositioned timely. On [DATE] at 2:00 PM Surveyor interviewed Resident (R) 22 regarding staffing. R22 has a Brief Interview of Mental Status (BIMS) score of 13, indicating R22 is cognitively intact. R22 stated there is not enough staff here. R22 stated a few weeks ago it took several hours for her to receive assistance with personal hygiene. R22 stated she was incontinent of urine, and it was so bad her urine was dripping on the floor. Staff came in with her breakfast tray and expected her to eat without being changed. R22 stated I was very upset by this. R22 also stated she is to receive a shower on Monday but did not get one this week due to the holiday and not enough staff. R22 stated the meals are generally cold as they sit in the hall too long. R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R6's ,d+[DATE] MAR (Medication Administration Record) or TAR (Treatment Administration Record) shows no evidence that R6's Oxygen and Treatment orders were transcribed or implemented until [DATE]. Surveyor requested a copy of R6's Admission Checklist from [DATE] and none was available. On [DATE] at 2:45 PM, Surveyor interviewed LPN L and asked if LPN L had training on transcribing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:00 PM, Surveyor interviewed DON B (Director of Nursing) about the process the facility follows for transcription of orders for new admissions. DON B stated DON B or other nursing management team members will transcribe the medication orders from the resident hospital Discharge summary to the resident MAR, then the staff nurse is supposed to put in the other orders. Surveyor reviewed R6's record with DON B who stated the orders for R6's oxygen and leg treatment should have been transcribed and were not. DON B thought R6 had oxygen at admission however this was not on R6's TAR. On [DATE] at 3:50 PM, Surveyor interviewed LPN JJ, who had worked on [DATE], about R6's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN JJ stated she did not receive training on how to complete admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN JJ stated the facility is short-staffed and that LPN JJ was the only nurse in the facility once. On [DATE] at 9:24 AM, Surveyor interviewed LPN HH. Surveyor asked LPN HH if written orders should be entered as written, LPN HH said yes. Surveyor asked LPN HH if they should be entered timely, LPN HH stated yes, they should, there just isn't enough time sometimes for everything. R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's quarterly MDS (Minimum Data Set) assessment on [DATE] notes R3 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R3 is cognitively intact. R3 is dependent on staff to meet toileting, and bathing/shower needs. On [DATE] at 9:50 AM, R3 reported to Surveyor the facility does not have adequate staff. R3 reported long wait times to have his call light answered. R3 reported that on [DATE] at 2:38 PM he turned his call light on to urinate. R3 reported an hour later, he had to urinate on a sheet on the floor because he could not wait any longer and his call light was still on after that. Record review notes R3 is scheduled to receive a shower on Monday and Thursday each week. On [DATE] at 10:20 AM, R3 reported to Surveyor that he had a concern about last evening (Monday [DATE]). R3 stated he did not receive a shower because the facility had only 3 aides in the building, and they didn't have time to give him a shower. R3 did not receive his scheduled shower on [DATE]. R3 stated he would have liked to have been given a shower and not just a wash up. R19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's quarterly MDS (Minimum Data Set) assessment on [DATE] notes R19 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R19 is cognitively intact. On [DATE] at 10:01 AM, Surveyor interviewed R19 about staffing in the facility. R19 reported to surveyor that the facility uses a lot of agency staff, and meals are frequently served over an hour late as they do not have enough staff. R19 did not have specific dates but said it's happened frequently in the past month. On [DATE] at 9:05 AM, Surveyor interviewed R7. Surveyor asked R7 if there's enough staff here to meet the needs of the residents. R7 said there's not enough staff. When Surveyor asked if the staff challenge was on a particular shift, R7 stated all shifts. Surveyor asked R7 what things don't get done when there's not enough staff. R7 said my shower and my wound treatment to my leg. Surveyor asked R7 how her meals were. R7 stated, All the meals are late, not the right items and last week received 1 half of a sandwich for dinner, that was it! On [DATE] at 9:44 AM, Surveyor interviewed R2. Surveyor asked R2 how things were going. R2 stated. I don't get how they run this place, all our staff have quit we only have agency now and you have to tell them everything. All new faces, every day. When Surveyor asked R2 is your call light answered timely, R2 replied no, it could take hours to be answered. When Surveyor asked R2 if this was any particular time of day, R2 said no, any time of day. Surveyor asked R2 if she had voiced any of these concerns to the management staff.R2 stated I don't talk to them, they are the worst, they all suck, nobody does anything about anything anyway. On [DATE] at 12:20 PM, Surveyor interviewed Cefrtified Nursing Assistant GG (CNA). Surveyor asked CNA GG if they are staff challenged, CNA GG said yes. Surveyor asked CNA GG what things don't get done. CNA GG stated showers because they take a longer period of time and in order to be able to get to everyone and be sure they are clean, fed and changed, something has to give. On [DATE] at 1:09 PM, Surveyor interviewed LPN BB. Surveyor asked LPN BB if a resident is supposed to get a shower, why would a bed bath be given? LPN BB stated, No staff. Surveyor asked LPN BB what would be the reason (s) why a resident would be marked unavailable. LPN BB replied if they are not in the building, or maybe if staff wasn't able. When Surveyor asked LPN BB if they are staff challenged, LPN BB said yes. Surveyor asked LPN BB what things don't get done. LPN BB stated, Mostly CNA stuff like showers. On [DATE] at 3:52 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if a resident wants a shower should they get a shower or a bed bath? DON B stated, They should have a shower. Surveyor asked DON B what if they are given a bed bath and not a shower? DON B replied, That's a problem, staffing is part of that. R21 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's MDS Admission Assessment, dated [DATE], indicated that R21 has a BIMS (Brief Interview of Mental Status) score of 12 indicating R21 is moderately impaired cognitively. R21's Care Plan, dated [DATE], with a target date of [DATE], states, in part: Focus: I have an ADL Self Care Performance Deficit r/t (related to) [CONDITION(S)]. Date Initiated: [DATE] . Goal: I will demonstrate the appropriate use of adaptive device(s) to increase ability in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date . Interventions: -Bathing/Dressing: Max assist for upper and lower extremities. Date Initiated: [DATE] Revision: [DATE] . -Bed Mobility: I require (x) staff participation to reposition and turn in bed. Date Initiated: [DATE] . -Bathing: I am totally dependent on staff to provide a bath (FREQ) and as necessary. Date Initiated: [DATE] . -Bathing: I require (x) staff participation with bathing. Date Initiated: [DATE] -Transfer: 2 assist with Hoyer Date Initiated: [DATE] . On [DATE], at 12:40 PM, Surveyor interviewed R21 and asked if R21 receives the care R21 needs here at the facility. R21 indicated no. Surveyor asked R21 to tell Surveyor about that. R21 indicated a couple of times R21 had to call 911 because staff would not answer R21's call light or respond to R21 calling out for help. R21 indicated R21 was having bad stomach cramping and needed help. Surveyor asked R21 how that made R21 feel. R21 indicated feeling so abandoned and no one to talk to. R21 indicated staff asks R21 before transferring R21 out of bed and into the wheelchair if R21 is sure about getting out of bed because once in wheelchair R21 is told R21 will be up for the day. R21 indicated staff tells her she will be in the wheelchair for hours. Surveyor asked R21 how that makes R21 feel. R21 indicated R21 has anxiety, and it adds to it by making R21 feel panicky and abandoned. Surveyor asked R21 if R21 has told staff how that makes R21 feel. R21 indicated yes and staff tells her that is just the way it is. R21 indicated on the weekends R21 is told by staff there is no administration in the building and R21 does not get dressed and lays in bed all day not by choice. On [DATE] at 8:30 AM Surveyor spoke with NHA A (Nursing Home Administrator) regarding the facility's onboarding process for agency and new facility hires. NHA A has been in her role for 1 month. NHA A stated agency staff should come 1 hour prior to their first shift to receive general orientation. NHA A stated to be honest it is almost impossible to get agency staff to do this. NHA A stated our staffing is bad; we accept the agency staff and most of the time the nurses on the floor direct the agency staff. Surveyor asked NHA A is there a time when there is only agency staff in the building? NHA A stated, Yes, I am sure this has occurred. Surveyor asked NHA A would it be possible to have all new agency staff? NHA A stated, It could be possible. Surveyor asked NHA A if agency staff receive training regarding emergency policies and procedures for things such as fire, elopement, CPR, change of condition (COC), and abuse. NHA A stated, I don't know, I would hope so. If Agency staff would come in 1 hour prior to their shift, we would give them the training. Honestly, I would say they are most likely not aware of these things prior to working. Surveyor asked NHA A about onboarding of facility staff. NHA A stated facility staff receive about 2 hours of training on abuse, dementia, payroll, and logging into our electronic health record/Point Click Care (PCC). NHA A stated the new employee is assigned a peer and they receive orientation on the floor until comfortable. NHA stated for seasoned staff this is usually three days, newer staff we allow longer. Surveyor asked NHA A during this orientation if staff are trained on the facility's emergency policies and procedures such as elopement, fire, COC, CPR, NHA A stated, No, I do not think this is part of the orientation process, but it should be. On [DATE] at 3:40 PM Surveyor interviewed CNA O (Certified Nursing Assistant) regarding the staffing. CNA O stated she has worked at the facility for 4 years. CNA O stated last night [DATE], Labor Day, was horrible. CNA O stated she was the only CNA in the building to start the shift. CNA O stated I was responsible for the 4 wings, one which is dementia care. CNA O stated about dinner time 2 staff came in to help for the remainder of the shift. CNA O stated between 40- 50% of the time the facility is significantly understaffed. CNA O stated the only reason I stay is because I love the residents. Surveyor asked CNA O if the facility is short of staff such as last night, how do you transfer residents that require two-person assistance? CNA O stated at times it is impossible to find a second person to assist you, you just transfer the resident alone or they wouldn't make it to the restroom or get out of bed. On [DATE] at 4:20 PM Surveyor interviewed CNA P (Certified Nursing Assistant) regarding staffing. CNA P has been at the facility for 3 months. CNA P stated there have been several times over the past three months where there has been inadequate staff in the building. CNA P stated there have also been several times there has been no staff in dietary and CNAs need to work in dietary to get food out to the residents. CNA P stated the facility staffs 1 CNA to a hall sometimes 1 CNA to two halls. Typically, the CNA to resident ratio is 1:18. Surveyor asked CNA P what she does if she has a resident that is a two-person transfer. CNA P stated I need to find assistance and that is not always easy. On [DATE] at 4:15 PM Surveyor interviewed DON B (Director of Nursing) regarding staffing. DON B stated he is working 7 days a week ,d+[DATE]-hour days, and most days he is working on the floor. Surveyor asked DON B how he completes his DON duties. DON B stated he tries to complete his role but it's difficult when he has to work the floor. DON B stated he had an Assistant Director of Nursing and a Unit Manager but they both quit. Surveyor asked DON B if he has heard concerns regarding staffing. DON B stated he is aware of staffing concerns and the facility is staffed almost 100 percent by agency. We are trying. Surveyor asked DON B if he was aware of lengthy medication pass going from one pass to another, treatment concerns and staff not following the care plan. DON B stated he would work with the nursing staff to make needed improvements. On [DATE] Surveyor interviewed NHA A (Nursing Home Administrator) regarding staffing at the facility. Surveyor asked NHA A about the facility turnover rate. NHA A stated our staffing is bad, our turnover rate is very high and we are now almost 100 percent agency staff. Surveyor asked NHA A if the facility completes an exit interview to gain insight on the high turnover rate. NHA A stated we have not, but we will be starting to implement this. Surveyor asked NHA A about staffing ratios. NHA A stated we do not staff according to acuity we are required to staff according to the census or per patient day. NHA A stated CNA ratio should be 1 CNA to ,d+[DATE] residents and 1 nurse to 25 residents. NHA A stated this does not always occur due to staffing shortages, but this is her comfort level. Surveyor asked NHA A If she has received concerns regarding staffing. NHA A stated, Yes, I have received concerns from staff, residents and families regarding not enough staff, staff being overworked and not able to complete daily duties. Surveyor asked NHA A knowing these concerns what has the facility done to ensure resident care? NHA A stated, I stopped admissions about a week ago, spoke with the Vice President of Clinical, and we will be receiving more oversight for nursing to ensure catching resident COC, and MD notification. We are looking to implement a charge nurse position. NHA A stated the facility is also running a job fair to attract new hires. Surveyor asked NHA A if she was aware staff are not following plans of care at times due to lack of staffing. NHA A stated she was not aware, but staff should follow the plan of care. Surveyor asked NHA A if licensed nursing staff voiced concern regarding medication pass going from one pass to the next with no time in between medication pass and difficulty completing treatments. NHA A stated she was not aware of this concern but would speak to the Director of Nursing (DON) B regarding these concerns. Surveyor asked NHA A about the dietary staff concerns. NHA A stated the dietary department does not have a dietary manager and they are very understaffed in the dietary department. NHA A stated she has worked in the kitchen as well as other management and nursing staff to ensure residents receive meals. NHA A stated we are working to obtain adequate staffing. I have no business being in the kitchen; we are doing the best we can. NHA A stated as of [DATE], she is working with a contracted dietary department to take over the kitchen. NHA A stated we have not signed an agreement but are working toward the company taking the dietary department over. On [DATE] at 11:25 AM Surveyor interviewed Scheduler Q and Human Resources J (HR) regarding licensed nurse staffing on [DATE]. Surveyor asked Scheduler Q and HR J if they had knowledge of the events that occurred regarding nurse staffing on [DATE]. Scheduler Q stated she job shares the scheduling with Human Resources (HR) J. Scheduler Q stated both she and HR J were aware there was no licensed staff scheduled for the day shift of [DATE]. HR J stated she alerted Director of Nursing B (DON) and NHA A the facility was not covered with a licensed nurse on the day shift of [DATE];albeit they had a call out to (Agency Name) requesting coverage but the shift was not filled. HR J stated she was then called on [DATE] in the morning by Student Nurse T stating there was no licensed nurse in the building. HR J stated she instructed Student Nurse T to print the schedule and call DON B. On [DATE] at 12:00 PM Surveyor interviewed DON B regarding the events on [DATE]. DON B stated he was not aware prior to the AM of [DATE], that the facility did not have a licensed nurse on the day shift. DON B stated he was getting dressed for work and saw a text from Student Nurse T that there was no licensed staff in the building. DON B stated he finished getting ready and headed to the facility. On [DATE] at 12:15 PM Surveyor interviewed NHA A regarding the events on [DATE]. NHA A stated the day before, [DATE], HR J had alerted her there was no coverage on [DATE], but they were still working on it and had a call out to agency. NHA A stated on [DATE] she received a text from the facility stating there was no licensed staff in the building and no dietary staff in the building. On [DATE] at 2:15 PM Surveyor spoke with Student Nurse T regarding the events on [DATE]. Student Nurse T stated she had volunteered to pick up a shift on [DATE]. Student Nurse T stated she was aware there was no nurse scheduled although Scheduler Q stated they were working on it. Student Nurse T stated she reported for the day shift on [DATE], which started at 6:00 AM. Student Nurse T stated the schedule was not posted when she entered the facility. Student Nurse T received report from agency nurses Licensed Practical Nurse (LPN) R and LPN S. Student Nurse T stated she was speaking with LPN R and informed her she was the only person in the building, there was not another nurse. Student Nurse T stated LPN R was aware there was no licensed staff in the building but still chose to leave the facility. Student Nurse T stated she called and had to leave a message with DON B and NHA A about 6:30 AM. Student Nurse T stated she was able to contact HR J shortly after 6:30 AM. HR J stated DON B should be there. HR J instructed Student Nurse T to print the schedule and try to find nurse coverage. Student Nurse T stated she went hall to hall to ensure there was adequate Certified Nursing Assistant (CNA) coverage. Surveyor asked Student Nurse T if there was adequate CNA coverage, to which Student Nurse T said there was. Student Nurse T stated DON B came in around 7:30 AM. Surveyor asked Student Nurse T how long she was left in the building without a licensed nurse. Student Nurse T stated there was no licensed staff in the building for 1.25 hours. Student Nurse T stated both LPN R and LPN S were aware she was an unlicensed Student Nurse, but LPN R and LPN S left the facility leaving the building not covered by a licensed nurse. Student Nurse T stated, moreover, there was no dietary staff in the kitchen on [DATE] either so I was pulling CNAs to start breakfast. Surveyor asked Student Nurse T if she informed DON B and NHA A of this in her message. Student Nurse T stated she let NHA A, DON B. and HR J know of the staffing crisis to include nursing and dietary departments. On [DATE] at 1:00 PM Surveyor interviewed FLPNM V (Former LPN Manager) regarding facility staffing and the events from [DATE]. FLPNM V stated she worked at the facility for one week. I was not risking my license to work in a facility where staff receive no training. The first week I worked over 70 hours. I had no training or orientation to the facility. I was needed to work a double shift; I had no idea where the emergency narcotic box or contingency medication was located. I had no idea where the crash cart was. It was all very overwhelming and stressful. The facility is extremely understaffed. Staff leave in the middle of the shift, do not show up to work, or show up two hours late. It's very dangerous. With the extreme staffing challenges, it is difficult to ensure residents are fed, repositioned, and receive the care they deserve. DON B is working a tremendous number of hours including double shifts and weekends. Surveyor asked FLPNM V if she had knowledge of what had occurred on the day shift of [DATE]. FLPNM V stated the day shift of [DATE] was insane. FLPNM V stated she had no idea there was not a licensed nurse in the facility until she reported for her shift at 8:00 AM. DON B was at the facility already and working the floor. I was told I needed to grab a medication cart and work the floor. We were already 2 hours behind for medication pass since day shift starts at 6:00 AM. I was later told the NOC (night) nurses left, leaving Student Nurse T alone in the building without a licensed nurse. FLPNM V stated on [DATE], the facility was also without staff in the kitchen and management and CNAs were trying to get breakfast out to the residents. In the week I was there, there were several days/shifts when there was inadequate dietary staff requiring management and nursing to cover. There was also at least a night or two with no dietary staff and the residents received Little Caesars pizza. On [DATE] at 1:30 PM Surveyor interviewed FADON U (Former Assistant Director of Nursing) regarding facility staffing and the events of [DATE]. FADON U worked at the facility for 1 week and quit due to staffing and other management concerns. FADON U stated on the morning of [DATE] when she reported to work, she was informed there was no licensed staff in the building until DON B arrived around 7:30 AM. FADON U stated she arrived around 8:00 AM and reported directly to the floor to assist with medication pass. FADON U stated it was reported to her by DON B that the two-night nurses left the facility leaving Student Nurse T in the building without a licensed staff. FADON U stated the facility is grossly understaffed. FADON U told Surveyor the first day she arrived to work for orientation she was immediately pulled to the floor with no orientation to the facility, policy and procedures or emergency procedures. Surveyor asked FADON U if she knew where the crash cart was. FADON U stated no I had no idea. I was put on the floor with no training at all. In the week I was at the facility I did not even complete my new hire paperwork I was on the floor every single day. I worked over 70 hours that week. On [DATE], I [TRUNCATED]

Based on observations and interviews, the facility did not ensure a qualified person is named as the dietary manager. This has the potential to affect all 71 residents. The facility's failure to ensure a qualified person is named as the dietary manager created a finding of immediate jeopardy that began on 08/27/22. NHA A (Nursing Home Administrator) and Regional Nurse Consultant W (RNC) were notified of the immediate jeopardy on 09/08/22 at 11:40 AM. The immediate jeopardy was removed on 09/13/22, however the deficient practice continues at a scope/severity of F (No Actual Harm/Widespread) as the facility continues to implement its action plan. This is evidenced by: The dietary manager is responsible for the overall coordination of the dietary department. The dietary manager assists the registered dietitian in assessing nutritional needs of residents and assuring resident preferences are followed; assures accurate implementation of regular and therapeutic diets to meet the specialized needs of residents; oversees the budget and purchasing of food and supplies, oversees food preparation, service, and storage techniques; and is also responsible for the hiring and scheduling of staff to assure there is adequate coverage to perform essential operations. On 9/3/22 at 8:10 A.M., Surveyor entered the dietary department and asked for the name of the dietary manager. DA C (Dietary Aide) indicated they do not have a dietary manager. Cook D joined the conversation. Cook D stated they haven't had a dietary manager in several months. Surveyor asked who completes the schedule, and Cook D stated there isn't one. Surveyor asked about ordering of food and supplies. Cook D stated facility management takes care of that. On 9/3/22 at 10:30 a.m., Surveyor spoke again with Cook D, DA C, and Cook E. Cook E stated that there was someone who came in on the weekends and did the ordering, however that only lasted a few weeks. On 9/3/22 at 12:35 P.M., Surveyor spoke with NHA A (Nursing Home Administrator) and asked if the facility had a full time dietitian on staff. NHA A stated the facility has a part time consultant dietitian. Surveyor asked NHA A if there was a person named as the dietary manager. NHA A indicated they do not have a dietary manager and have delegated ordering of the food and supplies to Director of Marketing F. 1. Residents were identified as having severe weight loss without and/or dehydration without appropriate interventions being implemented: R18 was diagnosed and treated for dehydration, failure to thrive, and malnutrition. When medically stable, R18 was admitted to the facility for rehab services and wound care with a goal of returning to her home, in the community. The facility failed to put aggressive measures in place to prevent R18 from significant weight loss or to maintain acceptable parameters of nutrition and hydration. Additionally, the facility failed to obtain admission weight and follow weight monitoring policy for R18, failed to consistently record and assess meal and fluid intake data being gathered to ensure R18 was meeting assessed nutrition and fluid needs, failed to accurately assess and complete assessments for signs and symptoms of weight loss and dehydration per plan of care, and failed to honor R18's food preferences when she asked for vanilla Ensure as ordered or ice cream, or to offer comparable options, and failed to notify R18's Medical Doctor/Nurse Practitioner when her weight was outside of set parameters. R4 had a weight loss and was to receive 60 cc's (cubic centimeters) of med pass supplement 4 times a day. there is no evidence that the supplement was provided until months later when it was first added to the TAR (Treatment Administration Record). R4 had a continued weight loss and Ensure was ordered to be provided 3 times a day. R4 did not always receive the Ensure as it was not available in the facility. There is no evidence that an alternate supplement was provided in the absence of the Ensure. In addition, R4 did not receive foods according to her preferences or that she was able to eat. R4 continued to experience an unplanned weight loss. R27 was nutritionally at-risk and did not have a recorded weight since 6/22/22. (Refer to F692 for issues related to weight loss.) 2. There was not sufficient dietary support staff to provide meals to residents of the facility. There were no qualified dietary staff to prepare and serve meals to residents for 5-7 meals each week. Nursing staff and management staff would provide foods as they were able, cook, or order pizza to feed to residents. (Refer to F802 for issues related to lack of sufficient dietary support staff.) 3. Ordering of food and supplies was delegated to the Marketing Director. Substitutions were made on an almost daily basis as the appropriate foods were not ordered. In addition, supplements such as Ensure were unavailable to residents. (Refer to F803 related to failure to follow planned menus. Refer to F692 for lack of prescribed supplements.) 4. Dietary staff were not following accepted standards of practice including the documenting the date opened on multi use foods and beverages. Dietary staff did not document food temperatures at the point of service to ensure foods were heated or cooled to a safe temperature. (Refer to F812 related to failure to store, prepare and serve foods in a sanitary manner.) 5. Residents complained of cold foods. There was no process to ensure residents received foods at appropriate temperatures. (Refer to F804 related to palatable temperatures. Refer to F812 related to serving foods in a sanitary manner.) The facility's failure to ensure a qualified person is named as the dietary manager, created a finding of immediate jeopardy (IJ). The IJ was removed on 09/13/22, when the facility began implementing the following: Plan initiated September 9, 2022 All staff will be educated prior to their next working shift 09/13/22 Thursday September 8, 2022 The administrator completed the following: 1. Food service director -Hired an interim food service director -Arrangements made and employment offer presented. -Started immediately on this date of September 8, 2022. 2. Dietician - Contracted Dietitian in house on September 8, 2022, and September 9, 2022. - Arrangements made for full time coverage 3. Competencies Association of Nutrition and Foodservice Professionals competency obtained. - Competency to be completed by the dietician with the food and nutritional service staff members prior to working. 4. New hires/orientation The dietician will complete: - Competency checks on the food and nutritional services employees prior to working. 5. Emergency preparedness - Outline developed on steps to take should there be a staffing concern - Call placed to supervisor immediately - Back up emergency food supply put together with location and menu items to meet nutritional servings and portions. 6. Scheduling - The schedule will be developed by the dietary manager and provided in advance for the food and nutritional services employees - Employees scheduled will have advanced notice. 7. Education - Food and nutritional services employees will receive training on F801 before working Qualified Dietary staff to include: F801 (Rev.173, issues 11-22-17, implementation: 11-28-17) 483.60(a) staffing . The facility must employ sufficient staff with the appropriate competencies and skills set to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e) This includes: 483.60(a) (1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who - (i) holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a state that does not provide for 483.60(a) (2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full time, the facility must designate a person to serve as the director of food and nutrition services who: For designation prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016 or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: o A certified dietary manager, or o A certified food service manager; or o Has similar national certification for food service management and safety from a national certifying body; or o Has an associates or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) in states that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a registered dietitian by the commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. (iii) Receives frequently scheduled consultation from a qualified dietitian or other clinically qualified nutrition professional. o Emergency preparedness plan o Scheduling o competencies 8. Audits - The Administrator/Designee will conduct audits 5 days a week: - Interviews confirm knowledge of qualified dietary staff - Interviews confirm knowledge of emergency food supply - New hires have competency checks completed - Schedule completed for dietary staffing. 9. QAPI The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and improvement.

Based on observations, interviews, and record reviews, the facility did not ensure there were sufficient dietary support staff to carry out the functions of the food service department. The facility currently has only 3 people employed in the dietary department which is not enough to ensure that residents receive meals that meet their preferences and their nutritional needs. The facility's failure to ensure there was sufficient dietary support staff created a finding of immediate jeopardy that began on 8/27/22. The NHA (Nursing Home Administrator) was notified of the immediate jeopardy on 9/8/22 at 11:40 AM. The immediate jeopardy was removed on 9/13/22, however the deficient practice continues at a scope/severity of F (potential for more than minimal harm that is not immediate jeopardy) as the facility continues to implement its removal plan. This is evidenced by: The census on 9/3/22 was 71. On 9/3/22, at 8:15 a.m., Surveyor entered the dietary department and met Cook D and DA C (Dietary Aide). Surveyor asked what the normal staffing is in the dietary department? Cook D stated, 1 cook and 1 dietary aide sometimes. When Surveyor asked what was meant by sometimes, Cook D stated when she and DA C are off, there is no one working in the dietary department. Surveyor asked for a copy of the schedule. DA C and Cook D stated there is no schedule because there is no dietary manager at this time. Surveyor asked how they know when to work. Cook D stated she, DA C, and Cook E have a set schedule. Surveyor asked what the usual schedule is. Cook D stated the following: Monday - Cook D and DA C breakfast/lunch. Cook E supper. Tuesday - Cook D and DA C breakfast/lunch. Cook E supper. Wednesday - Cook D and DA C breakfast/lunch. No supper cook Thursday - Cook D breakfast/lunch (no dietary aide). No supper cook. Friday - No cook or dietary aide breakfast/lunch. No supper cook. Saturday - Cook D and DA C breakfast/lunch. Cook E supper. Sunday - Cook D and DA C breakfast/lunch. Cook E supper, Cood D and DA C work every other weekend. On the weekends when they are off, there are no dietary staff working the breakfast/lunch meals. Surveyor asked what happens on Wednesdays when there is no supper cook. Cook D stated she is sometimes forced to stay over, but when she does not stay, one of management will cook. Surveyor asked what happens on Thursday when there is no dietary aide. Cook D stated she has to do all of the tasks, which includes cooking/serving breakfast and doing all breakfast dishes, and cooking/serving lunch and doing all dishes again. Surveyor asked if one person can do all the work on Wednesdays. Cook D stated that one person can't do it all, she just does her best. Surveyor asked what it was like when DA C and Cook D came into work today (Saturday 9/3/22). DA C stated resident dishes were piled up. Cook D stated dishes were piled in the sink as well. Cook D stated she had called off on Thursday, so there were 2 days of dishes piled up in the sink. DA C stated stock had come in on Thursday and was left on the floor and she and Cook D have been working on getting it put away as they were looking for foods they needed to prepare for meals today. On 9/3/22 at 10:30 a.m., Surveyor met with DA C, Cook D, and Cook E. Cook D stated that the supply of quick foods, like pre-made sandwiches, yogurt, and desserts had been depleted. Cook D stated that if Cook E hadn't come in at 10, she wouldn't have dessert for lunch today. Surveyor asked how many staff are in the dietary department? Cook D stated, The 3 of us. Cook E stated there was another person, DA J, but they thought he had quit because he did not show up for his last scheduled shift. Surveyor asked DA C, Cook D, and Cook E if they have voiced their concerns to management. Cook E stated management doesn't listen. Cook D stated it is a hostile environment. On 9/3/22 at 12:35 p.m., Surveyor spoke with NHA A and asked about the staffing in the dietary department. NHA A stated the facility does not have enough staff and there are only 4. Surveyor asked who the fourth person was and she indicated it was DA J. Surveyor stated dietary staff were not aware of DA J's status as he didn't show up for a shift. NHA A stated that she had spoken with DA J and that he is returning. NHA A stated they have increased dietary wages, but cannot get people to apply. Surveyor reviewed the staff roster provided by the facility and there were 2 additional dietary staff listed. NHA A stated that neither of those staff work at the facility and the roster was incorrect. On 9/3/22 at 10:15 a.m., Surveyor spoke with Resident (R) 4 about a variety of topics including food. R4 indicated the food is horrible. R4 stated that it got better for a short period of time, but it's worse now than what it was. R4 stated last night she received tomato soup and as soon as they took the lid off, you could smell that it was scorched. R4 stated that she cannot eat soup, but they keep sending it to her. R4 stated that she had received pizza a couple of nights. R4 stated she received 1 slice of pizza and that it was cold and tough. Surveyor asked R4 if there was anything else served with the pizza, like a vegetable or fruit? R4 stated, no fruits or vegetables but one night she did get plain jello with the pizza. Surveyor reviewed the dietary schedule and noted the facility did not have sufficient and competent staffing in the kitchen. On 9/7/22 at 2:45 PM, Surveyor reviewed the dietary staffing and noted the following: On 8/27/22 day shift, the kitchen was covered by Nursing Home Administrator A (NHA) and Maintenance Director OO. NHA A and Maintenance Director OO have not received the training or competencies to perform dietary duties. On 8/28/22 day shift, the kitchen was covered by Certified Nursing Assistant (CNA) QQ who has not received the training or competencies to perform kitchen duties. On 9/1/22 day shift, the kitchen was covered by CNAs and NHA A, who have not received the training or competencies to perform kitchen duties. Of note, Surveyor was not able to determine which CNAs covered the kitchen. On 9/2/22 day shift, the kitchen was covered by NHA A and Social Worker X (SW) who have not received the training or competencies to perform kitchen duties. On 9/2/22 lunch shift, the kitchen was covered by SW X who has not received the training or competencies to perform kitchen duties. On 9/3/22 dinner shift, the kitchen was covered by Human Resources J and Speech Therapy PP (ST) who have not received the training or competencies to perform kitchen duties. On 9/7/22 at 8:46 AM, Surveyor interviewed Agency CNA CC related to kitchen staffing. CNA CC indicated they had no kitchen staff and the CNAs had to go in and cook for the residents. CNA CC indicated they made toast, cereal, eggs, and maybe sausage one time. Cereal that was served was pre-packaged, toast was made on demand, and the warmer was used to warm food. CNA CC indicated for those receiving pureed diets, they grabbed yogurts, Ensure, applesauce, and cream of wheat, and sometimes oatmeal. CNA CC indicated staff would use leftovers with the dates on them for pureed residents also. CNA CC indicated she has not had education for the dietary department but reads the tickets of what each resident can and can't have. CNA CC indicated this has happened a few times in the last month. CNA CC indicated they've had pizza recently, she doesn't know why, she was just sent to get it. CNA CC indicated the facility is lacking communication because no one knows what anyone else is doing, or who is supposed to do what, feels it's disorganized and that something big could happen due to the lack of communication. On 9/7/22 at 11:25 AM, Surveyor interviewed Human Resources J (HR) regarding working in the kitchen. HR J stated she has worked in the kitchen and has not been trained. On 9/7/22 at 11:40 AM, Surveyor interviewed SW X regarding working in the kitchen. SW X stated she has worked in the kitchen but has not received training. On 9/7/22 at 1:30 PM, Surveyor interviewed NHA A regarding the kitchen staffing. NHA A stated the facility does not currently have a Certified Dietary Manager. NHA A stated the facility has struggled with staffing in the kitchen recently. NHA A stated several staff have covered the kitchen who have not been trained, however due to the staffing challenges it was necessary to ensure residents received their meals. Surveyor asked NHA A, if she has been trained to work in the kitchen; NHA A stated no. Surveyor asked if CNAs, ST, SW, HR, or maintenance have been trained? NHA A stated Maintenance Director OO has been trained to prepare ground meat by Cook E. On 9/7/22 at 3:26 PM, Surveyor interviewed RN KK (Registered Nurse) related to staffing. RN KK indicated she works all shifts. RN KK indicated one weekend, no one was in the kitchen. RN KK stated she noticed at 6:00 a.m. no one was in the kitchen and at 7:00 a.m. a CNA reported there still was no one in the kitchen. RN KK indicated she was worried about her diabetic residents. When RN KK checked the kitchen, the door was locked. RN KK indicated the laundry staff unlocked the kitchen and the CNAs made something to just fill the residents up like toast, cereal, and juice. RN KK indicated she told staff they were not trained to do this and not to make breakfast for the residents and to wait until someone comes to do it due to special diet orders and different portions. RN KK indicated later in the shift the NHA finally showed up to do the cooking. RN KK indicated this has been happening a lot. RN KK indicated they leave the schedule blank and just don't fill it, or they put names on the schedule and those people don't show up. RN KK indicated she is worried about the residents if things don't change, they keep doing the same things even after state has been here. On 9/7/22 at 3:59 PM, Surveyor interviewed Agency LPN LL (Licensed Practical Nurse) regarding staffing. LPN LL indicated one day she came in and there was no kitchen staff, and someone made calls for staff to come in. LPN LL indicated her and the CNAs helped make breakfast. LPN LL indicated they served cereal and toast. LPN LL indicated for the altered diets they gave yogurt, pudding, and applesauce. LPN LL indicated someone came in to make lunch and supper that day. On 9/7/22 at 4:04 PM., Surveyor interviewed CNA MM regarding staffing. CNA MM indicated a couple of times they have not had dietary staff. CNA MM indicated that on 8/27/22 no one was in the kitchen. CNA MM indicated she called management and CNAs were let into the kitchen around 7:20 AM and they grabbed items they didn't have to cook for the memory care unit. CNA MM indicated she tried to use the stove with direction from the maintenance man but could not figure it out. CNA MM indicated she works on the memory care unit often and knew what items they could have. CNA MM indicated for puree and soft diets, they can have yogurt, pudding, and applesauce and the rest of the residents got cereal and milk, if able to have regular, and used thickened liquids for those who needed it. CNA MM indicated she had no training in the dietary department. CNA MM indicated that her nurse was RN KK that day. CNA MM stated, State can come in and they still don't fix things or care. The facility's failure to ensure there was sufficient dietary support staff created a finding of immediate jeopardy (IJ). The IJ was removed on 9/13/22, when the facility began implementing the following: Plan initiated September 9-13,2022. - All staff will be educated prior to their next working shift 09/13/22. The Administrator will ensure the following: Food services Director and Dietitian will provide for services to ensure dietary staff are competent and sufficient to meet resident needs to include: - Resident needs and preferences are met, food is palatable, attractive, served at the proper temperatures and at appropriate times scheduled. - There are sufficient staff to prepare and serve meals in a timely manner and to maintain food safety and temperature. - Food and nutrition services are present at interdisciplinary team meetings - Meals and nutritional supplements are provided in accordance with a resident's medication requirements. - Meals intended to be hot are served as such and are maintained at the desired temperature when provided to the resident. - Meals or nutritional supplements are provided to residents within 45 minutes of either a resident request or less depending on the facility's scheduled time for meals. Emergency preparedness - Outlined steps to take should there be a staffing concern: o Call placed to Supervisor immediately o Back up emergency food supply put together with location and menu items to meet nutritional servings and portions. Education The administrator will ensure the dietician and/or the food services director educate the dietary staff: - Food and nutritional service employees will receive training before working on F802 Qualified Dietary Staff to include: - New hires/ orientation for food and nutritional service employees will receive training before working on F802 Qualified Dietary staff to include: F802 F802 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) S483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at S483.70(e). S483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. S483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in S 483.21(b)(2)(ii). DEFINITION S483.60(a)(3)-(b) Sufficient support personnel means having enough dietary and food and nutrition staff to safely carry out all of the functions of the food and nutrition services. This does not include staff, such as licensed nurses, nurse aides or paid feeding assistants, involved in assisting residents with eating. PROCEDURES S483.60(a)(3) and (b) o Through observations and interviews determine if there are sufficient support personnel to safely and effectively carry out the meal preparation and other food and nutrition services as defined by facility management. o Observe and interview residents to determine if their needs and preferences are met, if the food is palatable, attractive, served at the proper temperatures and at appropriate times? o Do observations and/or interviews indicate there are sufficient staff to prepare and serve meals in a timely manner and to maintain food safety and temperature? o Determine who represents food and nutrition services at interdisciplinary team meetings. When evaluating timeliness, factors that should be considered include but may not be limited to: Meals or nutritional supplements are provided in accordance with a residents medication requirements. Meals intended to be hot are served as such and are maintained at the desired temperature when provided to the resident. Meals or nutritional supplements are provided to residents within 45 minutes of either a resident request or less depending on the facilities scheduled time for meals. Audits The administrator/designed will conduct audits 5 days a week: - Observed and interview residents to determine if their needs and preferences are met, if the food is palatable, attractive, served at the proper temperature and at appropriate times? - Do observations and/or interviews indicate there are sufficient staff to prepare and serve meals in a timely manner and to maintain food safety and temperature? - Determine who represents food and nutrition services at the interdisciplinary team meetings. When evaluating timeliness, factors that should be considered include but may not be limited to: - Meals or nutritional supplements are provided in accordance with resident's medication requirements - Meals intended to be hot are served as such and are maintained at the desired temperature when provided to the resident. - Meals or nutritional supplements are provided to residents within 45 minutes of either a resident request or less depending on the facility's scheduled time for meals. QAPI The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and improvement.

Based on record review, observations, and staff interviews, the governing body did not implement policies regarding the management and operation of the facility to ensure residents received care that attained or maintained their highest practicable level of physical, mental, and psychosocial well-being this had the potential to affect all 71 residents. This resulted in 9 Immediate Jeopardy citations being issued at Nutrition/Hydration (F692), Sufficient Nurse Staffing (F725), Qualified Dietary Staff (F801), Sufficient Dietary Staff (F802), Menus Being Followed (F803), Transfer and Discharge Requirements (F622), Permitting Residents to Return to the Facility (F626), Provisions of Medically Appropriate Social Services (F745), and Governing Body (F837). Additionally, the governing body was experiencing issues with paying outside agencies/vendors and fulfilling and disclosing staff benefits and bonus payments. The governing body's failure to ensure adequate staffing, patient care, and financial accountability created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on [DATE] at 11:40 A.M. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of an F (Potential for more than minimal harm/widespread.) This is evidenced by: The following concerns show that the governing body and the facility did not have the capacity to meet the needs of, and to competently care for, their residents during day-to-day operations and uphold its financial obligations. Staffing: * The governing body and the facility did not ensure sufficient and competent staffing. On [DATE], a student nurse was left in the building for 1 1/2 hours without a licensed nurse in the building. In addition, there was no dietary staff in the building. The Director of Nursing (DON) has worked numerous shifts on the floor as a floor nurse and is unable to fulfill the duties of a Director of Nurses. The building is almost entirely staffed with agency staff, and they have not received training on emergency procedures or daily operations. Agency staff and new facility hires report receiving no training prior to working the floor. Multiple staff report they were not oriented on how to respond to emergency procedures. The facility had multiple days with insufficient or no dietary staff in the building. The Nursing Home Administrator (NHA), Social Worker, Activity Director, and Maintenance Director have cooked and worked in dietary with no dietary training. The facility was unaware as to if nursing staff who were scheduled were CPR (Cardiopulmonary Resuscitation) certified. (Cross Reference F725). Additionally, the facility did not ensure an RN (Registered Nurse) was scheduled for at least 8 consecutive hours a day, 7 days a week (Cross reference F727). Food and Nutrition Services: * The governing body and facility did not ensure a qualified person is named as the dietary manager. (Cross Reference F801). * The governing body and facility only had 3 dietary staff employed for a resident census of 71. (Cross Reference F802). * The facility substituted several meals as there were no dietary staff to work certain shifts or the facility did not have the food to adhere to the posted menu. Posted menus did not reflect the changes and a list of substituted foods were not provided. Resident preferences were not honored, and supplements were not provided as ordered. (Cross Reference F803). Quality of Care: * The governing body and the facility failed to put aggressive measures in place to prevent residents from significant weight loss or to maintain acceptable parameters of nutrition. Additionally, the facility failed to obtain admission weights and follow weight monitoring policies for residents, failed to consistently record and assess meal and fluid intake data being gathered to ensure residents were meeting assessed nutrition and fluid needs, failed to accurately assess and complete assessments for signs and symptoms of weight loss and hydration per plan of care, failed to honor food preferences, and failed to notify a physician when weights were outside of set parameters. (Cross Reference F692) * The governing body and facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Resident wounds increased in size due to the facility not completing scheduled wound care treatments. Daily weights were not completed for residents with 1) heart failure 2) orders for daily weights and 3) those who were deemed to be nutritionally at risk. (Cross Reference F684). * The governing body and facility did not ensure residents on [CONDITION(S)] were able to get to their [CONDITION(S)] treatments and did not notify [CONDITION(S)] when they were not going to be at treatments. (Cross Reference F698) Lab and Pharmacy Services: *The facility did not ensure the facility provided pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of residents. This included residents having to instruct nurses to go back to the medication cart to correct dosing of medication, residents' medications were noted to be unsecured on medication carts, and residents did not receive medications as prescribed as medications were not delivered from pharmacy. (Cross Reference F755) * The governing body and facility did not ensure residents are free of any significant medication errors. This included a medication that was given after being discontinued and not administering a medication for several months after it had been ordered. (Cross Reference F760) * The facility did not ensure laboratory services were obtained as ordered by the physician. (Cross Reference F773) Additionally, the facility has not ensured its employees' benefits and vendors/agencies are being paid. On [DATE] at 3:45 PM, Surveyor interviewed SW X (Social Worker) related to insurances. SW X indicated she elected coverage through the facility for life insurance. SW X indicated her premiums are expensive and she has recently received a letter related to a glitch with her life insurance premium lapsing. SW X indicated she was told it would be taken care of. SW X indicated her policy is for herself and her children and it's taken out of her checks each pay schedule. SW X indicated she was told she should receive a letter or notice when it's been resolved related to lapse in payments for her coverage. On [DATE] at 4:15 PM, Surveyor interviewed CNA P (Certified Nursing Assistant) related to benefits from the facility. CNA P indicated she was to receive a sign on bonus but has not been paid her sign on bonus. CNA P indicated she has asked for her pay stubs multiple times but has not been provided with them. She asked to see them because she feels they're not taking out taxes appropriately and she does not know what the facility is taking out of her paycheck. CNA P indicated several staff are talking about their insurance being lapsed since May of 2022. On [DATE] at 3:40 PM, Surveyor interviewed CNA O. CNA O stated she has a life insurance policy through the facility for her and her grandson and short-term disability. CNA O stated a few weeks ago she received a letter from the life (Insurance Company Name) regarding her policy. CNA O stated the letter stated her insurance had lapsed and she owed $500.00. CNA O stated the facility is still taking the premium out of her check every pay week. CNA O stated she spoke to Nursing Home Administrator A (NHA) regarding this and NHA A stated May and June were covered and not to worry about July and August, they will be covered as well. CNA O stated I have not received anything stating my insurance has been reinstated and I need to have surgery. CNA O stated how does your insurance lapse if the premiums are being paid, obviously the corporation is taking our money and not paying our premiums. Surveyor interviews with Maintenance Director OO ([DATE] at 9:58 AM) and Cook D ([DATE] at 9:19 AM) reveal that Maintenance Director OO had gone to the store to buy fish and pasta sauce for the [DATE] evening meal as the facility did not have the food necessary to provide the scheduled supper meal. Maintenance Director OO attempted to use the facility's debit card, but it was declined at the store and was unable to get the food the facility needed for its 71 residents. On [DATE] at 1:30 PM, Surveyor interviewed NHA A regarding facility finances. Surveyor asked NHA A if she could speak to the facility credit card being declined. NHA A stated Maintenance Director OO stated the card was declined but I had spoken to corporate, and they state there is no reason the card is being declined. Surveyor asked NHA A if she was aware of bills not being paid. NHA A stated a few weeks ago the staffing agency was not being paid but this has now been resolved. Surveyor asked NHA A about the staff life insurance and short-term disability. NHA A stated the bill was not paid for two months but staff did not lose coverage. NHA A also stated she was aware staff received letters however they should be receiving letters stating this is now resolved and that there was no break in coverage. Surveyor asked for invoices for staffing agency and insurance premiums, but no further information was received. Transfer and Discharge Requirements and Permitting a Resident to Return to the Facility: Resident (R) 33 signed out of the facility for an appointment on [DATE]. R33 was later found intoxicated by the local police department. Due to the extent of R33's intoxication, R33 was involuntarily detained at a detox center. R33 requested to return to the facility however, the facility would not permit R33 to return despite R33's desire to remain in the facility. The facility did not have a valid reason for R33's discharge, and did not allow R33 to return despite R33's desire to return to the facility. The facility failed to have a safe discharge plan for R33. R33 arrived at the facility and the facility required R33 to pack his belongings, gave R33 homeless shelter pamphlets, and R33 left the facility without means for medications, food, and shelter. Medically Appropriate Social Services: R33 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was aware R33 was using alcohol while at the facility. R33 admitted to the facility from a homeless situation. The facility did not address R33's alcohol use/abuse, did not assist or inquire if R33 had a desire to stop using alcohol, and did not address his alcohol use while at the facility. R33 left the faciity on a day pass, became intoxicated, was involuntarily detained by law enforcement, and the facility discharged the resident without proper discharge planning or assistance. R33 left the facility without medication, food, or shelter. The failure to ensure the governing body implemented policies and procedures related to the management and operation of the facility contributed to multiple care issues identified during this survey and created a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility implemented the following: The facility owners will provide cash box on site at facility, for all ancillary and emergency needs, and adequate funding to purchase supplies and food. Validation of ownership through submission of proof: *Identified employees selecting life insurance benefits *Confirmation these benefits are valid *Confirmation of payment submission to insurance carrier have been received *Confirmation payment process has been received, reviewed, and is in place Licensed nurses will be scheduled in accordance with the needs from the facility assessment and acuity as determined by the Director of Nursing. Emergency training has included staff to call the Administrator immediately with staffing concerns Training has included review of the Emergency Preparedness Manual. Education provided by administrator and governing body for licensed and unlicensed nursing staff: *Guideline: Governing Body Communication Guideline *Cash box on site at facility for all ancillary and emergency needs *Licensed nurses will be scheduled in accordance with the needs from the facility assessment and acuity as determined by the Director of Nursing

Based on record review and staff interviews, the facility did not permit a resident to remain in the facility and not discharge the resident from the facility without meeting the proper criteria for 1 of 3 sampled residents (R33). On [DATE], R33 was returning from pass after being placed under an involuntary protective custody from law enforcement at a detoxification center. R33 called the facility with his desire to return prior to his return. The facility failed to allow R33 to return despite R33's history of leaving on pass and know history of alcohol use/abuse. The facility discharged R33 without a valid reason to an unsafe place of homelessness. The facility does not know where R33 is residing. The facility did not document R33 receiving notice of rights to appeal. The facility's failed to permit R33 to remain in the facility, discharged R33 without medication, transportation or means to obtain food this created a finding of an IJ (Immediate Jeopardy) that began on [DATE]. The NHA A (Nursing Home Administrator) was notified of the IJ on [DATE] at 4:00 PM. At the conclusion of the survey the immediate jeopardy was not removed. This is evidenced by: According to an article by the Cleveland Clinic, Blood Alcohol Content ([NAME]), Blood alcohol level ([NAME]), is the amount of alcohol in your blood that develops from drinking alcoholic beverages. Levels can range from 0% (no alcohol) to over 0.4% (a potentially fatal level). A table included in the article shows the following: [NAME] 0.30% to 0.40%: In this percentage range, you'll likely have alcohol poisoning, a potentially life-threatening condition, and experience loss of consciousness. [NAME] over 0.40%: This is a potentially fatal blood alcohol level. You're at risk of coma and death from respiratory arrest (absence of breathing). https://my.clevelandclinic.org/health/diagnostics/ -blood-alcohol-content-[NAME]#:~:text=[NAME]%20Over%200.40%25%3A%20This%20is,arrest%20(absence%20of%20breathing) The facility Admission Agreement signed by R33 on [DATE] states, in part .Bed Hold. If you are on leave, or temporarily discharged (such as to a hospital for surgery or treatment) and have expressed a desire to return to the Center, you will not be denied readmission. The Center will hold your bed until you waive your right to have the bed held, or up to 30 days following the leave or discharge, whichever is earlier. The facility Discharging a Resident Procedure with a review date of ,d+[DATE], states, in part Purpose- The purpose of this procedure is to provide guidelines for the discharge process. Preparation- The resident should be consulted about the discharge. Discharges can be frightening to the resident. Approach the discharge in a positive manner. Reassure the resident that all his or her personal effects will be taken to his or her place of residence If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions . Assess and document resident's condition at discharge, including skin assessment, if medical condition allows . Assemble the equipment and supplies necessary to discharge the resident . Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the discharge was made. 2. The name and title of the individual(s) who assisted in the discharge. 3. All assessment data obtained during the procedure, if applicable. 4. How the resident tolerated the procedure, if applicable. 5. If the resident refused the discharge, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. R33's Hospital History and Physical, dated [DATE], showed R33 was admitted into the hospital presenting intoxicated after a bicycle accident resulting in a right ankle fracture. The hospital assessment and plan indicate for admission for Bimalleolar Right Ankle fracture and Alcohol Intoxification; CIWA (Clinical Institute Withdrawal Assessment) and an AODA consult (Alcohol and Other Drug Abuse), other: Worsening peripheral sensory [CONDITION(S)], suspect from ETOH (alcohol). R33's hospital active problem list includes Alcoholic liver failure, [CONDITION(S)], Depressive disorder, Neurosis, anxiety, panic type, Other and unspecified alcohol dependence, unspecified drinking behavior, Severe alcohol use disorder, Fracture-tibial plateau, [CONDITION(S)], Acute alcoholic liver disease, Ascites, and Static tremor. R33 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's quarterly MDS (Minimum Data Set) assessment on [DATE] indicates R33 had a BIMS (Brief Interview for Mental Status) score of 15 indicating R33 is cognitively intact. R33's cognitive impairment indicates he is able to be understood and has the ability to understand. R33's Functional Assessment: independent with no physical help from staff with bed mobility, transfers, dressing, and toilet use. Dressing, personal hygiene, eating, and bathing is independent with set up help only for R33. R33's functional limitation assessment indicates no impairment in the upper and lower extremity. Devices that R33 uses is a wheelchair. R33's bowel and bladder assessment indicates always continent of bowel and bladder. Pain assessment for R33 indicates that resident is frequently in pain and is not receiving scheduled pain medication and is receiving PRN (as needed) pain medication, rating pain level at moderate intensity. Fall assessment for R33 indicates no falls since admission. R33's Baseline Care Plan dated [DATE] states, in part; Discharge Plan: Length of Stay Unknown, currently homeless, staying at a shelter prior to hospital. Goal: Will be discharged to a lesser care setting once goals are met . Interventions: Discuss feelings/goals for placement as needed, SS (Social Services) to intervene as needed/requested . Arrange for discharge as needed, Obtain MD (Medical Doctor) order for discharge, set up Services and/or DME (Durable Medical Equipment) as needed for safe discharge. The resident is at risk for falls, accidents and incidents r/t (related to) recent fall, [CONDITION(S)]. Goal: the resident will not sustain serious injury through the review date. Interventions: . Fall on [DATE]; education on risks of drinking, maintaining safety when drinking out in the community, resident verbalized understanding. (Note: This intervention was initiated on [DATE], after resident fell in the community). Initiated on [DATE]: Behavior Problem: r/t Alcohol intoxication. Goal: behavior will not cause harm to self or others. Interventions: Educate resident regarding risks and benefits of not drinking, document findings . Update MD regarding alcohol intoxication and request to hold medications. Initiated on [DATE]: Actual Risk for Complication with Mood/Behavior RT DX (diagnosis) of Alcohol Dependence, uncomplicated with episodes of drinking alcohol while in this facility and in the community. Resident does not always sign himself out when going into the community. Goal: Will be safe in environment through next review date. Interventions: Call MD/NP (Nurse Practitioner) if resident present with symptoms of intoxication . Psych services as ordered/accepted. Physician Order: [DATE] May go on LOA (Leave of Absence) with medications. Facility provided census documentation for [DATE] indicates census was 64 and the facility has the ability to take 83 residents, indicating a 19-bed availability. Facility provided Sign in and out log from the front desk dated [DATE]- [DATE] indicates R33 has signed himself out on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Facility provided R33's face sheet indicated date and time of discharge of [DATE] at 12:00 PM. Surveyor was unable to interview R33 after unsuccessful attempts of calling R33's primary number, alternate number, emergency contact number, 2 local shelters in the area, and the primary care provider's supplied number. Surveyor reviewed R33's medical record/progress notes that showed in part, the following: On [DATE] at 10:24 AM, Writer informed by DON (Director of Nursing) that resident is OOB (out of building) and is currently at detox facility in (City Name). No POA (Power of Attorney) on file, resident is own decision maker. Will f/u (follow up) w (with) social worker for further info. (Note: No social worker documentation). On [DATE] at 4:27 PM, Resident found on University Ave, and was admitted to detox with an alcohol level of 4.28 and will be discharged from (facility). (Note: Facility made determination of discharge prior to R33 returning on [DATE]). On [DATE] at 9:15 AM, Surveyor interviewed Primary Care Provider's RN TT (Registered Nurse). Surveyor asked RN TT if R33 had a discharge order or any communication from the facility of a discharge plan, RN TT replied there is not a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 4:20 PM, Surveyor interviewed DOM F (Director of Marketing). Surveyor asked DOM F if the R33 called while on pass and if his room was available, DOM F replied R33 called 4 times on [DATE] and asked if his bed available and was reassured that he could return. DOM F further explained to Surveyor that she attempted to assist R33 to pack his belongings and was informed by Regional Nurse Consultant W that DOM F was not allowed to assist with packing as it was a violation of the rules. DOM F explained to Surveyor that DOM F asked Regional Nurse Consultant W if R33 could have a cab fare and was informed R33 could not because he was no longer a Resident. Surveyor asked DOM F if R33 indicated he wanted to be discharged , she replied he did not have any other plans, no friends and therefore R33 was coming back to the facility as he did not have any other plans. DOM F explained to Surveyor that she informed Regional Nurse Consultant W of R33's return, Regional Nurse Consultant W advised DOM F that R33 was not allowed to return and that R33 had checked himself into a facility. (Note: R33 was placed into involuntary protective custody by law enforcement and taken to a center for detoxification.) On [DATE] at 1:37 PM, Surveyor interviewed Detoxification Center RN UU. Surveyor asked the process for intake of protective custody from law enforcement to the facility, RN UU replied the patient is placed under involuntary protective custody for a maximum of 72 hours hold, the patient cannot sign themselves in as they are too intoxicated to sign, all belongings are removed during the intake process to protect belongings from theft, privacy, harm and social media reasons, staff does assist the patient if the phone numbers are needed from their personal phone and are assisted to use the facility hallway phone from the hours of 8:00 AM- 9:00 PM. On [DATE] at 3:35 PM, Surveyor interviewed SW X (Social Worker). Surveyor asked SW X of the process of R33's discharge, SW X replied she was informed that R33 was out of the building for about a week (Note: R33 was out of the building for approximately 3 days.), SW X was alerted by DOM F to obtain a list of shelters and explain to R33 that we do not have a room any longer. SW X further explained to the Surveyor she walked R33 to his room and observed R33 packing his belongings, SW X did not provide any money and was provided a list of homeless shelters. (Note: No indication of a notice of appeal was provided and no evidence of documentation that the notice of appeal was provided.) SW X reported to Surveyor she was then called away and did not see R33 leave. Surveyor asked SW X if discharging R33 was safe or planned, SW X replied that he is able-bodied and is going back to the same place he came from, we didn't plan anything, it is their choice of living. Surveyor asked SW X if this was R33's choice, SW X replied, he didn't flat out say I want to be homeless, but he didn't participate in any housing. Surveyor asked SW X if there was any documentation of a discharge plan or discharge summary, SW X replied, I am working on that, I am getting better at the discharge summaries and I keep a soft file. Surveyor asked SW X if there is a soft file or any documentation of discharge for R33 for discharge, SW X replied to no. Surveyor asked SW X if R33 had a discharge order, SW X replied to no. Surveyor asked SW X if there was a bed hold, SW X replied, I don't believe he had a signed bed hold. Surveyor asked SW X if R33 was able to have a bed hold, SW X replied, I'm not positive if he has Medicaid, then they would do a bed hold. (Note: R33 has Medicaid per medical record documentation). Surveyor asked SW X why did R33 get discharged , she replied because he signed himself into a different inpatient setting. Of note, R33 did not sign himself into a different setting he was involuntarily placed into an inpatient detoxification center. The facility did not complete a discharge plan, did not ensure R33 was being discharged to a safe setting and did not provide R33 information to appeal his discharge. On [DATE] at 4:37 PM, Surveyor interviewed law enforcement officer VV. Surveyor asked law enforcement officer VV about how he was called for R33, he replied a passerby called 911 and reported R33 was in the 700 block of University Avenue, R33 was not able to recall his address and so he was placed into protective custody and taken to detox. Surveyor asked law enforcement officer VV if he has seen R33 anywhere on the street, law enforcement officer VV replied to no. On [DATE] at 7:31 PM, Surveyor interviewed SW X again. Surveyor asked SW X if the Ombudsman has been informed of R33's discharge, SW X replied to no. On [DATE] at 4:01 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R33's bed was available, DON B replied, yes, we did have open beds. Surveyor asked DON B if R33 should have had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked DON B if R33 should have had a bed hold, DON B replied yes. Surveyor asked DON B if the discharge plan should be in R33's chart, DON B replied yes. Surveyor asked DON B if R33 had medication arrangements for his discharge, DON B replied he would have to check on it. (Note: Surveyor did not receive confirmation of the requested materials prior to survey exit.) The facility's failure to permit R33 to remain in the facility, created a finding of an IJ (Immediate Jeopardy) that began on [DATE]. R33 was discharged to homelessness without a safe and orderly discharge plan. R33 was discharged without medication, transportation or means to obtain food which caused a reasonable likelihood for harm. The immediate jeopardy was not removed at the conclusion of the survey. Cross Reference: 626 and 745

Based on interview and record review, the facility failed to permit 1of 3 sampled residents (R33) of a total sample of 33 residents reviewed to return to the facility after a pass that was for treatment. R33 was not allowed to return to the facility after R33 was out on pass. R33 was placed on an involuntary protective custody in a treatment center for 72 hours after being found on the street intoxicated. R33 called the facility 4 times to ensure his bed would be available and returned to the facility to be informed he did not have his bed and was discharged to a homelessness. The facility's failure to allow R33 to return to the facility after out on a pass created a finding of an IJ (Immediate Jeopardy) that began on [DATE]. The NHA A (Nursing Home Administrator) was notified of the IJ on [DATE] at 4:00 PM. The facility has not removed the IJ at the conclusion of the survey. This is evidenced by: According to an article by the Cleveland Clinic, Blood Alcohol Content ([NAME]), Blood alcohol level ([NAME]), is the amount of alcohol in your blood that develops from drinking alcoholic beverages. Levels can range from 0% (no alcohol) to over 0.4% (a potentially fatal level). A table included in the article shows the following: [NAME] 0.30% to 0.40%: In this percentage range, you'll likely have alcohol poisoning, a potentially life-threatening condition, and experience loss of consciousness. [NAME] over 0.40%: This is a potentially fatal blood alcohol level. You're at risk of coma and death from respiratory arrest (absence of breathing). https://my.clevelandclinic.org/health/diagnostics/ -blood-alcohol-content-[NAME]#:~:text=[NAME]%20Over%200.40%25%3A%20This%20is,arrest%20(absence%20of%20breathing) The facility Admission Agreement signed by R33 on [DATE] states, in part .Bed Hold. If you are on leave, or temporarily discharged (such as to a hospital for surgery or treatment) and have expressed a desire to return to the Center, you will not be denied readmission. The Center will hold your bed until you waive your right to have the bed held, or up to 30 days following the leave or discharge, whichever is earlier. The facility Discharging a Resident Procedure with a review date of ,d+[DATE], states, in part Purpose- The purpose of this procedure is to provide guidelines for the discharge process. Preparation- The resident should be consulted about the discharge. Discharges can be frightening to the resident. Approach the discharge in a positive manner. Reassure the resident that all his or her personal effects will be taken to his or her place of residence If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions . Assess and document resident's condition at discharge, including skin assessment, if medical condition allows . Assemble the equipment and supplies necessary to discharge the resident . Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the discharge was made. 2. The name and title of the individual(s) who assisted in the discharge. 3. All assessment data obtained during the procedure, if applicable. 4. How the resident tolerated the procedure, if applicable. 5. If the resident refused the discharge, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. R33's Hospital History and Physical, dated [DATE], showed R33 was admitted into the hospital presenting intoxicated after a bicycle accident resulting in a right ankle fracture. The hospital assessment and plan indicate for admission for Bimalleolar Right Ankle fracture and Alcohol Intoxification; CIWA (Clinical Institute Withdrawal Assessment) and an AODA consult (Alcohol and Other Drug Abuse), other: Worsening peripheral sensory [CONDITION(S)], suspect from ETOH (alcohol). R33's hospital active problem list includes Alcoholic liver failure, [CONDITION(S)], Depressive disorder, Neurosis, anxiety, panic type, Other and unspecified alcohol dependence, unspecified drinking behavior, Severe alcohol use disorder, Fracture-tibial plateau, [CONDITION(S)], Acute alcoholic liver disease, Ascites, and Static tremor. R33 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's quarterly MDS (Minimum Data Set) assessment on [DATE] indicates R33 had a BIMS (Brief Interview for Mental Status) score of 15 indicating R33 is cognitively intact. R33's cognitive impairment indicates he is able to be understood and has the ability to understand. R33's Functional Assessment: independent with no physical help from staff with bed mobility, transfers, dressing, and toilet use. Dressing, personal hygiene, eating, and bathing is independent with set up help only for R33. R33's Baseline Care Plan dated [DATE] states, in part; Discharge Plan: Length of Stay Unknown, currently homeless, staying at a shelter prior to hospital. Goal: Will be discharged to a lesser care setting once goals are met . Interventions: Discuss feelings/goals for placement as needed, SS (Social Services) to intervene as needed/requested . Arrange for discharge as needed, Obtain MD (Medical Doctor) order for discharge, set up Services and/or DME (Durable Medical Equipment) as needed for safe discharge. The resident is at risk for falls, accidents and incidents r/t (related to) recent fall, [CONDITION(S)]. Goal: the resident will not sustain serious injury through the review date. Interventions: . Fall on [DATE]; education on risks of drinking, maintaining a safety when drinking out in the community, resident verbalized understanding. (Note: This intervention was initiated on [DATE], after resident fell in the community). Initiated on [DATE]: Behavior Problem: r/t Alcohol intoxication. Goal: behavior will not cause harm to self or others. Interventions: Educate resident regarding risks and benefits of not drinking, document findings . Update MD regarding alcohol intoxication and request to hold medications. Initiated on [DATE]: Actual Risk for Complication with Mood/Behavior RT DX (diagnosis) of Alcohol Dependence, uncomplicated with episodes of drinking alcohol while in this facility and in the community. Resident does not always sign himself out when going into the community. Goal: Will be safe in environment through next review date. Interventions: Call MD/NP (Nurse Practitioner) if resident present with symptoms of intoxication . Psych services as ordered/accepted. Physician Order: [DATE] May go on LOA (Leave of Absence) with medications. Facility provided census documentation for [DATE] of census was 64 and the facility can take 83 residents, indicating a 19-bed availability. Surveyor was unable to interview R33 after unsuccessful attempts of calling R33's primary number, alternate number, emergency contact number, 2 local shelters in the area, and the primary care provider's supplied number. Facility provided R33's face sheet indicated date and time of discharge of [DATE] at 12:00 PM. Surveyor reviewed R33's medical record/progress notes that showed in part, the following: On [DATE] at 11:42 AM, Spoke with MD regarding intoxication noted on previous shift, Resident has been going out on pass frequently during the week and returning later in the evening and appears under the influence. Writer spoke with Resident, did not deny alcohol use however stated he plans on leaving this place soon and if he chooses to make poor choices it is his decision. Order was obtained to hold medications when he appears intoxicated and update MD in the morning. On [DATE] at 8:50 PM Nurse received call from nurse at (hospital) that resident had been found at a bus stop and had possible fall that was unwitnessed. He was brought to ER (emergency room ) where he was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He was found to be intoxicated. Hospital will be releasing him and making arrangements for transportation back to this facility. On [DATE] at 11:50 PM, Resident returned to facility at around 2300 (11:00 PM) from (hospital) via taxi for public intoxication, . resident denied having pain or discomfort, neuro intact, DON (Director of Nursing) was updated. Will continue to monitor resident. On [DATE] at 10:00 PM, Resident was not in facility during the entire PM shift remains out of the building. On [DATE] at 3:26 AM, Resident remains out of the facility DON made aware. On [DATE] at 10:00 PM, Resident [has] been out of facility all day. He returned at 9:45 PM smelling of alcohol, appeared intoxicated. No meds to be given. Continue to monitor. No complaints currently. Call light in reach. On [DATE] at 10:24 PM, Above writer noted resident out of the building today he left at 7 AM and still has not returned to facility DON aware. On [DATE] at 10:24 AM, Writer informed by DON that resident is OOB (out of building) and is currently at detox facility in (City Name). No POA (Power of Attorney) on file, resident is own decision maker. Will f/u (follow up) w (with) social worker for further info. (Note: No social worker documentation). On [DATE] at 4:27 PM, Resident found on University Ave, and was admitted to detox with an alcohol level of 4.28 and will be discharged from (facility). (Note: Primary Care was not notified of these incidents when R33 was intoxicated per Care Plan Interventions: Update MD regarding alcohol intoxication and request to hold medications.) Record Review of Interdisciplinary Team (IDT) note indicated: On [DATE], R33's IDT note written by SW X (Social Worker), Resident is physically ready to D/C from this facility. Discharge orders not able to be obtained at this time due to missed PCP (Primary Care Provider) appointments. (Note: Surveyor requested IDT notes and were not provided prior to exit). Note: All the above progress note documentation indicates that R33 frequently left the faciity on pass and was able to return to the facility. On [DATE] at 9:15 AM, Surveyor interviewed Primary Care Provider's RN TT (Registered Nurse). Surveyor asked RN TT if R33 had a discharge order or any communication from the facility of a discharge plan, RN TT replied there is not a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 4:20 PM, Surveyor interviewed DOM F (Director of Marketing). Surveyor asked DOM F if the R33 called the facility while on pass and if his room was available, DOM F replied R33 called 4 times on [DATE] and asked if his bed available and was reassured that he could return. DOM F further explained to the Surveyor that she attempted to assist R33 to pack his belongings and was informed by Regional Nurse Consultant W that DOM F was not allowed to assist with packing as it was a violation of the rules. DOM F explained to the Surveyor that DOM F asked Regional Nurse Consultant W if R33 could have a cab fare and was informed R33 could not because he was no longer a Resident. Surveyor asked DOM F if R33 indicated he wanted to be discharged , DOM F replied he did not have any other plans, no friends and therefore R33 was coming back to the facility as he did not have any other plans. DOM F explained to Surveyor that she informed Regional Nurse Consultant W of R33's return, Regional Nurse Consultant W advised DOM F that R33 was not allowed to return and that R33 had checked himself into a facility. (Note: R33 was placed into involuntary protective custody by law enforcement and taken to a center for detoxification unit.) On [DATE] at 1:37 PM, Surveyor interviewed Detoxification Center RN UU. Surveyor asked the process for intake of protective custody from law enforcement to the facility, RN UU replied the patient is placed under involuntary protective custody for a maximum of 72 hours hold, the patient cannot sign themselves in as they are too intoxicated to sign, all belongings are removed during the intake process to protect belongings from theft, privacy, harm and social media reasons, staff does assist if phone numbers are needed from their personal phone and are assisted to use the facility hallway phone from the hours of 8:00 AM- 9:00 PM. On [DATE] at 3:35 PM, Surveyor interviewed SW X (Social Worker). Surveyor asked SW X of the process of R33's discharge, she replied she was informed that R33 was out of the building for about a week (Note: R33 was out of the building for approximately 3 days.), SW X was alerted by DOM F that she was instructed to obtain a list of shelters and explain to R33 that we do not have a room any longer. SW X further explained to the Surveyor she walked R33 to his room and observed R33 packing his belongings, SW X did not provide any money and was provided a list of homeless shelters. SW X reported to Surveyor she was then called away and did not see R33 leave. Surveyor asked SW X if discharging R33 was safe or planned, SW X replied that he is able-bodied and is going back to the same place he came from, we didn't plan anything, it is their choice of living. Surveyor asked SW X if this was R33's choice of discharge, SW X replied, he didn't flat out say I want to be homeless, but he didn't participate in any housing. Surveyor asked SW X if there was any documentation of a discharge plan or discharge summary, SW X replied, I am working on that, I am getting better at the discharge summaries and I keep a soft file. Surveyor asked SW X if there is a soft file or any documentation of discharge for R33 for discharge, she replied, no. Surveyor asked SW X if R33 had a discharge order, SW X replied no. Surveyor asked SW X if there was a bed hold, SW X replied I don't believe he had a signed bed hold. Surveyor asked SW X if R33 was able to have a bed hold, SW X replied, I'm not positive if he has Medicaid, then they would do a bed hold. (Note: R33 has Medicaid per medical record documentation). On [DATE] at 4:01 PM, Surveyor interviewed DON B. Surveyor asked DON B if R33's bed was available, DON B replied, yes, we did have open beds. Surveyor asked DON B if R33 should have had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked DON B if R33 should have had a bed hold, DON B replied yes. Surveyor asked DON B if the discharge plan should be in R33's chart, DON B replied yes. Surveyor asked DON B if R33 had medication arrangements for his discharge, DON B replied he would have to check on it. (Note: No documentation of the facility provided Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .) On [DATE] at 10:20 AM, Surveyor interviewed NHA A and asked the discharge process if a Resident is out for a treatment, she replied, if the Resident has Medicaid, they have a 14-day bed hold. The facility failed to allow R33 to return from a pass despite bed availability and R33's desire was to return to the facility. R33's history of alcohol abuse and lack of safe discharge planning created reasonable likelihood that serious harm could occur. This led to a finding of immediate jeopardy. At the conclusion of this survey, the facility has not removed the immediate jeopardy. Cross Reference: F622, F745

Based on interview and record review, the facility did not ensure that each resident maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible in 3 of 6 residents (R) reviewed (R18, R4, and R27.) On 8/5/22, R18 was diagnosed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to put aggressive measures in place to prevent R18 from significant weight loss or to maintain acceptable parameters of nutrition and hydration. Additionally, the facility failed to obtain admission weight and follow weight monitoring policy for R18, failed to consistently record and assess meal and fluid intake data being gathered to ensure R18 was meeting assessed nutrition and fluid needs, failed to accurately assess and complete assessments for signs and symptoms of weight loss and dehydration per plan of care, and failed to honor R18's food preferences when she asked for vanilla Ensure as ordered or ice cream, or to offer comparable options, and failed to notify R18's Medical Doctor/Nurse Practitioner when her weight was outside of set parameters. These failures created a finding of Immediate Jeopardy that began on 8/25/22. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 9/8/22 at 4:00 PM. On 9/22/22 the Immediate Jeopardy was not removed at the conclusion of the survey. R4 had a weight loss and was to recieve 60 cc's of med pass supplement 4 times a day. there is no evidence that the supplement was provided until months later when it was first added to the TAR (Treatment Administration Record). R4 had a continued weight loss and Ensure was ordered to be provided 3 times a day. R4 did not always receive the Ensure as it was not available in the facility. There is no evidence that an alternate supplement was provided in the absence of the Ensure. In addition, R4 did not receive foods according to her preferences or that she was able to eat. R4 continued to experience an unplanned weight loss. R27 was nutritionally at-risk and did not have a recorded weight since 6/22/22. Evidenced by: The Risks of a Poor Diet for Seniors | Nutrition for Seniors notes, A lack of calories can lead to a debilitated immune system, which makes it harder for the body to fight infection and promote wound healing. It also leads to weak muscles, which make falls more likely, and low bone mass, which makes those falls more likely to cause breaks. It also carries an overall greater risk of hospitalization and death. https://blog.highgateseniorliving.com/the-risks-of-a-poor-diet-for-seniors-nutrition-for-seniors Unintended weight loss can have negative consequences for the individual. According to the Nutrition Care Manual of the Academy of Nutrition and Dietetics, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Unintended weight loss is linked to increased mortality among older adults discharged from hospitals . The Geriatric Anorexia Nutrition Registry demonstrated that residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight .Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death . Unintended weight loss often results in protein-energy undernutrition as the older adult loses critical lean body mass .and is more prone to pressure ulcers, infections, immune dysfunction, [CONDITION(S)], falls resulting in hip fractures, and other conditions. Malnutrition in the Elderly: A Multifactorial Failure to Thrive notes, Malnutrition and unintentional weight loss contribute to progressive decline in health, reduced physical and cognitive functional status, increased utilization of health care services, premature institutionalization, and increased mortality. According to CMS training, Implementing Measures in the Malnutrition Quality Improvement Initiative (MQii), malnourished individuals in the hospital are 5 times more likely to have an in-hospital death, are 54% more likely to be readmitted to the hospital within 30 days of discharge, with the leading cause of readmission being [CONDITION(S)], are at greater risk for hospital-acquired infections, falls, pressure injuries, and slower wound healing, and are likely to have a hospital stay that is two times longer than a non-malnourished individual. Facility policy, entitled Weight Assessment and Intervention, revised September 2008, includes, in part: The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . any weight changes of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will respond within 24 hours of receipt of written notification. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: . 1 month - 5% weight loss is significant, more than 5% is severe 3 months - 7.5% weight loss is significant, greater than 7.5% is severe 6 months - 10% weight loss is significant, greater than 10% is severe . The Physician and multidisciplinary team will identify conditions and medications that may be causing weight loss or increase the risk of weight loss . For example: . chewing or swallowing abnormalities . medication-related adverse consequences . increased need for calories or protein . fluid nutrition loss . inadequate availability of food or fluids . Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing straff, the Dietician the Consultant Pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address, to the extent possible: the identified causes of weight loss, goals/benchmarks for improvement and time frames and parameters for monitoring and reassessment. R18 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 is alert and oriented times 4, as stated on her hospital discharge notes. (It is important to note, the facility has not submitted an admission MDS (Minimum Data Assessment) on R18 as of 9/15/22. On 9/6/22 at 4:12 PM during an interview, R18 indicated she was treated in the hospital for malnutrition and dehydration, but now that she has been in this facility she is not receiving vanilla Ensure 3 times a day. R18 also indicated she asks staff every day for vanilla ice cream and they tell her no and sometimes say they don't have any here. R18 indicated she also thought she would get snacks offered to her between meals, but she isn't. R18 indicated staff at the hospital discussed with her about eating more small meals instead of just 3 big ones. R18 stated her goal is to gain weight and strength and return to her home. R18's Admission Notification, dated 8/25/22, includes, in part: . R18's preferred name . admission to facility on 8/25/22 at 4:00 PM . arriving from the hospital via friend . age 82 . height 4'10 . weight 97 lbs. (pounds) . extra information: rib fracture, groin incision with wound cares . Dietary needs: Regular Diet . Discharge plan: Home with family . R18's Hospital Progress and Discharge Notes, dated 8/5/22 - 8/25/22, include in part: . Orientation level: oriented times 4 . On 8/5/22 Admission weight: 70 lbs 3.2 ounces, noted as stated, taken weight at MD (Medical Doctor) office . weight 70 lbs . no leg [CONDITION(S)] . second weight on admission 74 lbs taken with bed scale . current weight 74 lbs . Usual weight per patient is 100 lbs . Patient was sent by her Personal Care Provider office due to failure to thrive, worsening generalized weakness, and coffee ground emesis. 8/6/22 Physical Examination findings: . not able to do, patient too tired/fatigued and having multiple emisis. Patient cachetic in appearance, with visible muscle wasting in temporalis and clavicles. Patient edentulous . Nutrition Assessment: Malnutrition related to decreased appetite/intake as evidenced by per patient report taking decreased intake for past 3 weeks with onset of intermittent nausea and vomiting. Patient taking less than 50% of estimated energy needs for greater than 5 days, with resulting weight loss of 11 lbs over past 5 months . 5 lbs of this was in the past one month/ Patient shows overall weight loss of 21 lbs over past 16 months. Patient meets criteria for Severe Malnutrition in the context of Acute Illness or Injury based on the Academy of Nutrition and Dietetics' and ASPEN's definition of malnutrition. Nutrition Prescription: Basal Energy Needs: 667 calories per day based on 70 lbs 2 oz. Estimated energy needs: 1029-1372 calories per day. Estimated protein needs: 48-63 grams per day. Nutritional Intervention: TNA (Total [MEDICATION(S)] Nutrition): Will initiate at 6:00 PM tonight pending PICC line placement . TNA will contain trace elements and multivitamin. Continue clear liquid diet. Plan for nursing bedside swallow after discontinuation of NG (nasal gastric) tube . Once diet advances will start liquid nutritional supplement drink of ensure [MEDICATION(S)] vanilla 8 ounces three times a day . on potassium, magnesium, and phosphorus replacement protocols . On 8/7/22, patient reported increased abdominal distention and abdominal pain in right lower quadrant. A loop of jejunum extends into a right inguinal hernia. There is a high grade small bowel obstruction at this level, with dilated upstream loops jejunum measuring to 3.6 cm. No evidence of bowel rupture. 8/8/22 Open right preperitoneal inguinal hernia repair with mesh, small bowel resection with primary stapled anastomosis 74 lbs . 8/9/22 Nutritional Support Pharmacy Consult: [MEDICATION(S)] Nutrition Support (TNA) is now indicated due to severe malnutrition. TNA is intended to slow or prevent the loss of lean body mass and help a patient heal wounds and fight infection. It will continue until the patient is better able to resume oral intake or in some cases may require transition to enteral nutrition when the digestive system is properly functioning . will begin TNA at 1030 calories and 50 grams of protein . full rate will be 45 ml/hour . has a history of fluid retention and [CONDITION(S)] so will watch intake and output .Multivitamins and trace elements added to daily nutritional solution. Liquid Nutritional Supplements: Plan to initiate at 1800 today pending PICC placement . [MEDICATION(S)] Access: Order in for central PICC placement . We are consulted to begin 8/10/22 NG tube discontinued . Diet orders: Dietary Nutritional Supplements: In addition to meals per facility Dietician recommendation: 4 ounces Vanilla . CIB Vanilla or Ensure [MEDICATION(S)] Vanilla with breakfast, lunch, and dinner . Regular diet, soft and bite sized solids, thin liquids . alternate solid and liquid, small bites/sips, eat/feed slowly 8/19/22 current weight 97 lbs 8 ounces. Physician Orders: . [MEDICATION(S)] 1250MG/5ML suspension: take 5 ML by mouth 2 times daily with meals, start date 8/31/22. (It is important to note R18's hospital admission weight was 74lbs on 8/5/22 and her discharge weight was 97 lbs. 8 oz. on 8/25/22.) R18's Baseline Care Plan, initiated 8/26/22, does not include interventions or goals related to weight gain, loss, hydration status, or maintenance. R18's Comprehensive Care Plan, initiated 8/26/22, includes, in part: R18 has an actual infection/oral thrush (admitted with) . goal infection will resolve without complications . (Oral thrush causes white [CONDITION(S)] on the tongue or inner cheeks. Symptoms may include: abnormality of taste, difficulty swallowing, burning, or loss of taste. It is important to note R18's Comprehensive Care Plan does not include her goal of gaining weight and does not include the interventions related to preventing weight loss,gain or hydration status.) R18's Physician Orders, for August and September 2022, include, in part: *Monitor weights daily . Notify Provider for weight less than 95 lbs. or greater than 105 lbs . start date: 8/31/22 . *Prostat Supplement 30ML by mouth daily . start date 8/30/22 *[MEDICATION(S)] 1250MG/5ML suspension: take 5 ML by mouth 2 times daily with meals, start date 8/31/22 (It is important to note the facility did not start daily weights or any weights until 8/31/22.) R18's Nurse Practioner Progress Note, dated 8/30/22, includes, in part: date of visit - 8/29/22 . General : thin, frail elderly female lying in bed with head of bed elevated to 90 degrees. Alert and oriented times 3. Speech clear. Though coherent . mood and affect appropriate for situation . She restarted [MEDICATION(S)] upon admission to the skilled nursing facility. Hospital discharge weight: 99 pounds 4.8 ounces. No weight completed since admission to the skilled nursing facility . plan: daily weights. Notify provider for weight less than 95 lbs or greater than 105 lbs. Consult dietician to evaluate and treat, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Nutrition Assessment, dated 9/1/22, includes, in part: . order - regular, soft and bite sized, thin liquids . intake- good . most recent height- 58 . most recent weight- 85.2 . recommended weight range- 90 lbs . underweight . significant weight changes- no . insidious weight changes- no . Diuretic Therapy: No medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Weight loss or gain in past 1 month: (blank) . past 3 months: (blank) . past 6 months: (blank) . Significant weight changes: No . Estimated Nutritional needs: total calories: 1230-1435 . total fluids: 1230 . RD Assessment: review of [AGE] year old female admitted to the long term care facility services with history/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident is admitted on a regular, soft and bite sized diet with thin liquids. By mouth intakes average 50-100% of meals. Feeds self. Resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Current body weight 85.2 pounds Body Mass Index: underweight. Goal is for gradual weight gain due to low Body Mass Index. Skin surgery site. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . currently meeting needs for weight gain . (It is important to note R18's Nutrition Assessment does not reflect the parameters set by R18's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also note R18 is on diuretic therapy and has had significant weight loss prior to admission in the hospital with malnutrition, dehydration, and failure to thrive.) R18's MAR/TAR (Medication/Treatment Administration Record) for 8/2022 and 9/2022, includes the following: *Monitor weights daily . Notify Provider for weight less than 95 lbs. or greater than 105 lbs . start date: 8/31/22 . R18's facility recorded weights are as follows: 8/31/2022 10:03 85.2 Lbs 8/31/2022 10:50 85.2 Lbs 9/1/2022 16:47 75.2 Lbs 9/1/2022 19:08 72.6 Lbs 9/2/2022 13:16 71.6 Lbs 9/3/2022 13:53 79.8 Lbs 9/4/2022 11:49 77.0 Lbs 9/4/2022 13:50 72.0 Lbs 9/5/2022 13:51 70.2 Lbs 9/6/2022 01:18 70.6 Lbs R18 had a 14.6 pound weight loss or a 17.14% weight loss in 6 days. The facility did not recognize this loss, did not notify the dietician or physician of this weight loss and did not assess R18 for potential dehydration as a result of this rapid weight loss. (It is important to note the facility did not weigh R18 on her admission or the day after admission as per facility policy for new admissions.) *Ensure with meals . start date 8/26/22 8/26/22- 9/6/22 3 times this was not signed out as given to R18. (It is important to note R18 indicated through interview that she was not receiving these drink supplements 3 times a day like she thought she was supposed to be.) R18's Meal Intake, includes the following: 8/25/22 Dinner (blank) 8/26/22 Breakfast 51-75% Lunch 51-75% Dinner 76-100% 8/27/22 Breakfast (blank) Lunch (blank) Dinner 76-100% 8/28/22 Breakfast (blank) Lunch (blank) Dinner (blank) 8/29/22 Breakfast 76-100% Lunch 76-100% Dinner (blank) 8/30/22 Breakfast (blank) Lunch (blank) Dinner (blank) 8/31/22 Breakfast 76-100% Lunch 51-75% Dinner 51-75% 9/1/22 Breakfast 51-75% Lunch 51-75% Dinner (blank) 9/2/22 Breakfast 51-75% Lunch 51-75% Dinner (blank) 9/3/22 Breakfast 76-100% Lunch 76-100% Dinner (blank) 9/4/22 Breakfast 76-100% Lunch 76-100% Dinner 51-75% 9/5/22 Breakfast 76-100% Lunch 76-100% Dinner 76-100% 9/6/22 Breakfast76-100% Lunch 76-100% Dinner 26-50% (It is important to note 13 times the facility staff did not record R18's meal/fluid intake.) On 9/6/22 at 2:36 PM CNA Z (Certified Nursing Assistant) indicated she does not know when R18 is supposed to be weighed, because there are no special instructions on her CNA Care Card or R18's Comprehensive Care Plan. On 9/6/22 at 2:44 PM CNA NN indicated if R18 was a daily weight it would say that on the CNA Care card. CNA NN showed Surveyor R18 did not have goals or interventions related to daily weights on CNA Care Card. On 9/6/22 at 4:53 PM DON B (Director of Nursing) indicated R18 should have been weighed on admission and the day after but wasn't. DON B indicated CNAs should be recording meal percentages after every meal. DON B indicated unit nurses are supposed to transcribe orders from the hospital discharge paperwork and start a baseline care plan. DON B indicated they should have picked up that R18 needed nutritional interventions when they read her hospital discharge paperwork. DON B indicated he expects interventions related to weight gain/prevention of weight loss to be added to baseline care plan within 48 hours of admission for someone who was in the hospital with dehydration, failure to thrive, malnutrition diagnoses. DON B indicated after R18's NP (Nurse Practitioner) ordered daily weights an entry should have been made on the comprehensive care plan and on the CNA Care Card. DON B indicated R18's NP should have been notified with her first weight gathered in facility because it was outside of parameters set by R18's NP. DON B indicated the facility has vanilla ice cream and staff should be offering it to R18 when she asks. The facility's failure to weigh R18 on admission, failure to accurately assess R18's risk for weight loss, dehydration and malnutrition, failure to develop a baseline care plan to ensure proper nutrition, failure to consistently record R18's intake and output, failure to notify R18's NP/MD when weight was outside of parameters, and failure to offer R18 vanilla ice cream or a comparable snack created a reasonable likelihood for serious harm occurring R18's had a significant weight loss of 14.6 pounds or 17.14% in 6 days. The facility's failure to recognize R18's weight loss, potential for dehydration and lack of intervention to prevent further loss/dehydration risk in a resident already compromised with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At the conclusion of the survey, the immediate jeopardy was not yet removed. Example 2 R4 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R4's most current MDS (Minimum Data Set) assessment indicates R4 has a BIMS score of 15 indicating no memory deficits. R4's car plan includes a problem dated 7/29/21 of at risk for potential for Complications with Nutrition/Hydration. Approaches include that R4 is to receive a regular diet, with regular consistency and thin fluids. Review of R4's medical record including weight as follows: 10/2021 - 138.6 pounds 11/2021 - 137.2 12/2021 - 132.218 01/2022 - 136.9 On 1/9/2022, the NP (Nurse Practitioner) ordered Famotidine 10 milligrams as needed for nausea and vomiting. Weights continue: 02/2022 - 135.6 03/2022 - 128.8 On 3/29/22, the dietitian documents, .Review of meal intakes in the past 7 days - 75-100% x8, 50-75% x4, 25-50% x6 reflective of improved intake. She is drinking adequate fluids. Height 63; weight 127.7# on 3/16/22; BMI 22.6; weight status - 1.4% gain in 30 days, 3.4% loss in 90 days, 10.7% loss in 180 days .reported having items such as fruit and yogurt on hand in her refrigerator. She eats this at breakfast as desired. She spoke of her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was able to find short cups with lids and a grip on the outside from Amazon for beverages. She is drinking adequate fluid. In discussing weight loss, she was willing to receive a nutrition drink. Recommendation to be submitted for Med Pass Supplement 60 cc (cubic centimeters) qid (4 times a day) for 480 cal. and 16 g. protein. Will review and update care plan as needed. The med pass supplement was not added to R4's care plan. *The MAR (Medication Administration Record) and TAR (Treatment Administration Record) did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that R4 was receiving the Med Pass supplement prior to 9/10/22. R4's weights continue: 04/2022 - 127.6 05/2022 - 130.8 06/2022 - 129.9 On 6/14/22, the dietitian notes, Writer was notified of significant weight loss 5.1% since 5/25/22. Res. was diagnosed with spinocerebeller ataxia type III in 1997 with symptoms noted in 2003, and severe debility by 2012 .that weight loss and altered taste perception have occurred because of this condition. She had previously lost weight due to gastroenteritis. Diet order is Regular. No change in ability to feed herself. Review of meal intakes - 75-100% x14, 50-75% x2, 25-50% x17, 0-25% x3, refusal x3. She receives Med Pass Sup. 60 cc qid for 480 cal. and 16 g. protein. No recommendations submitted at this time. Review of R4's MAR (Medication Administration Record) finds that Ensure three times a day was started on 6/29/22. Weights continue: 07/2022 - 129.6 08/2022 - 123.8 Review of R4's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In August, Ensure was not given 19 out of 93 scheduled administration times. Documentation in the medical record indicates that there was no Ensure available in the facility during those times. On 9/3/22, Surveyor spoke with R4. R4 indicated that the facility offers choices, but she rarely gets what she wants. R4 stated that she is not physically able to eat soup but continues to get it. When she does receive it, she has to have someone come and assist her with eating. R4 also indicated that there have been meals where she received a single slice of pizza for dinner and that it is cold and tough. Surveyor asked R4 what she does when she sees she gets pizza. R4 stated if she knows far enough ahead of time, she will ask her significant other to bring her something before he goes to work, otherwise, she doesn't eat. Example 3 R27 was admitted to the facility on [DATE] and has diagnose that include [CONDITION(S)]. R27's care plan states that due to a mechanically altered diet, he will maintain a weight of 119 pounds +/- 4 pounds. This was put into place on 11/15/21. Additionally, R27 has a stage 3 pressure injury to his right hip and rests on an air mattress to aid in wound healing. R27's skin care plan states, Air Mattress settings are based on weight. Set air mattress at 130 pounds. R27's signed monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R27 has a stage 3 pressure injury on his right hip. A 6/24/22 wound evaluation, completed by the wound doctor, states, Discussed nutrition and its impact on wound healing .plan of care discussed with facility staff. The facility's registered dietician (RD) on 8/24/22 at 11:57 AM noted that R27's weight on 6/22/22 was 121.8 lbs. but did not mention any weights since that time. R27 did not have a documented weight since 6/22/22. The facility was unable to provide any documentation as to whether R27 had been weighed since 6/22. On 9/8/22 at 2:38 PM, Surveyor interviewed DON B (Director of Nursing) who stated he was unsure why R27 had not been weighed since 6/22/22 but given his risk of continued weight loss and his stage 3 pressure injury, he should be weighed weekly at a minimum.

Based on observation, interview and record review, the facility did not provide medically related social services to address [CONDITION(S)] and to ensure appropriate social services are provided for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (R33) out of a total sample of 33. R33 was admitted from the hospital due to an ankle fracture from a bicycle accident and intoxication. The hospital listed R33's diagnoses as Alcoholic Liver Failure, Other and unspecified alcohol dependence, unspecified drinking behavior, Severe alcohol use disorder, Acute Alcoholic Liver Disease. The facility admitted R33 knowing he had a history of [CONDITION(S)] and came from a homeless situation. Despite knowing this, the facility did not have the resources or assist R33 in obtaining resources to assist his alcohol dependency to manage R33's drinking or assist in creating a safe discharge plan. R33's drinking was identified as a contributing factor resulting in R33 having multiple outings to the community, a fall in the community due to intoxication and missing medical doctor appointments. The interventions that were initiated on [DATE] indicate to educate resident regarding risks and benefits of not drinking and document the findings and to update the MD (Medical Doctor) regarding alcohol intoxication and request to hold medications. R33 had a history of [CONDITION(S)] and had two incidents with alcohol one requiring an emergency room visit and another requiring an involuntary inpatient stay at a detoxification center. The facility failed to assist R33 with his alcohol use/abuse, failed to create a safe discharge plan. R33 was discharged to homelessness without food, medication, or transportation there was no discharge planning since admission and R33 was not given any involuntary discharge information to appeal his discharge. The facility's failure to provide medically related social services, such as developing a plan of care addressing alcohol and drug abuse or a safe discharge plan, created a finding of an IJ (Immediate Jeopardy) that began on [DATE]. The NHA A (Nursing Home Administrator) was notified of the IJ on [DATE] at 4:00 PM. The facility has not removed the IJ and continued the deficient practice at the conclusion of this survey. This is evidenced by: According to an article by the Cleveland Clinic, Blood Alcohol Content ([NAME]), Blood alcohol level ([NAME]), is the amount of alcohol in your blood that develops from drinking alcoholic beverages. Levels can range from 0% (no alcohol) to over 0.4% (a potentially fatal level). A table included in the article shows the following: [NAME] 0.30% to 0.40%: In this percentage range, you'll likely have alcohol poisoning, a potentially life-threatening condition, and experience loss of consciousness. [NAME] over 0.40%: This is a potentially fatal blood alcohol level. You're at risk of coma and death from respiratory arrest (absence of breathing). The facility Admission Agreement signed by R33 on [DATE] states, in part .Bed Hold. If you are on leave, or temporarily discharged (such as to a hospital for surgery or treatment) and have expressed a desire to return to the Center, you will not be denied readmission. The Center will hold your bed until you waive your right to have the bed held, or up to 30 days following the leave or discharge, whichever is earlier. R33's Hospital History and Physical, dated [DATE], showed R33 was admitted into the hospital presenting intoxicated after a bicycle accident resulting in a right ankle fracture. The hospital assessment and plan indicate for admission for Bimalleolar Right Ankle fracture and Alcohol Intoxication; CIWA (Clinical Institute Withdrawal Assessment) and an AODA consult (Alcohol and Other Drug Abuse), other: Worsening peripheral sensory [CONDITION(S)], suspect from ETOH (alcohol). R33's hospital active problem list includes Alcoholic liver failure, [CONDITION(S)], Depressive disorder, Neurosis, anxiety, panic type, Other and unspecified alcohol dependence, unspecified drinking behavior, Severe alcohol use disorder, Fracture-tibial plateau, [CONDITION(S)], Acute alcoholic liver disease, Ascites, and Static tremor. R33 was admitted to the facility on [DATE] with a diagnosis of Disorder of the Autonomic Nervous System, Hepatic Failure, Displaced Bicondylar Fracture of unspecified tibia, and discharged on [DATE]. R33's quarterly MDS (Minimum Data Set) assessment on [DATE] indicates R33 had a BIMS (Brief Interview for Mental Status) score of 15 indicating R33 is cognitively intact. R33's MDS indicates that he is able to be understood and has the ability to understand. R33's Functional Assessment: independent with no physical help from staff with bed mobility, transfers, dressing, and toilet use. Dressing, personal hygiene, eating, and bathing is independent with set up help only for R33. R33's Baseline Care Plan dated [DATE] states, in part Discharge Plan: Length of Stay Unknown, currently homeless, staying at a shelter prior to hospital. Goal: Will be discharged to a lesser care setting once goals are met . Interventions: Discuss feelings/goals for placement as needed, SS (Social Services) to intervene as needed/requested . Arrange for discharge as needed, Obtain MD order for discharge, set up Services and/or DME (Durable Medical Equipment) as needed for safe discharge. The resident is at risk for falls, accidents and incidents r/t (related to) recent fall, [CONDITION(S)]. Goal: the resident will not sustain serious injury through the review date. Interventions: . Fall on [DATE]; education on risks of drinking, maintaining a safety when drinking out in the community, resident verbalized understanding. (Note: This intervention was initiated on [DATE], after resident fell in the community). Initiated on [DATE]: Behavior Problem: r/t Alcohol intoxication. Goal: behavior will not cause harm to self or others. Interventions: Educate resident regarding risks and benefits of not drinking, document findings . Update MD regarding alcohol intoxication and request to hold medications. Initiated on [DATE]: Actual Risk for Complication with Mood/Behavior RT DX (diagnosis) of Alcohol Dependence, uncomplicated with episodes of drinking alcohol while in this facility and in the community. Resident does not always sign himself out when going into the community. Goal: Will be safe in environment through next review date. Interventions: Call MD/NP (Nurse Practitioner) if resident present with symptoms of intoxication . Psych services as ordered/accepted. Physician Order: [DATE] May go on LOA (Leave of Absence) with medications. Surveyor was unable to interview R33 after unsuccessful attempts of calling R33's primary number, alternate number, emergency contact number, 2 local shelters in the area, and the primary care provider's supplied number. Surveyor reviewed R33's medical record/progress notes that showed in part, the following: On [DATE] at 11:42 AM, Spoke with MD regarding intoxication noted on previous shift, Resident has been going out on pass frequently during the week and returning later in the evening and appears under the influence, Writer spoke with Resident, did not deny alcohol use however stated he plans on leaving this place soon and if he chooses to make poor choices if [sic] his decision. Order was obtained to hold medications when he appears intoxicated and update MD in the morning. On [DATE] at 8:50 PM Nurse received call from nurse at (hospital) that resident had been found at a bus stop and had possible fall that was unwitnessed. He was brought to ER (emergency room ) where he was treated for a [an] abrasion on his knee and scans were done to R/O (rule out) possible head injury. He was found to be intoxicated. Hospital will be releasing him and making arrangements for transportation back to this facility. (Note: Fall was not listed on the facility's fall documentation report). On [DATE] at 11:50 PM, Resident returned to facility at around 2300 (11:00 PM) from (hospital) via taxi for public intoxication, . resident denied having pain or discomfort, neuro intact, DON (Director of Nursing) was updated. Will continue to monitor resident. On [DATE] at 10:00 PM, Resident [has] been out of facility all day. He returned at 9:45 PM smelling of alcohol, appeared intoxicated. No meds to be given. Continue to monitor. No complaints currently. Call light in reach. On [DATE] at 10:24 AM, Writer informed by DON that resident is OOB (out of building) and is currently at detox facility in (City Name). No POA (Power of Attorney) on file, resident is own decision maker. Will f/u (follow up) w (with) social worker for further info. (Note: No social worker documentation). On [DATE] at 4:27 PM, Resident found on University Ave, and was admitted to detox for intoxication and will be discharged from (facility name). (Note: Facility did not notify PCP (Primary Care Provider) of these incidents when R33 was intoxicated per Interventions in the Care Plan that state: Update MD regarding alcohol intoxication and request to hold medications.) Record Review of Interdisciplinary Team (IDT) note indicated: On [DATE] in R33's IDT note written by SW X (Social Worker), Resident is physically ready to D/C from this facility. Discharge orders not able to be obtained at this time due to missed PCP (Primary Care Provider) appointments. On [DATE] at 9:15 AM, Surveyor interviewed Primary Care Provider's RN TT (Registered Nurse). Surveyor asked RN TT if R33 had a discharge order or any communication from the facility of a discharge plan, she replied there is not a physician order for a discharge, and nothing noted in the chart for a discharge and no calls of notification of R33 being discharged . On [DATE] at 4:20 PM, Surveyor interviewed DOM F (Director of Marketing), if R33 had any plan or treatment to address his history of alcoholism, she replied there are not staffed trained here, we don't have any AA (Alcohol Anonymous) meetings, we all talked about it in meetings. Surveyor asked DOM F if R33 had any Phycological consultation or any other consultations or treatments, DOM F replied no. On [DATE] at 3:35 PM, Surveyor interviewed SW X. Surveyor asked SW X what was provided and explained to R33 on [DATE] when R33 arrived to the building from treatment; SW X replied that it was explained to him he did not have a room and was escorted to his room to gather his belongings, a list of homeless shelters, case managers and places for food that was printed off the internet was given to R33. Surveyor asked SW X if discharging R33 was safe or planned, SW X replied that he is able-bodied and is going back to the same place he came from, we didn't plan anything, it is their choice of living. Surveyor asked SW X if this discharge was R33's choice, SW X replied, he didn't flat out say I want to be homeless, but he didn't participate in any housing. Surveyor asked SW X if there was any documentation of a discharge plan or discharge summary, SW X replied, I am working on that, I am getting better at the discharge summaries and I keep a soft file. Surveyor asked SW X if there is a soft file or any documentation of discharge for R33 for discharge, SW X replied no. Surveyor asked SW X if R33 had a discharge order, SW X replied no. On [DATE] at 4:01 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R33 had a discharge plan, DON B replied, the last time he left, he called, sometimes he does not sign himself out, this time he called and said he was at detox, Surveyor asked DON B is R33's bed was available, DON B replied, yes, we did have open beds. Surveyor asked DON B who decides to discharge, he replied, the Social Worker would mention in nursing meetings. Surveyor asked DON B if R33 had any discharge arrangements, DON B replied he would have to check on that. Surveyor asked DON B if R33 should have had a physician order for discharge, DON B replied yes. Surveyor asked DON B if R33 should have had a discharge plan, DON B replied yes. Surveyor asked DON B if R33 should have had a bed hold, DON B replied yes. Surveyor asked DON B if the discharge plan should be in R33's chart, DON B replied yes. Surveyor asked DON B if R33 had medication arrangements for his discharge, DON B replied he would have to check on it. Surveyor asked DON B if services for [CONDITION(S)]/use should have been offered or provided to R33 DON B stated yes. The facility's failure to ensure R33 was offered medically appropriate social services for [CONDITION(S)], the facility's failure to facilitate a safe and orderly discharge plan created reasonable likelihood that serious harm could occur. This led to a finding of immediate jeopardy. At the conclusion of this survey, the facility has not removed the immediate jeopardy.

Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 5 of 11 sampled residents (R14, R16, R22, R7, and R27). R14 was admitted to the facility with a vascular wound to her left thigh that has deteriorated. Facility staff were not assessing or completing treatments as ordered. R16 has heart failure and is on a fluid restriction without evidence of intake and outputs being monitored or daily weights being done consistently. R22 had orders for daily weights that were not completed daily. R22 had large weight discrepancies without follow-up and re-weights. R7 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 is not having her wound treatment changed per order. R27 was nutritionally at risk for weight loss and the facility has not obtained a weight for R27 since 06/22/22. This is evidenced by: Example 1: R14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14 was admitted to the facility with a vascular wound to her right thigh. Hospital discharge orders dated 7/29/22 state: Right lateral thigh - Gently cleanse area with mild soap and water, pat dry. Paint black necrotic tissue with [MEDICATION(S)]. Cover whole area with Quick Change Chux [sic] (use 2 of them or alike to maintain clean and dry). Change daily and PRN (as needed). R14 had the following orders for wound care in her EHR (Electronic Health Record) with a start date of 7/30/22: Right lateral thigh - Gently cleanse area with soap and water, pat dry. Paint black necrotic area with [MEDICATION(S)]. Cover with ABD (Abdominal) pad and paper tape. Change daily and PRN (as needed). There is no evidence that staff completed wound care on 7/29/22 after the initial assessment. On 7/29/22, facility staff measured the wound: length 17.2 cm (centimeters), width 10.2 cm, and depth 0.1 cm. There is no documentation that staff completed wound care on R14 after measuring and assessing the wound. On 8/1/22, wound care orders were changed to: Right lateral thigh - Gently cleanse area with soap and water, pat dry. Paint black necrotic area with [MEDICATION(S)]. Cover entire area with Quick change Chux [sic] (may use 2 to maintain clean and dry wounds). DO NOT TAPE OR SECURE CHUX DRESSING TO SKIN - goal is to keep clean and dry. Dressing to stay in place via weight of patient leg. Change daily and PRN. Every evening shift for wound care. On 8/5/22, R14 was seen at the facility by the wound doctor. Wound measurements: length 18.54 cm, width 10.52 cm, depth 0.2 cm. This wound care order was not completed by facility staff on 8/6/22. On 8/7/22, wound care orders were changed to: Right thigh - Cleanse with 1/2 strength Dakin's Solution, protect peri-wound with skin prep, apply Santyl to wound bed, cover with gauze. Cover whole area with ABD pad and secure . This order was originally scheduled for day shift and then changed to evening shift on 8/10/22. This wound care order was not completed by facility staff on 8/11, 8/12, 8/16, 8/18, 8/23, 8/27, or 8/28. On 8/12/22, R14 was seen at the facility by the wound doctor. Wound measurements: length 22.42 cm, width 5.54 cm, depth 1.6 cm. On 8/16/22, wound care orders were changed to: Right thigh treatment - Cleanse with Dakin's Solution, protect peri-wound with skin prep, apply lightly moistened gauze in 1/2 Dakin's, cover with ABD pad and secure. Every evening shift for wound care. This wound care order was not completed by facility staff on 8/16, 8/18, 8/19, 8/23, 8/25, 8/26, 8/27, 8/28, or 8/29. On 8/19/22, R14 was seen at the facility by the wound doctor. Wound measurements: length 18.47 cm, width 4.74 cm, depth 2.80 cm. On 8/26/22, R14 was seen at the facility by the wound doctor. Wound measurements: length 21.38 cm, width 6.73 cm, depth 2.5 cm. Facility's measurements: length 22 cm, width 5.7 cm, depth 3 cm. On 8/30/22 wound care orders were changed to: Right thigh treatment - Cleanse with Dakin's Solution, protect peri-wound with skin prep, apply lightly moistened gauze in 1/2 Dakin's, cover with ABD pad and secure. Everyday shift for wound care AM (day shift) tx (treatment) per orders - NO Santyl on AM tx, cleanse and pack only. Additionally, an order stating: Right thigh - Cleanse 1/2 Dakin's Solution, protect peri-wound with skin prep, apply Santyl to wound bed, cover with gauze. Cover whole area with ABD pad and secure. Every evening shift for wound care. This wound care order was not completed by staff on 8/30, 8/31, and 9/3 on the day shift, as well as 9/1 and 9/3 on the PM (evening) shift. On 9/2/22, facility staff measured the wound: length 22 cm, width 5.7 cm, depth 3.0 cm. The facility's Weekly Wound Assessment for R14 indicates that on 8/5, 8/12, and 8/19 the Wound MD (Medical Doctor) debrided R14's wound. On 9/6/22, R14 was seen by her MD. MD progress notes state, in part: .Wounds: gradually healing though nursing home wound care is suboptimal. Will send message to wound provider for thoughts on d/c (discharge) to home with HH (Home Health) .Concerns: Poor care at facility. Not receiving 2/day dressing changes, often they are short on food and staff .She feels that she could go home and get better care with her husband doing dressing changes once a day and having HH services. On 9/7/22 at 12:22 PM, Surveyor interviewed R14. Surveyor asked R14 if the facility staff was providing wound care and dressing changes as ordered, R14 stated that she was unsure, because it is always changing. On 9/8/22 at 2:49 PM, Surveyor interviewed DON (Director of Nursing) B. Surveyor asked DON B what his expectations were for his staff in regard to wound care treatments? DON B stated that he expects that wound care be carried out as ordered and that it be carried out properly. Surveyor asked DON B what it means on the treatment record if a treatment isn't signed out? DON B stated that if the nurse didn't sign it out, then it wasn't done. Surveyor asked DON B to review R14's treatment record. Surveyor asked DON B if it was his expectation that the treatments be completed and signed out on the days and shifts they were scheduled for; DON B stated yes. On 9/8/22 at 2:56 PM, Surveyor interviewed NP (Nurse Practitioner) DD. Surveyor asked NP DD if she thought that R14's wound had gotten bigger due to missed treatments or due to the chronic nature of the wound? NP DD stated that R14 is being followed by the UW (University of Wisconsin) Wound Clinic and the facility's wound doctor. NP DD stated that at first the wound was necrotic and was then debrided, so it should be improving, not getting bigger. NP DD also stated that R14 reported to her that wound care was not being completed at the facility as it should be. NP DD stated that she is speaking with R14's MD and they are looking at discharging R14 to home with home health sooner than expected, due to the lack of care that R14 is receiving at the facility. It is important to note that Surveyor requested the facility's policies for vascular wounds and wound care; neither policy was received prior to exit. Example 2: R7 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's most recent MDS (Minimum Data Set) 7/23/22 documents that she scored 10 on her BIMS (Brief Interview of Mental Status) which indicates she is moderately impaired cognitively. R7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 12/3/21 - Daily weights. Parameters: Update NP (Nurse Practitioner) for weight gain of 2 lbs. (pounds) in one day and 5 lbs. in one week. R7's care plan documents the following: Focus - ALTERATION IN CARDIOVASCULAR STATUS R/T (related to): [CONDITION(S)] (hypertension), HLD ([CONDITION(S)]), Occlusion and stenosis of Left carotid artery, A-fib ([CONDITION(S)]) Hx (history) of NSTEMI .Interventions - Daily weight; notify provider if weight gain or 3 pounds/day (per) or 5 pounds in a week . [SIC] Focus - Therapeutic diet ordered due to DM (Diabetes Mellitus) and CHF (Congestive Heart Failure) dx's (diagnoses): potential of variable wts. (weights) due to [CONDITION(S)] management .Interventions .Monitor weights per orders . [SIC] R7's CNA (Certified Nursing Assistant) care plan documents the following: Daily Weight R7's weight record is missing daily weights for the following dates: 7/8/22, 7/9/22, 7/30/22, 7/31/22, 8/1/22, 8/2/22, 8/14/22, 8/19/22, 8/24/22, 8/26/22, 8/28/22, 9/4/22, and 9/5/22 On 9/7/22 at 12:20 PM, Surveyor interviewed CNA (Certified Nursing Assistant) FF. Surveyor asked CNA FF how you know who needs to be weighed? CNA FF stated all the new people get weighed every day. Surveyor asked CNA FF how you know if a resident is a daily, weekly, or monthly weight? CNA FF stated the nurse will tell you. Surveyor asked CNA FF what if the Nurse has never worked in the facility before? CNA FF said the weights are on the care sheets too. On 9/7/22 at 1:09 PM, Surveyor interviewed LPN (Licensed Practical Nurse) BB. Surveyor asked LPN BB how you know if a resident is a daily, weekly, or monthly weight? LPN BB said it should be in the MAR (Medication Administration Record)/TAR (Treatment Administration Record). On 9/7/22 at 3:52 PM, Surveyor interviewed DON (Director of Nursing) B. Surveyor asked DON B if weights should be done as ordered? DON B said yes. Example 3: R7 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's most recent MDS (Minimum Data Set) 7/23/22 documents that she scored 10 on her BIMS (Brief Interview of Mental Status) which indicates she is moderately impaired cognitively. R7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 7/1/22 - Left Lateral Leg - Cleanse wound with saline, protect peri-wound with Skin Prep, Apply Collagen to wound bed, Cover wound with Foam, change every other day, Change PRN (as needed) R7's care plan documents the following: Focus - Impaired skin r/t to DM (Diabetes Mellitus), PVD (Peripheral Vascular Disease), HX WOUNDS CALLUS AND DRY AREAS TO FEET/TOES .Interventions - Complete treatment as ordered and complete weekly measurements and assessment of open areas .Treatment as ordered by MD . R7's TAR for July 2022: No signature/blank spaces on 7/11/22, 7/15/22, and 7/19/22 R7's TAR for August 2022: No signature/blank spaces on 8/6/22 and 8/8/22 (This order started on 7/3/22) No signature/blank spaces on 8/9/22, 8/13/22, 8/15/22, 8/17/22, and 8/23/22 (This order started on 8/9/22) R7's TAR for September 2022: No signature/blank space on 9/6/22 On 9/7/22 at 1:09 PM, Surveyor interviewed LPN (Licensed Practical Nurse) BB. Surveyor asked LPN BB if not signed out/blank on MAR/TAR what does that mean? LPN BB said didn't get signed/didn't get done. On 9/7/22 at 3:52 PM, Surveyor interviewed DON (Director of Nursing) B. Surveyor asked DON B should wound treatments be signed out in TAR? DON B replied yes. Surveyor asked DON B what it meant if they were not? DON B stated either it was missed being signed out or it wasn't done. Surveyor asked DON B if wound treatments should be done as ordered? DON B said yes. Example 4: R16 was admitted on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's Admission MDS (Minimum Data Set) assessment was not available on 9/7/22. R16's Hospital Discharge Summary, dated 8/24/22, states in part: .admitted [DATE] .discharge date : 8/24/2022 . Active problems .Acute HFrEF (heart failure with reduced ejection fraction) Discharge plan: Follow-up issues for PCP (Primary Care Provider)/specialist: 1. see outpatient follow-up notes under each problem below.Acute Systolic CHF exacerbation .monitor intake and output as able (incontinence/spillage effect numbers), daily weights. low sodium diet . Things to follow-up on as an outpatient: blood pressure and fluid volume adequately controlled? . R16's order list for August and September 2022, indicates the following: - Daily weight, call provider for weight gain of 3 pounds or more in 1 day or 5 pounds in 1-week, everyday shift for monitoring. - Low-fat - no added salt diet, regular texture, regular consistency, for 2000 milliliters per day fluid restriction. R16's August 2022 & September 2022 MAR (Medication Administration Record) indicates that R16 is on a 2000 milliliter per day fluid restriction. There is no evidence provided to Surveyor that this is being monitored or tracked. There is no indication on R16's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's weights that are documented in R16's record are as follows: 8/24/22 173.9 9/1/22 173.1 9/4/22 171.2 9/6/22 170 9/7/22 172.8 The following dates were missing 8/25, 8/26, 8/27, 8/29 - 8/31/22, 9/2, 9/3, and 9/5. R16 was sent to the hospital on 8/27 around 10 AM and returned on 8/29/22 due to heart pain. On 9/7/22 at 10:30 AM, Surveyor spoke with R16 regarding his weight and fluids. R16 indicated he does not get weighed every day. R16 indicated he tries to keep track of his fluid himself and tries to limit them so he's not urinating all over. R16 indicated staff do not monitor his fluids. R16 had 3 Styrofoam cups stacked together in his room, the top cup had a lid and straw on it. R16 indicated that was his water. This cup appeared to be about an 8-ounce cup. R16 could not say how long the cups have been there, just that the cups are for his water. On 9/7/22 at 12:20 PM - 12:45 PM, Surveyor interviewed DON B. DON B indicated that he would expect R16's intakes and outputs to be monitored if on a fluid restriction, and would expect a resident with heart failure to be weighed daily. On 9/19/22 at 10:30 AM, Surveyor interviewed NP (Nurse Practitioner) DD regarding R16. NP DD indicated daily weights were written as an order on 8/25/22 by NP DD regarding R16's discharge summary. NP DD indicated R16's hospital discharge summary on 8/24/22 indicated daily weights and the order was not transcribed. NP DD would expect the facility to do daily weights on R16 and notify NP DD with changes due to R16 having heart failure and being on a fluid restriction. Example 6: R22 was admitted to the facility on [DATE]. R22 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's Minimum Data Set with an Assessment Reference Date of 8/25/22 indicates R22 has a Brief Interview for Mental Status score of 13 indicating R22 is cognitively intact. R22's September Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . One time a day related to Acute on Chronic Congestive Heart Failure. R22's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 9/1/22 - No weight recorded 9/2/22 - 322.5 9/3/22 - 322.5 9/4/22 - 322.5 9/5/22 - Not Applicable - no weight recorded 9/6/22 - No weight recorded 9/7/22 - 216.8 - *note this 105.7 pound weight loss in 2 days the facility did not reweigh R22. 9/8/22 - No weight recorded On 9/7/22 at 4:15 PM Surveyor interviewed DON B regarding R22's weights. DON B stated he would expect R22 to be weighed daily per physician orders. Surveyor asked DON B regarding R22's weight discrepancy of 105.7 pounds in 2 days. DON B stated he would expect R22 to have a reweight if weight discrepancy met the criteria for MD notification to contact the MD. Example 5: R27 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This was put into place on 11/15/21. Additionally, R27 has a stage 3 pressure injury to his right hip and rests on an air mattress to aid in wound healing. R27's skin care plan states, Air Mattress settings are based on weight. Set air mattress at 130 pounds. R27's signed monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R27 has a stage 3 pressure injury on his right hip. A 6/24/22 wound evaluation, completed by the wound doctor, states, Discussed nutrition and its impact on wound healing .plan of care discussed with facility staff. The facility's Registered Dietician (RD) on 8/24/22 at 11:57 AM noted that R27's weight on 6/22/22 was 121.8 lbs., but did not mention any weights since that time. R27 did not have a documented weight since 6/22/22. The facility was unable to provide any documentation as to whether R27 had been weighed since 6/22. On 9/8/22 at 2:38 PM, Surveyor interviewed DON B who stated he was unsure why R27 had not been weighed since 6/22/22 but given his risk of continued weight loss and his stage 3 pressure injury, he should be weighed weekly, at a minimum.

Based on observation, interview, and record review, the facility did not ensure adequate supervision or fall interventions were in place for residents who required increased supervision to prevent accidents/hazards from occurring for 3 of 5 sampled Residents (R9, R24, & R26). R9 did not have fall interventions in place. R9 fell out of bed on [DATE] requiring sutures. R24 is not adequately supervised to prevent him from wandering into other resident rooms. R26 did not receive adequate supervision with meals. R26 had a downgrade in meal texture however, R26's meal ticket was inaccurate. This is evidenced by: R9 was a long-term resident of the facility. R9 had the following diagnoses: [CONDITION(S)], other paralytic syndromes, dysphagia, weakness, volvulus, functional [CONDITION(S)], personal history of transient ischemic attach (TIA,) and cerebral infarction without residual deficits. R9's most recent MDS (Minimum Data Set) dated [DATE] documents the following: .bed mobility ,d+[DATE] (extensive assistance/2 persons physical assist), transfer ,d+[DATE] (total dependence/2 persons physical assist), locomotion on unit ,d+[DATE] (total dependence, one-person physical assist) .no falls since admission/entry or reentry . The facility's Policy and Procedure entitled Falls and Fall Risk, Managing dated ,d+[DATE] documents, in part: .1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls .5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . R9's Fall risk assessment dated [DATE] documents a score of 17 which indicates he is high risk. R9's EHR (Electronic Health Record) documents the following: Next Assessment Due: Fall Risk Assessment: 70 days overdue - [DATE]. R9's care plan documented the following: [DATE] Risk for falls secondary to weakness and MS; resident will not sustain any further falls; assist resident to and from destinations, has LAL mattress and will add bolsters to bed, observe for changes in level of consciousness, refer for therapy screen as needed, transfers with 2 assist and Hoyer [SIC] [DATE] SAFETY/FALLS: Actual/At Risk/and/or Potential for Complications with falls R/T (related to) current medical/physical status. Has meds (medications)/dx (diagnosis) that can/may affect fall risk; Will have reduced risk for falls with stated interventions through next review date, Will not be injured in falls though next review date; [DATE]: ensure resident is placed in center of bed with pillows placed for positioning and edge of bed definition, [DATE]: Bolsters on bed, Pillows for positioning, Call light positioned for easy access, Fall review per facility protocol, Reinforce need to use the call light to request assistance, Specialty- Chair [SIC] It is important to note that the facility's new intervention from the current fall on [DATE] is to ensure resident is placed in the center of the bed with pillows placed for positioning and edge of bed definition; pillows for positioning were supposed to be in place for R9 since [DATE]. R9's fall report documents the following: Incident description: Nursing Description: CNA (Certified Nursing Assistant) notified writer of resident being on the floor at 9:31 AM. Per CNA she stated that she found him on the floor prior to notifying writer. Resident was on floor, right side of his bed, positioned onto the front side of his body with his arms contracted in under him. Resident was also found with a pool of blood coming from his head. Resident Description: Resident was asked by staff including writer and EMS (Emergency Medical Services) how he fell out of bed, Resident stated I don't know. Resident was asked what he was doing prior to the fall by activities director and resident stated again, I don't know. Immediate Action Taken: Description: Writer called 911 at 9:35 AM and was able to obtain pulse and O2 (oxygen) levels which were 98% spo2 (oxygen saturation) and 98 for a pulse at 9:39 AM. Writer was unable to obtain a blood pressure due to position resident was in. Resident was lying on his front torso more so towards his right side with his arms contracted in towards his chest, making it difficult to access his arms for a blood pressure .Intervention: ensure resident is placed in center of bed with pillows placed for positioning and edge of bed definition. Level of PAINAD (Pain Assessment in Advanced Dementia Scale - ,d+[DATE]=mild pain, ,d+[DATE]=moderate pain, ,d+[DATE]=severe pain) . (R9's score) 10 .Mental Status: other - Resident was able to state his name and place of living but could not recall what happened leading up to the event. Resident was able to convey to staff including writer and EMS that he was aware that he fell out of bed. Once EMS was able to transfer and reposition resident onto sliding transfer board, they were able to make out where the blood was coming from which was a skin tear to the right temporal lobe where there was also a hematoma .Notes: [DATE] IDT (Interdisciplinary Team) met and discussed fall. Intervention: ensure resident is placed in center of bed with pillows placed for positioning and edge of bed definition [SIC] R9's ED (Emergency Department) report documents the following: .Chief Complaint: Head Injury and Fall .Laceration Location: right sided parietal scalp, Size: Length 2.5 and 1.5 cm .Sutures: Two sets of running sutures were placed . Is bed bound .He was in bed, and he ended up falling out of bed .unwitnessed fall .found on the ground during rounds .EMS report there may have been 250 cc of blood on the ground due to head laceration .denies headache or vision changes .Medical Decision Making .CT head and cervical spine showed no acute bleed or fracture. CXR (chest x-ray) and pelvic x-ray also negative for fracture. His labs were stable .He had no traumatic injury found on work up that required inpatient hospitalization and will discharge back to the nursing facility . [SIC] R9's progress notes document the following: [DATE] at 11:32 AM Activity Progress Note: No updates from .hospital as of yet. Family has been notified along with provider, ADON (Assistant Director of Nursing), DON (Director of Nursing). [SIC] On [DATE] at 3:12 PM Activity Progress Note: Resident returned back to facility at 1450 (2:50 PM) with no abnormal findings from diagnostic labs. Family updated; provider updated. Fall neuro check monitoring initiated. [SIC] On [DATE] at 7:49 PM Activity Progress Note: T: 97.4 (temperature) P:76 (pulse) R:19 (respirations) B/P: ,d+[DATE] (blood pressure) SpO2:96%; Resident returned from hospital around 1400 (2:00 PM) via ambulance. Residents discharge papers read that all scans and test were normal. Discharge also notes midline being placed which resident did not return with. He tolerated medications and bolus feeding well. Will continue to monitor. [SIC] On [DATE] at 7:47 AM Activity Progress Note: CNA informed writer at 0445 (4:45 AM) that resident had thick secretions in his mouth, and it appeared foamy. Resident was assessed right away, and writer began suctioning resident. Immediately after patient was suctioned, doctor . (on call) was contacted to notify of the patients change in condition as well as of the secretions in mouth. I was on the mobile phone with the provider when I entered residents' room and observed him unconscious. Writer immediately grabbed the emergency crash cart and called for help. CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called right away. Emergency services arrived and continued CPR. Resident was pronounced deceased at 0535 (5:35) AM. Family and DON were notified. Resident will be released to .funeral home. [SIC] On [DATE] at 1:00 PM, Surveyor interviewed AD (Activity Director) RR. Documentation showed that AD RR was present after R9 fell out of bed. Surveyor asked AD RR what he could explain about R9's fall? AD RR explained that a CNA came to the IDT's morning meeting stating that R9 had fallen; AD RR stated he could typically understand R9, so he went to the room to assist. AD RR went on to describe how R9 was lying on the floor with his arms underneath his chest, his head, right side of torso and right thigh resting on floor. On [DATE] at 1:13 PM, Surveyor interviewed Agency LPN (Licensed Practical Nurse) K. Surveyor asked LPN K if she could explain what she knew about R9's fall. LPN K stated, We were short CNAs that morning so we were discussing how we were going to split things up; we had 3 nurses for the building, 3 CNAs for the building, and only 2 back here for our four wings for that AM shift, a NOC (3rd shift) CNA stated that R9 and some others had refused to be changed, now that didn't make sense to me because that is very uncharacteristic of R9; I started medication pass on Pine wing, went back to Elm wing to administer a PRN (as needed) medication, when I went past R9's room, I waved to R9 and went back to finish medications; about 9:,d+[DATE]:30 AM a CNA overheard R9 yelling for help, she said she was passing breakfast trays at this time, so she went to the room and she found R9 on the floor and she yelled to me. I went to R9's room, I did not move him, I called 911 about 9:33 AM. Surveyor asked LPN K if there was an RN (Registered Nurse) that assessed R9 while he was on the floor? LPN K said no, another LPN was assisting her, and the DON was in and out of room assisting with directions of what needed to be done. Surveyor asked LPN K if she recalled how R9 was positioned when she saw him earlier in the morning when passing R9's room? LPN K said in just passing by he was upright in his bed. Surveyor asked LPN K if she saw the care planned pillows were in the bed or now on the floor that would've been used to position him in bed? LPN K replied just one pillow was in his bed. Surveyor asked LPN K if there were any pillows on the floor of R9's room? LPN K said no; LPN K further explained that once EMS arrived, they noted a skin tear to R9's head and hematoma, which is where blood was coming from. Surveyor asked LPN K if she spoke with anyone at the hospital regarding R9 returning to the facility? LPN K stated no, R9's paperwork documented his CT scan was negative, bloodwork was negative. Surveyor asked LPN K if neuro checks were started prior to R9 going to the ED? LPN K said no, they were started on 2nd shift upon his return. Surveyor asked LPN K if there's anything else that may be pertinent to know regarding this fall? LPN K stating when looking into care plans, he was supposed to have pillows for positioning; he had the bolsters on the mattress, but the bed height was high. Surveyor asked LPN K approximately how high? LPN K approximated about 3.,d+[DATE] feet off the ground. Surveyor asked LPN K if there was any education received after this fall? LPN K said verbal education to put bed lower once done with resident. It is important to note that the facility did not follow R9's care plan to have pillows in bed to position him. On [DATE] at 5:46 PM, Surveyor interviewed DON (Director of Nursing) B. Surveyor asked DON B if an RN should have assessed R9? DON B said yes, and it should be documented. Surveyor asked DON B if there were pillows in place to position R9 prior to fall? DON B said no, there was only the 1 pillow for his head, he was bleeding from his head, and we did apply ice. Surveyor asked DON B how many CNAs were present in the back of the facility for the four wings? DON B reviewed the schedule and the time clock punches and stated 2. Surveyor asked DON B what the new intervention was after R9's fall? DON B stated to have him centered in the bed with pillows to position him and define edge of bed. Surveyor asked DON B if they determined the root cause of R9's fall to be that he wasn't positioned well in bed? DON B stated, He couldn't move on his own, so it had to be. It is important to note that the facility did not follow R9's care plan to have pillows in bed to position him. On [DATE] at 6:24 PM, Surveyor interviewed DCE (Director of Clinical Education) SS. Surveyor asked DCE SS if there was any education provided to the staff following R9's fall? DCE SS stated not directly related to his fall. Example 2: The facility does not currently have a dietary manager. R26 was admitted on [DATE] and has diagnoses that include dysphagia following cerebral infarction. On [DATE], physician's orders were placed for R26 for a pureed texture diet as R26 had been pocketing food. Previous to [DATE], R26 had been on a mechanical soft diet. On [DATE] at 9:19 AM, Surveyor interviewed Cook D, who stated that resident meal cards are frequently incorrect. Surveyor then asked Cook D if there were any current meal cards that were incorrect. Cook D then stated yes, and pulled out the meal card for R26 which stated he was on a mechanical soft diet. Cook D then stated that she had to cross off mechanical soft every day and write puree. Cook D stated that the residents' meal cards are supposed to be updated by the dietary manager, but the facility has not had a dietary manager recently. Cook D also stated that she knew R26 was on a pureed diet because speech therapy passes diet texture physician's orders to the cooks via mailbox, but speech therapy does not change the dietary cards. When asked if non-dietary staff, including any new or agency CNAs (Certified Nursing Assistants) would know that R26 was on a pureed diet and not mechanical soft, Cook D responded, They wouldn't. On [DATE] at 10:20 AM, Surveyor interviewed Cook E while he was preparing the evening meal. Cook E stated he too, has to change R26's dietary card daily and pulled it out of a stack of dietary cards and showed Surveyor. The meal ticket read mechanical soft. Cook E stated he has to change the card right before meal. Cook E stated he was unsure how non-dietary staff would know if R26 was on any special type of diet. On [DATE] at 1:10 PM, Surveyor interviewed MD OO (Maintenance Director). MD OO stated that he has been working at the facility for 3 months and, due to his supervisory role, would often have to provide oversight to the kitchen due to the lack of a dietary manager. MD OO stated that on 3 or 4 occasions he has had to cook and plate the food for various meals. When asked how he knows what diet consistency a resident is supposed to follow, MD OO stated he follows the resident dietary cards. MD OO also stated that he does not get any mail or correspondence about resident diet textures or preferences. On [DATE] at 3:46 PM, Surveyor interviewed ST (Speech Therapist) PP, who has provided speech therapy services to the facility. ST PP stated that when a doctor makes an order for a new diet consistency, speech therapy will put that information in the mailbox of the cooks and then the dietary manager will update the resident's meal cards. R26 had not suffered any aspiration events and Surveyor observed R26 with the correct diet consistency on [DATE]. The facility was aware on [DATE] that R26's diet had been downgraded from mechanical soft to pureed but did not update R26's meal card and did not have a plan to prevent uneducated and non-dietary staff from serving R26 a non-pureed diet. Example 3: R24 was admitted on [DATE] with diagnoses that include vascular dementia without behavioral disturbance and metabolic [CONDITION(S)]. R24's admission MDS (Minimum Data Set) assessment as of [DATE] has not been completed. Unable to say what R24's cognition is or if he is able to understand others or if he is able to make himself understood. R24's Care Plan states in part: Focus. The resident is an elopement risk due/to as exhibited by cognitive impairment, impaired safety awareness, new admission and unfamiliar with surroundings, history of wandering, wandering into other resident's rooms. Date initiated: [DATE] .Goal: The resident will not leave the facility unattended through the review date .interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Date initiated [DATE].Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date initiated [DATE].Focus: Stop sign banners in place with resident's neighbors to reduce incidents of resident wandering into neighboring rooms. Date initiated [DATE]. Goal resident will have decreased incidents of wandering in neighboring rooms with stop sign banners in place . Interventions stop sign banners in place to reduce incidents of wandering into neighboring rooms. (No evidence that R24 is to be one on one based on his care plan or CNA (Certified Nursing Assistant) care plan/care guide for the unit provided to Surveyor on ,d+[DATE].) On [DATE] at 8:40 AM, Surveyor interviewed R8. R8 indicated the guy next door (R24) comes out into the hall and pees on the floor. R8 indicated to Surveyor that he hears the nurse every morning telling him (R24) not to pee on the floor. R8 indicated that this resident (R24) also wanders into rooms. Please note R8's quarterly MDS dated [DATE], indicates R8 has a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating R8 is cognitively intact. On [DATE] at 11:03 AM, Surveyor interviewed Agency LPN (Licensed Practical Nurse) L regarding the urine smell in the hall. LPN L indicated that R24 has urinated across the hall in the ladies room, then after he did that, he asked where the bathroom was and urinated in the bathroom also. On [DATE] at 11:05AM, Surveyor interviewed roommates R7 and R28 regarding R24. R28 indicated a couple days ago R24 was wandering around looking for his room, then came back and urinated on the floor, urinating on the floor a couple days ago. R28 indicated R24 comes into her room at least three times a day and it takes staff a while to get him out of the room. R28 indicated that R24 peed on the floor today. R7 indicated that R24 came into her room at 3:00 AM. R7 indicated she does not like R24 coming into her room. R7 stated she is afraid he will pee on her things. R7 indicated that R24 has come into her room and has peed on the floor and beds. R7 indicated a Velcro stop sign was placed across the door to keep R24 from entering her room but a CNA took it down. (No stop sign observed on R7 and R28's doorway at this time.) R7 feels the stop sign was helping, but a CNA took it off a couple days ago. R7 would like the stop sign to be put back up. Surveyor observed the stop sign folded and sitting on a chair in R7's room. On [DATE] at 11:02 AM, CNA Z brought R8 back in from smoking, which left the unit without a CNA at that time. Surveyor asked CNA Z who monitors or watches the hall while she's out with R8. CNA Z responded no one. During this time no one would have been on the hall to keep R24 from wandering on the unit or into other rooms. On [DATE] at 11:55 AM, R8 indicated to Surveyor that he does not want (R24) coming in his room to pee while he's sleeping. R8 indicated they need to move him (R24). (R7's room is across the hall from R24, and R8's room is next door to R24. R8 and R24 share a bathroom between their rooms.) On [DATE] at 3:45 PM, Surveyor spoke to SW (Social Worker) X regarding R24's wandering. SW X indicated she does not have a grievance or concern voiced by R7 or R28 related to R24 going into their room. On [DATE] at 4:15 PM, Surveyor interviewed CNA P regarding R24 urinating on the floor. CNA P indicated R24 gets up and walks across the hall and will pee on the floor and the bed. CNA P indicated when trying to redirect R24 he would sit on the bed. CNA P indicated that R24 peed in inappropriate areas three times in one day, indicating on the floor and a bed. CNA P indicated that R7 and R8 were hollering and cussing that he (R24) urinated on the floor. CNA P indicated she told DON B about this. On [DATE] at 10:55 AM, R7 indicated to Surveyor that R24 came into his room last night and threatened him. R24 was not observed as being one on one at this time. On [DATE] at 11:00 AM, Surveyor interviewed LPN L regarding R24. LPN L is the nurse for R7, R8, R24, and R28. LPN L indicated that R24 wandered into R8's room last night (,d+[DATE]) and that LPN L was called over from another hallway to assist. R24 was observed as not being one on one while speaking with LPN L. Surveyor also observed R7 has a stop sign banner up on her doorway. On [DATE] at 11:05 AM, Surveyor interviewed DON B. DON B indicated he was not aware of the incident with R8 on ,d+[DATE], but was aware of R24 threatening his old roommate, and the roommate was moved and they're doing one to one with R24. R24 was observed as not being one on one during this time. On [DATE] at 11:15 AM, Surveyor observed CNA Z assisting R24 back to bed after using the rest room. CNA Z then left to answer call lights on the unit. On [DATE] at 11:30 AM, Surveyor heard yelling in the hallway while in the library room. R7 and R28 were both hollering at R24 to leave their room. Surveyor went out to observe what was happening. Surveyor observed CNA Z, escorting R24 out of R7 and R28's room, due to R24 wandering into their room. R7 indicated that R24 did not touch anything in the room, but indicated he was trying to make a phone call. On [DATE] at 11:40 AM, Surveyor interviewed CNA Z regarding R24 and his wandering. CNA Z stated, nothing else for him to do. CNA Z indicated that R24 doesn't do anything but wander or watch TV. R24 was observed laying in his bed at this time with the TV on. R24 was not one on one with staff currently. On [DATE] at 12:15 PM, Surveyor interviewed LPN L regarding R24's brace. R24 was not on one to one with staff. On [DATE] at 12:20 PM Surveyor interviewed DON B related to R24's action with R26. DON B indicated they made R24 one to one on [DATE]. DON B indicated there is to be a CNA there to watch over him and should be occupying him. Surveyor asked if R24 was to be one to one, should he have been able to go into R7 and R8's room on ,d+[DATE]? DON B replied no. Surveyor informed DON B that R24 has been observed without a one to one with staff on ,d+[DATE] and ,d+[DATE]. DON B indicated he is to be one on one, and staff should not be leaving him. On [DATE] at 1:00 PM, Surveyor observed R24 lying in bed resting, and no staff were doing one on one with him. There is a chair in the room for staff to sit in while doing one to one, but no staff was observed in the room. On [DATE] at 4:40 PM, Surveyor observed a staff member sitting in a chair in R24's doorway. The facility failed to ensure R24 had adequate supervision to prevent wandering into other resident's rooms.

Based on observation, interview and record review the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety to prevent foodborne illness affecting 2 residents (R3 and R20) who were served running yolk eggs. Failure to ensure unpasteurized eggs were fully cooked placed R3 and R20 at risk for becoming infected by Salmonella and created a finding of Immediate Jeopardy (IJ) that started on [DATE]. INHA A (Interim Nursing Home Administrator), VPO G (Vice President of Operations), and RN LL (Registered Nurse) were informed of the Immediate Jeopardy on [DATE] at 2:46 PM. The Immediate Jeopardy was removed on [DATE], when the facility started to implement their removal plan. The deficient practice continues at a scope/severity of an F (potential for harm/widespread) as the facility continues to implement its removal plan and as evidenced, in part, by staff failure to use hairnets and masks in the kitchen, to wash hands/change gloves when indicated while cooking, to check temperatures of the dishwasher, to ensure the dishwasher had detergent, to ensure opened food was dated and not expired, to ensure a fan was not blowing across the steam table, and by the use of plastic dinnerware. This is evidenced by: According to the 2017 FDA Food Code: ,d+[DATE].13 Pasteurized Eggs, Substitute for Raw Shell Eggs for Certain Recipes. Raw or undercooked eggs that are used in certain dressings or sauces are particularly hazardous because the virulent organism Salmonella Enteritidis may be present in raw shell eggs. Pasteurized eggs provide an egg product that is free of pathogens and is a ready-to-eat food. The pasteurized product should be substituted in a recipe that requires raw or undercooked eggs. Highly susceptible population means PERSONS who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining FOOD at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [CONDITION(S)] center, hospital or nursing home, or nutritional or socialization services such as a senior center. ,d+[DATE].11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food. In a FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION: (B) Pasteurized EGGS or EGG PRODUCTS shall be substituted for raw EGGS in the preparation of . (2) A partially cooked animal FOOD such as lightly cooked FISH, rare MEAT, soft-cooked EGGS that are made from EGGS, and meringue; The CDC notes that Salmonella causes 1.2 million cases of illness each year in the United States and 450 deaths. According to Salmonella enteritidis Infection, A bacterium, Salmonella enteritidis, can be inside perfectly normal-appearing eggs, and if the eggs are eaten raw or undercooked, the bacterium can cause illness .A person infected with the Salmonella enteritidis bacterium usually has fever, abdominal cramps, and diarrhea beginning 12 to 72 hours after consuming a contaminated food or beverage. The illness usually lasts 4 to 7 days, and most persons recover without antibiotic treatment. However, the diarrhea can be severe, and the person may be ill enough to require hospitalization . The elderly, infants, and those with impaired immune systems may have a more severe illness. In these patients, the infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics. https://wonder.cdc.gov/wonder/prevguid/p 03/p 03.asp#:~:text=A%20person%20infected%20with%20the,persons%20recover%20without%20antibiotic%20treatment. Because of aging-related changes, older adults have an increased susceptibility to foodborne illness. According to the USDA's Food Safety A Need-to-Know Guide for Those At-Risk, Adults 65 and older are at a higher risk for hospitalization and death from foodborne illness. This increased risk of foodborne illness is because our organs and body systems go through changes as we age. These changes include: The gastrointestinal tract holds on to food for a longer period of time, allowing bacteria to grow. The liver and kidneys may not properly rid our bodies of foreign bacteria and toxins. The stomach may not produce enough acid. The acidity helps to reduce the number of bacteria in our intestinal tract. Without proper amounts of acid, there is an increased risk of bacterial growth. Underlying chronic conditions, such as diabetes and cancer, may also increase a person's risk of foodborne illness. https://www.foodsafety.gov/people-at-risk/older-adults#:~:text=Adults%20age%2065%20and%20older,time%2C%20allowing%20bacteria%20to%20grow. The facility policy Food Preparation and Service, undated, version 2.1 (H5MAPL0333) states in part . Food Preparation, Cooking and Holding Time/Temperatures .13. Unpasteurized eggs are cooked until all parts of the egg (yolk and whites) are completely firm . Food Service/Distribution .6.Gloves are worn when handling food directly and changed between tasks. 7. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. On [DATE] at 9:12 AM, During the initial tour of the kitchen Surveyor observed shelled eggs in the facility's walk-in refrigerator, in a box. Surveyor observed that there was no P mark on the eggs, which would indicate the eggs were pasteurized. Surveyor observed no indication on the box the eggs were pasteurized. The box was labeled Item# L3370, Shell eggs Grade AA, packed date [DATE]. On [DATE] at 7:23 AM, Surveyor pointed to the box of shelled eggs and asked Cook S if she uses those eggs. Cook S stated she sometimes uses them on the Cedar wing and for another resident. Cook S reports she could not think of their name until she would see the name in the tray line and would let writer know. Cook S then said to the Surveyor, To be honest, I thought we could do that. I was told that if the resident was able to make their own decisions, we could serve those. Surveyor asked Cook S the procedure of how they were cooked. Cook S said she sprays the pan, cracks the egg and cooks it. Surveyor asked Cook S how the residents like their eggs, Cook S replied sunny side up or over easy. Surveyor asked Cook S how frequently the eggs are made sunny side up; she replied she made them last week. Surveyor asked Cook S if she received any training on pasteurized versus non-pasteurized eggs. Cook S indicated she had not. Surveyor reviewed the order details of facility's food supplier from [DATE]-[DATE]. Surveyor noted an order for item number L3370 with a description of Egg shell on white Grade AA is the same item number observed on the box of eggs in the walk-in cooler that the cook identified as using for food preparation of over easy eggs. Date: [DATE] Item# L3370 1 CASE/15DOZ EGG SHL ON WHITE XLG GRD AA LOOSE PACK REF Date: [DATE] Item# L3370 1 CASE/15DOZ EGG SHL ON WHITE XLG GRD AA LOOSE PACK REF Date: [DATE] Item# L3370 1 CASE/15DOZ EGG SHL ON WHITE XLG GRD AA LOOSE PACK REF Date: [DATE] Item# L3370 1 CASE/15DOZ EGG SHL ON WHITE XLG GRD AA LOOSE PACK REF Date: [DATE] Item# L3370 1 CASE/15DOZ EGG SHL ON WHITE XLG GRD AA LOOSE PACK REF Date: [DATE] Item# L3370 1 CASE/15DOZ EGG SHL ON WHITE XLG GRD AA LOOSE PACK REF On [DATE] at 7:30 AM, Cook S reported the names of the two residents who received running yolk unpasteurized eggs as the residents names came across in the tray line. Cook S picked up the tray ticket and provided Surveyor both names of: R3 and R20 confirming both residents received sunny side up eggs last week. On [DATE] at 11:31 AM, Surveyor interviewed R20. R20 reports he loves eggs over easy because he loves to dip toast into it. R20 states he cannot remember when he last had one over easy because you don't get what you want when you write it down on the menus, they used to do it all the time. R20 reported to Surveyor he does not eat the scrambled because it is the powder stuff. R20 stated he does not like to eat breakfast anymore because it sits in the hall and it's too cold to eat. On [DATE] at 11:47AM, Surveyor interviewed R3. Surveyor asked R3 if he likes his eggs over easy or sunny side up, R3 replied yep. When Surveyor asked R3 when he last ate eggs that were over easy or sunny side up, R3 replied, Last week. When Surveyor asked R3 if the yolk was runny or liquid, R3 stated, yes. On [DATE] at 4:48 PM, Surveyor spoke to INHA A regarding the concern the facility served unpasteurized eggs to two residents R3 and R20. INHA A asked Surveyor the difference of the eggs. Surveyor educated the difference of pasteurized and unpasteurized eggs and the ability to use them if cooked completely. Surveyor asked INHA A for RD (Registered Dietician) information and was advised the facility will obtain the name of the RD. INHA A stated the position is vacant for the Dietary Manager and the facility has been without a Dietary Manager for a couple of weeks. On [DATE] at 11:49 AM, Surveyor interviewed RD X (Registered Dietician). Surveyor asked RD X if it is appropriate to serve unpasteurized eggs sunny side up or over easy, RD X replied, No. Surveyor asked RD X what she expected staff to do. RD X replied staff should cook the yolk not soft or runny. Surveyor asked RD X what the process staff should take, RD X replied to remove the item and prepare an egg to be cooked thoroughly, further discuss why it is risky and discuss cooking temperatures with staff. RD X stated she would also advise nursing staff if they saw a runny yolk egg that was not a pasteurized egg nursing should take it back to the kitchen. Serving unpasteurized eggs that were not fully cooked created the potential that residents could contract Salmonella and created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy (IJ). The IJ was removed, on [DATE], when the facility began implementing the following: 1. Ad Hoc Meeting QA meeting was held to educate the entire leadership team on our plan and follow up. Completed [DATE] 2. Dietary Cooks educated on the facility policy regarding using unpasteurized eggs, the new order guide that only allows the dietary staff to order pasteurized eggs, how to check the eggs if they are pasteurized, and what to do if the facility receives unpasteurized eggs. Completed [DATE] 3. Current residents at risk for potentially receiving undercooked eggs. The facilities policy and procedures were reviewed to ensure they are based upon current standards of practice. Completed [DATE] 4. Residents that received the undercooked/runny eggs have the potential to be affected: Two residents were identified with no adverse outcome; Education has been completed and it was determined that only one cook was serving residents undercooked eggs. All unpasteurized eggs have been removed from the facility and can no longer be order from the facility food vendor. Completed [DATE] 5. All education completed for all cooks in the facility. Any new cooks hired will have the education at orientation. Dietary Manager/Designee will educate on coming staff. Completed [DATE] 6. IDT revised the Preventing Foodborne Illness-Food Handling policy and procedure. All education completed for all cooks. 7. Unpasteurized eggs have been removed from the ordering guide per the food vendor. Dietary Manager/Designee [NAME] check each order that is delivered that the eggs are label pasteurized eggs on the carton. Any unpasteurized eggs received will be immediately discard. INHA will conduct random audits weekly for four weeks upon food delivery to ensure the facility is not receiving unpasteurized eggs. Audits will be taken to QAPI to review for any concerns addressed immediately and to discuss if audits need to continue. Completion date [DATE]. The deficient practice continues at a severity/scope of an F (potential for harm/widespread) as evidenced by: INFECTION CONTROL: On [DATE] at 12:28 PM, Surveyor observed CNA Z (Certified Nursing Assistant) to enter the kitchen without performing hand hygiene or wearing a hairnet. On [DATE] at 7:23 AM, Surveyor observed breakfast tray line with Cook S. Cook S left the tray line with her gloves on touching various items within the kitchen. On return to the tray line Cook S did remove her gloves or wash her hands. On [DATE] at 11:34 AM, Surveyor observed DA V (Dietary Aide) with his mask under his chin. Surveyor asked DA V how his mask should be worn, DA V replied on his nose and that he has difficulty breathing with the mask on. On [DATE] at 11:45 AM, Surveyor observed DA T with her mask under nose and asked how her mask should be worn, DA T replied No, it's supposed to be on my nose. On [DATE] at 11:45 AM, Surveyor observed DA T during tray line and was asked by Cook S to take temperatures of the desserts. DA T obtained a thermometer and took temperatures, removed her gloves by curling them in her hand and obtaining another pair of gloves, no hand hygiene performed. After the tray delivery cart was full, DA T delivered the cart to the unit with the same gloves on and returned to the kitchen. Surveyor asked DA T if she has changed her gloves or washed her hands. DA T replied No and washed her hands. On [DATE] at 12:56 PM, Surveyor asked DA T to locate the ice machine. DA T opened the ice machine cover and found a covering of brown spotted substances throughout the cover. Surveyor asked DA T if the machine appears clean and the maintenance schedule. DA T replied that she didn't know what that was, and she does not know the cleaning schedules and that someone comes to clean it. PERSONAL ITEMS: On [DATE] at 12:45 PM, Surveyor observed a personal backpack on a shelf with clean dessert dishes below. The backpack has cords coming out and plugged into an outlet above the clean silverware cart. Surveyor asked DA T if a personal backpack should be on a clean kitchen utility rack. DA T replied, No. WET STACKING: On [DATE] at 9:21AM, During the initial tour with Cook S, Surveyor observed wet substance in a 3L container upside down stacked on top of another alike container. Surveyor asked Cook S what the substance was inside the top container. Cook S pulled the container down from the clean utility rack and touched it. Cook S replied, I don't know what that is, maybe it wasn't cleaned well enough. Surveyor asked Cook S if drying could occur with a wet substance tightly packed inside of another alike size container, she replied, I don't think it can. DISHWASHING: On [DATE] at 9:21 AM, During initial tour with Cook S, Surveyor observed the dishwasher spraying out approximately 4 feet of water and an alarm sounding. Surveyor asked Cook S if the dishwasher normally sprays out that far, she replied she didn't know anything about it. Surveyor asked DA V what the alarm was for. DA V reports it goes off all the time. Surveyor asked to read the reason for the alarm. DA V replied, he did not know. Surveyor asked DA V if this was reported, he replied he has informed DOM W (Director of Marketing). On [DATE] at 1:01 PM, Surveyor asked DA V to demonstrate temperature checks on the dishwasher. DA V replied, I don't have time, I am sorry, I am the only one today. On [DATE] at 11:20 AM, Surveyor asked Cook U if he has had any dishwasher training and identified any alarms, he reported, Yes, I talk to DOM W a thousand times every day until I bang my head against the wall. On [DATE] at 1:33 PM, Surveyor asked INHA A and VPO G to come to the kitchen for observations. Surveyor asked INHA A if there should be an alarm on the dishwasher, she replied no. Surveyor asked INHA A if the staff should be wearing an apron, she replied yes. On [DATE] at 4:20 PM, Surveyor asked to come to INHA A's office for the dishwasher service technician staff present. The dishwasher service technician reports he looked at the dishwashing machine and that it is limed up; deliming the machine must be done at least monthly. Surveyor asked dishwasher service technician regarding the alarms going off, dishwasher service technician reported because the machine is out of detergent and that he has demonstrated to Cook U how to add detergent. TEMPERATURES/DOCUMENTATION: On [DATE] at 12:49 PM, Surveyor provided temperature logs on the freezer to Cook S. Surveyor asked Cook S why the boxes from the past few days on the log were not filled out. Cook S replied, I didn't think you would notice. On [DATE] at 1:33 PM, Surveyor provided temperature logs of the freezer and the food to INHA A. Surveyor asked INHA A when the logs should be filled out, INHA A replied on the same day. Surveyor asked INHA A if the logs should always have the same temperatures every day, she replied No. On [DATE] at 5:03 PM, Surveyor observing dinner tray line and asked AD E (Activities Director) if the food had temperatures taking prior to serving. AD E replied he thought Cook S checked everything before she left, we don't normally check. Note: Surveyor observed temperature logbook and no temperatures were documented for dinner meal. SCOOPS: On [DATE] at 9:21 AM, During initial tour with Cook S, Surveyor asked Cook S what was inside the container located on the prep table and what the product of the container was. Cook S reports it is thickener and that is a scoop inside. Surveyor asked Cook S if there should be a label of identification and date, she replied yes and stated, There probably should not be a scoop in there either. Surveyor asked Cook S about the dry cereal for identification and what was the product inside the container. Cook S replied, It was Froot Loops. I will label, and I will take out the scoop. On [DATE] at 8:09 AM, Surveyor asked INHA A what was inside the container of the thickener, she replied it was a scoop and shouldn't be in there. FAN: On [DATE] at 5:18 PM, Surveyor observed dinner tray line with AD E cooking. Surveyor observed the floor fan on pointing air in the direction of the tray line. Surveyor observed a paper tray card blow into the steam table onto the meatballs. AD E looked at Surveyor and stated, That's not good. On [DATE] at 8:09 AM, Surveyor observed breakfast tray line with INHA A. Surveyor asked INHA A the appearance of the fan that is sitting on the floor. INHA A reports the fan is dirty and should not be in here. DINNERWARE: On [DATE] at 11:47 AM, Surveyor observing lunch tray line. Surveyor asked Cook S how the food stays warm. Cook S replied, the metal plate warmer is broke and I have asked maintenance to look at it. Surveyor asked Cook S if the dinner plate warmer worked, she replied, It's okay. On [DATE] at 12:12 PM, Surveyor observed lunch tray line. Surveyor asked DA V if he was placing plastic disposable spoons on the trays. DA V replied yes, because they do not have enough spoons for all the residents, and they have informed DOM W. On [DATE] at 12:16 PM, Surveyor asked Cook S the reasoning for using lipped plates and portioned plates. Cook S replied because they don't have enough dinner plates for all the residents and have informed DOM W. On [DATE] at 8:09 AM, Surveyor observed breakfast tray line. Surveyor demonstrated to INHA A disposable spoons being used in the tray line. When Surveyor asked INHA A if she was aware of the shortage of the spoons for the residents, she replied she did not know and would order some. DA T stated to INHA A DOM W was previously informed. On [DATE] at 8:50 AM, Surveyor observed breakfast tray line. RN LL was observed asking where more plates are kept. Note: There were no DAs or cooks scheduled at this time. Surveyor informed RN LL of observations with lack of regular plates and dietary staff using lipped or portion plates due to lack of regular plates. Surveyor asked RN LL if it is appropriate to use lipped plates or portioned plates when residents do not require specialized dishes. RN LL replied, the residents should have regular plates. OUTDATED FOOD: On [DATE] at 9:21 AM, Surveyor asked Cook S while pointing to the large 3-gallon container on the shelf with white substance to identify, date and if it is covered. Cook S reports I just poured that yesterday, it is flour. I will date it and our covers don't fit well on these containers. During the tour of the dry storage room with Cook S, Surveyor asked what the substances were on the floor under the utility racks. Cook S replied they are spilled brown substance and a peanut butter individual cup. Surveyor provided to Cook S 2 bags of hoagie buns from the bread rack. Surveyor asked Cook S what the green substance was in both bags, she replied that it was mold, and we don't get our bread fresh anymore, it's frozen. Surveyor asked Cook S the process of how items are handled once they come from the vendor. Cook S reports she usually puts some away. Surveyor asked Cook S how the dating system works for receiving product. Cook S reports items are dated when they arrive, when opened and when they are to use them by. Surveyor asked Cook S if the country dry sausage 6-pound can should be dated, she said yes. Note: 6 cans are dated received ,d+[DATE], 1 is not dated. Surveyor asked Cook S if the brownie mix should be dated, she replied, yes. Note: 4 total brownie mix boxes, one box is opened and not dated, 3 unopened boxes are not dated. Surveyor asked Cook S if the yellow cake mix boxes should be dated, she replied yes. Note: 5 yellow cake mix boxes are not dated. Surveyor asked Cook S if the 25-pound bag of flour is dated, she replied no. Surveyor asked Cook S to read the date of the flour, she replied manufacturer expiration [DATE]. Note: Flour is expired. Surveyor asked Cook S the 5-gallon container of breadcrumbs of the expiration date, she reports [DATE]. Surveyor asked if the breadcrumbs were outdated, she replied yes. Note: the cover was off the container of breadcrumbs and is expired. Surveyor went to reach in cooler with Cook S. Surveyor asked Cook S what was in a 5-gallon bucket, she replied Chicken base dated ,d+[DATE]. Surveyor asked Cook S to describe the appearance. She replied it is crusted on the top and is probably bad. Surveyor asked Cook S to identify the bowl on the top shelf. She replied a tomato soup bowl with a cover that has spilled down the side with a cracked lid, the date is ,d+[DATE]. Cook S removed tomato soup. Surveyor also observed: Applesauce, opened date ,d+[DATE], use by date ,d+[DATE] Pasta salad individual dated ,d+[DATE] Dressing of unknown substance, dated [DATE] good for 3 days Whipped cream squeeze, no date, has a loose baggie on the opened end Cottage Cheese 5 pounds, opened date ,d+[DATE] Fruit juice for puree, dated ,d+[DATE], use by ,d+[DATE] Folgers coffee opened and crusted in bag, no date, removed by Cook S Initial tour continued into the walk-in freezer with Cook S. Cook S reports the freezer was broke yesterday and was fixed, she was not aware how long it was broke, maybe a few hours. Note: freezer temperature log does not have documentation for yesterday. Note: the internal thermometer does not have a glass cover and the needle is crystalized. The freezer was covered with crystallization with frozen water droplets on the ceiling and 4 inches of ice mounded up near the door frame and along the metal shelving. Cook S scratched off the thermometer to move the ice to read it. Cook S scratched off freezer items to read labels. Surveyor asked Cook S if the thermometer is reading correctly, she replied she did not think so. Surveyor observed the following items: Baker boy pastry, use by date [DATE] Mighty Shake Vanilla, low sugar, not dated, suggested manufacturer use by date [DATE] x6 items Mighty Shake Strawberry, not dated, suggested manufacturer use by date [DATE], unopened case Surveyor went into the walk-in cooler with Cook S during initial tour. Surveyor asked Cook S to identify the items on the racks in the trays. Cook S replied, the desserts of pears, pudding with whipped cream and a full sheet of cake. Cook S reports unable to locate dates. Surveyor asked Cook S if the items should be dated, she replied yes. Surveyor asked Cook S to identify the 5-pound bags in the cooler. Cook S was not able to identify the 4 bags of a liquid brown substance and stated, I would not eat this. Note: no identification of the item, no dates. Surveyor asked Cook S the date of the cooked noodles, she replied ,d+[DATE] with a use by ,d+[DATE]. Surveyor asked Cook S if the noodles are outdated, she replied yes. Surveyor asked Cook S the use of the 6 gray tubs that contained 3 juices, milk, thickener. Cook S reports each wing will get a tub during meals for the beverages. Surveyor asked Cook S if the pitchers should be dated, she replied yes. Note: Pitchers were noted to be topped off after meals and placed back into the cooler. Surveyor asked Cook S to open the BUN juice machine. Surveyor asked Cook S for the dates, she reports I know one was just changed yesterday. Note: dates were not found on the opened juice containers in the BUN machine. Cross Reference: F801, F802, and F804

Based on interview and record review, the facility did not immediately notify and consult with the resident's physician when a significant change in the resident's physical, mental, or psychosocial status occurred for 3 residents (R118, R45 and R46) of a total sample of 21 residents reviewed. On [DATE] R118 had two (2) seizures with subsequent falls. The first [CONDITION(S)]/fall occurred at 7:30 AM. The facility did not notify R118's Physician. R118's second [CONDITION(S)] occurred at approximately 3:00 PM (during shift change). During R118's second [CONDITION(S)]/fall, DOT OO was walking down the hall when he observed R118 falling forward right before hitting the floor. DOT OO reported to Surveyor that no staff were with R118 at the time of his [CONDITION(S)]/fall. Facility staff moved R118 and never consulted with his Physician. When R118 was sent to the ED (Emergency Department) approximately 2 hours later, he was diagnosed with life-threatening injuries including: [NAME] I and II (two facial fractures), SAH (Subarachnoid Hemorrhage), and C7 fracture (7th cervical spinal vertebra). R118 passed away at the hospital on [DATE]. The facility failed to notify R118's Physician of two falls/seizures on [DATE]. The second [CONDITION(S)]/fall resulted in R118's death two (2) days later. R46 had a weight loss in [DATE] of 6.1% and a weight gain in June of 6.39%. The facility did not consult with the physician about the weight changes. R45 had a [CONDITION(S)] event without a [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As evidenced by The facility's policy, Change in a Resident's Condition or Status, dated [DATE], indicates the following: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care,) Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; d. significant change in the resident's physical/emotional/mental condition e. need to alter the resident's medical treatment significantly g. need to transfer the resident to a hospital/treatment center 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: e. It is necessary to transfer the resident to a hospital/treatment center. Example 1 R118 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R118's Admission MDS (Minimum Data Set) dated [DATE] indicates R118 has a BIMS (Brief Interview of Mental Status) of a 5 out of 15, which indicates he is severely cognitively impaired. Section G indicates that R118 is independent for walking in the corridor, locomotion on the unit, supervision and 1 staff assist with transferring. (Note, R1 was independent with transfers at the time of his seizures/falls.) R118's Comprehensive Care Plan indicates the following focus area: (Date Initiated: [DATE], Date Revised: [DATE]) R118 is at risk/has potential for falls, accidents and incidents r/t (related to deconditioning, generalized weakness, seizures. Resident is able to place self on the floor safely and is able to get off floor safely, however this does increase risk of falls. Goals: Injuries will be minimized through review date. Interventions: Update MD PRN (Medical Doctor as needed). ([DATE]) Follow therapy recommendations for transfers and mobility. On [DATE] R118 had two (2) seizures with subsequent falls. (Note, this is a late entry for a fall that occurred on [DATE] at 7:30 AM.) On [DATE] at 11:21 PM, R118's Progress Notes indicates the following: R118 observed by staff in hallway conversating with another resident when he leaned back and hit his upper back/shoulder area against the wall. Resident then slightly leaned forward and went onto the floor on his butt. When staff member got closer to resident, he was actively having a [CONDITION(S)]. Seizing lasted about 3 minutes, then another 3 minutes in the post-ictal stage, prn (as needed) [MEDICATION(S)] was administered. Resident was agitated after [CONDITION(S)] and repeating tour. hospice updated and APOAHC (Activated Power of Attorney for healthcare). Note, the physician was not notified regarding this [CONDITION(S)]. The Fall Report documents the following: Date: [DATE] at 7:30 AM - Same description as above Immediate Action Taken: hospice updated and came to see resident (Note, the hospice nurse did not arrive until R118 was being sent out nearly 2 hours after the 2nd fall at approximately 5:00 PM.) Resident Taken to Hospital: No Level of Pain: 0 Mental Status: Oriented to person Level of Consciousness: Alert Mobility: Ambulatory without assistance Predisposing Environmental Factors: None Predisposing Situation Factors: Ambulating without assist Witness (and writer): No longer employed at facility Agencies/People Notified: Hospice [DATE] at 7:30 AM, Family Member (APOAHC) [DATE] at 11:30 PM (Note, this is a late entry for a fall that occurred on [DATE] around 3:00 PM.) On [DATE] at 6:28 PM, R118's Progress Note indicates the following: Found resident face down on the floor and had [CONDITION(S)] in hallway near nurses station. [CONDITION(S)] lasted for 5 mins (minutes)/assisted R118 to lying position on his side. Resident was bleeding from nose, face, nose swollen and bruises on face. Called hospice, notified on unable to stop bleeding and need of resident to send to hospital/will send nurse ASAP (as soon as possible) to do evaluation for resident per hospice triage nurse. Called resident's APOAHC (Activated Power of Attorney for Health Care), APOAHC said resident's family member is coming to see resident and hospice will come an evaluate resident and do not want resident to send to hospital for evaluation. Res (resident) was bleeding from face, combative with staffs [sic], refusing to do vitals, assessments or take any meds (medication). Received call back from APOAHC at 4:45 PM and APOAHC stated that she wants the resident sent to the hospital for evaluation after a second family member was in the building (family member sent pictures to APOAHC). Called 911 send resident to hospital for evaluation. Hospice nurse was at facility when 911 paramedic took resident to hospital/will update APOAHC per hospice nurse. DON (Director of Nursing) was with writer when res was found on the floor and paramedic took resident to hospital for evaluation. Note, the physician was not notified regarding the second [CONDITION(S)]. R118's hospital reports documents the following: First documented care in emergency room : [DATE] 5:47 PM admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Steps to Achieve Goals: Provide supportive care, Pain management Goal review with: Patient and family Admitting Service: Palliative care Brief Summary: R118 is a 73 y/o (year old) man with hx (history) of dementia, [CONDITION(S)], presenting after having a [CONDITION(S)], fall [NAME] I and II (two facial fractures), SAH (Subarachnoid Hemorrhage), and C7 fracture (7th cervical spinal vertebra). C-collar overnight. No invasive cares. Sonorous respirations. Rescinded hospice for trauma eval (evaluation). Talk to trauma/palliative regarding any acute changes. Patient had interim discussions with trauma and palliative and ultimately was admitted to the palliative care service. Code Status: DNR/DNI (Do not Resuscitate/Do not intubate) .While in the ER he experienced 2 subsequent seizures and received 1 mg IV [MEDICATION(S)]. .Briefly R118 was admitted after a fall with facial fractures and found (SAH) (Subarachnoid Hemorrhage), with goals discussed to pursue comfort care. He died [DATE] and was pronounced deceased at 3:44 AM. On [DATE] at 10:49 AM, Surveyor spoke with VPO G (Vice President of Operations) and INHA A (Interim Nursing Home Administrator). Surveyor asked VPO G, regarding R118's first [CONDITION(S)]/fall on [DATE], if staff should have contacted R118's Physician. VPO G stated, yes. Surveyor asked VPO G, why is this important? VPO G responded, to ensure there are no active changes that would require different interventions. Surveyor asked VPO G if staff contacted R118's Physician on [DATE] after his second [CONDITION(S)]/fall with injuries. VPO G stated the facility contacted hospice, however, there is no evidence that the facility or hospice contacted the Physician. R118 remained at the facility with life-threatening injuries for nearly 2 hours prior to being transferred to the ED. Surveyor asked VPO G should R118's Physician have been consulted. VPO G stated, yes. Surveyor asked VPO G why is it important to contact the Physician. VPO G stated once the Physician is notified staff should follow the Physician's instructions about what to do next. Surveyor asked VPO G how often R118 had seizures. VPO G stated, [DATE] is the last [CONDITION(S)] we witnessed and documented. Surveyor asked VPO G, did the facility provide education to staff following R118's seizures and falls. VPO G stated, yes, we had fall education and she believe there are several educations that stem from this. VPO G stated she will have to look at the education sheets and give that information to Surveyor. Note, no additional information was provided to Surveyor. The facility failed to notify R118's Physician of two falls/seizures on [DATE]. The second [CONDITION(S)]/fall resulted in R118's death two (2) days later. Example 2 Facility policy titled Weight and Hydration Management Practice Guidelines, revision date ,d+[DATE] states in part .2. Weigh all residents upon admission and readmission, and then monthly or as indicated by physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are reweighed within 24 hours. Weight variance include and require reweight: a. Weight change of 5 lbs (pounds). b. Weight change of 3 lbs. if weight is less than 100lbs .Significant Weight Loss: d. 5% in one month (30 days) .8. Residents identified as a significant weight loss with have a SBAR (Situation, Background, Assessment, and Recommendation) completed and physician and family will be notified. R46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R46 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], R46 weighed 203.4 lbs. On [DATE], the resident weighed 191 pounds which is a 6.10 % loss. Facility staff did not reweigh R46, and there is no documentation that the physician or family was updated. On [DATE], the resident weighed 191 lbs. On [DATE], the resident weighed 203.2 pounds which is a 6.39 % gain. Facility staff did not reweigh R46, and there is no documentation that the physician or family was updated. The facility did not have any documentation that R46 was assessed for potential worsening CHF. On [DATE] at 10:40 AM Surveyor interviewed IDON B (Interim Director of Nursing). Surveyor asked IDON B what her expectations was for notifying the physician regarding weight loss or weight gain, IDON B stated that the physician and dietician should be notified if there is a 5% weight loss. Surveyor asked IDON B if she would expect staff to notify the physician if a resident with CHF had weight gain, IDON B stated that staff should be notifying the physician with a 5 pound weight gain. Example 3 R45 was admitted to the facility on [DATE]. Most recent MDS (Minimal Data Set) with ARD (Assessment Reference Date) of [DATE] indicates R45's cognition is severely impaired with a BIMS (Brief Interview of Mental Status) score of 1 out of 15. R45 has the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R45 has an activated POA (Power of Attorney). R45's Progress Note on [DATE] at 10:09 PM, written by LPN BB (Licensed Practical Nurse) state: Resident had a [CONDITION(S)] this PM. Resident was lowered to the floor by the CNA (Certified Nursing Assistant). Writer and CNA placed resident on bed. Resident is resting peacefully. No noted injury. Message left for POA and Provider. Note: Surveyor does not find any documentation confirming the POA and Provider have received the message and any revision of care. This is the only note in the electronic medical record pertaining to this event. On [DATE] at 4:20 PM, Surveyor interviewed CNA DD. Surveyor asked CNA DD if she was aware of R45 having a [CONDITION(S)], she replied yes, today and before today. Surveyor asked CNA DD if there was any training after the [CONDITION(S)] of what to do if there is a [CONDITION(S)], she replied, no, I know it has happened before with R45 and we talk about it. Surveyor asked CNA DD if anything has been added to the care plan for seizures, she then pulled out a piece of paper from her pocket and replied no, there is nothing there in the Kardex. On [DATE] at 4:35 PM, Surveyor interviewed LPN CC. Surveyor asked LPN CC, if you had a resident that has a [CONDITION(S)] what would you do, she replied, to keep them safe, time it, if it was not stopping to tell someone else like a Nurse Practitioner or Doctor. Surveyor asked LPN CC how she would notify the Doctor, she replied, on the phone. Surveyor asked LPN CC if she should get a nurse to do an assessment, she replied, yes, definitely. On [DATE] at 4:52 PM, Surveyor interviewed LPN BB. Surveyor asked LPN BB to describe R45's [CONDITION(S)] of what she did, she replied I called the on-call and left message with a physician and Nurse Practitioner, left on their voicemail. Surveyor asked LPN BB if she ever heard back from the Nurse Practitioner or physician, she replied, I was waiting, and it was close to the end of my shift and so I reported to the night nurse and let her know about the [CONDITION(S)] and awaiting a call back. Surveyor asked LPN BB if she has had any training of what to do if you do not hear back, she replied No. I tried to call the acting DON (Director of Nursing) at the time and the INHA (Interim Nursing Home Administrator) but couldn't get ahold of anyone. On [DATE] at 4:42 PM, Surveyor interviewed IDON B (Interim Director of Nursing). Surveyor asked IDON B what the expectation is if a resident is having a new [CONDITION(S)], she replied, document, call physician, call POA, and check the MAR (Medication Administration Record) for any medications, if an LPN is on duty, notify the RN (Registered Nurse). Surveyor asked IDON B what the standards of practice is for physician notification, she replied notify the physician for any change of condition, we put a note in the chart and on the 24-hour log.

Based on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice related to assessment and monitoring for change in condition for 3 residents (R117, R118, R45) reviewed for change of condition out of a total of 21 sampled residents. R117's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R118 was not assessed after a [CONDITION(S)] resulting in a fall. R118 had a second [CONDITION(S)] with signifcant injury. R45 had [CONDITION(S)] activity 11 days prior to admission to the facility, the facility failed to implement at risk interventions upon admission. R45 had [CONDITION(S)] activity in the facility, the facility failed to confirm notification resulting in failure for further treatment or diagnostic testing for standards of practice, to allow for clinical interventions and any care plan implementations. R45 had another [CONDITION(S)]. The Nurse Practitioner could not confirm a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: Example 1 R117 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R117's MDS (Minimum Data Set) was not completed. R117 is his own person. R117's hospital discharge orders, signed [DATE], including the following: [CONDITION(S)] (Continuous Positive Airway Pressure) release to patient: Immediate. Settings: As at home; Equipment: Home; [CONDITION(S)] Level: 11; Bleed in oxygen (LPM): 1L; Full mask, Size large; Use at night and when napping; Oxygen administration Mode: Nasal Cannula; Flow: (LPM only): 1; Titrate/Maintain O2 sat equal or great than 88%; Maintain O2 sat less than 94%; Titrate oxygen per facility policy, procedure, or guidelines. Order for DME (Durable Medical Equipment) - Complete as directed Patient transferring care to [provider name] for [CONDITION(S)] and will need all related [CONDITION(S)] supplies. Specify Length of Need: Lifetime Specify Type of Device: Auto [CONDITION(S)] Humidification: Heated Humidifier Supplies Needed: Filter (2 per mo.-month), nondisposable filter (1 per 6 mo.), water chamber (1 per 6 mo.), headgear (1 per 6 mo.) Mask Type: Mask of patient preference On [DATE] at 8:12 PM R117's progress notes document the following: Type: Change of Condition What is the resident exhibiting: C/O (complaining of) SOB (shortness of breath), visibly lethargic, spitting pink frothy sputum. Describe current condition and your assessment: Residents' [sic] daughter asked writer what needs to be done to send resident out. Resident seemed tired, spitting up pink frothy sputum, and belly breathing. Vital Signs: Temperature 97.9, Oxygen ,d+[DATE] (NC) (Nasal Cannula), Blood Pressure ,d+[DATE], Pulse: 79, Respirations: 16 Physician and Family notification and response: Daughter was present and requested resident to be sent out, on call Physician gave permission to send resident out. New orders or interventions put into place: No new orders at this time, DON (Director of Nursing) made aware of change in condition, resident sent to ER (emergency room ). R117 Hospital Stay: Admit [DATE] and discharged [DATE] R117's hospital information includes the following: Arrival Date/Time: [DATE] 8:35 PM Admission Type: Emergency Means of Arrival: Ambulance Admission Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Chief Complaint: This patient is a [AGE] year-old male with a history of CHF (Congestive Heart Failure), vocal cord paralysis, aortic valve replacement, [CONDITION(S)] (Chronic Obstructive Pulmonary Disease) and normally on 3L (liters) of oxygen by nasal cannula who presents to the emergency department with increased shortness of breath and generalize weakness. He lives at a local nursing home and staff is concerned that he see [sic] more lethargic today. EMS (Emergency Medical Services) was called, and patient was transported to the emergency department. Oxygen saturation was 100% on his normal 3L of oxygen by nasal cannula. He has a wet sounding cough. Patient otherwise is a poor historian but able to answer yes/no questions. He denies chest pain, abdominal pain. No nausea or vomiting. He has chronic leg swelling which is unchanged. No documented fevers. Lab results reviewed. On recheck, patient remains drowsy, somnolent. Family member is in the room here and states that this is a big change from his normal mentation. Oxygen saturation remains 100% on his normal 3L. However, he does have a lot of gurgling sounds and frequent coughing. Assessment and Plan Clinical Impressions: [CONDITION(S)], Dyspnea R117 was treated with IV [MEDICATION(S)] 80 mg (milligrams) and initiation of [CONDITION(S)]. Primary Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Acute on chronic HFrEF (Heart Failure with Reduced Ejection Fraction) 2. Acute on chronic hypoxic and hypercarbic resp (respiratory) failure 3. [CONDITION(S)] (Chronic Obstructive Pulmonary Disease) 4. Bronchiectasis 5. CAD ([CONDITION(S)]) 6. [CONDITION(S)] 7. s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] 8. CKD (chronic kidney disease) Stage IV (4) 9. Secondary [CONDITION(S)] 10. [CONDITION(S)] 11. DM type II (Diabetes Mellitus Type 2) R117's hospital report documents, in part, the following: .During a prior hospitalization he was on PAP therapy but while at the nursing home some preliminary reports state he has not been on such as initial reports from patient's family member state he has not been on [CONDITION(S)] or [CONDITION(S)]. There are reports that his previous home [CONDITION(S)] machine was 9 years old and covered in mold and thus unusable. (Note, at R117's discharge on [DATE], the hospital ordered the [CONDITION(S)] and all needed parts.) On [DATE] at 5:41 AM, R117's the facility's progress notes document the following: Resident admitted to hospital for Altered mental status, SOB (shortness of breath) and difficulty breathing. Resident put on [CONDITION(S)] (Bilevel Positive Airway Pressure). Hospital nurse states there will be testing done later today, further update will be available then. On [DATE], R117's Discharge Summary includes, in part, the following: Acute on Chronic Hypoxic Hypercarbic Respiratory Failure, [CONDITION(S)] and bronchiectasis: On 2L O2 (oxygen) via nasal cannula at baseline; required [CONDITION(S)] with up to 35% FiO2 (fraction of inspired oxygen). Based on his last admission and work up done, he qualified for a [CONDITION(S)] machine. However, unfortunately, he was not able to get one after his discharge from the SNF (Skilled Nursing Facility). His case was discussed again with his primary pulmonologist, and it was advised that he needs his [CONDITION(S)] machine to keep him stable at home and prevent frequent hospitalization . The hospital report documents the following: Writer met with R117's family member in patient's room to discuss discharge planning. Last hospitalization patient discharged to the facility and family member will not allow patient to return there due to the care he received. R117 did not return to the facility. The facility submitted a self-report to the State Agency with the following information: Date occurred: [DATE] Date discovered [DATE] Describe the incident: Significant medication error regarding the [sic] an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Describe the effect that the incident had on the affected person: none known (Note, R117 was hospitalized for 11 days.) Explain what steps the entity took upon learning of the incident to protect the affected person(s) and other from further potential misconduct: See attached summary Summary of Investigation: On [DATE], R117 was admitted to the facility after hospital stay. R117 was admitted with orders for a [CONDITION(S)] to be worn at night. R117's orders were transcribed and faxed over to the Pharmacy. The order for [CONDITION(S)] was omitted. R117's family member was informed of the omitted [CONDITION(S)] order. Resident's family member states she called the facility after resident was admitted and spoke with a nurse, but resident's family member was not able to identify who she spoke with. Family member stated she told the nurse that resident's personal [CONDITION(S)] is moldy and that we need to order one for R117. (Note, there was an admission order for a new [CONDITION(S)] and all needed parts.) Summary: The Regional Consultants were notified of the transcription error by R117's Case Manager. Investigation into error was immediately initiated and a 24-hour self-report to Wisconsin DHS (Department of Health Services) was submitted. Investigation revealed that R117 was admitted to the facility [DATE], after a hospital stay. R117's orders were transcribed and sent to pharmacy. The order for the [CONDITION(S)] was not transcribed and resident was without the [CONDITION(S)] for 6 days. R117's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During the investigation, it was discovered that the family's Admission Department was informed that R117's family member was going to deliver the [CONDITION(S)] to the facility for resident's use. R117 was monitored daily and was stable throughout his stay. (Note, R117 was not stable throughout his stay and was hospitalized for 11 days.) On [DATE], R117 had a change in his respiratory status and was sent to the hospital and admitted with respiratory failure. Conclusion: The resident was admitted to the facility after hospital stay with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The [CONDITION(S)] order was not transcribed d/t (due to) being omitted by both the nurse entering orders and 2nd nurse checking orders for accuracy. The nurse the family member spoke with was never identified. R117 was monitored during his stay and was stable from ,d+[DATE]-[DATE]. He had no c/o (complaint of) SOB (shortness of breath) and did not exhibit any outward s/s (signs and symptoms) of respiratory distress. On [DATE], when R117 was exhibiting s/s respiratory distress, the MD (Medical Doctor) was called, and orders received to send resident to the hospital. Resident's family member was present. The facility believes that although there was an omission in transcribing the [CONDITION(S)] order, there was no intent to cause harm to the resident. Steps take to prevent reoccurrence: Education was provided to two staff members involved (1 no longer is employed at the facility) and to DOM W (Director of Marketing) regarding checking orders thoroughly and informing nursing management of needed equipment/devices for new residents. On [DATE] at 1:47 PM, Surveyor spoke with VPO G (Vice President of Operations) regarding this self-report. Surveyor asked VPO G, do you expect staff to follow Physician orders. VPO G stated, Yes. Surveyor stated, R117 had an order a [CONDITION(S)] on admission that was not provided to him. Surveyor asked VPO G, would you expect staff to provide the ordered [CONDITION(S)]. VPO G stated, Yes. Surveyor asked VPO G, did R117 have a [CONDITION(S)] for the 7 days he was at the facility. VPO G stated, No. Surveyor reviewed training documentation for the two (2) staff members involved in this error, DOM W (Director of Marketing) and an RN (Registered Nurse) that is no longer employed at the facility. Surveyor asked VPO G, did you educate all staff. VPO G stated, there was a root cause analysis and R117's [CONDITION(S)] order was not transcribed. When our fairly new employee, DOM W, was told from somebody at the hospital that the resident would be coming with the [CONDITION(S)]. DOM W didn't put that in as something he needed. VPO G stated, We didn't order the ([CONDITION(S)]) and we didn't confirm. VPO G stated, DOM W didn't verify information for admission, and we didn't validate. VPO G stated, the family said he had one but it's molded, that's where the education started, with DME (Durable Medical Equipment) and new admissions. We educated the nursing staff (Note, there is no documentation of this). VPO G stated she does not know where the education sign in sheet is for this training. VPO G stated, those people that are no longer here hold the secrets to where things went. VPO G stated, it is her expectation that all elements of an investigation and training will be kept together and accessible. VPO G stated the facility looked at other residents with CPAPs and ensured they are in functioning order (Note, there is no documentation of this). VPO G stated, we also had the oxygen company come and look at all of our CPAPs (Note, there is no documentation of this). Surveyor asked VPO G, should R117 have had his [CONDITION(S)] while he was at the facility. VPO G stated, Yes. Note, there is no evidence that the facility educated all staff, interviewed other residents with CPAPs, conducted a sweep of the building for other residents with CPAPs to ensure they are in place and orders are being followed. Example 2 The facility did not follow DOT OO's (Director of Therapy) recommendation, dated [DATE], Supervision recommended when outside of room - tends to wander and is impulsive. R118 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] R118 had two (2) seizures with subsequent falls. The first [CONDITION(S)]/fall occurred at 7:30 AM. The facility did not obtain vitals, complete an assessment, nor monitor R118. R118's second [CONDITION(S)] occurred at approximately 3:00 PM (during shift change). During R118's second [CONDITION(S)]/fall, DOT OO was walking down the hall when he observed R118 falling forward right before hitting the floor. DOT OO reported to Surveyor that no staff were with R118 at the time of his [CONDITION(S)]/fall. Facility staff moved R118 and never consulted with his Physician. R118's APOAHC (Activated Power of Attorney for Health Care) initially told staff to not send R118 to the ED. Staff report to Surveyor they were unable to control R118's bleeding. Approximately two hours later, a family member at the facility took pictures of R118 and sent them to R118's APOAHC. The APOAHC then notified the facility to call 911 and send R118 to the ED (Emergency Department). R118 was admitted to the hospital where with life-threatening injuries including: [NAME] I and II (two facial fractures), SAH (Subarachnoid Hemorrhage), and C7 fracture (7th cervical spinal vertebra). R118 passed away at the hospital on [DATE]. R118 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R118's Admission MDS (Minimum Data Set) dated [DATE] indicates R118 has a BIMS (Brief Interview of Mental Status) of a 5 out of 15, which indicates he is severely cognitively impaired. Section G indicates that R118 is independent for walking in the corridor, locomotion on the unit, supervision and 1 staff assist with transferring. (Note, R1 was independent with transfers at the time of his seizures/falls.) On [DATE] a PTA (Physical Therapy Assistant) documents R118's transfer status as Independent and Assistive Device None. On [DATE] DOT OO (Director of Therapy) documented an Admission Functional Status Form that indicated R118's Transfer Status is Independent, Assistive Devices: None, and Special Instructions Supervision recommended when outside of room - tends to wander and is impulsive. Refuses FWW (four wheeled walker). (Note, the facility did not implement Therapy's safety recommendation.) R118's Comprehensive Care Plan indicates the following focus area: (Date Initiated: [DATE], Date Revised: [DATE]) R118 is at risk/has potential for falls, accidents and incidents r/t (related to deconditioning, generalized weakness, seizures. Resident is able to place self on the floor safely and is able to get off floor safely, however this does increase risk of falls. Goals: Injuries will be minimized through review date. Interventions: Update MD PRN (Medical Doctor as needed). ([DATE]) Follow therapy recommendations for transfers and mobility. Note, R118's last witnessed and documented [CONDITION(S)] is [DATE]. On [DATE] R118 had two (2) seizures with subsequent falls. (Note, this is a late entry for a fall that occurred on [DATE] at 7:30 AM.) On [DATE] at 11:21 PM, R118's Progress Notes indicates the following: R118 observed by staff in hallway conversating with another resident when he leaned back and hit his upper back/shoulder area against the wall. Resident then slightly leaned forward and went onto the floor on his butt. When staff member got closer to resident, he was actively having a [CONDITION(S)]. Seizing lasted about 3 minutes, then another 3 minutes in the post-ictal stage, prn (as needed) [MEDICATION(S)] was administered. Resident was agitated after [CONDITION(S)] and repeating tour. hospice updated and APOAHC (Activated Power of Attorney for Healthcare). Of note, the physician was not updated regarding the [CONDITION(S)] and there is no evidence the facility completed a thorough assessment or continued assessments for R118 post [CONDITION(S)]. Subsequently, R118 had another [CONDITION(S)] resulting in signifciant injury. The Fall Report documents the following: Date: [DATE] at 7:30 AM - Same description as above Immediate Action Taken: hospice updated and came to see resident (Note, the hospice nurse did not arrive until R118 was being sent out nearly 2 hours after the 2nd fall at approximately 5:00 PM.) Resident Taken to Hospital: No Level of Pain: 0 Mental Status: Oriented to person Level of Consciousness: Alert Mobility: Ambulatory without assistance Predisposing Environmental Factors: None Predisposing Situation Factors: Ambulating without assist Witness (and writer): No longer employed at facility Agencies/People Notified: Hospice [DATE] at 7:30 AM, Family Member (APOAHC) [DATE] at 11:30 PM (Note, this is a late entry for a fall that occurred on [DATE] around 3:00 PM.) On [DATE] at 6:28 PM, R118's Progress Note indicates the following: Found resident face down on the floor and had [CONDITION(S)] in hallway near nurses station. [CONDITION(S)] lasted for 5 mins (minutes)/assisted R118 to lying position on his side. Resident was bleeding from nose, face, nose swollen and bruises on face. Called hospice, notified on unable to stop bleeding and need of resident to send to hospital/will send nurse ASAP (as soon as possible) to do evaluation for resident per hospice triage nurse. Called resident's APOAHC (Activated Power of Attorney for Health Care), APOAHC said resident's family member is coming to see resident and hospice will come an evaluate resident and do not want resident to send to hospital for evaluation. Res (resident) was bleeding from face, combative with staffs [sic], refusing to do vitals, assessments or take any meds (medication). Received call back from APOAHC at 4:45 PM and APOAHC stated that she wants the resident sent to the hospital for evaluation after a second family member was in the building (family member sent pictures to APOAHC). Called 911 send resident to hospital for evaluation. Hospice nurse was at facility when 911 paramedic took resident to hospital/will update APOAHC per hospice nurse. DON (Director of Nursing) was with writer when res was found on the floor and paramedic took resident to hospital for evaluation. Of note, despite residents significant R118's hospital reports documents the following: First documented care in emergency room : [DATE] 5:47 PM admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Steps to Achieve Goals: Provide supportive care, Pain management Goal review with: Patient and family Admitting Service: Palliative care Brief Summary: R118 is a 73 y/o (year old) man with hx (history) of dementia, [CONDITION(S)], presenting after having a [CONDITION(S)], fall [NAME] I and II (two facial fractures), SAH (Subarachnoid Hemorrhage), and C7 fracture (7th cervical spinal vertebra). C-collar overnight. No invasive cares. Sonorous respirations. Rescinded hospice for trauma eval (evaluation). Talk to trauma/palliative regarding any acute changes. Patient had interim discussions with trauma and palliative and ultimately was admitted to the palliative care service. Code Status: DNR/DNI (Do not Resuscitate/Do not intubate) .While in the ER he experienced 2 subsequent seizures and received 1 mg IV [MEDICATION(S)]. .Briefly R118 was admitted after a fall with facial fractures and found (SAH) (Subarachnoid Hemorrhage), with goals discussed to pursue comfort care. He died [DATE] and was pronounced deceased at 3:44 AM. Surveyor reviewed the facility's self-report. On [DATE] at 6:09 PM, Surveyor spoke with DOM W (Director of Marketing). Surveyor asked DOM W to share with Surveyor what she witnessed the on [DATE] regarding R118. DOM W stated, we were walking from a meeting (later afternoon) a couple colleagues and a couple colleagues and myself saw R118 walking that way. R118 had fallen right onto his face and may have hit the door on the way down. DOM W stated, we immediately went to help him. DOT OO (Director of Therapy) and a CNA (Certified Nursing Assistant) and possibly an RN (Registered Nurse) jumped in to help. On [DATE] at 7:49 AM and 8:57 AM, Surveyor spoke with DOT OO (Director of Therapy). DOT OO stated, he was walking down the hall and heard a noise. DOT OO stated, he saw R118 starting to fall, and he was really close to the ground. DOT OO stated, people gathered to the area. DOT OO stated, R118 was face down with a lot of blood, a pool of blood essentially. DOT OO stated, R118 was basically breathing in blood, there was a gargling sound because his nose and mouth was completely into the ground. DOT OO stated he asked staff to call an ambulance. DOT OO stated, as that gargling action was worse it sounded like he was having a lot of trouble breathing, it was very gargled. DOT OO stated, since he was face down his neck was supported just enough to open his airway, R118 was still having a [CONDITION(S)] but a lot of blood came out of his mouth, and he was able to settle and come out of [CONDITION(S)]. DOT OO stated, we were keeping him positioned like that until the ambulance came. As we were waiting for 911, we were told the POA (Power of Attorney) wanted him to stay in the building. At that point he's in a resting position and started coming out of [CONDITION(S)] (reaching out and kicking trying to get himself up). This was after we were told he was not going out per his POA. Staff were cleaning the blood from his face with warm compresses and trying to stop the bleeding. Staff then transferred R118 to a wheelchair and took him back down to his room. While R118 was on the floor, CNA/Med Tech L (CNA) was wiping R118's face and getting him cleaned up, we were figuring out what the next steps were going to be. The previous DON was present and contacted the family. DOT OO stated the floor nurse may have been there too. DOT OO stated R118 was not sent out until his family member came to the facility and saw him and wanted him to be sent out. DOT OO stated, sometime earlier that same day, between 7:00 AM and 9:00 AM, R118 had a [CONDITION(S)] and ending up on the ground in a sitting position. DOT OO stated the second [CONDITION(S)]/fall was after 3:00 PM. DOT OO stated, R118 was somebody who could walk but was impulsive and would try to get up. DOT OO stated R118 was turned so he could breathe. Surveyor asked DOT OO regarding his assessment on [DATE]. DOT OO stated, Therapy gives recommendations and it's up to Nursing whether they accept (and implement) them. DOT OO stated, that R118 would throw the four wheeled walker that he used to have at the facility. DOT OO stated, R118 was not an assistive device kind of guy, and the walker was more of a detriment to him. DOT OO stated, no staff or other residents were with R118 at the time of his second [CONDITION(S)]/fall that DOT OO witnessed. On [DATE] at 8:40 AM, Surveyor left a message for the RN Q (Registered Nurse) who was on duty at the time of R118's fall. RN Q did not return Surveyor's call. On [DATE] at 8:41 AM, Surveyor spoke with CNA/MT L (CNA/Medication Technician). CNA L stated, she was in the nurses station getting report when she heard a loud thump. CNA L stated, she got up and ran out to the hall. CNA L stated, R118 was face down and somebody (staff) was by him (she cannot recall who). CNA L stated she does recall that DOT OO, DOM W and RN Q were by R118. CNA L stated, R118 was seizing, and she recalls telling DOT OO he needs to be on his side. CNA L stated, we could see blood and he was still in the middle of a [CONDITION(S)], but he was right in the doorway (just past Therapy and approaching the nurses station). CNA L stated, he fell in the middle of the double doors. Surveyor asked CNA L were there any residents around him at the time. CNA L stated, it was about 3:00 PM so everybody was out. Surveyor asked CNA L, is there any indication that another resident may have hurt or pushed him. CNA L stated, No, no. CNA L stated she has dealt with R118 having a [CONDITION(S)] previously. CNA L stated, R118 goes into fight or flight. CNA L stated, when R118 was coming out of the [CONDITION(S)] he was trying to hit us and when he went to get up, he couldn't get up by himself, so we got him a wheelchair. CNA L stated, R118 doesn't use a wheelchair he walks. CNA L added, we got wheelchair and convinced him to sit down. CNA L stated once he was in the chair staff needed to get him out of everybody's view. CNA L wheeled him into his room in the wheelchair. CNA L stated hospice and family were called immediately before he got up off floor. (Note, there was no Physician notification). CNA L stated, when family member came in to visit R118 and sent pictures to his APOAHC, at that point R118;s APOAHC stated to send him to the ED. CNA L stated, that was, two hours later. CNA L stated, by this time R118 was still bleeding from his nose and we couldn't get the bleeding to stop. CNA L stated, one of his eyes (cannot recall which) was swollen. Surveyor asked CNA L, how many people was R118 care planned to assist him when walking. CNA L stated, R118 was independent. CNA L stated, you could try to help R118, but he was set in his ways and wouldn't accept help. CNA L stated, he was care planned to be independent walking. That day there was staff walking with him. Had people with him that day, it was at shift change. CNA L stated, we did try to keep staff with him. (Note, per interview with DOT OO (above), R118 was walking independently at the time of his fall and no staff were with him.) On [DATE] at 10:49 AM, Surveyor spoke with VPO G (Vice President of Operations) and INHA A (Interim Nursing Home Administrator). Surveyor asked VPO G, was the Therapy recommendation Supervision recommended when outside of room - tends to wander and is impulsive. Refuses FWW (four wheeled walker). VPO G stated, They're just that, recommendations, some recommendations we get don't add up to care we can provide. VPO G stated, we discontinued R118's walker as it was more of a threat to him (per interview with multiple staff, R118 would throw his walker which was a safety risk.) Surveyor asked VPO G, regarding R118's first [CONDITION(S)]/fall on [DATE], did staff take vitals, complete an assessment and monitoring. VPO G stated, no, there is no documentation of vitals, an assessment, nor monitoring for the first [CONDITION(S)]/fall on [DATE]. VPO G stated, typically when somebody falls, we get vitals and complete an assessment however, we couldn't get vitals or do an assessment due to the resident not cooperating. Surveyor asked VPO G, is there documentation for the first [CONDITION(S)]/fall on [DATE] that R118 refused vitals or an assessment. VPO G stated, no, there is no documentation that R118 refused vitals, an assessment and monitoring for the first fall on [DATE]. Surveyor asked VPO G, if a resident refuses vitals, assessment, and monitoring would you expect this to be documented. VPO G stated, yes. Surveyor asked VPO G why is this important. VPO G stated, to ensure there are no active changes that would require different interventions. Surveyor asked VPO G, would you expect staff to obtain vitals, complete an assessment, and contact the Physician for R118. VPO G stated, yes. Surveyor asked VPO G, was there an SBAR (Situation, Background, Assessment, Recommendations) or any type of change in condition completed for R118's second fall on [DATE]. VPO G stated, an SBAR would not be done in a 911 emergency. VPO G stated, staff should have completed vitals, assessments, and notifications. VPO G stated once the Physician is notified staff should follow the Physician's instructions about what to do next. Surveyor asked VPO G, how often did R118 have seizures. VPO G stated, [DATE] is the last [CONDITION(S)] we witnessed and documented. Surveyor asked VPO G, did the facility provide education to staff following R118's seizures and falls. VPO G stated, yes, we had fall education and she believes there are several educations that stem from this. VPO G stated she will have to look at the education sheets and give that information to Surveyor. Note, no additional information was provided to Surveyor. In summary, the facility failed to do the following: 1. Follow DOT OO's recommendations to ensure R118's safety. 2. 1st [CONDITION(S)]/fall: Did not obtain vitals, complete and assessment, nor monitor R118. 3. 2nd [CONDITION(S)]/fall: Moved R118 and never consulted with the Physician, waited approximately 2 hours before transporting R118 to the Emergency Department when he had uncontrollable bleeding and life-threatening injuries. Example 3 R45 has the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R45 was admitted to hospital from an Adult Family Home on [DATE]. R45's (EHR) Electronic Health Record reports, sat hard into his chair to eat lunch, took one bite and let out a cry. He then became unresponsive in an unclear manner which was described as suspicious for possible [CONDITION(S)]. He had immediate pain in the hip and inability to bear weight. However, he was then reported to return to his normal cheerful demeanor, imaging revealed the presence of bilateral hip fractures . EEG (Electroencephalogram) was performed given concern for seizures and no focal and no definite epileptiform abnormalities were evident. On [DATE] R45 was then discharged from the hospital and admitted to the facility following hip surgery. R45 was admitted to the facility on [DATE] from a recent hospitalization from ,d+[DATE]-[DATE] for bilateral hip fractures. Most recent MDS (Minimal Data Set) with ARD (Assessment Reference Date) of [DATE] indicates R45's cognition is severely impaired with a BIMS (Brief Interview of Mental Status) score of 1 out of 15. R45's Functional Assessment indicates: Bed Mobility, transfer, dressing, toilet use, personal hygiene are 3 indicating extensive assistance. Bowel and bladder assessment indicate always incontinent. Fall assessment history indicated 2 falls since admission of no injury. R45 has an activated POA (Power of Attorney). R45's Care Plan in part states: Focus- Cognition: Alteration in cognition related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions- . Observe for a change in cognition- level of alertnes

Based on interview and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 2 of 3 sampled residents (R1 and R4). R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 developed facility acquired ulcerations to her left great toe (12/11/21) and right second toe. The facility was not completing daily diabetic foot checks, a nursing standard of practice, and was unaware of the open area to R1's right second toe. On 4/17/22, R1's Activated Power of Attorney for Healthcare (APOAHC) who is also an Registered Nurse (RN) came to visit her. R1's APOAHC was concerned regarding the dramatic change in R1's mentation and assessed what she believed to be [CONDITION(S)] and open areas to her bilateral feet. R1's APOAHC shared her concern with RN G (Registered Nurse), the agency nurse on duty. RN G, did not obtain a set of vitals, assess R1, complete an SBAR (Situation, Background, Assessment, Recommendation) for R1's change in condition, notify the Physician or assist with arrangements to transfer R1 to the ED (emergency department). As a result, R1's APOAHC transported R1 to the ED herself. As of 4/27/22, R1 remained hospitalized (10+ days) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] This is evidenced by: The facility policy, Change in a Resident's Condition or Status, revised May 2017, indicates in part, the following: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in the level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; g. need to transfer the resident to a hospital/treatment center; specific instructions to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA (Omnibus Budget Reconciliation Act) regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. According to American Medical Doctors Association - The Society for Post-Acute and Long-Term Care Medicine - Pressure Ulcers - Clinical Practice Guideline - http:// www.amda.com/ tools/ guideline.cfm#pressureulcer .to the extent feasible, caregivers should educate patients about daily foot care (e.g., washing, moisturizing), nail care, and about the importance of avoiding walking barefoot, avoiding foot trauma, and promptly telling a caregiver about foot pain or changes in the appearance of the feet . treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Risk Category: At-risk foot (patients who smoke; have vascular insufficiency, [CONDITION(S)], retinopathy, [CONDITION(S)], history of ulcers or amputations, structural deformities, infections, skin/nail abnormality; are on anticoagulation therapy; cannot see, feel, or reach their feet.) treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] · Refer for podiatric care at least annually and as needed for specific foot problems · Train caregivers to perform daily foot care and inspection · To the extent feasible, train patients to perform daily foot care and inspection . R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Skin assessment dated [DATE] indicates R1 does not have any skin integrity concerns. R1's MDS (Minimum Data Set) assessment dated [DATE] notes a BIMS (Brief Interview for Mental Status) score of 11/15 indicating R1 is moderately cognitively impaired. Section M (Skin), indicates R1 has no ulcers, wounds, or skin problems. R1's Comprehensive Care Plan includes in part: (Date Initiated: 10/9/21) At risk for complications with cognitive status r/t [related to] Alzheimer's and [CONDITION(S)]; Goal: Will make simple decisions regarding activities of daily living through next review date. Interventions: .Observe for a change in condition - level alertness, confusion, forgetfullness, reorient as needed, determine of able to reorient. Review changes with MD/NP (Medical Doctor/Nurse Practitioner). Skin Integrity: (Date Initiated: 10/9/21) At risk / and/or Potential for Complications with impaired skin integrity AND/OR pressure R/T [related to] Decreased mobility, incontinent of B/B [bowel/bladder]; 12/21.21 - left great toe diabetic wound; Interventions: Assist as needed to reposition Q2 [every 2 hours] in bed an chair and PRN [as needed]; Follow facility skin protocol; .Observe skin with AM/PM cares and with toileting for redness, rashes, open areas, pain, swelling and report to team leader, weekly skin check. Lotion to dry skin. Review skin problems with MD. Treatments as ordered; Pressure reduction cushion in in W/C [wheelchair]; Pressure reduction mattress on bed; Observe skin during cares and report alterations in skin integrity to the nurse. R1's Physician orders, signed 4/4/22, indicate the following: (Start Date: 2/17/22) Monitor LLE [left lower extremity] for signs/symptoms of infection/[CONDITION(S)] with noted [CONDITION(S)] on LLE. Update NP (Nurse Practitioner) if further symptoms present every shift for [CONDITION(S)]. It is important to note, the facility is not completing nor documenting daily diabetic foot checks for R1. Daily diabetic foot checks are a nursing standard of practice that could have led the facility to identify R1's skin integrity issues timely. On 4/17/22 at 2:30 PM, R1's Progress Notes indicates the following: Resident's family came, they were horrified of the condition there [sic] mother was in. Toes bilaterally presented with narcotic [sic] ) (necrotic) injuries and left leg has severe [CONDITION(S)]. Family stated they will not be bringing mother (R1) back. Resident was going to hospital left at 2:30 PM. It is important to note, the agency RN on duty did not obtain a set of vitals, assess R1, complete an SBAR (Situation, Background, Assessment, Recommendation) for R1's change in condition, notify the Physician, or assist with arrangements to transfer R1 to the ED (emergency department). This agency RN no longer works at the facility. On 4/17/22, R1's ED (emergency department) notes document the following: Patient is an [AGE] year-old female with history of dementia, diabetes mellitus, [CONDITION(S)] of the left great toe, and recurrent Cutis [urinary tract infections] who presents with a chief complaint of left lower extremity [CONDITION(S)]. Based on history provided primarily by patient's daughter, she went to visit her today and found her to be more confused than baseline. Patient's daughter states she had a normal conversation with her approximately 1 week ago but today she appeared to be agitated, presenting similarly to prior episodes where she has had underlying infection. Patient's daughter noted she had significant [CONDITION(S)] to her left calf. There has been no reported fevers, falls, diarrhea, vomiting from the care facility. Patient's daughter also expresses concern about patient's hygiene at her current care facility. She presented to the emergency department today for further workup. On arrival, patient frequently stating I'm scared, unable to provide any additional history. Based on chart review, patient was recently admitted in January where she was noted to have evidence of a left great toe [CONDITION(S)] as well as [CONDITION(S)] [CONDITION(S)] [urinary tract infection] and [CONDITION(S)] [[CONDITION(S)]-Resistant Staphylococcus Aureus] bacteremia. Physical Exam: .Skin: Warm and dry. Ulceration present to the left great toe and right 2nd toe. [CONDITION(S)] without purulence or induration to the left calf, warm to touch. Final Impression: Left lower extremity [CONDITION(S)], altered mental status, [CONDITION(S)] of the left great toe and right 2nd toe. Labs show elevation of CRP (C-Reactive Protein) [A high CRP test results can be a sign of acute inflammation. It may be due to serious infection, injury or chronic disease] and ESR (Erythrocyte Seimentation Rate) [An increased ESR ate may be due to an infection]. Procalcitonin is negative. [MEDICATION(S)] is normal. Patient with [CONDITION(S)] to left lower extremity. X-rays also concerning for possible [CONDITION(S)]. Given patient's concern for [CONDITION(S)] with history [CONDITION(S)] was given a dose of [MEDICATION(S)]. Patient with mental status changes concern for more systemic infection. Patient admitted to hospital for further workup and management. R1 was transferred to a different hospital with a Podiatry Unit. The second hospital documented the following: .Daughter noted [CONDITION(S)] of both legs L>R [left greater than right] when she went to visit her today. Pt [sic] [patient] also thought pt more confused and agitated and is not care for correctly at SNF [Skilled Nursing Facility]. Per daughter she last saw R1 on 4/3/22 and R1 was able to have conversation and had no redness. Today pt was agitated and screaming out intermittently. X-ray results: Right Foot: Impression: Intrac-articular fracture of the base of the proximal phalanx of the great toe, possibly acute 2. Near complete resorption of the distal phalanx of the second toe with surrounding soft tissue irregularity. ***These finings are concerning for [CONDITION(S)]. Left Foot: Indication: Left great toe lesion; Impression: Unchanged appearance of the distal phalanx of the great toe, with no definite new areas of erosion or periosteal reaction. It is important to note, the facility was unaware of any open area to R1's right toes/foot. In addition, the facility was not completing, nor documenting daily diabetic foot checks for R1. As of 4/27/22, the date of this complaint investigation, R1 remains hospitalized (10+ days) while continuing to receive IV (intravenous) [MEDICATION(S)] and oral antibiotics. On 4/27/22 at 12:38 PM, Surveyor spoke with RN C (Registered Nurse) who is the Wound Care Nurse. RN C is not WCC (Wound Care Certified). Surveyor asked RN C when is the last time she saw R1's toes. RN C stated she last saw R1's left foot/toes on 4/11/22 when she rounded with the physician. RN C stated R1's wound had no necrotic tissue and neither did her toes. Surveyor asked RN C were you aware of any open areas to R1's right foot/toes. RN C stated, No. Surveyor asked RN C, if staff note a new open area what should they do. RN C stated staff should alert the floor nurse. The floor nurse should complete an assessment and if RN C is in the building, staff notify her so she can complete an assessment. On 4/27/22 at approximately 12:50 PM and 3:05 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated that RN G (Registered Nurse) was terminated. DON B stated, RN G wrote about R1 having [CONDITION(S)]; however, she had no means to determine [CONDITION(S)]. DON B stated she told her to put it in quotes so it does not look like she's diagnosing. Surveyor asked DON B were daily diabetic foot checks completed and documented for R1. DON B stated, I could not find daily diabetic foot checks. Surveyor asked DON B should the facility have been completing daily diabetic foot checks for R1. DON B stated, Yes. Surveyor asked DON B, would you expect the facility to have been aware of open areas to R1's foot? DON B stated, yes. Surveyor asked DON B would you expect the facility to identify a change in condition DON B stated, yes. Survyeor asked DON B, when R1's APOAHC brought concerns regarding [CONDITION(S)] to RN G's attention, would you have expected her obtains vitals, complete an assessment/document an SBAR, notify the Physician, and assist with arrangement to transfer R1 to the ED. DON B stated, yes, RN G should have completed each of these steps. Example 2 R4's initial admission to the facility was on 1/31/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's BIMS (Brief Interview of Mental Status) Score on the Minimum Data Set completed 3/1/22 was 14, indicating R4 is cognitively intact. On 4/27/22, at 10:21 AM, Surveyor spoke with R4 regarding wound care for her right hip. R4 indicated she is supposed to have a daily dressing change on the PM shift, but stated, It doesn't always get done. R4 stated her dressing did not get changed last weekend. R4 acknowledged there have been times she has chosen not to have it done until the next day, but also stated, I know there are staffing struggles. I don't like new nurses who've never done my dressing before. There have been times when the nurse still hasn't come in to change it and it is after 9:30 (PM), so I sometimes say forget it. Surveyor reviewed R4's Treatment Administration Record (TAR) and Nurse's Notes. - In March 2022, according to the TAR, R4 did not receive wound treatment on four occasions (3/9, 3/18, 3/25, and 3/29) with no supporting documentation to indicate why it was not completed or with an update to the provider to inform of the missed treatment. - In April 2022 (through 4/26/22), according to the TAR, R4 did not receive wound treatment on five occasions (4/1, 4/5, 4/11, 4/12, 4/24) with no supporting documentation to indicate why it was not completed or with an update to the provider to inform of the missed treatment. On 4/27/22, at 1:30 PM, Surveyor spoke with RN D (Registered Nurse) and asked if R4 ever refused treatments. RN D indicated R4 never refused cares and stated, I wish they were all like her. Surveyor asked RN D what steps she would take if R4 did refuse or miss a scheduled treatment, and RN D stated she would document the reason and pass it on to the next shift to have it completed then. RN D stated she would also contact the provider if it was a big concern. On 4/27/22, at 1:46 PM, Surveyor spoke with DON B (Director of Nursing) regarding wound treatments and asked if she expects treatments to be completed as ordered. DON B stated, Yes. Surveyor asked if a treatment is not signed out as completed and there is a blank box on the TAR, is it assumed the treatment was not done? DON B replied, Yes. Surveyor asked if a resident refused a treatment or there was an extenuating circumstance, would DON B expect a nurse's note to explain, and she stated, Yes.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing of PIs, or prevent new PIs from developing for 1 of 3 Residents sampled for PIs (R5). - R5 developed a PI in the facility, which was not discovered until it was a stage 3. After discovery, the facility did not update the care plan until 18 days later. The facility did not follow wound care treatment as ordered and did not reposition R5 as often as would be indicated. This is evidenced by: The facility policy titled, Wound Care, from MED-PASS, Inc, last revised October 2010, which states, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The policy reads, in part . Preparation; 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. A. For example, the resident may have PRN (as needed) orders for pain medication to be administered prior to would [sic] care. The policy indicates the following should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment date (i.e., wound bed color, size, drainage, etc. obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. The policy reads as follows regarding reporting on wounds, 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice. R5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Admission MDS (Minimum Data Set) assessment indicates she had a BIMS (Brief Interview of Mental Status) Score of 13, indicating she was cognitively intact. R5's Admission MDS also indicated in Section M regarding skin, she was admitted to the facility at risk of developing PIs, but on admission did not have any unhealed PIs. R5's Care Plan for skin integrity which was initiated on 3/26/22 and revised on 4/25/22 reads: - Focus o Resident has actual impaired skin integrity r/t [related to]: decreased mobility, Diabetes, Pain - preventing active movement. - Goal o The Resident skin will remain intact and remain free of irritation, redness, blisters, discoloration, etc. through next review date. - Interventions/Tasks o Wound RN and wound MD as ordered (Date initiated 4/25/22) o Assist to reposition approximately q [every] 2-3 hours and prn (date initiated 3/26/22) o Complete Braden scale upon admission, weekly x4, quarterly, with SCOC [sudden change of condition] and prn (date initiated 3/26/22) o Lotion skin with cares (date initiated 3/26/22) o Weekly skin assessment (date initiated 3/26/22) o Pressure redistribution mattress (date initiated 3/26/22) o Monitor skin with all cares. Report any changes to nurse (date initiated 3/26/22) o Update MD PRN (date initiated 3/26/22) o Refer to RD PRN (date initiated 3/26/22) o Refer to therapy PRN (date initiated 3/26/22) On 4/7/22, the facility document Weekly Wound Assessment shows R5's PI on right buttock measured 1.2 cm x 0.9 cm x 0.1 cm and was documented as a Stage III. Other notes in the assessment indicate the wound is 100% granulation, no abnormalities to the wound edges, no exudate is indicated but serosanguinous [sic] is checked, no odor, physician has been notified, wound progress is stable, treatments that apply include turning and repositioning and wound treatment/application of dressing, no pain associated with the wound, and pain management is Tylenol as needed. Other comments indicate, Current treatment: Right buttocks, cleans with NS [Normal Saline], apply skin prep to peri-wound, cover with foam dressing, change every 3 days and PRN. This wound assessment is signed by RN C (Registered Nurse) on 4/19/22. *Note - R5's PI was discovered on 4/7/22 and there were no changes to her care plan or new care plan interventions initiated until 4/25/22, when wound RN and wound MD as ordered was added. On 4/11/22, an identical facility document of R5's Weekly Wound Assessment was completed with the only difference being the wound measurement date and onset date of treatment both reading 4/11/22 (not 4/7/22) and signed by RN C on 4/19/22. On 4/18/22, the facility document Weekly Wound Assessment indicates R5's PI on right buttock measured 1.08 cm x 1.10 cm x 0.1 cm and was documented as a Stage III. Other notes in the assessment indicate the wound is 100% granulation, no abnormalities to the wound edges, a moderate amount of exudate which was marked as Serous, no odor, stable, onset date of treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicates the treatment has changed in the past two weeks on 4/18/22. No pain associated with the wound, with Tylenol as needed for pain management. Other comments indicate, Current treatment Right & Left buttocks, cleans wound with saline, protect periwound with Skin Prep, Cover wound with Foam, Change MWF [Monday, Wednesday, Friday], Change PRN for soiling and/or saturation. Signed by RN C on 4/19/22. Surveyor requested wound clinic/wound physician documentation and was provided with partial documentation. The following was provided to Surveyor: 1. R5 Wound Evaluation Page 1 of 4 and 2 of 4 dated 4/18/22, Location: Left buttock; Wound ID: 7972. o Measurements: Length: 0.81 cm, Width: 0.55 cm, LxW: 0.45 cm2, Depth: 0.10 cm, Total: 0.29 cm2 o Observations: Depth [cm]: 0.10; Etiology: Trauma; Margin Detail: Attached edges; Wound bed Assessment: Early/Partial granulation; Drain amount: Moderate; Moderate; Drain description: Serous; Odor; Normal Odor; Periwound: Clean, dry, intact. o Orders: Wound cleansing and Dressing: Cleanse wound with saline, protect periwound with skin Prep, Cover with Foam, Change MWF, Change PRN for soiling and/or saturation Nutrition: Discussed nutrition and its impact on wound healing o Plan of Care: Plan of Care discussed with Facility Staff 2. R5 Wound Evaluation Page 1 of 6 and 2 of 6 dated 4/25/22, Location: Right buttock; Wound ID: 7971 o Measurements: None listed o Observations: Depth (cm): 0.10; Etiology: Pressure Ulcer - Stage 3; Margin Detail: Attached edges; Wound bed Assessment: Fully Granulated; Drain amount: Moderate; Drain Description: Serous; Odor: Normal Odor; Periwound: clean, dry, intact. o Orders: Wound Cleansing and Dressing: Cleanse wound with saline, protect periwound with skin Prep, Cover wound with Foam, Change MWF, Change PRN for soiling and/or saturation Nutrition: Discussed nutrition and its impact on wound healing o Plan of Care: Plan of Care discussed with Facility Staff Review of R5's Treatment Administration Record (TAR) shows the following: - Start date - 4/7/22: Apply [MEDICATION(S)] dressing to right buttock wound one time only for 1 day. This order is signed out as completed. - Start date - 4/12/22, D/C date 4/18/22: Wound care: Right buttocks, cleanse with NS, apply skin prep to peri-wound, cover with foam dressing, change every 3 days and PRN. This order was not signed out as completed until 4/15/22. Also note, this order was charted as the current treatment on the facility Weekly Wound Assessment documentation but was not on the TAR. - Start date - 4/20/22: Wound care: Right and Left buttocks, Cleanse wound with saline, protect periwound with Skin Prep, Cover wound with Foam, Change MWF, Change PRN for soiling and/or saturation. This order was not signed out as completed on the TAR on 4/20/22 or 4/22/22. The first time this order was documented as completed on the TAR was 4/25/22. On 4/27/22, at 10:20 AM, Surveyor observed R5 being assisted with morning cares and transferring out of bed. On 4/27/22, at 10:52 AM, Surveyor spoke with R5 and asked if she had any current open areas or skin concerns. R5 indicated she had something on my bottom. Surveyor asked if nursing was doing dressing changes or if the treatment she was to get was being done when it was supposed to be done. R5 indicated nursing was doing it, but she wasn't sure if it was being done when it was supposed to be done. On 4/27, at 3:44 PM, Surveyor spoke to R5 again while waiting for staff to return to R5's room with stand lift. Surveyor observed R5 sitting in wheelchair in the same location as this morning when interviewed. Surveyor asked R5 if she had been toileted since breakfast or been off her bottom at all. R5 stated she had not used the restroom and stated, I have not used the commode at all yet. On 4/27/22, at 3:49 PM, Surveyor observed staff complete a dressing change to R5's left and right buttock with LPN E (Licensed Practical Nurse) and CNA F (Certified Nursing Assistant). LPN E and CNA F assisted R5 from her chair to her bed with a standing lift. While R5 was standing in the lift next to her bed and her pants were taken down, a large amount of serosanguineous drainage was visible on the outside of R5's incontinent brief. R5 was assisted into bed and LPN E asked R5 if she had any pain in her bottom. R5 stated, Yeah, and LPN E said, I'll get you something for that. R5 then mentioned she has stayed up in her wheelchair longer than this before, saying, I've stayed up longer. What was it, 9:00 that one night? LPN E and CNA F assisted R5 to turn and removed incontinent brief, revealing several small, shallow open areas on both left and right buttocks. Surveyor felt the areas presented as Stage II pressure. No dressing was observed on R5's skin or attached to the incontinent pad. Surveyor asked LPN E if there was a dressing that had fallen off with the removal of the pad, and LPN E said, No. Surveyor asked R5 if she knew when the dressing was last changed or when it might have been removed or fallen off, but R5 could not recall. On 4/27/22, at 1:30 PM, Surveyor spoke with RN D an asked if R5 ever tended to refuse cares or wound treatment. RN D indicated R5 never refused. RN D stated if a resident does refuse, she would document the reason and pass it on to the next shift to have it completed then. RN D stated she would also contact the provider if it was a big concern. On 4/27/22, at 1:46 PM, Surveyor spoke with DON B (Director of Nursing) regarding wound treatments and asked if she expects treatments to be completed as ordered. DON B stated, Yes. Surveyor asked if a treatment is not signed out as completed and there is a blank box on the TAR, is it assumed the treatment was not done? DON B replied, Yes. Surveyor asked if a resident refused a treatment or there was an extenuating circumstance, would DON B expect a nurse's note to explain, and she stated, Yes. The facility did not ensure a resident who was at risk for Pressure Injury development did not develop a PI. Once this resident did develop a PI (4/7/22), the facility did not implement any changes in the resident's Care Plan until 4/25/22 and did not perform treatments as ordered.

Based on interview and record review, the facility did not ensure that it provided each resident with sufficient fluid intake to maintain proper hydration and health for 1 of 4 records reviewed (R1) unless the resident's clinical condition demonstrates this is not possible. The facility identified that R1 was experiencing a change in condition (COVID-19 positive) and care planned the change in condition. However, there is no evidence that the facility assessed R1's fluid intake to determine if interventions were needed to prevent dehydration. The facility did not push fluids, assist R1 to meet her fluid needs, monitoring her fluid intake, and holding [MEDICATION(S)] when R1 did not meet her fluid needs. On 1/30/22 R1 was treated in the emergency room (ER) for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was given nearly 6 liters of fluids (a high amount of fluid particularly in an elderly patient). Following R1's return to the facility on [DATE], there is no evidence the facility is currently offering sufficient fluid intake to maintain hydration, monitoring her fluid intake, holding [MEDICATION(S)] when R1 is not meeting her fluid needs, and notifying the Physician when R1 is not meeting her fluid needs. In the past 30 days, R1 has not met her fluid intakes requirements for 13 of the last 30 days. There has been no further consultation with R1's Physician regarding her lack of fluid intake. This is evidenced by: The facility policy entitled Hydration - Clinical Protocol, dated 9/2017, states, in part: 1. The Physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). 1. a. The physician will distinguish various types of fluid and electrolyte imbalance (for example, [CONDITION(S)], [CONDITION(S)], pre-renal azotemia, etc.) from true dehydration (clinically significant loss of total body water). 2. The staff, with the physician's input will identify and report to the physician individuals with signs and symptoms (for example, [CONDITION(S)], lethargy, increased thirst, etc.) or lab test results that might reflect existing fluid and electrolyte imbalance. 3. The physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance; for example, individuals with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitions and who are not eating or drinking well. Cause Identification: 1. The physician will help identify the cause(s) of any existing fluid and electrolyte imbalance or help the staff document why the individual should not be tested or evaluated. a. A limited review for causes (for example, based on the clinical situation and basic metabolic panel (BMP) may be appropriate even if an extensive work-up is not. Treatment Management: c. Any medications that are contributing to fluid and electrolyte imbalance should be tapered or stopped (at least temporarily), or the physician should provide clinically valid documentation as to why they cannot or should not be changed, even temporarily. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 1/21/22, indicates R1 had a BIMS (Brief Interview of Mental Status) of 9/15 indicating moderately impaired cognition. Section GO110 indicates R1 required extensive assistance with all areas of activities for daily living, except required supervision and set up for eating. Section J1550 C indicates R1 was not dehydrated. Section K0300 indicates R1 had no weight loss and Section K0510 indicates R1 was not on a mechanically altered diet. R1 has DNR orders (Do Not Resuscitate) and an APOAHC (Activated Power of Attorney for Health Care). On 1/17/22 the facility tested R1 for COVID-19. R1 was asymptomatic at the time she was tested . On 1/19/22 R1's test result indicated R1 is COVID-positive (+) and she was moved to the COVID-positive wing and put on contact and droplet isolation precautions. On 1/20/22 the facility updated R1's Comprehensive Plan of Care from At risk for infection, signs and symptoms, of COVID-19 to COVID+ 1/19/22, collected 1/17/22. Goal: Will be free of s/sx (signs/symptoms) of COVID-19 through next review date. Will receive recommended treatment per MD (Medical Doctor) if contracts/becomes infected with COVID-19 through next review date. Interventions .Monitor resident's hydration needs. Offer fluids of choice to ensure adequate hydration. Update physician as indicated regarding change in condition/treatment. R1's Nutritional Risk Assessment, dated 12/10/21, states, in part: resident daily fluid needs 1400 - 1680 cubic centimeters [cc's] daily. Swallowing difficulty r/t [related to] dysphagia dx [diagnosis], hx [history] of pneumonia, and aspiration risk AEB [as evidenced by] refusal of modified textures with monitoring of coughing or oral residue. The facility began monitoring R1's fluid intake on 1/24/22. R1's fluid intake (in milliliters) is as follows: 1/24: 0 1/25: 0 1/26: 0 1/27: 960 1/28: 0 1/29: 800 1/30: 0 (admitted to hospital) 1/31: hospitalized 2/1: hospitalized 2/2: hospitalized R1's current Physician Orders, signed 2/23/22, indicate R1 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR (Medication Administration Record) indicates R1 received [MEDICATION(S)] daily. It is important to note, the facility's January MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/28/21 Order to push fluids / encourage meals - every shift for weakness On 1/28/22 at 4:42 AM, R1's Progress Note indicates the following: Resident has poor intake, refusing meals and meds, VS [vital signs] Temp 97.8, Respirations 26, Blood Pressure 82/54, O2 saturation 90% RA [room air], resident has audible wheezing, and crackles on bilateral lower lobes, called on call Physician who gave order for 1 view chest x-ray, BMP [Basic Metabolic Panel] and CBC [Complete Blood Count] with diff [differential] labs for weakness/lethargy, to continue pushing fluids and update PCP [Primary Care Provider], message left for NP [Nurse Practitioner], message left for R1's APOAHC. On 1/28/22 NP wrote the following in-person visit note: R1 is an [AGE] year old female who is seen today for follow up for change in condition as reported by nurse. Chief Complaint: COVID positive 10 days ago with decrease in oral intake for the past 2 days, refusing to eat and drink, or take medications last night. Assessment at that time revealed crackles at lung bases and some wheezing. CXR [chest x-ray], CBC [complete blood count] and BMP [Basic Metabolic Panel] ordered by on-call physician earlier this morning. Today, upon exam, she is lying in bed with HOB [head of bed] elevated a meal tray sitting in front of her. She is alert and oriented to self. Answers some questions with short answers and other questions she just stares. Patient reports not feeling hungry but is thirsty and requests assistance with fluids. Intention tremor and intermittent congested cough noted during exam. Denies shortness of breath, fevers or chills. Vitals: Blood Pressure 116/58, Pulse 88, Temperature 98.1, Respirations 18, SpO2 94%. Exam General: chronically ill appearing, tired but not toxic appearing, in no acute distress female, lying in bed, Skin: red and flaky skin surrounding her mouth and chin, Neuro: alert and oriented x1 [person/place/situation] with limited speech; intention tremor. Psych: somnolent [abnormally drowsy]. Decreased oral intake [primary encounter diagnosis]. Comment: Patient reports not feeling hungry, denies nausea and no vomiting reported. Tolerating fluids, abd [abdomen] soft and non-tender, BS [bowel sounds] active. Two loose and formed BMs yesterday. Cough - Comment: Congested sounding. Nurse reported crackles and wheezing previously. No dyspnea, [CONDITION(S)] or fevers. Plan: CXR ordered, BMP and CBC results pending. Mucinex PRN [as needed]. R1's chest x-ray results indicates the following: There are mild patchy bibasilar densities, right greater than left, compatible with pneumonia. The costophrenic angles are sharp with no pleural effusion. Impression: 1. Mild patchy bibasilar densities, right greater than left, compatible with pneumonia. Follow up chest x-ray suggested. On 1/28/22 at 3:17 PM, staff called R1's NP to report a critical lab value HCT [hematocrit] of 61 waiting to call back. R1's BMP was not able to be run and was not re-attempted. On 1/28/22 at R1's Physician ordered [MEDICATION(S)]-Pot Clavulanate 875-125 milligram - 1 tab BID [two times a day] x 10 for pneumonia and [MEDICATION(S)] 1 tab PO every day for 10 days. R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/28/22 at 3:22 PM, R1's Progress Note indicates the following: Spoke with mobile imaging x-ray was obtained, radiologist is reading that and they will fax results. Labs were drawn this AM from residents left hand. Lab called they had to reject BMP, but can run CBC. Left message to update NP. On 1/30/22 the facility obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/30/22 at 10:45 AM, R1's Progress Note indicates the following: Writer updated Physician on patient's change in condition. Physician made a verbal order to send patient to ER if she cannot maintain O2 greater than 90% on 2L. Writer rechecked patient's O2, O2 was 88% on 2L. Writer called ambulance for pick up to go to hospital, called and spoke with R1's APOAHC, and update the facility's nurse on call. R1 was hospitalized on [DATE] (4 days) and readmitted to the facility on [DATE]. R1 was initially treated with [MEDICATION(S)]/azithro, then broadened to vanc/[MEDICATION(S)] earlier this week in setting of septic shock requiring vasopressors, ultimately transitioned to [MEDICATION(S)] and will complete 7 days course. [MEDICATION(S)] initially 2.1 then peaked at 3.4 then normalized. Multiple fluid boluses given, now nearly 6L (liters) + fluid balance. She was also started on stress dose HC earlier in week, which was weaned back to oral [MEDICATION(S)] once more hemodynamically stable. Will complete 10-day course [MEDICATION(S)] for COVID pneumonia. COVID-19 pneumonia --diagnosed at SNF [Skilled Nursing Facility] 1/18/22 [Note: she was diagnosed on [DATE]]. She was hypoxemic on admission but since weaned to room air, though intermittent mild [CONDITION(S)] noted. [MEDICATION(S)] started on admission and later escalated to stress dose HC earlier this week as above. Currently back on oral decantation and will complete 10-day course. [MEDICATION(S)] deferred due to time since diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . not requiring supplemental O2. On 1/30/22 the hospital diagnosed R1 with the following: 1. Shock, suspect multifactorial ([CONDITION(S)] + hypovolemia) Note: hypovolemia is a condition in which the liquid portion of the blood (plasma) is too low. R1's prolonged lack of fluid intake combined with diuretic use contributed to hypovolemia. Symptoms include weakness, fatigue, [CONDITION(S)] and dizziness. This can lead to shock, a life-threatening condition in which the organs aren't getting enough blood or oxygen. 2. COVID-19 pneumonia 3. Aspiration pneumonia, ongoing high aspiration risk 4. Multiple cardiac arrhythmias including SVT (Supraventricular [CONDITION(S)] - in setting of [MEDICATION(S)] use) and sinus [CONDITION(S)] R1's hospital report indicates the Physician met with R1 and her APOAHC (Activated Power of Attorney for Health Care to review the next steps in care. We reviewed her fragile baseline status being bedbound with history of aspiration. We shared concern that she may have setbacks following this hospitalization given COVID recovery and ongoing aspiration risk. We introduced hospice philosophy and discussed this at length. R1's APOAHC values quality over quantity of life and is recognizing this hospitalization as a sentinel event (A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm) that may culminate in further decline. She values treatment within reason but feels hospice care aligns most with her goals of care. On 2/3/22 R1 was readmitted to the facility. R1's fluid intake (in milliliters) is as follows: 2/3: 480 (Returned from the hospital) 2/4: 960 2/5: 390 2/6: 0 2/7: 0 2/8: 360 2/9: 240 2/10: 0 2/11: 240 2/12: 0 2/13: 240 2/14: 240 2/15: 360 2/16: 600 (On 2/16/22 R1 enrolled in hospice care.) 2/17: 0 2/18: 480 2/19: 0 2/20: 0 2/21: 1,000 2/22: 240 2/23: 900 2/24: 0 The facility has not notified R1's Physician or NP that R1 has not met her fluid requirements since she returned from the hospital 21 days prior. The facility is not: 1. Providing R1 with the necessary assistance to ensure her daily fluid intake requirement is met. 2. Identifying when R1 is not meeting her daily fluid intake requirements. 3. Contacting R1's Physician or NP when R1 is not meeting her fluid requirements. R1 has not met her fluid intake requirements for 21 days following readmission and the facility has not identified nor acted on this by consulting R1's Physician or NP. On 2/23/22 at 10:04 AM, Surveyor spoke with R1's APOAHC. R1's APOAHC stated she is at the facility 6-8 hours per days since R1 returned from the hospital on 2/3/22. R1's APOAHC stated that R1 experienced a change in condition when she was diagnosed with Covid-19 and began requiring assistance from staff to eat and drink. R1's APOAHC stated when R1 was COVID positive (+) and on the COVID isolation wing, the facility did not identify R1's change in condition when she required assistance to eat and drink. R1's shaking increased a left her unable to eat independently. R1's APOAHC stated the facility's failure to identify her change in condition lead to her hospitalization and dehydration. It is important to note, the facility did not identify R1's change in condition and need for assistance with meals and fluid intake. As a result, R1 was hospitalized for 4 days and diagnosed with shock due to [CONDITION(S)] and hypovolemia (low fluid volume due to lack of intake), aspiration pneumonia and multiple cardiac arrhythmias. Of note, R1 did not meet her fluid requirement prior to being hospitalized and has not met fluid requirements since returning to the facility on [DATE]. The facility failed to assess and monitor R1's fluid intake prior to being hospitalized and after hospitalization . On 2/24/22 at 9:25 AM, Surveyor spoke with CNA C (Certified Nursing Assistant). Surveyor asked CNA C if she is familiar with R1. CNA C stated, yes. Surveyor asked CNA C if she noticed any difference with R1's eating and drinking since she had COVID in January 2022. CNA C stated R1 used to be able to eat and drink herself, but now she can no longer eat by herself and needs assistance. CNA C stated R1's shaking has become so bad that she can no longer hold a fork or spoon to eat independently. Surveyor asked CNA C is R1 able to eat finger foods independently. CNA C stated, yes. Surveyor asked CNA C is R1 able to drink fluids independently. CNA C stated R1 is able to drink independently. CNA C stated before R1 had COVID she would eat independently. On 2/24/22 at approximately 3:00 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated she is not aware of any fluid related concerns with R1. DON stated she has not received any alerts related to R1 not meeting her fluid needs. Surveyor asked DON B if she is aware that R1 has not met her fluid needs for a single day over the past month. DON B stated she is unaware of this. DON B is not aware that 13 of the last 30 days, R1 has no fluid intake documented. DON B stated staff should have been actively monitoring R1 and aware of her daily fluid intakes. Surveyor asked DON B why is it important to monitor R1's fluid intake. DON B stated to monitor R1, to be aware of the need to push fluids, monitor signs and symptoms of dehydration, and to contact the Physician when necessary. DON B indicated staff should have been monitoring R1 closely (before and after hospitalization ) and identified that she was not meeting her fluid needs, holding [MEDICATION(S)], and contacting the Physician.

Based on record review and interview, the facility failed to have a system in place to ensure residents who have diagnostic testing scheduled attend the scheduled appointment as ordered, and, if a scheduled appointment is missed/cancelled, the physician who requested the testing is updated and alternate scheduling occurs to ensure residents receive the care and treatment required in accordance with professional standards of practice. This affected 2 of 5 sampled residents (R2 and R4). R2 had a CT (computed tomography) scan scheduled for [DATE] following months of abdominal pain and to rule out the potential of kidney stones which the nurse practioner felt could be the contributing cause of R2's pain. R2 did not attend this appointment. The facility did not reschedule the appointment or inform the ordering physician that the resident had missed the appointment. This delayed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], R2 had a severe change in condition where she ended up going to the ER (emergency room ) and then directly to the OR (Operating Room) to have a [CONDITION(S)] stent due to finding a large kidney stone. R2 was diagnosed with urosepsis. R2 spent 7 days in the ICU (Intensive Care Unit) and expired as a result. The facility's failure to have a system in place to ensure residents attend scheduled appointments for diagnostic testing or a system to reschedule a missed appointment to ensure resident receives the necessary care and treatment required created a finding of immediate jeopardy which began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 2:15 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a severity/scope of D (Isolated/Potential for No More than Minimal Harm) as the facility continues to implement its action plan. This is evidenced by: The Facility's Policy and Procedure entitled Transportation Scheduling for Resident Appointments dated [DATE], documents, in part: a.will facilitate the arrangement of transportation to and from medical appointments, as necessary, to meet the needs of the residents . Example 1 R2 was a [AGE] year-old resident that had been a resident of this facility since 2015. R2 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Per R2's medical record, she had been having abdominal pain on/off since July. The Facility was working with NP G (Nurse Practitioner) to attempt different interventions to diagnose the root cause of the pain and attempt to alleviate this pain. Per NP G's visit note dated [DATE] for visit on [DATE]; R2 was complaining of continued abdominal pain. NP G documented in part: .Abdominal pain, chronic .Unclear etiology, R2 does have multiple chronic conditions that may be contributing to abdominal pain including hx. (history) of nephrolithiasis, bilateral adnexal masses (known), chronic constipation with recent diarrhea . NP G also documented that she was going to speak to R2's Guardian regarding CT scan of abdomen and pelvis. The CT scan would show the provider if R2 has kidney stones that could be the source of her pain or contributing to her pain. Per typed fax from NP G in R2's medical record dated [DATE] an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . --please call .radiology .to schedule CT scan .--please ensure that .Radiology department is aware that R2 is a Hoyer transfer . Also documented on this fax in handwriting is the following: [DATE] Fri 730 A (AM), Cr (creatinine) 30 days- [DATE] (date R2 had this lab completed), NPO (nothing by mouth) 4 hours prior, short sleeve There is no nurse initials or signature. In the facility's appointment planner on [DATE] it documents: R2's name .radiology, phone number. This information is crossed off with X, handwritten above is 5 20 53 canceled. To right of [DATE] in the Notes section, says R2's name, GI clinic GI, phone number for tube replacement. This has arrow to the [DATE] square. The arrow is then scribbled out. Surveyor nor Facility were sure if this appointment at the GI clinic played a role in R2 missing her appointment for scheduled CT scan on [DATE]. According to Kidney Stones: Overview, The usual symptoms of kidney stones can provide a basis for a diagnosis, but they aren't always enough to tell what the exact cause is. Ultrasound scans can be used to detect most kidney stones. If doctors still aren't sure, they may also use a computed tomography (CT) scan. https://www.ncbi.nlm.nih.gov/books/NBK 7/. Failing to ensure this resident made her appointment prevented the physician and nurse practitioner from diagnosing what was causing her pain and prevented early intervention. Per R2's Nurses Notes: On [DATE] at 06:15 (6:15 AM) R2 had large yellow emesis at around 0400 (4:00 AM), reported having nausea, left lower abdominal pain of ,d+[DATE], distention, tenderness, hypoactive (less than normal) BS (bowel sounds). VS (vital signs): 97.5 (temperature), 20 (respirations), ,d+[DATE] (blood pressure), 82 (pulse), 97% (RA- room air) (oxygen level). Resident is NPO, G-Tube fed, 0cc (cubic centimeter) residual on PEG tube aspiration. Called on-call Provider .who gave order to send to ER for further eval (evaluation), called .gave report to Nurse, transported by .ambulance .DON B (Director of Nursing) and . (son) were updated. Left voicemail for NP G. On [DATE] at 16:11 (4:11 PM) ED (Emergency Department) RN (Registered Nurse) called this AM to inquire about when last had tube feeding and or meds (medications) as res (resident) was on way to OR to have stent placed due to finding large kidney stone. Res is definitely being admitted to hospital. Admitting d/x (diagnoses) is urosepsis (severe infection of the urinary tract). On [DATE] at 14:42 (2:42 PM) Update on res, per . ICU RN that res is still in ICU but VS were stabilized, still receiving IV (intravenous) ATB (antibiotics) for urosepsis. RN states res kidney function levels remain very poor and no improvement seen in levels each day. Under discussions by MD's (Medical Doctors) whether or not to start res on a temp (temporary) [CONDITION(S)] until kidney function levels improve. RN states to expect res to be in hospital this week yet. On [DATE] at 1:56 PM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F what the process was when a resident received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN F went on to explain and made it clear that the following is her system when she receives these type of orders, not the Facility's; LPN F said she puts a red dot next to the information on the planner when she has filled out the transportation slip that goes to DMR C (Director of Medical Records), then she writes noted, her name, and date. Surveyor asked LPN F why she gives the transportation slip to DMR C, LPN F said because she sets up the transportation for the appointments. On [DATE] at 2:25 PM, Surveyor interviewed LPN F. Surveyor asked LPN F if there were transportation issues with R2's [DATE] appointment. LPN F stated she had transportation set up, I don't know what happened. Surveyor asked LPN F if R2's appointment was canceled from the Clinic site would that be written somewhere in the planner, LPN F said no, possibly in a Nurse's Note. It is important to note that there are no Nurse's Notes in R2's medical record about receiving an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:53 PM, Surveyor interviewed NP G. Surveyor asked NP G to explain what transpired from her visit with R2 on [DATE] to her passing away; NP G stated she spoke to R2's Guardian on [DATE] and R2's Guardian stated if R2 was willing to complete the scan then she would agree; if R2 did not want to complete the scan then they would need to discuss a different course of action. NP G said she then faxed the Facility the order for the CT scan on [DATE]; NP G said she was told the appointment had been scheduled when she was in the facility to see her patients. NP G explained between her visit with R2 in September and the day R2 went to ER, the Facility had contacted on call Providers twice due to R2's pain, one of which was abdominal and the other that was not. NP G stated she and R2 had been trying one intervention at a time in an attempt to pin-point the cause of the pain. Surveyor asked NP G if it were possible that the Radiology Clinic canceled R2's appointment, NP G verified in computer system that R2's GI appointment was actually scheduled for [DATE] and R2 was documented as no show; and R2's CT scan appointment was scheduled for [DATE] and R2 was documented as no show. NP G also then read a note from Radiology dated [DATE] saying Radiology attempted to call the Facility with a time change of CT scan for R2 but no one answered the phone. Surveyor asked NP G if she thought that R2 would have agreed to place the stent if the CT scan had shown the stone sooner, NP G said yes, R2 would have been agreeable to stent placement as she has had them in the past and they had helped. Surveyor asked NP G from the time R2 was sent to the OR for the stent placement, what happened; NP G explained R2 was intubated (breathing tube placed) during stent placement surgery and was never extubated (breathing tube removal), her blood pressure dropped putting her in septic shock and requiring [MEDICATION(S)] and [MEDICATION(S)] (medications to attempt to stabilize blood pressure); she spent 7 days in the ICU and then passed away. Hospital documentation supports NP G's interview regarding R2's hospital course. On [DATE] at 3:49 PM, Surveyor interviewed NP G. Surveyor asked NP G if R2 would have had the CT scan when she was supposed to ([DATE]) would this have changed the outcome for R2. NP G stated yes, she would have had the option of placing the stent much sooner and avoiding urosepsis. Surveyor asked NP G if R2 didn't want the stent at the time the CT scan was supposed to be done ([DATE]), if that would still change the outcome for R2; NP G stated yes, we could have discussed hospice and remaining in the facility versus dying alone in the ICU. On [DATE] at 4:10 PM, Surveyor interviewed NM E (Nurse Manager) and DON B (Director of Nursing). Surveyor asked NM E and DON B what happened with R2 having her CT scan on [DATE]. NM E stated she was aware R2 did not have CT scan completed but wasn't sure what had gotten canceled whether it was the appointment or the transportation; DON B concurred. Surveyor asked NM E and DON B if anyone from the Facility contacted NP G to alert her that the CT scan had not been done. NM E said no; DON B concurred. When Surveyor asked NM E and DON B if anyone had attempted to re-schedule the CT scan, DON B said no; NM E concurred. According to Kidney Stones: Overview, Left untreated, kidney stones can block the ureters or make them narrower. This increases the risk of infection, or urine may build up and put added strain on the kidneys. Another article notes that, Apart from causing symptoms such as pain, vomiting and blood in the urine, kidney stones can cause serious medical complications. These include: Severe infections including [CONDITION(S)] (blood poisoning) which can be life-threatening. Renal scarring and damage to the kidneys, resulting in permanent renal failure. Loss of function of a kidney resulting in the need for removal of the kidney (nephrectomy). Bladder blockage can result when a large kidney stone has managed to pass into the bladder but gets stuck in the urethra resulting in painful urinary retention. https://kidneystonemelbourne.com.au/diagnosis/complications-kidney-stones [CONDITION(S)] occurs when bacteria enter the bloodstream and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure. [CONDITION(S)] is the leading cause of death in hospitals in the United States, severe [CONDITION(S)] is associated with an estimated in-hospital mortality risk between 25 and 30 percent. In the U.S. alone, more than 500,000 adult patients are admitted to hospitals every year with evidence of [CONDITION(S)] and organ dysfunction. Each year in the U.S. there are approximately 750,000 cases of severe [CONDITION(S)], which result in 215,000 deaths. https://www.theatlantic.com/health/archive/,d+[DATE]/[CONDITION(S)]-to-shock-what-happens-when-bacteria-invade-the-body/ 2/ The failure to have a system in place to ensure that residents who have diagnostic testing scheduled are able to attend these appointments to obtain the results required for them to receive the treatment and care required and if a scheduled appointment is canceled/missed/delayed that the Provider who requested the testing is updated, created a reasonable likelihood for serious harm occurring and a finding of immediate jeopardy, which began on [DATE]. The facility removed the jeopardy on [DATE], when it had completed the following: * Licensed Nursing staff to be educated on the Radiology & Other Diagnostic Policy and Procedure - Date 4.1.2008 Revised 11.2016, [DATE] * Staff to be educated on the Resident Appointment and Transportation Scheduling Policy and Procedure - Dated 9.3.2021 Revised 11.23.2021 * Staff to be educated on the community centralized process of appointments, transportation requests and cancellation tools utilized in the process. * Discussed IJ (immediate jeopardy) and education at team huddle/cross shift report on 11.23.2021. Even though CNAs (Certified Nursing Assistants) do not answer telephones in general, want them to be aware of the process. Communication will continue through huddles/cross-shift reports. * On 11.23.2021, community reviewed the Radiology & Other Diagnostic Policy and Procedure - Date 4.1.2008 Revised 11.2016, [DATE] to ensure it include the accountability to the timeliness of diagnostic procedures being completed. * On 11.23.2021, community reviewed the Policy and Procedure Resident Appointment and Transportation Scheduling - dated, 09.03.2021 to ensure it included process is in place regarding canceled/missed appointments. Policy updated to include the process of canceled/missed appointments: 10.1 - Nursing staff will be responsible to ensure resident, responsible party and/or family are notified of the cancellation. 10.2 - Nursing staff will be responsible to ensure Primary provider is notified of cancellation and will obtain orders as needed. 10.3 - Medical Records Director and/or Designee will be notified of the cancellation to assure appointment is rescheduled 10.4 - Medical Records Director and/or Designee will track the cancellation. * On 11.23.2021, the clinical leadership team at community reviewed the desktop calendars in each of the nurse stations that contain appointment calendars. Appointments were reviewed from 09.01.2021 to ensure compliance with orders and that any cancellations had been rescheduled. In addition, the team reviewed orders in EPIC to ensure those orders had been scheduled. * Numerous staff received education via the phone. Any individual receiving phone education will receive the written education upon their first shift back at the facility. They will then sign the training log next to their name where by phone has been written. * DON and/or Designee will conduct audits daily x2 weeks, weekly x 8 weeks, and monthly x3 months resident's appointments to ensure appointment was completed, if not completed Primary Provider was notified, upon notification new orders received, and if appointment was missed was it rescheduled. * Results will be brought to QAPI (Quality Assurance Performance Improvement) meeting for tracking and trending purposes. Example 2 R4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 had been hospitalized prior to admission with acute heat stroke and core body temperature of 107 Fahrenheit. R4's admission MDS (Minimum Data Set, a standardized assessment tool) dated [DATE] indicates R4 had a BIMS (Brief Interview for Mental Status) score of 11 which suggests moderate cognitive impairment. Per The Mayo Clinic article entitled, 'Heat Stroke,' [DATE], heatstroke can cause your brain or other vital organs to swell, possibly resulting in permanent damage. X-rays and other imaging tests may be ordered to check for damage to your internal organs. Through record review, Surveyor was able to ascertain that R4 had an echocardiogram and vascular referral ordered on [DATE]. On [DATE] there is medical record evidence of hospital schedulers attempting to contact R4 directly and were unsuccessful. The record was also updated on [DATE] that R4 was living at the facility and to contact R4 or the nursing staff at the facility (telephone number documented) to schedule the appointment. On [DATE] at 10:45 AM, Surveyor asked DON B (Director of Nursing), did the facility had knowledge of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? DON B replied, R4 had the vascular referral. Surveyor asked for this report. DON B produced a Doppler study-which may have been a recommendation from the vascular referral but DON B never produced the actual vascular referral. The Doppler study report produced by DON B was completed on [DATE]. Surveyor asked DON B, why was scheduling of the vascular referral and subsequent Doppler study not completed until November? DON B responded, Because we didn't know about it, R4 takes his own phone calls and probably never told us. Surveyor showed DON B the communication notes in R4's medical record between schedulers attempting to contact R4 for appointments and then the schedulers realizing R4 was a resident of the facility. The record shows on [DATE] that a scheduler then left a message with a nurse at the facility to call to schedule the echocardiogram. DON B, stated That is not true, no message was left. Surveyor asked DON B, when was the echocardiogram completed? DON B stated, It is scheduled. Surveyor asked DON B, when was the appointment made? DON B responded, Today. Surveyor asked DON B, would you consider this a delay in service? DON B answered, No, because we didn't know about it. On [DATE] at 12:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the facility knowledge of the physician ordered tests on [DATE]. NHA A responded, R4 has his own phone and probably took the call and didn't tell us. Surveyor showed NHA A, the communication between schedulers attempting to make appointments on [DATE]. NHA A stated, These communication notes were not printed until [DATE] so we didn't know about these orders until then. That is why the Doppler study wasn't completed until November. On [DATE] at 1:55 PM, Surveyor attempted to speak with MD J (Medical Doctor), R4's primary care provider, and left a message requesting a return call. On [DATE] at 2:11 PM, Surveyor spoke with RN D (Registered Nurse) at MD J's clinic. RN D was able to confirm via medical record documentation that R4 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN D states The echocardiogram was ordered to check heart function secondary to peripheral [CONDITION(S)] and an elevated BNP (brain natriuretic peptide-a blood test that measures levels of a protein called BNP that is made by your heart and blood vessels. BNP levels are higher than normal when you have heart failure). The vascular referral was based on R4's lower extremity [CONDITION(S)] to check for blood flow. On [DATE] at 2:35 PM, Surveyor contacted RN H to verify through R4's medical record when the appointment for the Doppler study had been made. RN H states, The Doppler study appointment was made on [DATE]. Surveyor asked RN H were there any cancellations prior to [DATE]? RN H states No. Surveyor asked RN H, when was the echocardiogram appointment made? RN H states, Today, [DATE]. On [DATE] at 2:52 PM, Surveyor contacted RN D at MD J's office. Surveyor asked RN D, is there any documentation regarding physician notification that the echocardiogram and vascular referral were not completed? RN D states, No, Surveyor asked RN D, is there any documentation that the facility knew about the orders? On [DATE] at 3:00 PM, Surveyor noted a progress note in R4's facility record dated [DATE] and written by DON B that states, .MD J put in a reveral [sic] for vascular and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:15 PM, Surveyor showed NHA the progress note of [DATE] and asked NHA A Do you think the facility had information regarding the echocardiogram and vascular referral? NHA A stated, Oh, yes, it looks like we missed it. On [DATE] at 3:35 PM, Surveyor showed DON B the progress note of [DATE] and asked DON B, Did you have information about the echocardiogram and vascular referral orders for R4? DON B replied, Yes, I guess I missed it. Surveyor asked DON B, Do you have the vascular referral report? DON B stated, I'm having trouble printing it from the hospital electronic medical records. The facility failed to provide timely assistance in making appointments for diagnostic testing per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 1 residents (R4) reviewed for medication errors. R4 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 received [MEDICATION(S)] and [MEDICATION(S)] (medications used to control diabetes) prior to hospital discharge. The facility administered a 2nd dose of [MEDICATION(S)] and a double dose of [MEDICATION(S)] at bed time which resulted in R4 having multiple episodes of vomiting requiring physician intervention and orders for [MEDICATION(S)]. R4 also received [MEDICATION(S)] ER (Extended Release) 100 mg (milligrams). R4 had received [MEDICATION(S)] IR (Immediate Release) 25 mg in two doses in the hospital prior to admission. ([MEDICATION(S)] is a medication to control blood pressure). This is evidenced by: The facility policy titled, Medication Administration from a Cart, revised May, 2020, states in part . Policy: It is the policy to administer all medications and treatments in a safe and effective manner. Procedure: 7. Read medication orders on medication sheet and have medication cup ready. 8. For solid medications, remove medication container (blister pack or bottle) and compare label with medication sheet. Place appropriate dosage into medication cup. Re-read label and check label. Re-read label and medication sheet, and return drug to its proper location (triple check). 9. For liquid medications, remove prescribed liquid medications and compare label with medication sheet. Pour prescribed amount into calibrated cup. Pour away from label and check label. Re-read label and medication sheet and return drug to its proper location (triple check). Certain medications may be required to be calibrated with a syringe. According to [MEDICATION(S)].com, the most common side effects of [MEDICATION(S)] may include in part . nausea, diarrhea, and vomiting. DOSAGE AND ADMINISTRATION2.1 Important Dosing and Administration Instructions: Inject [MEDICATION(S)]® subcutaneously once-daily at any time of day, independently of meals. If a dose is missed, resume the once-daily regimen as prescribed with the next scheduled dose. Do not administer an extra dose or increase the dose to make up for the missed dose. OVERDOSAGE: Overdoses have been reported in clinical trials and post-marketing use of [MEDICATION(S)]®. Observed effects have included severe nausea, severe vomiting, and severe [CONDITION(S)]. In the event of over dosage, appropriate supportive treatment should be initiated according to the patient's clinical signs and symptoms. Evidenced by: R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Hospital Discharge Packet including Final Discharge Medication List includes the following medications in part . - [MEDICATION(S)] 18MG (milligrams)/3ML (milliliter) soln (solution) pen injector. Inject: 1.2 mg under skin one time daily. Notes: Indication: Type 2 Diabetes Mellitus. - [MEDICATION(S)] FlexTouch 100 Unit soln pen-injector. Inject 30 units under skin at 10 am and 15 units at 8 pm. Purpose: Type 2 diabetes Mellitus. - [MEDICATION(S)] [MEDICATION(S)] 100 MG 24hr (hours) ER (extended release) tab. Take 1 tab by mouth every day at bedtime. Notes: Take for high blood pressure. R4's Hospital Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . - Custom medication unit dose. Freq (frequency): 1x (time) daily. Last given on 6/29/21 at 9:13 AM (morning). - [MEDICATION(S)] 100 Unit/mL injection 20 units. Freq: 1x daily (HS) (bedtime). Last given on 6/28/21 at 8:30 PM (evening). - [MEDICATION(S)] [MEDICATION(S)] tab 25 mg. Dose 25 mg. Freq: 4 X daily. Last dose given 6/29/21 at 11:59 AM. Note: R4 was not receiving [MEDICATION(S)] in the hospital. On 9/07/21 at 1:20 PM, Surveyor spoke with Hospital RPH C (Registered Pharmacist) who indicated the Custom Medication that is listed above is [MEDICATION(S)]. The medication was brought into the hospital by the resident and administered by the hospital at the time indicated on the Medication Administration Record. The facility eMAR (Electronic Medication Record) for R4 from the time of admission indicates the following in part . - [MEDICATION(S)] [MEDICATION(S)] ER tablet Extended Release 24 hour. Give 100 mgs (milligrams)by mouth at bedtime for blood pressure. Given on 6/29/21 and 6/30/21 at HS (bedtime). Start 6/29/21 20:30 (8:30 PM). - [MEDICATION(S)] Solution Pen-Injector 18 MG/3ML. Inject 1.2 mg subcutaneously one time a day for DM2 (Diabetes Mellitus Type 2). Start 6/30/21 0730 (7:30 AM). - [MEDICATION(S)] FlexTouch Solution Pen-Injector 100 Unit/ML ([MEDICATION(S)]). Inject 30 unit subcutaneously two times a day for DM2. Start Date: 6/29/21 2000 (8:00 PM), D/C (Discontinued) Date: 6/30/21 1059 (10:59 AM). - Note: R4 was not scheduled to get [MEDICATION(S)] until 6/30/21 in the morning. [MEDICATION(S)] was transcribed incorrectly to give 30 units at HS, instead of the ordered 15 units. R4 had also already received two doses of [MEDICATION(S)] 25mg immediate release prior to admission. Thus R4 received an extra dose of [MEDICATION(S)], a double dose of [MEDICATION(S)] and a daily total of 150 mgs of [MEDICATION(S)]. Note: Discharge medications orders do not match the eMAR orders. On 6/30/21 R4 was seen by PA (Physician's Assistant) for Transitional Visit from Hospital to SNF (Skilled Nursing Facility). PA notes state the following in part . Visited patient today (6/30/21): Upon arrival to room, patient comfortable lying in bed watching TV. States feels better after getting the medication for my upset stomach. Patient reported vomiting 4-5x last night - starting around 0100 (1:00 AM): 0100 (1:00 AM): medium amount of undigested food 0200 (2:00 AM): medium amount of undigested food 0600 (6:00 AM): medium amount of mostly 7up and water Ate breakfast at hospital yesterday, missed lunch because of transfer to SNF, ate dinner (beef stroganoff) at SNF. No reports of nausea or abdominal discomfort until right before emesis. Had soft formed BM (bowel movement) at 0300 (3:00 AM) and 0930 (9:30 AM) this morning - no blood noted in stool. No fever or chills. Today, denies any N/V/F/C/D (Nausea, Vomiting, Fever, Chills, Diarrhea). Denies any abdominal pain or distention. Given [MEDICATION(S)] around 0800 (8:00 AM). Ate a little breakfast: 1-2 French toast sticks and cartoon [sic] of milk. Took AM (morning) PO (by mouth) medications. No further vomiting since 0600 (6:00 AM). Did take PO antibiotics on empty stomach around 2300 (11:00 PM) - however he endorses doing that all the time at the hospital without GI issues. ++ He reported getting [MEDICATION(S)] at hospital yesterday morning and at SNF last night around 2300 (11:00 PM). He is only supposed to receive once daily in AM. Per his report, he questioned SNF RN about this second dose, but she was adamant and gave it. [MEDICATION(S)] orders were transcribed wrong at SNF. He was discharged from hospital on [MEDICATION(S)] BID, 30 units in AM and 15 units in PM - HOWEVER SNF ordered [MEDICATION(S)] 30 units BID (twice a day). So not only did he get a second dose of [MEDICATION(S)] at (11:00 PM) he also received 15 extra units of [MEDICATION(S)] at HS. Wonder if this may have caused the nausea/vomiting. 6/29 HS blood sugar = 105; 6/30 AM blood sugar = 115; noon blood sugar -143. Order given to HOLD [MEDICATION(S)] this AM. Denies any symptoms of [CONDITION(S)]. Discussed PM RN's medication error and blatant disregard to patients concerns re: (regarding) [MEDICATION(S)] with SNF RN manager. She will be following up with PM RN. Nurses Notes reviewed and state the following in part . 6/29/21 at 20:30 (8:30 PM), Nurse Progress Note. Note Text: Resident got [MEDICATION(S)], but [MEDICATION(S)] was scheduled for 30 units. Called place out to Doctor if resident should get the 30 units [MEDICATION(S)]. Order gave to give because is long acting. Resident got the insulin and [MEDICATION(S)] antibiotic after Pharmacy got to the facility. 6/30/21 at 03:12 (3:12 AM), Nurse Progress Note: Resident threw up undigested food several times. He also had a large BM (bowel movement). MD (Medical Doctor) on call notified and order for TUMS given. Nurse Manager notified. 6/30/21 at 07:09 (7:09 AM), eMAR Administration Note: [MEDICATION(S)] HCL ([MEDICATION(S)]) tablet 4 MG. (medication for nausea and vomiting) Give 1 tablet by mouth every 6 hours as needed for GI upset/nausea. 6/30/21 at 07:41 (7:41 AM), Nurse Progress Note: PRN (as needed) [MEDICATION(S)] (medication for nausea and vomiting) given per new orders. Resident ate poorly for breakfast but had good fluid intake. Resident reports nausea has improved and has had no further emesis as of present time. Will cont (continue) to monitor. 6/30/21 at 08:00 (8:00 AM), Nurse Progress Note: Received follow-up call from NP (Nurse Practitioner) to discuss GI (Gastrointestinal) sx (symptoms). Writer updated on prn (as needed) orders given from on-call on NOC (night) and NP approved of use. Writer updated that prn [MEDICATION(S)] was given with no further emesis and plan to monitor for further sx (symptoms). NP approved. 6/30/21 at 09:15 (9:15 AM), eMAR Administration Note: [MEDICATION(S)] HCL ([MEDICATION(S)]) tablet 4 MG. Give 1 tablet by mouth every 6 hours as needed for GI upset/nausea. PRN Administration was: Effective 6/30/21 at 11:28 (11:28 AM), Nurse Progress Note: [MEDICATION(S)] FlexTouch Solution Pen-injector 100 UNIT/ML. Inject 30 unit subcutaneously two times a day for DM2. Held per NP order. Clarified dose on shift. 6/30/21 at 13:03 (1:03 PM), Nurse Progress Note: Resident request writer take BP (blood pressure) as he was feeling like his BP may have dropped. Fatigue and overall weakness reported. BP 101/71 at this time. No parameters for [MEDICATION(S)] which is due HS tonight. Writer left message to report low BP reading, indifferent from 141/80 taken this am. BG (blood glucose) 125 on check of BP as well. Will cont (continue) to monitor. 6/30/21 at 14:57 (2:57 PM), Nurse Progress Note: Call placed to APP (Advanced Practice Provider) line to request BP parameters for [MEDICATION(S)] as there are no current orders. Resident was getting 25mg QID (three times a day) in hospital, however new order upon admit is for 100 mg ER tabs QHS (every bedtime). This dose was given last night in addition to the two 25 mg given in hospital yesterday for total dose of 150mg. Above info (information) given to APP team via voice-message. Request for clarification and/or parameters ASAP (as soon as possible) today. RNCM (Registered Nurse Case Manager) also notified. 6/30/21 at 22:05 (10:05 PM), Nurse Progress Note: Resident did not have any emesis in this shift. Denies Nausea, no c/o (complaints of) pain noted. 6/30/21 at 23:39 (11:39 PM), Nurse Progress Note: On call MD called and [MEDICATION(S)] ([MEDICATION(S)]) discontinued per pharmacy recommendation. 7/01/21 03:43 (3:43 AM), Comprehensive Nursing Note: GI status/Appliances- Continent of Bowel - Yes Date of Last Bowel Movement - 6/30/21 Change in Bowel Status - No Abdomen - Soft Bowel Sounds - Within Normal Limits Drain - No Ostomy - No 7/01/21 (1:30 PM), Comprehensive Nursing Note: GI status/Appliances- Continent of Bowel - Yes Date of Last Bowel Movement - 6/30/21 Change in Bowel Status - Yes Abdomen - Soft Bowel Sounds - Within Normal Limits Drain - No Ostomy - No Denies N/V/D (Nausea/Vomiting/Diarrhea) states he feels better than yesterday. 7/02/21 13:52 (1:52 PM), Comprehensive Nursing Note: GI status/Appliances- Continent of Bowel - Yes Date of Last Bowel Movement - 7/02/21 Change in Bowel Status - Yes Abdomen - Soft Bowel Sounds - Within Normal Limits Drain - No Ostomy - No On 8/31/21 at 10:40 AM, Surveyor interviewed R4. R4 stated, On my day of admission the Nurse came in between 10:00 PM and 11:00 PM to give me night medication. She had [MEDICATION(S)] with her and [MEDICATION(S)] 30 units. I told the nurse I had received the [MEDICATION(S)] that morning in the hospital and shouldn't get it again and I also explained I don't get that much insulin at night. The nurse insisted on giving both medications to me anyway. I was up most of the night after that vomiting. On 8/31/21 at 2:00 PM, Surveyor interviewed DON B. Surveyor asked DON B for any medication error information. DON B stated she would look. Surveyor asked DON B about R4's admission medication errors. DON B stated, I did some informal education with the nurse about listening to residents who are alert and oriented. No formal education. DON B states, R4's vomiting more than likely from the [MEDICATION(S)] as I have seen that before. Surveyor asked about education to the nurse on [MEDICATION(S)] dosing. DON B stated, I wasn't aware that a wrong dose of [MEDICATION(S)] was also given that same night. On 8/31/21 at 4:35 PM, Surveyor interviewed APNP D (Advanced Practice Nurse Prescriber). Surveyor asked APNP D about R4's admission. APNP D states, R4 was seen on 6/30/21 by my colleague. When she saw R4 he reported to her he had received an extra dose of [MEDICATION(S)] and a double dose of [MEDICATION(S)] at bedtime. R4 informed her he had questioned the nurse and she gave him the medication anyway. I have attributed his GI symptoms to the extra dose of [MEDICATION(S)] as it has a lot of side effects. The dose increase, increases the chance of adverse effects and attributed to an overdose reaction. Surveyor asked APNP D what her expectation would be if a resident who is cognitively intact questioned a dose or stated they have already received a medication. APNP D stated, I would expect they question that and call a provider, not give it. I would also expect blood sugars to be checked more frequently but not too concerned as this was long acting insulin. From what I can see she only called the Physician about the [MEDICATION(S)] not the double dose of [MEDICATION(S)]. I would expect that if I hadn't seen the resident yet they call and clarify the medication with the hospital. Surveyor asked APNP D if dose orders for [MEDICATION(S)] were every clarified with her. APNP D stated, Note was on line on 6/30/21, there is a note that states someone tried to call stayed on the line for 5 plus minutes but there is no note that they ever clarified the [MEDICATION(S)]. On 7/06/21, R4 was hospitalized with GI symptoms. Hospital note states in part . Vomiting x7 days. Last emesis yesterday afternoon. Was able to tolerate soup and Jell-O for dinner. Loose stools over the weekend. Patient in no distress on arrival. ED (Emergency Department) Note from 7/06/21 states in part . R4 states he was discharged from the hospital on 6/29/21 to rehab, that night was having vomiting, vomits up to 4 times a day, also recently developed diarrhea. Has not vomited today at all, last emesis yesterday. Currently does not endorse any nausea. States that his diarrhea has continued however. MDM (Medical Decision Making): There is evidence of diarrhea. Discussed results of w/u (work up) with patient, symptoms possible due to [CONDITION(S)] GI infection, plan to discharge back to facility given asymptomatic at least from n/v (nausea/vomiting) standpoint for which he was initially sent to ED. Note: Though R4 was seen in the ED on 7/06/21 and states he has been vomiting since 6/29/21 at least 4 times a day, the medical record for R4 does not show evidence of such. In fact, the medical record shows that R4's nausea and vomiting began on 6/30/21 [MEDICATION(S)] until approximately 6:00 AM, with no further emesis documented until 7/04/21. R4's medication were incorrectly transcribed from the discharge orders to the eMAR. This resulted in a double dose of [MEDICATION(S)], a 2nd dose of [MEDICATION(S)], and additional dose of [MEDICATION(S)] on top the 50 mg he received in the hospital prior to admission. After receiving these medications R4 developed severe nausea and vomiting which required physician intervention and orders for [MEDICATION(S)].

Based on interview and record review, the facility did not promptly consult with the physician for 3 of 23 (R4, R27, and R15) sampled residents when they experienced significant changes in condition or met parameters set by the physician to be notified. The facility failed to promptly consult with R4's physician when R4 presented with worsening symptoms of CHF (Congestive Heart Failure) on [DATE], resulting in R4 being sent to the hospital with acute exacerbation of chronic diastolic CHF. The resident returned with orders to monitor weight and to consult with the physician when the resident had weight increases that exceeded the parameters established in the physician orders. The facility did not consult with the physician when R4's weights exceeded parameters on 5 dates in [DATE]. R4 was sent to the hospital again on [DATE] with wheezing and pitting [CONDITION(S)] with a final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to immediately consult with R4's physician when she was experiencing significant changes in condition created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. The NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ on [DATE] at 12:43 PM. The IJ was removed on [DATE]; however the deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement their action plan and as evidenced by the following The facility did not consult with the physician and inform the MD that weekly weights were not being completed for R27 and R15. (Both residents have care plans directing staff to monitor weights.) R27 did not have weights taken between [DATE] and [DATE], between [DATE] and [DATE], and between [DATE] and [DATE]. R15 did not have weekly weights taken between [DATE] and [DATE] and between [DATE] and [DATE]. The weight taken on [DATE] showed a 24.6% increase in 7 weeks; the facility did not reweigh the resident and did not consult with the physician about this significant weight increase. Evidenced by: AMDA (American Medical Directors Association) definition of Acute Change of Condition (ACOC): An ACOC is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional domains. Clinically important means a deviation that, without intervention, may result in complication or death. According to an article by the Harvard Medical School, Fluid buildup indicates worsening heart failure .The buildup of excess fluid in your body can take a variety of forms from belly bloating and swollen ankles to nausea, persistent coughing and fatigue. You may be tempted initially to dismiss this hodgepodge of problems as having little to do with your heart. However, they all signal water retention, which can mean trouble for people with a history of heart failure. Fluid buildup can quickly escalate into a life-threatening situation . https://www.health.harvard.edu/heart-health/fluid-retention-what-it-can-mean-for-your-heart According to WebMD's Heart Failure Health Center, Sometimes your symptoms may get worse very quickly. This is called sudden heart failure. It causes fluid to build up in your lungs, causing congestion. (This is why the problem is often called congestive heart failure.) .Sudden heart failure is an emergency. You need care right away. http://www.webmd.com/heart-disease/heart-failure/tc/heart-failure-symptoms The facility policy titled Change of Condition, dated [DATE], states in part . When a change of condition occurs, assessments are updated to reflect the change (pain, fall, skin, elope, etc.). Physician and responsible party notified of changes. Change of condition documented on the 24-hour report sheet; discussed at the morning meeting with f/u (follow-up). Stop and Watch completed and reviewed. System is in place to identify resident who require monitoring, assessment, and intervention. Care plan revised to reflect changes in conditions. On [DATE] R4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 is [AGE] years-old According to R4's most recent MDS (Minimum Data Set) dated [DATE], her BIMS (Brief Interview for Mental Status) is 7, indicating she has severe cognitive impairment. She requires limited assistance of two for transferring, dependent of one toileting, is independent with locomotion on unit and requires supervision of one with eating. R4 is frequently incontinent of bowel and always incontinent of bladder. R4 is not her own person with an AHCPOA (Activated Health Care Power of Attorney). R4 is a Full Code (resident would like CPR (Cardiopulmonary Resuscitation) performed in the event her heart stops). R4's CNA (Certified Nursing Assistant) Care Sheet, printed [DATE], indicates in part . Diet Orders: Frequent supervision, 2L (Liters) FR (Fluid Restriction)/24 hours, encourage to drink H2O (water) as long as within fluid restriction. ADL's (Activities of Daily Living): Showers Thursday AM (morning) and Sunday AM, weights on shower days. R4's comprehensive Care Plan, last reviewed on [DATE], includes the following focus areas: Focus: Therapeutic diet served due to DM 2 and obesity. [DATE] recent weight fluctuations due to fluid overload f/b (followed by) diuresis. Interventions: Fluids restricted to 2 liters/24 hours which is distributed at meals and by NSG (Nursing) staff. Monitor weights. Focus: Alteration in cardiovascular status r/t (related to): [CONDITION(S)] and CAD (Coronary Artery Disease). Interventions: Daily weights. Observe for [CONDITION(S)] or congestion. Resident will inform staff of chest pain or SOB (shortness of breath). Observe for signs of SOB. On [DATE], R4 was transferred to the ER (emergency room ) for evaluation due to complaints of chest tightness. R4 returned the same day with new orders to monitor for [CONDITION(S)]. On [DATE] at 1:16 PM, NN's (Nurses Notes) written by LPN-J state the following: Report by CNA (Certified Nursing Assistant) on night shift that resident left top of hand was puffy. Noted this AM during AM cares that resident left hand, arm, bilateral legs and bilateral feet are 3+ (plus) pitting [CONDITION(S)] and hard to touch. No SOB. Lung sounds are clear. No cough. Doctor on call called and received order to send resident to the ER for evaluation of possible fluid overload. Son (AHCPOA) was called and informed of resident transport. Resident left per stretcher per ambulance at 12:00 PM. Hospital ER RN was called and given resident information. Also had 2 other nurses assess resident with initial assessment by this nurse. Temperature: 98.1, O2 (oxygen) at 94% on room air. On [DATE] at 9:17 AM, Surveyor interviewed LPN J. Surveyor asked LPN J what she could tell Surveyor about R4 and her hospitalization s. LPN J stated, R4 went to hospital in March for fluid overload. NOC (night) shift CNA reported to me at shift change that R4's arm was swollen. When R4 got up for the day right before lunch I went and looked at it and called 2 other Nurses one being LPN H to come look with me. Surveyor asked LPN J if she got an RN to assess R4. LPN J stated, No, I didn't I had the other two LPN's in the building at the time come look at the R4 with me. Surveyor asked LPN J if she observed R4 immediately being informed of R4's hand being edematous. LPN J stated, I didn't get it in report from NOC nurse. The CNA reported it to me but R4 doesn't get up until later so I waited until staff got her up for the day around lunch time. Note: The CNA reported the change in R4 to the LPN during shift change and the LPN did not observe R4's condition until staff had gotten R4 up for lunch, did not get an RN to assess R4, and did not promptly consult with a physician regarding R4's changed condition. R4's Hospital discharge summary states in part Primary Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Chest x-ray showed stable cardiomegaly with possible pulmonary venous congestion. A proBNP (N-terminal prohormone of brain natriuretic peptide is a lab test that monitors the non-active prohormone produced by the heart) with a value of 4100. The normal range for proBNP in someone under the age of 75 is 125pg/mL (picograms/milliliter). R4 received IV (Intravenous) [MEDICATION(S)] (diuretic) while in the hospital. On [DATE], R4 discharged back to the facility with new orders for daily weights: Call the physician if weight gain of > (greater than) 3 lbs (pounds) in a day or >5 lbs in a week. Daily Weights: There were no weights taken on ,d+[DATE] or [DATE] [DATE]: 207.2 There are no weights taken from [DATE] to [DATE] [DATE]: 213.8 lbs. The facility did not immediately consult with R4's physician regarding a weight gain greater than 5 lbs. in one week. There were no weights taken on ,d+[DATE] or [DATE] [DATE]: 218.8 lbs. - increase of 5 lbs in 3 days. The facility did not immediately consult with R4's physician regarding a weight gain greater than 5 lbs. in one week. [DATE]: 220 lbs. [DATE]: 218.8 lbs. [DATE]: 220.8 lbs. [DATE]: 222.8 lbs. [DATE]: 211.7 lbs. [DATE]: 217.8 lbs. Weight increase of 6 pounds in 1 day. The facility did not immediately consult with R4's physician regarding a weight gain greater than 3 lbs. in one day. [DATE]: 222.2 lbs. Weight increase of 4.4 lbs in a day. The facility did not immediately consult with R4's physician regarding a weight gain greater than 3 lbs. in one day. [DATE]: No weight recorded [DATE]: 227 lbs. - increase of 4.8 lbs in 2 days and 9.2 lbs. in 3 days. The facility did not immediately consult with R4's physician regarding a weight gain greater than 5 lbs. in one week. [DATE]: 227.8 lbs. On [DATE] at 10:09 AM, NN's for Daily Skilled / Comprehensive Review Completed (by an LPN): BP (Blood Pressure) ,d+[DATE], P (Pulse) 70, Temperature 98.1, Respirations 16. [CONDITION(S)]: No, Chest Pain/Tightness: No. Individual Observation: No shortness of breath or Trouble breathing Noted when Sitting at Rest Individual Observed - No shortness of breath or Trouble breathing Noted when Lying Flat - No Shortness of breath or Trouble Breathing Noted with Exertion (e.g., walking, bathing, transferring). Lung sounds: Clear. However, later that day R4 had an outpatient Nephrology appointment where she was sent to the ER by the Nephrologist due to fluid overload. Office Visit Note from Nephrology on [DATE] states in part . Recently discharged from Hospital on [DATE] after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Exam: Lungs: wheezing. Extremities: ,d+[DATE]+ pitting [CONDITION(S)] all the way up her thigh. Assessment: Decompensated CHF, CKD (chronic kidney disease) [CONDITION(S)]. She is grossly volume overloaded today. She will need IV diuretics to control volume status. I will send her to the Hospital ER to get admitted . Plan: Will refer to the ER. Will inform POA. On [DATE] at 5:38 PM, NN notes indicate, Spoke with RN, undetermined if and when they will be sending R4 back. C/o (Complaints of) SOB/satting (sic) at 100% on RA (room air). Lungs not clear but 'not bad' either per RN. R4 is still being worked up. They will call when they know more. Writer let them know that she was having hematuria and had a UA (urinalysis) done but that C&S (culture and sensitivity) was pending. On [DATE] at 1:03 AM, NN's note states, Called hospital and informed that R4 was admitted , diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Discharge Summary hospital stay [DATE] to [DATE] states in part .Primary Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient was sent to the ER by nephrologist with concern for decompensated heart failure volume overload - she has been with increasing shortness of breath and leg swelling for a month. Hospital Course: Diuresed with IV [MEDICATION(S)] and [MEDICATION(S)] (diuretic). BNP showed improvement from over 4000 to 3000 and improved clinically with resolution of shortness of breath. Possible type 2 demand MI - due to Acute Diastolic Heart Failure - troponin elevated but no symptoms of ACS (Acute Coronary Syndrome). Note: A Type 2 MI occurs secondary to an acute imbalance in [CONDITION(S)] oxygen supply and demand without atherothrombosis (clot). On [DATE] at 4:17 PM, Surveyor interviewed LPN H. Surveyor asked LPN H what she does when a resident's weights are up requiring MD notification. LPN H stated, I always update the physician with weight changes, especially for R4. R4 is independent when up in her wheelchair and will frequently get pop from the pop machine. Surveyor asked LPN H if she could provide documentation of physician notification. Documentation of physician notification was not provided to Surveyor prior to leaving the facility. On [DATE] at 8:49 AM, Surveyor interviewed DON B. Surveyor asked DON B if R4's weights showing an increase of >3 lbs in a day or > 5 lbs in a week if that should be reported to the physician. DON B stated, Absolutely. Surveyor asked DON B if she could provide Surveyor with documentation that the physician was notified of R4's weight changes. Surveyor was not provided with physician notification documentation prior to leaving the facility. On [DATE] at 09:56 AM, Surveyor interviewed NP T (Nurse Practitioner). Surveyor asked NP T if she would expect to be updated on weights not being completed. not following R4's FR, and weights of >3 lbs in a day or >5 lbs in a week. NP T stated, Yes. Surveyor asked NP T if not doing the above things could have contributed to her exacerbation of CHF. NP T stated, It certainly could be. The facility failed to promptly consult with the physician when R4 experienced a change of condition on [DATE] and afterwards when weights were outside the parameters set by the physician. This failure created a situation of Immediate Jeopardy, which was removed on [DATE] when the facility implemented the following action plan On [DATE], R4's record was reviewed to determine if there were any existing evidence of a change of condition which warrants an appropriate nursing assessment, notification to the physician, follow-up and subsequent documentation. On [DATE], a full facility, physical review of all residents will be completed to determine if there were any residents that present with evidence of a Change of Condition that requires implementation of a thorough systems assessment, notification to physician of a change of condition and appropriate documentation of immediate follow-up. On [DATE], a general review of nursing documentation of all residents' statuses to include 24-hour report sheets to determine if there were any residents that present with evidence of a Change of Condition that requires implementation of a thorough systems assessment, notification to physician of a change in condition and appropriate documentation of immediate follow-up. Existing policies related to Change of Condition, Notification of Physician, Nursing Assessments, Documentation and Measuring Weights will be reviewed by the DON and clinical leadership to determine if they remain appropriate. Prior to the start of their next working shift, licensed nursing staff and certified nursing assistants will be provided education on policies procedures related to proper notification of changes to the PCP/POA/Family. Prior to the start of their next working shift, licensed nursing staff and certified nursing assistants will be provided education on identification of change of condition in accordance with the American Medical Directors Association's (AMDA) Acute Change of Condition in Long Term Care Setting Guideline, with special emphasis on acute exacerbation of Congestive Heart Failure (CHF). Prior to the start of their next working shift, licensed nursing staff and certified nursing assistants will be provided education on the requirement to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, the education will include the necessity to notify the physician if a weight increases by 3 lbs. in one day or 5 lbs. in one week. All licensed nursing staff will be checked for competency regarding identification of acute change of condition (emphasis on signs / symptoms of CHF exacerbation) and the appropriate response to include notification to the physician. The mechanism by which competency will be established is a quiz. The nurse care management under the oversight of the DON and clinical leadership team will review resident weights in Point-Click-Care to ensure compliance with physicians orders and to ensure proper follow-up if necessary. In addition, the nurse case managers will monitor changes of condition through daily rounding of all nurse areas and utilize the Sop-N-Watch tool for any acute changes. Resident care plans will be updated if resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The DON or their designee(s) will conduct random audits of Change of Condition to ensure proper identification at the following rates: All residents daily x2 weeks; X10 residents daily x1 month; X3 residents weekly x2 weeks; X2 resident monthly x1 month; monthly random audits will be instituted thereafter for a period of 9 months unless deemed otherwise by the QAPI committee. The DON or their designee(s) will conduct random audits of Point-Click-Care (PCC) nursing assessments to ensure proper care and treatment oat the following rates: X10 residents daily x1 month; X3 residents weekly x2 weeks; X3 residents monthly x1 month; monthly random audits will be instituted thereafter for a period of 9 months unless deemed otherwise by the QAPI committee. The DON or their designee(s) will conduct random audits of Physician's Notification of Resident Change of Condition to ensure timely reporting and appropriate follow-up at the following rates: All residents daily x2 weeks; X10 residents daily x1 month; X3 residents weekly x2 weeks; X3 residents monthly x1 month; monthly random audits will be instituted thereafter for a period of 9 months unless deemed otherwise by the QAPI committee. The DON or their designee(s) will conduct random audits of daily or weekly resident weights to ensure proper completion, as well as, to determine if any concerns identified required immediate follow-up with an assessment and / or notification to a physician at the following rates: X10 residents daily x1 month; X3 residents weekly x2 weeks; X3 residents monthly X1 month; monthly random audits will be instituted thereafter for a period of 9 months unless deemed otherwise by the QAPI committee. Audit trends will be reviewed at the monthly Quality Assurance / Performance Improvement (QAPI) meeting x 12 months to validate substantial compliance. On [DATE], the immediacy will be removed when all staff will be educated, policies reviewed and revised as needed and competency checks completed. Cross Reference F684 J The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement the above plan and as evidenced by: Example 2 R27 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to complete weekly weights for R27 and failed to report weights not being completed to the physician. R27's care plan dated [DATE] with revision date of [DATE] and target date of [DATE] has a focus of altered nutrition; resident having a recent weight loss. Stated goal of care plan, resident will have no significant weight loss. Interventions include: Monitor weights, encourage meal and beverage intake, provide meal set up, supervision and cues to eat. R27's care plan focus of alteration in cognition related to dementia initiated on [DATE], revised on [DATE] and target date of [DATE] has interventions that include MD notification as needed. The facility shower and weight schedule for R27, dated [DATE], indicates R27 should be showered, weighed weekly on Wednesdays. Current standards of practice for nursing home residents include . weighing the resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends such as insidious weight loss. Weighing may also be pertinent if there is a significant change in condition, food intake has declined and persisted (e.g., for more than a week), or there is other evidence of altered nutritional status or fluid and electrolyte imbalance. R27's weights were obtained only on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 4:55 PM, Surveyor interviewed DON B (Director of Nursing) regarding lack of weekly weights and lack of physician notification of weight changes. Surveyor asked DON B, what is your expectation in regards to residents being weighed and notification of the physician? DON B indicated, It is our expectation for residents to be weighed weekly on their shower day and that the nurse on duty ensure the weights are completed, recorded and the doctor updated as needed. Surveyor asked DON B, have there been any weights on R27 since [DATE]? DON B replied No. Surveyor asked DON B, are weights being monitored if not completed for a two month period? DON B answered, No. Surveyor asked DON B, who supervises that the weekly weights and showers are being completed? DON B indicated, I would expect the nurse on duty to ensure that weights are completed as ordered, recorded and the provider is notified of changes. On [DATE] 9:53 AM, Surveyor interviewed NP T (Nurse Practitioner) regarding the facility not notifying providers of weight changes & not weighing residents as ordered. NP T stated, Yes, I would expect the facility to notify me if weights were not done. Surveyor requested resident be weighed during survey; this was not completed. Example 3 R15 was admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & frequent falls. The facility failed to weigh and monitor R15's weight as ordered and report an increase to the physician. R15's care plan dated [DATE] with revision on [DATE] has a goal of resident will maintain weight range of ,d+[DATE] pounds. Interventions include, .monitor weights, encourage meals and beverages, provide meal set up . R15's weights and vitals summary revealed weights were obtained on [DATE] at 111.4 pounds and [DATE] at 138.2 pounds. This is a 24.6 % increase in weight in seven weeks for R15. There is no evidence the facility consulted with the physician about this weight gain. R15's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . and the facility shower and weight schedule for R15 dated [DATE], indicates R15 should be showered & weighed .weekly on Wednesdays. Dietary progress note of [DATE] for R15 states reweight to be requested. There was no facility documentation of reweight or physician notification of weight change in R15's record. On [DATE] at 4:55 PM, Surveyor interviewed DON B regarding lack of weekly weights, lack of physician notification of weight changes, lack of reweights. DON B, Yes, it is our expectation for residents to be weighed weekly on their shower day. Surveyor asked DON B, have there been any weights on R15 since [DATE]? DON B answered, No. Surveyor asked DON B, are weights being monitored if not completed in a two month period? DON B replied, No. Surveyor asked DON B, who supervises that the weekly weights and showers are being completed? DON B indicated, I would expect the nurse on duty to ensure that weights are completed as ordered, recorded and the provider is notified of changes. Surveyor asked DON B, should the physician have been notified of this weight change? DON B stated, Yes. Surveyor asked DON B, should the reweight have been completed? DON B replied, Yes, that is on us, it should have been done. On [DATE] at 9:53 AM Surveyor interviewed NP T regarding the facility not notifying providers of weight changes, not weighing residents as ordered. NP T, Yes, I would expect them to notify me if weights weren't done. Surveyor requested resident be weighed during survey; this was not completed.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 2 of 19 (R4 and R52 ) sampled residents. The facility failed to complete comprehensive assessments for R4 when R4 presented with changes of condition related to worsening symptoms of CHF (Congestive Heart Failure) on [DATE], [DATE], and [DATE], resulting in R4 being sent to the hospital on these dates. The facility did not monitor R4's weights as ordered and update the physician with weight increases to prevent exacerbation of CHF. R4 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to assess R4 when she was experiencing an exacerbation of CHF and its failure to monitor weights and fluid intake so that more immediate intervention could occur when symptoms of an exacerbation of R4's congestive heart failure presented created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ on [DATE] at 12:43 PM. The IJ was removed on [DATE]; however the deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan and as evidenced by Resident 52. The facility failed to have a system in place to monitor daily weights and to assess R52, who has a history of CHF, for potential CHF exacerbation when weight increases were identified. Evidenced by: According to Chapter N6 of the Wisconsin Nurse Practice Act, An RN (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment: Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient, which includes goals and priorities derived from the nursing diagnosis . According to an article by the Harvard Medical School, Fluid buildup indicates worsening heart failure .The buildup of excess fluid in your body can take a variety of forms from belly bloating and swollen ankles to nausea, persistent coughing and fatigue. You may be tempted initially to dismiss this hodgepodge of problems as having little to do with your heart. However, they all signal water retention, which can mean trouble for people with a history of heart failure. Fluid buildup can quickly escalate into a life-threatening situation . https://www.health.harvard.edu/heart-health/fluid-retention-what-it-can-mean-for-your-heart According to WebMD's Heart Failure Health Center, Sometimes your symptoms may get worse very quickly. This is called sudden heart failure. It causes fluid to build up in your lungs, causing congestion. (This is why the problem is often called congestive heart failure.) .Sudden heart failure is an emergency. You need care right away. http://www.webmd.com/heart-disease/heart-failure/tc/heart-failure-symptoms Example 1 On [DATE] R4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 is 66-years-old. R4's most recent MDS (Minimum Data Set) dated [DATE] indicates her BIMS (Brief Interview for Mental Status) is 7, indicating she has severe cognitive impairment. R4 requires limited assistance of two for transferring, is dependent on one for toileting, is independent with locomotion on unit, and requires supervision of one with eating. R4 is frequently incontinent of bowel and always incontinent of bladder. R4 is not her own person with an AHCPOA (Activated Health Care Power of Attorney). R4 is a Full Code (resident would like CPR (Cardiopulmonary Resuscitation) performed in the event her heart stops). R1's CNA (Certified Nursing Assistant) Care Sheet, printed [DATE], indicates in part . Diet Orders: Frequent supervision, 2L (Liters) FR (Fluid Restriction) /24 hours, encourage to drink H2O (water) as long as within fluid restriction. ADL's (Activities of Daily Living): Showers Thursday AM (morning) and Sunday AM, weights on shower days. R4's comprehensive Care Plan, last reviewed on [DATE], includes the following focus areas: Focus: Therapeutic diet served due to DM 2 (diabetes) and obesity. [DATE] recent weight fluctuations due to fluid overload f/b (followed by) diuresis. Interventions: Fluids restricted to 2 liters/24 hours which is distributed at meals and by NSG (Nursing) staff. Monitor weights. Note: There is no documentation that staff was accurately monitoring fluid intake each day to ensure R4 did not have more than 2000 cc fluid per day. Focus: Alteration in cardiovascular status r/t (related to): [CONDITION(S)] and CAD (Coronary Artery Disease). Interventions: Daily weights. Observe for [CONDITION(S)] or congestion. Resident will inform staff of chest pain or SOB (shortness of breath). Observe for signs of SOB. Note: R4 has orders for daily weights. No weights were obtained between [DATE] and [DATE]. On [DATE], R4 was transferred to the ER (emergency room ) for evaluation due to complaints of chest tightness. R4 returned the same day with new orders to monitor for [CONDITION(S)]. On [DATE] at 1:16 PM, NN's (Nurses Notes) state the following: Report by on night shift that resident left top of hand was puffy. Noted this AM during AM care resident's left hand, arm, bilateral legs and bilateral feet are 3+ (plus) pitting [CONDITION(S)] and hard to touch. No SOB (Shortness of breath). Lung sounds are clear. No cough. Doctor on call called and order received to send resident to the ER for evaluation of possible fluid overload. Son (AHCPOA) was called and informed of resident transport. Resident left per stretcher per ambulance at 12:00 PM. Hospital ER (emergency room ) RN was called and given resident information. Also had 2 other nurses assess resident with initial assessment by this nurse. Temperature: 98.1, O2 (oxygen) at 94% on room air. This note was written by LPN J. Surveyor interviewed LPN J on [DATE] at 9:17 AM. Surveyor asked LPN J what she could tell Surveyor about R4 and her hospitalization s. LPN J stated, R4 went to hospital in March for fluid overload. NOC (night) shift CNA reported to me at shift change that R4's arm was swollen. When R4 got up for the day right before lunch I went and looked at it and called LPN H to come look with me. Surveyor asked LPN J if she got an RN to assess R4. LPN J stated, No, I didn't. I had the other two LPNs in the building at the time come look at the R4 with me. Surveyor asked LPN J if she observed R4 immediately after being informed of R4's hand being edematous. LPN J stated, I didn't get it in report from NOC nurse. The CNA reported it to me but R4 doesn't get up until later so I waited until staff got her up for the day around lunch time. Note: The CNA reported the change in R4 to the LPN during shift change (at approximately 6:00 AM) and the LPN did not observe R4's condition until staff had gotten R4 up for lunch. There is no evidence that a registered nurse (RN) was called to assess R4 and to determine the most appropriate course of action. There is also no documented assessment of R4's lung sounds, pulse or respirations. The above documentation was completed by a LPN (Licensed Practical Nurse) who is unable to assess. The two other nurses consulted by documenting LPN were also LPNs. R4's Hospital discharge summary states in part Primary Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Chest x-ray showed stable cardiomegaly with possible pulmonary venous congestion. A proBNP (N-terminal prohormone of brain natriuretic peptide is a lab test that monitors the non-active prohormone produced by the heart) with a value of 4100. The normal range for proBNP in someone under the age of 75 is 125pg/mL (picograms/milliliter). R4 received IV (Intravenous) [MEDICATION(S)] (diuretic) while in the hospital. On [DATE], R4 discharged back to the facility with new orders for daily weights: Call the physician if weight gain of > (greater than) 3 lbs. (pounds) in a day or >5 lbs. in a week. Daily Weights: There were no weights taken on ,d+[DATE] or [DATE] [DATE]: 207.2 There are no weights taken from [DATE] to [DATE](facility is not assessing residents weights daily as per MD order) [DATE]: 213.8 lbs. - weight is up 6.6 pounds. There is no indication R4 had a respiratory or cardiac assessment completed with this increased weight gain. There is no indication the staff assessed R4 for increased [CONDITION(S)], a sign of CHF exacerbation. There is no evidence staff informed the physician of a weight gain of greater than 5 pounds in a week. There were no weights taken on ,d+[DATE] or [DATE] [DATE]: 218.8 lbs. - R4's weight has increased another 5 pounds. There is no indication R4 had a respiratory or cardiac assessment completed with this increased weight gain there is no indication the staff assessed R4 for increased [CONDITION(S)] a sign of CHF exacerbation or that staff informed the MD of a weight gain greater than 5 lbs. in a week. [DATE]: 220 lbs. R4's weight has increase another 1.2 pounds or 6.2 pounds in 4 days; there is no indication R4 had a respiratory or cardiac assessment completed with this increased weight gain there is no indication the staff assessed R4 for increased [CONDITION(S)] a sign of CHF exacerbation. [DATE]: 218.8 lbs. [DATE]: 220.8 lbs. R4 weight increased 2 pounds with no assessment completed for R4. [DATE]: 222.8 lbs. R4's weight increased another 2 pounds or 4 pounds in 2 days with no assessment completed. [DATE]: 211.7 lbs. [DATE]: 217.8 lbs. R4's weight has increased 6.1 pounds in a day with no assessment completed. [DATE]: 222.2 lbs. - R4's weight has increased 4.4 pounds in a day or 10.5 pounds in 2 days with no assessment completed [DATE]: No weight recorded [DATE]: 227 lbs. - R4's weight has increased 5 pounds in 2 days with no assessment. [DATE]: 227.8 lbs. The facility was not monitoring R4's fluid intakes accurately. Recorded fluids in March, during the timeframe in which R4's weight increased from 211.7 lbs. to 227 lbs. were: [DATE]. 480 cc (cubic centimeter) [DATE]. 480 cc [DATE]. 1630 cc [DATE]. 800 cc [DATE]. 480 cc The MAR's for February and March indicate no intakes were recorded for the following dates and times: There are no recorded fluid intakes from [DATE] to [DATE] and [DATE] to [DATE]. There are no recorded fluid intakes on day shift [DATE] to [DATE] and [DATE] and [DATE]. There are no recorded fluid intakes on PM (evening) shift on [DATE], [DATE], [DATE], [DATE] and [DATE]. There are no recorded fluid intakes on NOC (night) shift on [DATE], [DATE], and [DATE]. On [DATE] at 10:09 AM, NN's for Daily Skilled/Comprehensive Review Completed: BP (Blood Pressure) ,d+[DATE]; P (Pulse) 70; Temperature 98.1; Respirations 16. [CONDITION(S)]: No; Chest Pain/Tightness: No. Individual Observation: No shortness of breath or Trouble breathing Noted when Sitting at Rest. Individual Observed - No shortness of breath or Trouble breathing Noted when Lying Flat - No Shortness of breath or Trouble Breathing Noted with Exertion (e.g., walking, bathing, transferring). Lung sounds: Clear. Note: This Daily Skilled/Comprehensive Review was completed by an LPN. Later in the day on [DATE], R4 had an outpatient Nephrology appointment. Office Visit Note from Nephrology on [DATE] states in part . Recently discharged from Hospital on [DATE] after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Exam: Lungs: wheezing. Extremities: ,d+[DATE]+ pitting [CONDITION(S)] all the way up her thigh. Assessment: Decompensated CHF, CKD, [CONDITION(S)]. She is grossly volume overloaded today. She will need IV diuretics to control volume status. I will send her to the Hospital ER to get admitted . Plan: Will refer to the ER. Will inform POA. On [DATE] at 4:17 PM, NN's notes state the following: Received call from Transport Company that resident was transferred to ER, call placed to determine why? On [DATE] at 5:38 PM, NN's notes indicate, Spoke with RN, undetermined if and when they will be sending R4 back. C/o (Complaints of) SOB/satting (sic) at 100% on RA (room air). Lungs not clear but 'not bad' either per RN. R4 is still being worked up. They will call when they know more. Writer let them know that she was having hematuria and had a UA (urinalysis) done but that C&S (culture and sensitivity) was pending. On [DATE] at 1:03 AM, NN's state, Called hospital and informed that R4 was admitted , diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Discharge Summary hospital stay [DATE] to [DATE] states in part .Primary Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient was sent to the ER by nephrologist with concern for decompensated heart failure volume overload - she has been with increasing shortness of breath and leg swelling for a month. Hospital Course: Diuresed with IV [MEDICATION(S)] and [MEDICATION(S)] (diuretic). BNP showed improvement from over 4000 to 3000 and improved clinically with resolution of shortness of breath. Possible type 2 demand MI - due to Acute Diastolic Heart Failure - troponin elevated (lab showing heart muscle insult/injury) but no symptoms of ACS (Acute Coronary Syndrome). Note: A Type 2 MI occurs secondary to an acute imbalance in [CONDITION(S)] oxygen supply and demand without atherothrombosis (clot). On [DATE] at 4:17 PM, Surveyor interviewed LPN H. Surveyor asked LPN H how staff monitor fluid restrictions and weights. LPN H stated, I don't do any of that but I write down what the CNAs tell me they give the residents. As for weights I am good about making sure my staff get weights and report them to me. Surveyor asked LPN H what she does when a resident's weights are up requiring MD (Medical Doctor) notification. LPN H stated, I always update the physician with weight changes, especially for R4. R4 is independent when up in her wheelchair and will frequently get pop from the pop machine. On [DATE] at 4:53 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B who is responsible to ensuring weights are obtained and documented in the facility. DON B stated, They do a poor job. We give them the education. We are working on this. This is one of the systems that is broke and we are working on it. Surveyor asked DON B about daily weights. DON B stated, Daily weights are done by the CNAs. Nurse should update MD with weight. Surveyor asked DON B what assessments should be completed for a resident with CHF. DON B stated, Should be assessing VS including [CONDITION(S)] and lung sounds regularly. Surveyor asked DON B what the process was for monitoring intake and output for R4 with CHF. DON B stated, Not sure but someone with that diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She is on a FR (fluid restriction) which the nurse would implement. Don't need MD orders for FR. I believe they are doing I&O's for R4. Surveyor asked DON B who is responsible for ensuring staff are aware of a resident's fluid restriction and how much they allowed to consume at meals. DON B indicated, Nursing staff are and the dietician doesn't have anything to do with I&O's. Surveyor asked DON B if a resident should have thorough systems assessment in a resident with CHF showing increased weight gain. DON B stated I would expect the nurses to complete a thorough assessment. On [DATE] at 8:47 AM, Surveyor interviewed Dietician I. Surveyor asked Dietician I what the facility process if for monitoring intakes and residents with a FR. Dietician I stated, Someone would let me know if someone is not drinking or eating. As for FR's we have chart as to what is to be served on meal trays and what should be given by nurses. I am not sure if on fluid restriction without looking in chart. The Dietary Manager sets that up and monitors FR's. On [DATE] at 8:49 AM, Surveyor interviewed DON B. Surveyor asked DON B about monitoring intakes. DON B stated, I don't think we monitor outside of meals. Surveyor asked DON B about monitoring output for R4. DON B stated, Resident is incontinent. She refuses to use the toilet but whatever fluids she takes in should be counted and monitored by staff. We should also be monitoring outputs. [DATE] at 8:56 AM, Surveyor interviewed DM E (Dietary Manager). Surveyor asked DM E what the process for the facility was for fluid restrictions. DM E stated, Tray cards have fluid restrictions on them. The CNA's serve the drinks and follow the fluid restriction. We do not measure liquid taken in with meals. On [DATE] at 9:56 AM, Surveyor interviewed NP T (Nurse Practitioner). Surveyor asked NP T if she would expect to be updated on no weights, not following R4's FR, and weights of >3 lbs. in a day or >5 lbs. in a week. NP T stated, Yes. Surveyor asked NP T if she not doing the above things could have contributed to her exacerbation of CHF. NP T stated, It certainly could be. On [DATE] at 3:35 PM, Surveyor interviewed CNA K. Surveyor asked CNA K what the facility process is for monitoring a resident's fluid restrictions. CNA K stated, We CNAs do the fluid restriction for the residents. We have a chart that has pictures with numbers of cc's in each glass. I then put it in the log and tell the nurse. On [DATE] at 3:42 PM, Surveyor interviewed CNA L. Surveyor asked CNA L what FR stand for on the CNA care sheet. CNA L stated, I think it means fluid restriction. Dietary does it. The facility failed to assess R4 when she experienced a change in condition on [DATE] when R4 complained of chest tightness, on [DATE] with CHF exacerbation and again on [DATE] with CHF exacerbation. Weights were not completed as ordered per physician, the facility failed to recognize increased [CONDITION(S)] and weight gain as a potential significant change of condition and failed to complete a thorough systems assessment for potential CHF exacerbation. The facility failed to have a process in place to monitor R4's intake and output and ensure staff and R4 were following her fluid restriction. On [DATE], when notified of a change in R4's condition LPN J did not contact an RN (Registered Nurse) for a thorough systems assessment. Subsequently, R4 experienced a change of condition on [DATE] and again on [DATE], R4 was hospitalized for exacerbation of CHF with fluid volume overload. These failures created a situation of Immediate Jeopardy, which was removed on [DATE] when the facility implemented the following action plan. On [DATE], R4's record was reviewed to determine if there were any existing evidence of a change of condition which warrants an appropriate nursing assessment, notification to the physician, follow-up and subsequent documentation. On [DATE], a full facility, physical review of all residents will be completed to determine if there were any residents that present with evidence of a Change of Condition that requires implementation of a thorough systems assessment, notification to physician of a change of condition and appropriate documentation of immediate follow-up. On [DATE], a general review of nursing documentation of all residents' statuses to include 24-hour report sheets to determine if there were any residents that present with evidence of a Change of Condition that requires implementation of a thorough systems assessment, notification to physician of a change in condition and appropriate documentation of immediate follow-up. Existing policies related to Change of Condition, Notification of Physician, Nursing Assessments, Documentation and Measuring Weights will be reviewed by the DON and clinical leadership to determine if they remain appropriate. Prior to the start of their next working shift, licensed nursing staff and certified nursing assistants will be provided education on policies procedures related to proper notification of changes to the PCP/POA/Family. Prior to the start of their next working shift, licensed nursing staff and certified nursing assistants will be provided education on identification of change of condition in accordance with the American Medical Directors Association's (AMDA) Acute Change of Condition in Long Term Care Setting Guideline, with special emphasis on acute exacerbation of Congestive Heart Failure (CHF). Prior to the start of their next working shift, licensed nursing staff and certified nursing assistants will be provided education on the requirement to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, the education will include the necessity to notify the physician if a weight increases by 3 lbs. in one day or 5 lbs. in one week. All licensed nursing staff will be checked for competency regarding identification of acute change of condition (emphasis on signs / symptoms of CHF exacerbation) and the appropriate response to include notification to the physician. The mechanism by which competency will be established is a quiz. The nurse care management under the oversight of the DON and clinical leadership team will review resident weights in Point-Click-Care to ensure compliance with physicians orders and to ensure proper follow-up if necessary. In addition, the nurse case managers will monitor changes of condition through daily rounding of all nurse areas and utilize the Sop-N-Watch tool for any acute changes. Resident care plans will be updated if resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The DON or their designee(s) will conduct random audits of Change of Condition to ensure proper identification at the following rates: All residents daily x2 weeks; X10 residents daily x1 month; X3 residents weekly x2 weeks; X2 resident monthly x1 month; monthly random audits will be instituted thereafter for a period of 9 months unless deemed otherwise by the QAPI committee. The DON or their designee(s) will conduct random audits of Point-Click-Care (PCC) nursing assessments to ensure proper care and treatment oat the following rates: X10 residents daily x1 month; X3 residents weekly x2 weeks; X3 residents monthly x1 month; monthly random audits will be instituted thereafter for a period of 9 months unless deemed otherwise by the QAPI committee. The DON or their designee(s) will conduct random audits of Physician's Notification of Resident Change of Condition to ensure timely reporting and appropriate follow-up at the following rates: All residents daily x2 weeks; X10 residents daily x1 month; X3 residents weekly x2 weeks; X3 residents monthly x1 month; monthly random audits will be instituted thereafter for a period of 9 months unless deemed otherwise by the QAPI committee. The DON or their designee(s) will conduct random audits of daily or weekly resident weights to ensure proper completion, as well as, to determine if any concerns identified required immediate follow-up with an assessment and / or notification to a physician at the following rates: X10 residents daily x1 month; X3 residents weekly x2 weeks; X3 residents monthly X1 month; monthly random audits will be instituted thereafter for a period of 9 months unless deemed otherwise by the QAPI committee. Audit trends will be reviewed at the monthly Quality Assurance / Performance Improvement (QAPI) meeting x 12 months to validate substantial compliance. On [DATE], the immediacy will be removed when all staff will be educated, policies reviewed and revised as needed and competency checks completed. Cross Reference F580 J The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy) as the facility continues to implement its action plan and as evidenced by: Example 2 R52 is a long term resident of the facility. R52 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R52's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE]-[DATE] Weight Daily in morning. Notify MD (Medical Doctor) of weight greater than or equal to 3 pounds in 24 hours. [DATE] Daily weight before breakfast R52's Weight record documents the following: [DATE]= 306.4 [DATE]= 307 [DATE]= 319.2 - this is a 12.2 lb. weight increase in 1 week and there is no evidence the facility completed a thorough systems assessment for R52 to rule out CHF exacerbation. [DATE]= 316.4 [DATE]= 312 [DATE]= 308.4 [DATE]= 298.2 [DATE]= 303.8 - this is a 5.6 lb weight increase in 1 day and there is no evidence the facility completed a thorough systems assessment for R52 to rule out CHF exacerbation. [DATE]= 303.6 [DATE]= 300.4, [DATE]=304 [DATE]= 298.8 It is important to note that the dates documented are the only dates that weights are recorded in R52's medical record. From [DATE] through [DATE] there are 18 days of missed weights. R52's CNA Care Delivery Guide documents daily weights, document refusals. R52's Care Plan for Self-care deficit and risk for falls R/T (related to) recent hospitalization for UTI (Urinary Tract Infection) dated [DATE], documents the following in part: .Use wheelchair scale for weights. Resident often refuses to get weighed . R52's Care Plan for ALTERATION IN CARDIOVASCULAR STATUS R/T: CHF, [CONDITION(S)], A-Fib dated [DATE], documents the following in part: .OBSERVE FOR [CONDITION(S)] OR CONGESTION .OBSERVE FOR SIGNS OF SOB. R52's CNA documentation was reviewed for 30 days with no documentation of refusals of weights. R52's Progress Notes were reviewed from [DATE] through [DATE] with no documentation of refusals of weights. The facility failed to have a system in place to monitor daily weights and to assess resident with a history of CHF for potential CHF exacerbation with weight increases.

Based on observation, interview, medical and record review the facility did not implement professional standards of practice to prevent PIs (pressure injuries) from developing, worsening, or to promote healing of PIs, and assessments of PIs are not consistently being completed by a RN (Registered Nurse), for 1 of 3 resident reviewed for PIs out of a sample of 23 residents (R55). R55 has [CONDITION(S)] and no feeling from his waist down. Per interview with R55, he stated he was admitted to the facility on [DATE] with a small pressure injury on his bottom that he has had for years. The facility did not identify R55's PI on the Admission Skin Assessment. The facility identified R55's PI on 3/18/21 (9 days after admission). When the PI was discovered it measured 2.2 cm (centimeters) x 1.7 cm and the wound bed contained 85% slough and 15% granulation tissue (Unstageable PI/Stage 3). The facility did not have a care plan with skin interventions in place until 3/19/21. Per interview with staff, R55 refuses repositioning about 50% of the time on AM and PM shifts and 100% of time when sleeping. The facility did not document R55's refusals to reposition or that staff provided the risks and benefits of refusing repositioning. The facility did not provide education to R55 related to the risk of sheering with slide board transfers, particularly due to his decreased trunk strength. Surveyor observed R1 lying directly on his back in bed putting pressure on his buttocks and left gluteal fold; CNA O (Certified Nursing Assistant) stated R55 refused repositioning that morning, however, she did not document R55's refusal or notify the nurse or DON B. There is no documentation that R55 refused repositioning or that staff provided the risks and benefits of refusing repositioning or slide board transfers that can increase the risk of sheering, particularly due to R55's decreased trunk strength. This is evidenced by The facility's policy, Pressure Injury/Skin Integrity/Wound Management, revised November 2016, states, in part, as follows: Policy: A system is in place for the prevention, identification, treatment, and documentation of pressure injuries and non-pressure wounds. Evaluate the resident's clinical condition and pressure injury risk factors; Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; Monitor and evaluate the impact of the interventions; and/or revise the interventions as appropriate. Eschar/slough: Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light in colored, soft, moist, and stringy (at times). Friction/Shearing: Friction is the mechanical force exerted on skin that is dragged across any surface. Shearing is the interaction of both gravity and friction against the surface of the skin. Friction is always present when shear force is present. Shear occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage. Stages of Pressure Injuries: The staging system is one method of summarizing certain characteristics of pressure injuries, including the extent of tissue damage. Stage 3 Pressure Injuries: Full-thickness skin loss - Full-thickness of loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of the tissue damage varies by anatomical location, areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Procedure: 1. Wound Assessment ii. All residents are preventatively placed on a pressure reduction mattresses and cushions in wheelchairs based on the skin assessments. Those residents who represent a high risk will have further preventative interventions put in place. Appropriate turning and repositioning schedules will also be put in place per assessment. An initial/immediate care plan will be initiated. NPIAP (National Pressure Injury Advisory Panel) defines a pressure injury (PI) as: Any skin lesion, usually over a bony prominence, caused by unrelieved pressure resulting in damage of underlying tissue. Major Risks Factors for Developing Pressure Injuries: Alterations in sensation or response to discomfort: [CONDITION(S)] neurological disease, [CONDITION(S)] disease, Central nervous system (CNS) injury, depression, drug that adversely affect alertness. Alterations in mobility: Neurological disease/injury, fractures, pain, restraints. Significant changes in weight (greater than 5% is 30 days or greater than 10% in the previous 180 days): Protein -calorie malnutrition, [CONDITION(S)]. The NPIAP classifies a pressure injuries as follows: Stage 3: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and [MEDICATION(S)] tracts may be associated with Stage 4 pressure ulcers. This is evidenced by: R55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R55's BIMS (Brief Interview of Mental Status) is 15/15, indicating he is cognitively intact. R55 is his own decision maker. On 3/9/21 at 4:11 PM, R55's Admission Skin Assessment documented the following: Site: Back Type: healing pressure Measurements: 0.8 x 0.5 x 0 R55's Admission MDS (Minimum Data Set) assessment, dated 3/13/21, Section C0200 Cognitive Patterns indicates R55's BIMS (Brief Interview of Mental Status) is 15, indicating he is cognitively intact. Section G Functional Status, indicates R55 is dependent on staff for bed mobility, Section M0150 Risk of Pressure Injuries indicates R55 is at risk for PI development. Section M0210 Unhealed Pressure Injuries indicates R55 has an unhealed PI. Section M0300 Current Number of Unhealed Pressure Injuries at Each Stage indicates R55's PI is a Stage 1: Intact skin with non-blanchable redness of localized area usually over a bony prominence (Note, this PI was noted to be higher on R55's back). Stage 2: 0 (zero), Stage 3: 0 (zero), Stage 4 0 (zero), Unstageable-slough/and/or eschar: 0 (zero), Unstageable-DTI (Deep Tissue Injury): 0 (zero). Section M1200 indicates Skin and Ulcer Treatments: A. Pressure reducing device for chair, B. Pressure reducing device for bed, C. Turning/repositioning program, E. Pressure ulcer care. Note, a care plan with skin interventions was not put in place until 3/19/21. R55's Braden Score (Risk factor for PI development) on 3/10/21 and 3/18/21 = 19, indicating R55 is not at risk of skin breakdown. Note, R55 was admitted with two pressure injuries. One PI is on his back (documented) and the PI on his left gluteal fold was present, however, it was not documented on admission. R55's Care Plan for Skin Integrity and pressure injury interventions was not put in place until 3/19/21. Note, this is one (1) day after the PI was discovered by staff and ten (10) days after admission. The facility did not have a temporary care plan in place. R55's CNA (Certified Nursing Assistant) Care Delivery Guide, dated 4/18/21, indicates the following: LAL (low air loss) mattress, Encourage/assist repositioning Q2 (every two) hours and PRN (as needed), Reposition side to side, not on back, Encourage to lay down after lunch. Mobility: w/c (wheelchair) 2 assist for bed mobility; Transfer: 1 assist with slide board On 3/18/21 at 9:24 PM, RN F (Registered Nurse) completed the Weekly Skin Check Tool indicating the following: Pressure sore noted to left buttock measuring 1.7 cm (centimeter) x 2.0 cm, has yellowish slough in wound bed. Will pass it on shift report for PCP (Primary Care Provider) to be notified/updated in the morning 3/19/21. On 3/19/21 at 3:40 PM, R55's Nurse Progress Notes indicates the following: Wound observation today resident has a wound to left gluteal fold with a yellow wound bed. Resident did not have any pain during assessment however he has no feeling from the torso down due to [CONDITION(S)] [sic]. He has been sitting up in his w/c (wheelchair) from morning till evening getting his room and computures [sic] situated. Resident agreed to lay down in bed after lunch and to lay and turn side to side. Resident was given an air mattress. Care plan and staff updated. Treatment order obtained. Note, there was no care plan with skin interventions in place until 3/19/21. There is no evidence that the facility offered to assist R55 with repositioning. There is no documentation that R55 refused repositioning or staff provided the risks and benefits of refusing repositioning or slide board transfers that can increase the risk of sheering, particularly due to R55's decreased trunk strength. On 3/19/21 R55's Physician Telephone Order: Apply Bordered gauze change every 3 days and as needed. On 3/23/21 at 8:31 PM, the facility's Weekly Wound Round Documentation indicates the following: 1. Reason for assessment a. New Wound, Date of Onset: Blank, 2. Notifications c. Individual/Self, Physician notified, Additional Information: Notified on 3/19/21 of wound new orders. Message left for MD (Medical Doctor) requesting new TX (treatment) order due to moderate/large drainage. 3. Type of Wound: Pressure Wound - Left gluteal fold, a. Acquired 3/18/21, Site: Left Gluteal Fold. Type: Pressure, Measurements 2.2 cm x 1.7 x? Stage Unstageable, 2. Wound base/bed: Granulation 85%, Slough 15% (Note, RN M later corrected to 85% slough & 15% granulation). Additional Information: Serosang (Serosanginous) drainage moderate to large amount, soft slight maceration to periwound. Undermining/Tunneling Present: Unable to visualize. Current treatment: Clean and apply bordered gauze q3 days (every 3 days) and PRN (as needed). Progression/Interventions: Improving, slough appears to be thinner than first observation on 3/19/21. Positioning Plan: Off left side. Nutrition: RD (Registered Dietician). Pressure Relieving Mattress/Device: Air mattress ROHO. On 4/16/21 at 2:33 PM, R55's Nurse Progress Notes indicate the following: Occupational Therapy screen due to return from day surgery s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Pt states PT (Physical Therapy) provided pt. with recommended ROM (range of motion) exercise for the weekend. OT recommends screen pt. on 4/19 - Monday when pt. is ready to participate in self-cares and functional mobility tasks. Note, R55 declined to get out of bed on 4/16/21 and was lying prone (on his back) for the day. There is no evidence that facility staff provided education related to refusing skin interventions and repositioning. On 4/18/21 at 11:54 AM, Surveyor conducted a resident interview with R55. R55 stated he was admitted to the facility with a small pressure injury on his bottom that he has had for years. On 4/20/21 at 1:35 PM, RN G (Registered Nurse) documented the following Progress Note: Skin - new or worsening skin concerns-No, Current Skin interventions: Resident has a dressing on his back/buttocks area according to him but would to let me look at it. [sic] Resident got upset when I asked to look at it and told me to leave his room. Note, there is no evidence the facility educated R55 related to refusing skin assessments, interventions, and treatments. Measurements - Left Gluteal Fold - Onset 3/18/21 3/18/21: 1.7 x 2.0 yellowish slough in wound bed Note, this PI was a Stage 3 when discovered by the facility. 3/23/21: 2.2 x 1.7 x? Unstageable, 85% granulation, 15% slough Slough appears to be thinner than first observation on 3/19. *Note correction to this entry below. 3/25 wound tx changed *3/28/21 Correction to wound round documentation (above) wound is 85% yellow slough and 15% granulation. MD (Medical Doctor) was updated on wound this week ad new treatment orders this week from MD. 3/30/21: 1.6 x 1.0 x less than 0.1 Unstageable 100% granulation 4/7/21: 2.0 x 1.5 x less than 0.1 decreased drainage, 100% granulation 4/13/21: 2.4 x 2.0 x less than 0.1 100% granulation - Updated MD, let her know it was a little bit bigger, macerated around edges, not being changed enough d/t drainage. The treatment was changed to daily. 4/20/21 2.4 x 1.4 x less than 0.1 100% granulation R55's Care Plan for Skin was not implemented until 3/19/21, the day after R55's Stage 3 left gluteal fold PI with 85% slough was noted by staff. The facility's matrix indicates R55 has a Stage IV, facility acquired PI. Note, based on interview with RN M, this wound is unstageable versus a Stage 4. On 4/20/21 10:23 AM, Surveyor spoke with RN M. RN M stated initially the nurse found the PI on the skin check & she assessed it. RN M stated she would call it unstageable RN M stated, there was slough- a lot of slough and she could not see the wound bed. On 4/20/21 at 8:20 AM, NHA A (Nursing Home Administrator) stated, When nurses ask to take a look at his skin he flips out. The moment he gets out of bed he does not want to get back in bed. Nurses do dressing changes first thing in AM (before R55 gets out of bed.). Everything has to be on his time at his schedule. On 4/20/21 at 8:50 AM Surveyor observed R55 lying in bed on his back. R55 declined to have Surveyor observe PI dressing change and PI. On 4/20/21 at 8:57 AM Surveyor interviewed CNA O (Certified Nursing Assistant) who is the assigned CNA on R55's unit. Surveyor asked CNA O to tell Surveyor about R55's skin interventions. CNA O stated she repositions him from bed to his chair. CNA O stated R55 is capable of communicating and she listens to what he says because it's his body. CNA O added, she looks at the Care Delivery Guide. CNA O stated, my Care Deliver Guide says reposition him from side to side not on back & encourage him to lay down after lunch. CNA stated I encourage repositioning every 2 hours but he has his own ideas. If he's cool with you he'll be open minded (clarified cooperative). CNA O stated, I think the people that position him side to side is on 3rd shift. CNA O added, on the AM shift he is repositioned from bed to chair, he will sometimes lay down. CNA O stated R55 does not like to acknowledge his disability. CNA O stated she is working from 6:00 AM - 2:00 PM today. Surveyor asked CNA O did you offer to reposition R55 this morning. CNA O stated yes, this AM he didn't want me to touch him, due to the pain he was aggravated. He was extremely upset due to pain; the pain is in his back. He'll say, I'm f***ing in pain. I'll tell the nurse to go see R55. Surveyor asked CNA O does R55 refuses repositioning. CNA O stated, Yes. Surveyor asked what percentage of the time R55 refuses to reposition. CNA O stated he refuses repositioning 50% of the time. CNA O stated if he refuses I'll ask him why. If he gives me a why, I work with him. He'll say I already done it, I don't need it. He didn't want me to touch him this morning. Do you know what position R55 is in right now. CNA O stated, he is on his back currently. I just give him cues & remind him. He uses a GB to pull himself up. He can do things without assist. Surveyor asked CNA O if a resident refuses repositioning what do you do. CNA O stated, I report to the RN. If it's an issue I could tell DON B (Director of Nursing). It's becoming a serious issue & not helping his sore - I would talk to DON B. Have you spoken with DON B about R55 not wanting to reposition. CNA O stated, No. Surveyor asked CNA O is it ok for R55 to lay on his back. CNA O stated, Not for a long extent of time. CNA O stated, He doesn't have a PI on his backside. Note, the CNA caring for R55 is unaware that he has a PI and should not be laying on his back. On 4/20/21 at 5:30 PM, Surveyor spoke with NHA A and DON B regarding this R55. NHA A added they think the PI may have been due to shear from the slide board R55 requested to use for transfers. R55 refused to use the Hoyer for transfers. NHA A added R55 was using his wheelchair from home at the facility. This wheelchair was missing the right side arm. The facility obtained a new arm for the wheelchair. NHA A feels the PI may have been due to shear from slide board, and/or the w/c was from his house that was missing the right side arm, causing R55 to lean to the left, thus putting pressure on R55's left buttock and left gluteal fold. NHA A added Therapy increased pressure on R55's Roho to account for this. NHA A added there were great interventions on Therapy's side and not great on the Nursing side. Note, there was no care plan with any skin interventions in place until 3/19/21. There is no evidence the facility offered to assist R55 with repositioning. There is no documentation R55 refused repositioning or staff provided the risks and benefits of refusing repositioning. There is no evidence staff educated R55 related to the use of slide board transfers. On 4/20/21 at 9:38 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B has the facility provided R55 the risk and benefits to refusing repositioning. DON B stated, We do not have any risk and benefits. DON B added she spoke with RN G (Registered Nurse) and she can complete the risks and benefits with R55. Surveyor asked DON B can you tell me when R55's air mattress was put in place. DON B looked this information up in R55's medical record and stated the air mattress was added 3/19/21 and R55 was admitted to the facility on [DATE]. DON B added upon admission R55 had a Panacea mattress. Surveyor asked DON B would you have expected R55 to have a care plan for skin upon admission. DON B stated, Yes, we're working on our admission system to make the process smoother (makes sure consents in place equipment in place, anticipate the needs of the resident.) Surveyor asked DON B is R55 currently a 2A (2 assist) for turning and repositioning. DON B stated, No, he should be a 1 assist for this (turning and reposition). R55 had a rotator cuff (debridement) on 4/15/21. R55 told us it was a rotator cuff tear but reading the notes it was a debridement that was done. Surveyor asked is R55 able to use his arms. DON B stated, absolutely. R55's paralysis is from the chest down. Surveyor asked DON B what the root cause of R55's PI is. DON B stated, I want to say because he doesn't like to get off his butt until he's ready. DON B added, He's not compliant with getting off his rump; he will let us know in no uncertain terms. Surveyor asked DON B do staff document R55's refusals to turn and reposition. DON B stated, it should be charted by the nurse. CNA's should be able to document, but currently that feature is not available for CNA's to document refusals. Should staff have provided risk/benefits of refusing turning and repositioning? DON stated, Absolutely! That is definitely on my radar now. Surveyor asked DON B why this is important. DON B stated, so he's aware of the consequences of not being repositioned and what that entails. Should staff have provided risk/benefits of slide board transfers? DON B states, yes. Surveyor stated the matrix indicates that R55 has a Stage IV facility acquired pressure injury. Surveyor asked DON B was R55's pressure injury to his left gluteal fold facility acquired. DON B stated, I believe he came in with it but we didn't get it documented, that's our responsibility. DON B added, Because we missed it we have to own it. Surveyor asked DON B does R55 refuse to reposition. DON B stated, Yeah, he does. DON B stated since admission R55 was adamant about staff not coming in his room when he was sleeping not even to empty his urinal; he doesn't like to be disturbed. DON B added, R55 is not being repositioned at night if he doesn't want to be disturbed. DON B stated she will see if that is documented anywhere. Note, no further information was provided. Surveyor asked DON B has anybody discussed the risk and benefits with R55 related to his refusals of repositioning. DON B stated, No, I don't believe they have. DON B stated the PI was discovered on 3/18/21 at 9:21 PM, the Physician was notified 3/19/21 at 9:41 AM. On 3/19/21 R55 agreed to lay down, R55 was given an air mattress, staff were updated, and treatment orders obtained. On 4/20/21 at 10:02 AM, Surveyor spoke with RN G. Surveyor asked if she is Wound Care Certified. RN G stated, No. Surveyor asked if any nurses in the building are Wound Care Certified. RN G stated she believes their Corporate Consultant who is not in the building is Wound Care Certified. Surveyor asked RN G how you identified the PI as a Stage 4. RN G stated when I came in it was already identified as a Stage 4. Note, the wound documentation indicates the wound is unstageable. RN G stated, I don't know what the PI looked like originally. RN G added, when I first saw it, it was 100% granulation tissue. Surveyor asked RN G how you would describe the appearance of the PI today. RN G stated, it was 100% granulation tissue, nice red, beefy tissue, and measured 2.4 cm x 1.4 cm x less than 0.1. Surveyor asked RN G can you see the wound bed. RN G stated, Yes. Surveyor asked could you see any bone. RN G stated, No. At 4/20/21 at 1:10 PM, Surveyor spoke with PT Y (Physical Therapist). PT Y stated he worked with R55 within a day or so of after R55's initial evaluation. PT Y stated some things I documented is R55 stated, We'll do things my way. PT Y stated, R55 has a strong personality. R55 is a max (maximum) t4 (fourth [MEDICATION(S)] vertebra) spinal injury of [AGE] years. PT Y stated, it wasn't the rolling piece it was the trunk stability. R55 refused the Hoyer lift multiple times, which limits him to a plywood transfer. PT Y added R55 needs two (2) shoulder surgeries. PT Y stated he listed R55 as a maximum assist due to his spinal injury. Note, PT Y added, R55 is plenty strong enough with his arms to roll, however, the pain in his shoulders prevents him from rolling. Note, this is why offering turning and reposition for R55 is of critical importance. R55 was able to roll but with his lack of trunk control he needs assistance to get to the edge of the bed; that's where he would need the help and to sit at the edge of the bed. PT Y added R55 doesn't want to be in bed much and he'll fight it. On 4/21/21 at 2:41 PM, Surveyor spoke with Interim MDS Z (Minimum Data Set) / Director of Therapy. MDS Z documented the timeline of events since R55's admission. PT (Physical Therapy) recommended to the pt. (patient) (R55) he be a Hoyer transfer which pt. (R55) stated he would not do. He want to use a slide board since this is what he had done at home. Limiting factors for slide board - BLE (bilateral lower extremity) [CONDITION(S)] and bad shoulders needing RTC (rotator cuff) repair surgery. Decision was made not to put an air mattress in place for the following reasons: 1. He does not use an air mattress at home. 2. He has decreased trunk stability 3. He has decreased UE (upper extremity) strength because of the need to have the RTC repair surgery and pain 4. Using a slide board on an air mattress with the decreased trunk stability and decreased BUE strength make those problems even worse. Doing a slide board without an air mattress was still not the #1 recommendation. There was a risk of sheering because his arm strength was not what it should be and his decreased trunk strength caused a balance deficit that could be more of a challenge. PT wanted to work with him for a period of time before transitioning to slide board, but his refusal of the Hoyer forced it to be the mode of transfer. Other things we did to help with his immobility r/t (related to) his [CONDITION(S)]: 1. Assessed and adjusted his ROHO cushion in the chair (3/12/21) 2. Added straps with his direction to the foot of the bed which helped him to mobilize better on his own. This was set up like he has at home. (3/12/21) 3. Pursuit of the arm rest for his w/c. When he came in he informed us it was on order. We were then told by the vendor/care management team that it had come in but since he is in a SNF (Skilled Nursing Facility) it could not be delivered until he discharged . We continued to pursue it being delivered here as it assisted him being able to independently unweight himself, allow for equal UE support when seated (won't lean more toward the left to put LUE (left upper extremity) on the arm rest) and provided safety on the right side of the chair (deficits in trunk control). (3/10/21 and 3/2/21) MDS Z stated PT Y couldn't complete R55's evaluation. R55 told PT Y he was not willing to do a Hoyer transfer because of the location of his spinal cord injury and lack of trunk control, shoulder pain & weakness. MDS Z stated we were hesitant to do slide board transfers because of those things. MDS Z stated we were hesitant to put him on an air mattress being a paraplegic. He didn't have one at home, an air mattress is going to make his balance issues more difficult, and because of his pain and decreased shoulder strength, we did think a slide board with air mattress would be difficult and put him more at risk. Bottom line we wanted to do a Hoyer and not a slide board. It's ok for him to not be on an air mattress. We wanted to work on strengthening and pain management (shoulder strength). If you're not lifting someone on a slide board there's shearing. On 3/12 we adjusted the inflation on ROHO cushion. On the day of admission we added straps to the end of his bed per his request (Documentation indicates this was done 3/12/21). We wanted him to be able to be better with bed mobility. We asked about his missing right wheelchair arm. R55 stated it was on order. We were able to get the wheelchair arm here (around the first week in April 2021). He uses it to unweight (shift) without it he tends to lean more to the left because that's where his arm rest would be. When he uses his right upper extremities he stabilizes himself and shifts left. I don't feel the skin issue is related to the bed (not having an air mattress). A gluteal fold issue is more of a sitting than a bed issue. We never documented on his rolling abilities. He had enough trunk strength to partial range on a gravity eliminate plane, so he isn't able to get up from a supine to a sitting position because that's against gravity but in a gravity eliminate position (supine) he is able to move his trunk through a partial range. That's tested and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . 2/5 is a full range on gravity related plane (meaning he can completely go through a full rom on his own). (Highlighted). MDS Z stated R55 refused to leave the wheelchair during the day and would say I've been a para for [AGE] years, I don't need your crap. Note, there is no evidence the facility offered to assist R55 with repositioning. There is no documentation R55 refused repositioning or staff provided the risks and benefits of refusing repositioning or slide board transfers that can increase the risk of sheering, particularly due to R55's decreased trunk strength.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for 1 of 3 residents reviewed (R7) out of a total sample of 12. R7 had the following events occur with no evidence that the facility notified R7's physician or an on-call provider: 1) A coffee ground emesis, which can be indicative of bleeding in the gastrointestinal tract, 2) No urine output for almost 8 hours with a foley catheter present Findings include The facility's Policy and Procedure entitled, Notification to Physician/Family/Resident Representative of Change in Resident Health Status - HDGR, states, in part: Policy The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is: .Acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) .A decision to transfer or discharge the resident from the community . The facility's Policy and Procedure entitled, Foley Catheter - Care, states, in part: Policy Proper care will be provided for the management of a Foley catheter to drain urine from the bladder and to prevent reflux of urine back into the bladder. Procedure .2. If the resident is in bed, Foley tubing (clear) may be clipped to the bedding along the side of the bed .The Foley bag should be hooked to the metal bed frame when resident is in bed and covered with a privacy bag .7. Note color of urine and any sediment (particles in the urine) .12. Document amount, color, and the presence of sediment in the Foley bag and report to the charge nurse or designee. 13. Record output per facility's procedure. The facility's Policy and Procedure entitled, Catheter - Management, states, in part: Policy The facility will have a system for the management of urinary catheters. Procedure .2. Only licensed nurses or physicians may insert a urinary catheter .6. Monitoring of urinary output will be done at least each shift . According to the AMDA (American Medical Directors Association) Acute Change of Condition in Long Term Care Setting Guidelines, Examples of Condition Changes to Report to a Practitioner, a bloody or coffee ground emesis is to be reported immediately. R7 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. R7's chart notes a telephone order dated 6/9/20 and is signed by Nurse Practioner (NP) E on 6/15/20. The order states, 1) Change indwelling foley catheter every 30 days - use 16fr (French) 10cc balloon. If problems in between the 30 days, call NP/MD. 2) May irrigate/flush foley catheter use 30cc - 60cc sterile H20 as flush prn(as needed)/Foley patency. R7's physician orders, with a printed date of 10/18/20 for 11/20 note a hand written order for Foley catheter change every 4 weeks at facility or make appointment with urology. Last change at urology clinic was 9/29/20. R7's progress notes for 10/30/20 at 10:48 PM note: LPN and RN changed resident's catheter after being unable to flush it. Foley was blocked by blood clots. Resident was feeling pressure in his abdomen which was relieved immediately after new cath was inserted. 16fr. 10cc balloon. 300cc urine returned. A visit note from NP E, dated 11/3/20, notes: R7 reports Foley was changed at SNF (Skilled Nursing Facility) a few days ago .Nursing reports that indwelling foley catheter was changed on 10/30 as it was blocked - not draining after flushing . Of note, there was no evidence of a physician, NP or Urologist was notified R7 Foley was unable to be flushed due to occlusion with blood clots and was unable to be flushed. Orders dated November 10, 2020 and electronically signed by NP E for R7 included, in part, a BMP (Basic Metabolic Panel) to be completed on 11/13/20. Of note these labs were not completed as ordered. R7's urine output notes the following: 11/16/20 5:17 AM total: 300 11/16/20 8:21 PM total: 650 11/17/20 3:54 AM total: 0 The facility was unable to provide any nursing assessment documentation or documentation of communication that R7's physician was notified regarding no urine output from 8:21 PM to 3:54 AM. R7's progress notes indicate the following: 11/17/20 at 5:20 AM, Resident vomited burgundy color emesis in the AM. This was documented by LPN C, who, according the facility provided schedule, was the nurse on night shift for R7's hall. (Of note, there was no evidence in the chart of a physical assessment, vital signs, or provider notification associated with this nursing note. Additionally, it should be noted the night shift is from 10:00 PM to 6:30 AM and the day shift begins at 6:00 AM.) Vital Signs are recorded as follows for 11/17/20 at 7:00 AM: Blood Pressure 162/82 (Of note, this is not out of the norm for R7); Pulse 62; Respirations 18; Temperature 97.9F; Pain Level 0. On 1/14/21 at 8:07 AM Surveyor interviewed LPN C via telephone. Surveyor asked LPN C if she recalled caring for R7 and she stated, a little. Surveyor asked LPN C if she recalled R7 having an emesis when she worked with him on 11/17/20. LPN C stated, I don't really remember. When Surveyor asked LPN C if she recalled any concerns with R7's catheter draining, she stated, not really. Surveyor asked LPN C how often she checks resident's urinary catheters during her shift. LPN C stated, I remember the nurse telling me in report that he was draining good and I looked at his catheter and there was some drainage in there, so I encouraged him to drink some more water. Surveyor asked LPN C if she recalled a CNA (Certified Nursing Assistant) or anyone reporting to her R7 had no output. LPN C stated, no, I don't remember them reporting anything to me. Surveyor asked LPN C, if you had a resident that had an emesis that was burgundy in color, would you contact the MD? LPN C stated, yes. Surveyor reviewed the note written by LPN C on 11/17/20 regarding the burgundy emesis and asked if she could help the Surveyor to understand why a provider was not contacted. LPN C stated that she reported it to the next nurse to contact the MD. Surveyor asked LPN C if she did not feel the emesis needed to be reported immediately. LPN C stated, there has to be some reason, but I can't remember, because normally I would. I think I was told in report that he was declining and so I assumed the doctor knew. On 1/14/20 at 9:43 AM, Surveyor interviewed CNA (Certified Nursing Assistant) F via telephone and asked if she recalled working with R7 on the night shift of 11/16/20 into 11/17/20 when it is documented that he had a burgundy emesis. CNA F stated she did and that she has worked at the facility for 7 years so she knows R7. Surveyor asked CNA F to walk through what she recalled about the night. CNA F stated she took care of R7 and that he wasn't feeling well and had an emesis one time while she was in there. She stated she held a bucket for him and then reported it to the LPN C. LPN C did come down and she said he drinks a lot of soda and said it wasn't much but it was and it was dark in color - no undigested food- liquidity to not real thick. The whole evening I could tell he wasn't feeling well. Surveyor asked if R7 complained of pain. CNA F stated, yes, he said he had stomach discomfort. When Surveyor asked if R7 stated it was worse than normal, CNA F stated he didn't really say, just could tell he didn't feel good. Surveyor asked CNA F if she recalled anything about his urine output. CNA F stated, there wasn't anything through the shift. I don't remember when I told LPN C. I told her a few times throughout the night and I was surprised she didn't do more. I was concerned. Surveyor asked CNA F what her normal routine is for residents with catheters. CNA F stated she does rounds every 2 hours and last rounds she empties the catheter bag. I don't know if we are required to look at it, but that night I was checking it because I knew he didn't feel good. He isn't much of a talker. Surveyor asked if she performed catheter care and if she recalled if there were any other concerns or if the catheter was secured. CNA F stated she did cath care and doesn't recall if the catheter was secured, but doesn't recall any concerns with anything during cares, he didn't complain of pain during cares. 11/17/20 at 1:47 PM, Patient reported to have had coffee ground like emesis on NOC (night) shift. Writer obtained VS (Vital Signs) at onset of shift. Patient denied pain but did note some mild discomfort to abdomen. Patient refused AM meds. Writer called NP (Nurse Practitioner) and notified them of previous emesis on NOC shift and gave them recent vital signs. NP gave verbal order to send patient out for evaluation at (UW) ER (emergency room ). Awaiting call from hospital on patient status. On 1/14/21 at 7:42 AM Surveyor interviewed LPN (Licensed Practical Nurse) D via telephone and asked if she could walk me through the events of the morning of 11/17/20 when she cared for R7. LPN D stated that in report she was told that R7 had a small emesis but the nurse said it was nothing major-she did not say coffee ground. Surveyor asked if the nurse who reported off to her mentioned any other concerns, such as pain. LPN D stated, she honestly didn't remember. LPN D stated a CNA reported to her that there was coffee ground emesis on a gown in the laundry and said she needed to come to see R7 and I assumed they got the gown from his room. Surveyor reviewed LPN D's note dated and timed 11/17/20 at 1:47 AM. LPN D stated that was a late entry and that she completed the SBAR documentation immediately. Surveyor asked about the wording of the note and it saying patient reported to have a coffee ground like emesis on NOC shift. LPN D stated she wrote coffee ground emesis on NOC shift because they found it at the beginning of the shift and so it would have had to happen on NOC shift. Surveyor asked LPN D, if the note then did not mean that it had been reported to her by the previous nurse, LPN D stated no,that was in regard to the CNA reporting it to her. Surveyor asked LPN D what events happened next. LPN D stated, I went to R7's room right at the beginning of the shift and took vital signs. At that time he was presenting fine, didn't complain of pain, just said his stomach hurt, didn't really say it was bad, couldn't say where. LPN D stated, R7 didn't really like it when you asked too many questions, he would get mad. Surveyor asked, according to his chart, R7 had a history of [REDACTED].? LPN D stated, honestly, I don't remember, he just seemed off and after seeing the gown there was no question I needed to call the NP. When Surveyor asked, did you contact NP E, LPN D stated yes. When asked if NP E told you to send R7 out, LPN D stated, yes, he was stable at that point, so we didn't send him out emergency transport. His vitals were good, he was breathing fine, he didn't say he was in terrible pain and NP E didn't tell me to send emergency transport. When Surveyor asked if NP E normally would specify, LPN D stated yes. Surveyor asked LPN D approximately what time he left the facility. LPN D stated it was around 8:30 AM. Surveyor asked LPN D if she rechecked his vitals between the first set and the time transport arrived. LPN D stated, no, he was stable, vitals at the time were stable and NP E didn't tell me to recheck them. We had reviewed vitals from previous and it was within normal for him, he didn't look or seem super sick at the time. Surveyor asked LPN D if she recalled when non-emergent transport arrived that R7's blood pressure was lower and they couldn't transport him. LPN D stated, she was not present when they arrived, she believed it was the acting DON who met the transport service. LPN D stated she had alerted the DON during morning meeting of what was going on and so she was the one who met the transport. I think his blood pressure was lower and so they called 911 but I'm not sure who called. Surveyor asked LPN D if when the night nurse reported off to her if she had mentioned anything about R7's urine output or catheter. LPN D stated, not that I remember. Surveyor asked LPN D if she recalled checking R7's catheter when she went to assess him that morning. LPN D stated, I don't remember if I looked at the catheter, he didn't say anything specific to that though, no complaints of pain over the bladder. Surveyor asked LPN D if she felt a coffee ground emesis would be a reason to contact the provider immediately. LPN D stated, yes, that's why I did. A SBAR (Situation, Background, Assessment, Request) with a effective date of 11/17/20 at 7:00 AM notes the following: Situation: 1. The change in condition, symptoms, or gins I am calling about is/are: Coffee ground like emesis, increased lethargy. 2. This started on: 11/17/20 3. Since this started it has gotten: Stayed the same. 4. Things that make the conditions or symptoms better are: N/A 5. Things that make the conditions or symptoms worse are: N/A This condition, symptom or sign has occurred before: No. 6. Other relevant information: N/A B. Background: 1. Member description - This member is in the NH (Nursing Home) for: Long-Term Care 2. Primary Diagnosis: [REDACTED].>3. Other pertinent history : See Chart 4. Medication Alerts : N/A . 8. List allergies [REDACTED].> List Vitals: 162/82, 62, 18, 97.9, 96% 10. Oximetry: Room air Mental Status changes-(compared to baseline; check all that you observe): Decreased consciousness (sleepy, lethargic). Functional Status Changes (compared to baseline; check all that you observe) Weakness or [MEDICAL CONDITION] Respiratory: N/A GI/Abdomen: Vomiting GU/Urine changes: N/A Advance Care Planning Information (the member has orders for the following advance directives): DNR (Do Not Resuscitate) C. Assessment: .2. For LPN's: The member appears .: The patient appears to have increased lethargy and complains of upset stomach. Patient noted to have had a large coffee ground like emesis x1 on NOC (night) shift. D. Request: a. Monitor vital signs, b. Lab work . f. Transfer to Hospital .h. Nurses Notes: Patient reported to have had coffee ground like emesis on NOC shift. Writer obtained VS (Vital signs) at onset of shift. Patient denied pain but did note some mild discomfort to abdomen. Patient refused AM meds. Writer called NP (Nurse Practitioner) and notified them of previous emesis on NOC shift and gave them recent vital signs. NP gave verbal order to send patient out for evaluation at (UW) ER (emergency room ). Emesis x 1 prior to tran. i. Name of Family/Health Care Agent Notified: Self . k. Reported to Primary care Clinician (MD/MP/PA): NP E 7:00 AM. Hospital records obtained for R7, ED to Hosp-Admission Encounter, dated 11/17/20, note the following: .He is brought in by EMS from his assisted living facility. Per EMS, the patient had 2 episodes of coffee-ground emesis at his facility, a 3rd episode of maroon/dark brown emesis for EMS. He was hypotensive at 70/40 upon EMS arrival, received 1 L of IV fluids and responded with blood pressure to 90 systolic .He does not take any blood thinners . .Physical Exam: Constitutional: General: He is not in acute distress. Appearance: .He is ill-appearing. He is not toxic-appearing . Abdominal: Palpations: Abdomen is soft. Tenderness: There is abdominal tenderness . [MEDICAL CONDITION]: Comments: Scrotum is [DIAGNOSES REDACTED]tous, [MEDICAL CONDITION] . .CBC (Complete Blood Count) with Differential: White Cell Count: 6.6 (Within Reference Range) Hemoglobin 11.0 (L) Hematocrit 34 (L) . .Filed Vitals: 11/17/20 at 4:30 PM: BP (Blood Pressure): 122/65; P (Pulse): 95; Temp: 98F; Resp (Respirations): 18 11/17/20 at 4:55 PM: BP: 96/50; P: 89; Resp: 24; 11/17/20 at 5:15 PM: BP: 87/51; P: 89 11/17/20 at 5:30 PM: BP 86/50; P: 86 . .MDM (Medical Decision Making) .Given [MEDICAL CONDITION] and concern for GI bleed, he was given 2 units of PRBC's (Packed Red Blood Cells) .Abdominal CT demonstrates a Foley catheter that terminates in and obstructs the urethra, as well as an extraperitoneal bladder rupture. Discussed with Urology, who replaced his catheter with return of notable foul-smelling purulent urine. Given confirmed infected urine with persistent [MEDICAL CONDITION], antibiotics were expanded to [MEDICATION NAME] and [MEDICATION NAME]. He was signed out pending admission and CT cystogram. Will need upper endoscopy as well. Disposition: Signed out pending admission Impression:[MEDICAL CONDITION] due to urinary tract infection (primary encounter diagnosis) Bladder rupture Upper gi (sic) bleed [MEDICAL CONDITION] . Attending Addendum: .Initially presumed GI bleed as the cause of his [MEDICAL CONDITION] however also found to have perforated bladder and infected appearing urine once foley placed by urology and treated accordingly. Initially discussed TLC (Trauma and Life Support Center) but BP did appear to respond to resuscitation and will plan for likely IMC (Intermediate Care) vs TLC admission pending further assessment . Impression: GI Bleed, [MEDICAL CONDITION], Bladder Rupture, Urine Infection Disposition: Admit . H&P (History and Physical) with a date of service of 11/7/20 at 7:06 PM notes the following: Reason for Admission/CC (Chief Complaint): Altered mental status . Impression: R7 is a [AGE] year old male admitted on [DATE] .who presents from SNF (Skilled nursing facility) with AMS (Altered mental status) and 3 episodes of coffee-ground emesis with possible UGIB and CT findings c/w (consistent with) extraperitoneal bladder rupture c/f (concerning for) urosepsis. 1. Neuro: Dx: Acute Metabolic [MEDICAL CONDITION]. This is likely secondary to urosepsis in the s/o bladder rupture noted on CT scan and urinalysis revealing pyuria and bacteria. 2. Cardiovascular Dx: NSTEMI (Non-ST-elevation [MEDICAL CONDITION] infarction) in the s/o (setting of)[MEDICAL CONDITION]; Dx: Elevated BNP; Dx: [MEDICAL CONDITION]; Dx: [MEDICAL CONDITION] 3. [MEDICAL CONDITION]: Dx: Right pleural effusion persistent with RLL (Right Lower Lung) Collapse 4. Renal: Dx: AKI (Acute Kidney Injury) with likely [MEDICATION NAME] etiology; Dx: Extraperitoneal bladder rupture. 5. FEN/GI: Dx: C/f (concerning for) UGIB given 3 episodes of coffee-ground emesis 6. ID: Dx: Urosepsis; Dx: Lower extremity excoriations with c/f possible fungal infection. 7. Heme: Dx: Normocytic [MEDICAL CONDITION] Inpatient Discharge Summary CRITICAL CARE with a date of service 11/20/20, notes: Brief Overview: . admitted : 11/17/20 discharge date : 11/20/20 Primary Discharge Diagnosis: [REDACTED].>Secondary Discharge Diagnosis: [REDACTED]. Details of Hospital Stay Presenting Problem/History of Present Illness and Hospital Course R7 .is a [AGE] year old male admitted on [DATE] .Upon initial presentation to hospital, he was thought to be decisional capacity and ACE (Acute Care for Elders) became involved and verified patient was not decisional. He continued to note severe pain and stated repeatedly to let me go. Patient has previously signed DNR/DNI paperwork in the past and had old DNR bracelet on admission. Had ethics meeting given lack of family, patient clearly not decisional but asking not to receive aggressive care. The conclusion of the meeting was to make patient comfort care given his high mortality and almost certain morbidity in the coming days to weeks and patient passed on 11/20/2020. On 1/13/21 at 3:49 PM, Surveyor interviewed NP E via telephone. Surveyor asked NP E if she would have expected to be called when R7 had the emesis that was documented as burgundy in color. NP E stated, the on-call provider should have been notified when the burgundy emesis happened. Surveyor asked NP E what she recalls were the chain of events reported to her the morning of 11/17/20 with the emesis and the urinary output. NP E stated, LPN D had called and said she was told in hand off by the previous nurse that R7 had a small coffee ground emesis and hadn't had time to change the gown and that when LPN D went in there it was all over him, large coffee ground emesis, and I told her to send R7 out. Urine was never reported to me. Surveyor asked NP E if LPN D had given her an idea of when the emesis had happened. NP E stated, no, I don't think she knew. Surveyor asked NP E when she would expect a call for low urine output. NP E stated, if they ever encountered zero output for 4 hours a provider should be notified - should be at least 30ml/hr. Surveyor asked NP E when she was alerted that the lab that was ordered for 11/13/20 had not been completed. NP E stated when I got the call from LPN D about the emesis I asked about the lab. The BMP (Basic Metabolic Panel) was supposed to be done due to worsening kidney function after [MEDICATION NAME], LPN D saw the orders were noted but never faxed to lab. Surveyor asked NP E if she would have expected a call prior to the Foley catheter being changed on 10/30/20. NP E stated R7 was followed by urology so they didn't necessarily need to call her, but there was no note to urology of notification either, should have notified occluded and about clot. NP E stated she was out on 10/30/20, so any calls should have went to a colleague. It was a PM shift and should have went to on-call but was on my voicemail, so I got the message on Monday 11/2. I called the facility to check if it was draining and then I saw him on 11/3 and visit was unremarkable. On 1/14/21 at 10:19 AM, Surveyor interviewed DON B and asked her to recall the events of the morning of 11/17/20 in regard to R7. (Of note, DON B was not in this role during these events). DON B stated, to the best of her recollection, LPN D had reported that R7 needed to go out because of coffee ground emesis and apparently he had a small brown emesis in the night. The CNA had cleaned him up, so the CNA had showed me the gown from the bin and I was like, ok, he needs to go out. I told the CNA to get him ready to go and the NP had already been called. When we were transferring R7 to the gurney he had a large coffee ground emesis. The non-emergent EMS (Emergency Medical Service) was here and thought R7's blood pressure was low and so 911 was called. When the 911 team came they said R7's blood pressure was ok. Surveyor asked DON B if she recalled what the blood pressure was and she did not. Surveyor asked DON B if she recalled R7 complaining of pain. DON B stated, that he did not complain of pain initially, but after they got him ready for EMS he said he had a little tenderness. DON B, pointed to just under her umbilicus and this location was verified verbally by surveyor. Surveyor asked DON B if she noticed if there was urine in R7's catheter bag. DON B stated, yes. Surveyor asked if she knew how much. DON B said, not a full bag, but it wasn't a scant amount either. Surveyor asked DON B if she would expect the provider to be notified if a resident has a burgundy or coffee ground emesis. DON B stated, definitely, let them know right away. Surveyor asked DON B what her expectations are of nursing when caring for a resident with a urinary catheter. DON B stated it should be checked during the shift, take a look at the catheter bag when you first encounter the resident. The CNA's empty the bag at the beginning of the shift and report to the nurse. Throughout the shift CNA should look at the bag and report to nurse if output is low or none. Nursing should check with CNA's for output numbers and they should check throughout shift when in room, like during med pass for example. Should check for color, appearance, hanging correctly, no kinks. Surveyor asked DON B, what her expectation of nursing is if a resident is having low or no urine output. DON B stated, we have a bladder scanner, so if we have someone with low output they can check for kinks, check for pain/abdominal distention, and check with bladder scanner. Some residents do have orders for straight cath if no output, but if no orders then they should call the MD with no output. Surveyor asked DON B when nursing should contact MD for low to no urine output. DON B stated, if less than 30/ml hour or less than 200ml in 6 hours then it would be an immediate call. When Surveyor asked DON B if the labs ordered on [DATE] should have been completed. DON B stated, yes. When Surveyor asked DON B if she expects the nursing staff to follow provider orders as written, DON B stated, yes. Surveyor reviewed the orders and notes shown above for R7. When Surveyor asked DON B if she would have expected the nurse to contact the provider prior to changing the catheter based on those orders. DON B stated, if they could change it at will, would expect to see an order for [REDACTED].>

Based on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice related to assessment for 1 of 12 sampled residents (R7). R7 experienced a change in condition with symptoms indicative of [MEDICAL CONDITION] and no urine output for almost 8 hours despite presence of a urinary catheter. The facility did not complete a full nursing assessment despite R7's change of condition to include an abdominal, [MEDICAL CONDITION] assessment and functionality of the foley catheter. R7 had a burgundy colored emesis. R7 was transferred to the ER and was diagnosed , in part, with:[MEDICAL CONDITION] due to urinary tract infection; bladder rupture; and upper GI (gastrointestinal) bleed (Of note, R7 was given 2 units of PRBC's). Findings include: The facility policy . The facility's Policy and Procedure entitled, Foley Catheter - Care, states, in part: Policy Proper care will be provided for the management of a Foley catheter to drain urine from the bladder and to prevent reflux of urine back into the bladder. Procedure .2. If the resident is in bed, Foley tubing (clear) may be clipped to the bedding along the side of the bed .The Foley bag should be hooked to the metal bed frame when resident is in bed and covered with a privacy bag .7. Note color of urine and any sediment (particles in the urine) .12. Document amount, color, and the presence of sediment in the Foley bag and report to the charge nurse or designee. 13. Record output per facility's procedure. The facility's Policy and Procedure entitled, Catheter - Management, states, in part: Policy The facility will have a system for the management of urinary catheters. Procedure .6. Monitoring of urinary output will be done at least each shift . R7 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R7's progress notes indicate the following: 11/17/20 at 5:20 AM, Resident vomited burgundy color emesis in the AM. This was documented by LPN C, who according to the facility provided schedule, was the nurse on night shift for R7's hall. Of note, R7 has a change of condition vomiting burgundy colored emesis. There is no evidence the nurse completed a gastrointestinal (GI) assessment for R7 despite this change of condition. R7's urine output notes the following: 11/16/20 5:17 AM total: 300 11/16/20 8:21 PM total: 650 11/17/20 3:54 AM total: 0 Of note, R7 has a urinary catheter and R7 had no urinary output during the night shift. There is no evidence the nurse checked R7's foley catheter or completed an assessment of R7's abdomen/bladder due to lack of urinary output in the presence of a foley catheter. It should be noted the night shift is from 10:00 PM to 6:30 AM and the day shift begins at 6:00 AM. On 1/14/21 at 8:07 AM Surveyor interviewed LPN C via telephone. Surveyor asked LPN C if she recalled caring for R7 and she stated, a little. Surveyor asked LPN C if she recalled R7 having an emesis when she worked with him on 11/17/20. LPN C stated, I don't really remember. Surveyor asked LPN C if she recalled any concerns with R7's catheter draining, she stated, not really. Surveyor asked LPN C how often she checks resident's urinary catheters during her shift. LPN C stated, I remember the nurse telling me in report that he was draining good and I looked at his catheter and there was some drainage in there, so I encouraged him to drink some more water. Surveyor asked LPN C if she recalled a CNA (Certified Nursing Assistant) or anyone reporting to her R7 had no output. LPN C stated, no, I don't remember them reporting anything to me. Surveyor reviewed the note written by LPN C on 11/17/20 regarding the burgundy emesis and asked if she could help the Surveyor to understand why a provider was not contacted. LPN C stated that she reported it to the next nurse to contact the MD. On 1/14/20 at 9:43 AM, Surveyor interviewed CNA (Certified Nursing Assistant) F via telephone and asked if she recalled working with R7 on the night shift of 11/16/20 into 11/17/20 when it is documented that he had a burgundy emesis. CNA F stated she did and that she has worked at the facility for 7 years so she knows R7. Surveyor asked CNA F to walk through what she recalled about the night. CNA F stated she took care of R7 and that he wasn't feeling well and had an emesis one time while she was in there. She stated she held a bucket for him and then reported it to the LPN C. LPN C did come down and she said he drinks a lot of soda and said it wasn't much emesis but it was and it was dark in color - no undigested food- liquidity to not real thick. The whole evening I could tell he wasn't feeling well. Surveyor asked if R7 complained of pain. CNA F stated, yes, he said he had stomach discomfort. Surveyor asked if R7 stated it was worse than normal. CNA F stated, he didn't really say, just could tell he didn't feel good. Surveyor asked CNA F if she recalled anything about his urine output. CNA F stated, there wasn't anything through the shift. I don't remember when I told LPN C, I told her a few times throughout the night and I was surprised she didn't do more. I was concerned. Surveyor asked CNA F what her normal routine is for residents with catheters. CNA F stated she does rounds every 2 hours and last rounds she empties the catheter bag. I don't know if we are required to look at it, but that night I was checking it because I knew he didn't' feel good. He isn't much of a talker. Surveyor asked if she performed catheter care and if she recalled if there were any other concerns or if the catheter was secured. CNA F stated she did cath care and doesn't recall if the catheter was secured, but doesn't recall any concerns with anything during cares, he didn't complain of pain during cares. A SBAR (Situation, Background, Assessment, Request) with a effective date of 11/17/20 at 7:00 AM, completed by LPN D, notes the following: Situation: 1. The change in condition, symptoms, or gins I am calling about is/are: Coffee ground like emesis, increased lethargy. 2. This started on: 11/17/20 3. Since this started it has gotten: Stayed the same. 4. Things that make the conditions or symptoms better are: N/A 5. Things that make the conditions or symptoms worse are: N/A This condition, symptom or sign has occurred before: No. 6. Other relevant information: N/A B. Background: 1. Member description - This member is in the NH (Nursing Home) for: Long-Term Care 2. Primary Diagnosis: [REDACTED].>3. Other pertinent history : See Chart 4. Medication Alerts : N/A . 8. List allergies [REDACTED].> List Vitals: 162/82, 62, 18, 97.9, 96% 10. Oximetry: Room air Mental Status changes-(compared to baseline; check all that you observe): Decreased consciousness (sleepy, lethargic). Functional Status Changes (compared to baseline; check all that you observe) Weakness or [MEDICAL CONDITION] Respiratory: N/A GI/Abdomen: Vomiting GU/Urine changes: N/A Advance Care Planning Information (the member has orders for the following advance directives): DNR (Do Not Resuscitate) C. Assessment: .2. For LPN's: The member appears .: The patient appears to have increased lethargy and complains of upset stomach. Patient noted to have had a large coffee ground like emesis x1 on NOC (night) shift. D. Request: a. Monitor vital signs, b. Lab work . f. Transfer to Hospital .h. Nurses Notes: Patient reported to have had coffee ground like emesis on NOC shift. Writer obtained VS (Vital signs) at onset of shift. Patient denied pain but did note some mild discomfort to abdomen. Patient refused AM meds. Writer called NP (Nurse Practitioner) and notified them of previous emesis on NOC shift and gave them recent vital signs. NP gave verbal order to send patient out for evaluation at (UW) ER (emergency room ). Emesis x 1 prior to tran. i. Name of Family/Health Care Agent Notified: Self . k. Reported to Primary care Clinician (MD/MP/PA): NP E 7:00 AM. Hospital records obtained for R7, ED to Hosp-Admission Encounter, dated 11/17/20, note the following: .He is brought in by EMS from his assisted living facility. Per EMS, the patient had 2 episodes of coffee-ground emesis at his facility, a 3rd episode of maroon/dark brown emesis for EMS. He was hypotensive at 70/40 upon EMS arrival, received 1 L of IV fluids and responded with blood pressure to 90 systolic .He does not take any blood thinners . .Physical Exam: Constitutional: General: He is not in acute distress. Appearance: .He is ill-appearing. He is not toxic-appearing . Abdominal: Palpations: Abdomen is soft. Tenderness: There is abdominal tenderness . [MEDICAL CONDITION]: Comments: Scrotum is [DIAGNOSES REDACTED]tous, [MEDICAL CONDITION] . .CBC (Complete Blood Count) with Differential: White Cell Count: 6.6 (Within Reference Range) Hemoglobin 11.0 (L) Hematocrit 34 (L) . .Filed Vitals: 11/17/20 at 4:30 PM: BP (Blood Pressure): 122/65; P (Pulse): 95; Temp: 98F; Resp (Respirations): 18 11/17/20 at 4:55 PM: BP: 96/50; P: 89; Resp: 24; 11/17/20 at 5:15 PM: BP: 87/51; P: 89 11/17/20 at 5:30 PM: BP 86/50; P: 86 . .MDM (Medical Decision Making) .Given [MEDICAL CONDITION] and concern for GI bleed, he was given 2 units of PRBC's (Packed Red Blood Cells) .Abdominal CT demonstrates a Foley catheter that terminates in and obstructs the urethra, as well as an extraperitoneal bladder rupture. Discussed with Urology, who replaced his catheter with return of notable foul-smelling purulent urine. Given confirmed infected urine with persistent [MEDICAL CONDITION], antibiotics were expanded to [MEDICATION NAME] and [MEDICATION NAME]. He was signed out pending admission and CT cystogram. Will need upper endoscopy as well. Disposition: Signed out pending admission Impression:[MEDICAL CONDITION] due to urinary tract infection (primary encounter diagnosis) Bladder rupture Upper gi (sic) bleed [MEDICAL CONDITION] . Attending Addendum: .Initially presumed GI bleed as the cause of his [MEDICAL CONDITION] however also found to have perforated bladder and infected appearing urine once foley placed by urology and treated accordingly. Initially discussed TLC (Trauma and Life Support Center) but BP did appear to respond to resuscitation and will plan for likely IMC (Intermediate Care) vs TLC admission pending further assessment . Impression: GI Bleed, [MEDICAL CONDITION], Bladder Rupture, Urine Infection Disposition: Admit . H&P (History and Physical) with a date of service of 11/7/20 at 7:06 PM notes the following: Reason for Admission/CC (Chief Complaint): Altered mental status . Impression: R7 is a [AGE] year old male admitted on [DATE] .who presents from SNF (Skilled nursing facility) with AMS (Altered mental status) and 3 episodes of coffee-ground emesis with possible UGIB and CT findings c/w (consistent with) extraperitoneal bladder rupture c/f (concerning for) urosepsis. 1. Neuro: Dx: Acute Metabolic [MEDICAL CONDITION]. This is likely secondary to urosepsis in the s/o bladder rupture noted on CT scan and urinalysis revealing pyuria and bacteria. 2. Cardiovascular Dx: NSTEMI (Non-ST-elevation [MEDICAL CONDITION] infarction) in the s/o (setting of)[MEDICAL CONDITION]; Dx: Elevated BNP; Dx: [MEDICAL CONDITION]; Dx: [MEDICAL CONDITION] 3. [MEDICAL CONDITION]: Dx: Right pleural effusion persistent with RLL (Right Lower Lung) Collapse 4. Renal: Dx: AKI (Acute Kidney Injury) with likely [MEDICATION NAME] etiology; Dx: Extraperitoneal bladder rupture. 5. FEN/GI: Dx: C/f (concerning for) UGIB given 3 episodes of coffee-ground emesis 6. ID: Dx: Urosepsis; Dx: Lower extremity excoriations with c/f possible fungal infection. 7. Heme: Dx: Normocytic [MEDICAL CONDITION] Inpatient Discharge Summary CRITICAL CARE with a date of service 11/20/20, notes: Brief Overview: . admitted : 11/17/20 discharge date : 11/20/20 Primary Discharge Diagnosis: [REDACTED].>Secondary Discharge Diagnosis: [REDACTED]. Details of Hospital Stay Presenting Problem/History of Present Illness and Hospital Course R7 .is a [AGE] year old male admitted on [DATE] .Upon initial presentation to hospital, he was thought to be decisional capacity and ACE (Acute Care for Elders) became involved and verified patient was not decisional. He continued to note severe pain and stated repeatedly to let me go. Patient has previously signed DNR/DNI paperwork in the past and had old DNR bracelet on admission. Had ethics meeting given lack of family, patient clearly not decisional but asking not to receive aggressive care. The conclusion of the meeting was to make patient comfort care given his high mortality and almost certain morbidity in the coming days to weeks and patient passed on 11/20/2020. On 1/14/21 at 10:19 AM, Surveyor interviewed DON B and asked her to recall the events of the morning of 11/17/20 in regard to R7. (Of note, DON B was not in this role during these events). DON B stated, to the best of her recollection, LPN D had reported that R7 needed to go out because of coffee ground emesis and apparently he had a small brown emesis in the night. The CNA had cleaned him up, so the CNA had showed me the gown from the bin and I was like, ok, he needs to go out. I told the CNA to get him ready to go and the NP had already been called. Surveyor asked DON B if she noticed if there was urine in R7's catheter bag. DON B stated, yes. Surveyor asked if she knew how much. DON B said, not a full bag, but it wasn't a scant amount either. Surveyor asked DON B what her expectations are of nursing when caring for a resident with a urinary catheter. DON B stated it should be checked during the shift, take a look at the catheter bag when you first encounter the resident. The CNA's empty the bag at the beginning of the shift and report to the nurse. Throughout the shift CNA should look at the bag and report to nurse if output is low or none. Nursing should check with CNA's for output numbers and they should check throughout shift when in room, like during med pass for example. Should check for color, appearance, hanging correctly, no kinks. Surveyor asked DON B, what her expectation of nursing is if a resident is having low or no urine output. DON B stated, we have a bladder scanner, so if we have someone with low output they can check for kinks, check for pain/abdominal distention, and check with bladder scanner. Some residents do have orders for straight cath if no output, but if no orders then they should call the MD with no output. The facility was unable to provide evidence that: 1) LPN C gathered further clinical data when the emesis occurred and when R7 had no urine output; or contacted an RN to complete an assessment. 2) A Registered Nurse was consulted regarding the emesis and no urine output; 3) An abdominal system, [MEDICAL CONDITION] system, or foley catheter assessment were completed by a Registered Nurse at the time these concerns were noted.

Based on observation, interview and record review the facility failed to ensure each Resident received adequate supervision to prevent accidents for 2 of 5 Residents (R1 & R2) reviewed for accidents and/or smoking out of a total sample of 8 Residents. R1 is protectively placed and has a guardian. He is described as being impulsive, having poor safety awareness and not able to make sound decisions. R1 left the facility unsupervised on multiple occasions to smoke, go for a walk or go to the gas station without the knowledge of facility staff. After the second elopement on 3/12/20, no long-term plan was put in place to supervise R1's whereabouts. When a wanderguard bracelet was added 5/1/20, there was no evidence R1's wandering bracelet was checked for functioning or placement. R1's care plan was not updated timely. R1 was not placed in the wander guard book after the wandering bracelet was placed. R1 did not return smoking materials after smoking and was found smoking in his room. R2 is a known smoker, who was found smoking in his room upon re-admission. The Facility's failure to provide supervision of a protectively placed resident who has left the faciity on multiple occasions, failure to prevent and assess residents who are at risk for elopement, failure to ensure wanderguard equipment is in functioning order, failure to appropriately assess a residents' risk for injury related to smoking and not ensuring smoking materials are contained to prevent injury created a finding of immediate jeopardy that began on 3/12/20. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 5/26/20 at 2:00 PM. The immediate jeopardy was removed on 6/2/20. However the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The Facility's Policy entitled 'Elopement/Missing Resident,' dated April 2009, states, in part: . It is the facility's policy to implement all possible measures to protect/minimize any resident who attempts to elope. Definition: Elopement, for purposes of this policy and procedure, is defined as a situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety needs, and therefore at risk for injury outside the confines of the facility, has left the facility without the knowledge of staff. Procedure: 1 .Residents will be re-assessed for elopement risk if the resident makes attempts to elope and/or as needed. 2. If a resident is found to be at risk for elopement, the resident's care plan will include interventions for the prevention of elopement. The resident's picture will be located at stations or reception areas to alert staff of the possible risk of elopement.5. When the resident is found, an in-depth physical assessment is completed by the charge nurse or designees with a specific focus on hypothermia, injuries etc., and treated as ordered by physician. The physician is notified along with the family and police, as needed. An incident report is completed. Documentation in nurse's notes is made. 6. Care plan interventions are documented and/or revised. 7. An immediate intervention is implemented to prevent further elopement. This may include 15-30 minute checks for at least eight hours or more, placement to secured unit, or use of a wander-guard.10. The Director of Nursing completes an investigation of the elopement, including possible causes, the timeline, witness statements, immediate interventions, any permanent interventions, or any prevention measures . Facility Policy entitled 'Elopement Monitoring of Door Alarms, dated June 2014, states, in part: A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents. Door alarms are tested each shift as least (sic) once a month. The results of the tests are then recorded. Testing of the systems includes not only that the alarms function, but also that staff respond appropriately to the alarms . Facility Policy entitled ' Resident Smoking Policy,' revised on 5/14/20, states, in part: It is the policy of this community to meet the needs and provide a safe environment for our residents to smoke. The facility will have a designated smoking area with designated supervised smoking times. Smoking will be prohibited in any other area and not allowed in any area inside of the facility. If it becomes necessary to restrict individual residents smoking privileges because of safety and/or a medical reason, such information will be noted in the resident's care plan. The smoking policy will be reviewed with resident and/or responsible party upon admission and as needed on an individual basis. Procedure: Smoking Environment, 1. The facility will provide an appropriate safe smoking area. This will be located outside the facility. 2. The facility will provide approved cigarette receptacles for residents to use. Ashtrays will only be emptied into a receptacle provided for such use. The facility will provide smoking blankets, fire extinguishers, and no oxygen signs in smoking area. 3. All smoking privileges shall be suspended during a disaster, emergency situation, severe weather or a drill. 4. (Facility name) reserves the right to suspend or terminate smoking privileges at any time.Designated smoking times. 1. Residents will have designated supervised smoking times, before and after meals, and prior to bedtime with the following times: 0700am (7:00 AM), 0900am (9:00 AM), 11:00 am, 1:00 pm, and 4:00 pm, unless otherwise designated by (Facility name) leadership. 2. Each smoking time will last no longer than 15 minutes, unless otherwise designated by (facility name) leadership. Assessment of Resident: .3. All residents that smoke will be assessed by the Life Enrichment Department, Nursing Personnel, or designees on admission, readmission, when there is a change in condition, quarterly and annually. This will determine if the resident can participate in supervised smoking. 4. There is to be no smoking in the facility at any time.Smoking Equipment: .2. The facility has the right to conduct periodic checks in the resident's room if there are any safety concerns.3. Smoking Material will be kept in the LTC (long term care) back nurses' station and the Aspen/Birch nurses' station for all residents.Non-compliance corrective action. 1. If a resident is non-compliant with the smoking policy or exhibits ongoing unsafe smoking practices, they will be re-educated on the policy, reassessed on their ability to smoke independently and any of the following occur: a. Loss of ability to smoke while residing at the facility. b. be involuntary discharged from facility. 2. The actions taken will be documented in the medical records and the care plan will be updated . Example 1: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 is protectively placed and has a Guardian. Guardianship papers effective on August, 19, 2013 indicate that (R1) lacks evaluative capacity in full. Guardian of the person to exercise full power. R1's Annual MDS (Minimum Data Set) dated 3/13/20 indicates R1 has a BIMS (Brief Interview of Mental Status) of an 8 out of 15, which indicates he is moderately cognitively impaired. Section B indicates that R1 has clear speech, is able to make himself understood and can understand others. Section G indicates that R1 ambulates independently and is able to transfer independently with setup. R1's CNA (Certified Nursing Assistant) Care sheet received on 5/21/20 states, in part: Smoker; cigarettes locked in med cart (medication cart), nurse to dispense no more then 5 per day . provide walks outside as needed with supervision. Wanderguard 5/1/20. R1's Smoking Care Plan states in part: Focus: Resident is a smoker. Goal: will continue to be independent with smoking . Interventions: All smoking materials will remain locked in nurse med. cart. Date initiated: 04/16/2020. Facility will maintain safe place for smoking. Date initiated 03/07/2019. Resident receives 5 cigarettes per day that nursing distributes. Remind/encourage to keep within daily allotment. Date initiated: 03/12/2019 . Resident will be re-assessed for change in condition through 24 hours report and nurse observation. Date initiated 03/07/2019. Smoking assessment will be done at least quarterly and as needed. Date initiated 03/07/2019. Staff will manage smoking materials. Items to be given to resident when he/she wishes to smoke then collected upon re-entering the building. Date initiated: 03/07/2019. Will be assessed for changes in condition .Will be informed of smoking policy and will be assessed for compliance. Date initiated 03/07/2019. R1's Wanderguard Care Plan, states, in part: Focus: Problematic manner in which resident acts characterized by ineffective coping; wandering related to: Purposeful walks to w/o (sic) alerting staff. Date initiated: 05/12/2020. Goal: Resident will wander only within specified boundaries . Interventions: Allow Resident to wander on unit . Check daily to ensure resident has a wanderer's bracelet on .Document resident's whereabouts hourly on wanderer's checklist. Date initiated: 05/12/2020. Of note, the Wanderguard Care plan was not implemented timely, as it was not developed until 5/12/20 which is 11 days after R1's wanderguard was placed on 5/1/20. On 1/14/20 at 6:59 PM, R1's Nurses Note, states, in part: At approx. (approximately) 1840 (6:40 PM), community member came into building to report a resident was walking down the center of the frontage road towards Milwaukee St. (street). Upon locating resident at corner of street, writer interviewed (R1) I'm going for a walk. He was facing direction of convenience store. Writer helped (R1) negotiate traffic to cross the street and waited outside of convenience store while (R1) purchased a soda. (R1) was reminded to tell nursing staff if he was going for a walk. He shared with writer during the walk back that he bought a diet mountain dew. Writer educated (R1) that we had that soda in the machine. (R1) replied, I just wanted some exercise. (R1) chose to enter the building through the smoking area. (Note: To get to the convenience store/gas station, one would have to cross Milwaukee Street, which is a heavily-trafficked four lane road. There is not a cross walk where the frontage road intersects Milwaukee Street.) On 1/14/20, R1's Elopement Risk Full Screen tool indicates R1 does not have a history of wandering, elopement or getting lost. R1 is indicated as not being at risk for elopement. (R1) is aware of where he lives and has relationships with staff/peers, but he exhibits impulsive behaviors. He chose to go for a walk. Staff attended due to uneven surfaces present and traffic safety. Of note the facility was unaware R1 left the building until they were alerted by a community member that a resident was walking down the street, only then did a staff member intervene and walk with R1 to the convenience store. There is no indication that R1's Guardian was updated on R1 leaving the facility at this time. On 1/14/20 at 9:16 PM, R1's Nurses Note states, in part: Res. (Resident) continues on 15 min (minute) checks and educated on not to leave building without sign out/letting staff know for resident's own safety . On 1/15/20 at 4:02 AM, R1's Nurses Note states, in part: Patient continues to be on 15 minute checks . No further indication or mention of R1 being on 15 minutes checks after 1/15/20 and no evidence of a Care Plan being initiated for elopement at this time. On 3/12/20 at 10:47 AM, R1's Social Services Note states, in part: Voicemail left with resident's guardian rt (related to) resident walking to (gas station name) again this AM. Staff's desire to approach resident for consent to wear a wanderguard, and staff's desire to implement regular checks on resident if wanderguard not in place. Awaiting return call. There is no incident report or documentation regarding R1 going to the gas station on 3/12/20, in R1's medical record other than the Social Services Note indicated above. On 3/12/20 at 2:08 PM, R1's Social Services Note, states, in part: Spoke with Residents guardian regarding request for resident to wear wanderguard rt recent trips to (gas station name). Guardian in agreement with wanderguard and check ins, as well as planning for more supervision if refusing wanderguard . Of note, there is no documentation in R1's chart indicating whether or not R1 refused to have a wanderguard placed or that increased supervision was utilized. There is no evidence that an at risk for wandering/elopement or a wanderguard Care Plan was developed or implemented at this time. On 3/16/20 R1's Smoking Safety Full Screen Tool indicates R1 is able to use ashtray to self-extinguish cigarette. R1 can use lighter or matches safely. R1 is indicated as having a history of smoking-related incidents of burned clothing. Interventions indicated as 1. Independent and 7. Facility storage of tobacco products and fire materials. On 3/19/20 at 2:40 PM, R1's Social Services Note, states, in part: Phone conference held with .nurse case manager, resident's guardian . Resident's compulsive behaviors rt (related to) sugary foods/drinks has increased again. Blood sugars continue to spike and drop.Resident's walks to gas station are most dangerous at this time. Currently managed as COVID-19 precautions require locked doors and supervised smoking. Guardian and staff concerned that in any unlocked unit resident may choose to leave facility for a walk or a trip to a nearby store.Goal is to have a plan for limiting unsupervised trips out of the building before the end of Covid-19 precautions. Of note, R1's walks to the gas station are indicated as most dangerous at this time, yet there is no documentation of a plan for limiting unsupervised trips out of the building indicated in R1's care plan or R1's medical record. On 3/19/20 at 3:36 PM, R1's Nurses Note, states, in part: writer was notified that this resident was outside smoking around 2:30 PM, outside of the designated supervised smoking time. Resident was educated on 3/18/2020 by this writer that the smoking policy had changed, policy provided to resident. Writer found resident outside smoking a cigarillo and reminded resident of the policy. Resident proceeded to curse at writer and put out the cigarillo. Writer reminded resident of the next smoking time and where to find the smoking times were posted. Resident continued to curse at writer but then went back inside. Unit nurse was notified of the above. On 3/20/20, R1's Elopement Risk Quarterly Screen Tool indicates Resident is not at risk for elopement he has left the facility with purpose to go to the gas station and returns. However this is unsafe therefore resident is currently on 15 minute checks. (Note: Facility policy does not use the criterion of purposeful when describing what is elopement. As noted earlier, facility policy states: Elopement, for purposes of this policy and procedure, is defined as a situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety needs, and therefore at risk for injury outside the confines of the facility, has left the facility without the knowledge of staff.) On 4/13/20 at 12:04 PM, R1's Nurses Note, states, in part: Writer witnessed resident outside smoking during non-smoking times. Writer educated resident regarding smoking times. Resident threw cigarette out and states I hate you and followed writer back into the building. Will continue to monitor. Of note, there is no indication in R1's chart how R1 obtained smoking material to be outside during non-designated smoking times, or whether staff collected R1's smoking material upon reentering the building. On 4/16/20, R1's Smoking Safety Full Screen Tool, indicates R1 has a history of smoking-related incidents, indicated as other which states smoking after scheduled times. Interventions indicated as independent and all smoking materials are kept on nurses cart and a cigarette and lighter are given at allotted time. No assistant devices are needed. On 4/20/20 at 11:29 AM, R1's Nurses Note, states, in part: Pt (patient) observed outside at approx. 1110 (11:10 AM) picking up a cigarette butt from the cement and smoking. Writer observed this from inside window. Pt. came inside after a few minutes and denied smoking stated I just went outside. Writer educated pt. on smoking policy and risk of losing privileges. Will cont (continue) to monitor. Of note, there is no indication in R1's chart how R1 obtained a lighter in order to be smoking on his own outside designated smoking times, or whether staff collected R1's smoking material upon re-entering the building. On 4/21/20 at 1:34 PM, R1's Nurses Note states, in part: Pt. went outside and was observed through nursing station smoking pt was not with staff. Nor did he inform staff of going out. Resident became combative, agitated w (with) writer. Was upset that I saw him and was concerned about when he would get his next smoke. Writer informed resident of next scheduled smoking time, 1245 (12:45 PM) and that it was only 1120 (11:20 AM). Pt. re-educated on smoking policy. Will cont. to monitor behaviors. Of note, there is no indication in R1's chart how R1 obtained smoking material to be outside during non-designated smoking times, or whether staff collected R1's smoking material upon re-entering the building. On 4/22/20 R1's Elopement Risk Full Screen Tool indicates R1 is independently mobile and is not at risk. Observation and evaluation states Resident chooses to leave the building at times to go on a walk, each exit is purposeful/intentional. Not at risk for wandering. On 4/22/20 at 2:30 PM, R1's Nurses Note, states, in part: Resident left building to go For a walk without notifying staff. Staff observed resident outside of smoking entrance gate, resident was given education by DON (Director of Nursing) and Social Services about asking for staff to accompany him on his walks. SW (Social Worker) to call guardian. Completed an elopement assessment, resident is not at risk for elopement. Each exit of the building is purposeful. Will update care plan and care delivery guide to provide walks outside as needed weather permitting, initiated 15 min checks at this time. Of note, there is no indication in R1's chart how R1 obtained smoking material to be outside during non-designated smoking times, or whether staff collected R1's smoking material upon re-entering the building. This is approximately the 7th time that has been documented that R1 has went outside without informing staff. 15 minute check sheets completed for R1 on 4/22/20, 4/23/20 and 4/24/20. On 4/30/20 at 11:33 AM, R1's Nurses Note, states, in part: Resident observed to be outdoors smoking without a staff member at approximately 1115 (11:15 AM). Writer observed this from inside therapy dining room window as resident was sitting in front of this door so as not to be seen. Writer educated him on smoking policy, scheduled times and possible risk of losing privileges Resident put out his cigarette which appeared to be a shorter one possibly saved from a previous smoking time. Resident then came inside saying I hate this place several times. Of note, there is no indication in R1's chart on whether staff collected R1's smoking material upon re-entering the building. On 5/1/20 at 3:15 PM, R1's Nurses Note, states, in part: Resident doesn't have cigarettes left. He says I have cigarettes in my room stashed from previous times. I am good for today. The activity assistant refilled his cig. (Cigarette) box in the end of the shift. Of note, there is no indication that R1's smoking materials had been removed to be placed and stored in the Nurses cart after staff were made aware that R1 possessed smoking materials in his room. On 5/1/20 at 4:24 PM, R1's Nurses Note, states, in part: Call placed to (Guardian's name), guardian to report resident independent purposeful walk to (gas station name). Resident is free from injuries. DON and Social Worker provided education to resident about safety and inability to walk freely in the community at this time. Resident became agitated but stated he understands. Immediate interventions: Place on 15 min checks and apply wanderguard to left ankle. Resident states he will keep this on. Education provided to PM facility staff and unit nurse about the above. DON and Social Worker updated (Guardian's name) and voiced concerns about resident unsafe choices that put him and the facility at risk. DON and SW also discussed residents noncompliance with smoking times and inability to follow the policy and procedures related to smoking. (Guardian's name) stated understanding. DON and SW updated (Guardians name) about the non-diabetic items found in residents drawer. Resident is safe at this time and stated understanding of the above . On 5/1//20 at 10:45 PM, R1's Nurses Note, states, in part: Resident was found outside, wandering across the street in (gas station name). On 15 minute checks, isolation and wanderguard place on L ankle (sic). Guardian notified by DON . On 5/2/20 at 1:45 AM, R1's Nurses Note, states, in part: .Resident during the night did come out of room to go smoke without any PPE (personal protective equipment) items on. But as soon as the wanderguard alarm went off resident went back to room & (and) did not go out to smoke. Resident again reminded that he is on isolation & con (sic) not come out of room without PPE on or go out to smoke until designated times . On 5/3/20 at 1:55 PM, R1's Nurses Note, states in part: Resident was found in his room w (with) a partial pack of cigarettes. Pt initially denied having them but then said he has been saving them. 4 (four) full cigarettes and several short cigarettes. Pt did give them to writer, and apologized. Writer will f/u (follow up) w RNCM (Registered Nurse Case Manager) tomorrow. Pt. stated awareness of smoking policy and risks of noncompliance. Of note, there is no indication in R1's chart how R1 was able to save cigarettes, if staff are to be collecting and handing out R1's smoking material during designated smoking times. There is no indication of follow up in R1's chart from the RNCM regarding this incident. On 5/4/20 at 6:47 AM, R1's Nurses Note, states in part: Resident was found outside smoking today before 6AM - outside of the scheduled smoking times. Resident came inside when informed that he was not to be out smoking. Resident is aware of the smoking times and was educated again that he was not to be out smoking outside of those times for the safety of all residents during this pandemic. Of note, there is no indication in R1's chart how R1 obtained smoking material to be outside during non-designated smoking times, or whether staff collected R1's smoking material upon re-entering the building. There is no indication of how R1 was able to get outside without staff supervision due to having a wanderguard on his left ankle which should have set off the door alarm. On 5/4/20 at 9:38 AM, R1's Nurses Note, states in part: Pt seen in room holding pack of cigarettes, second time in 2 days. Pt immediately stated he needed to use bathroom and was then observed flushing the toilet. Pt then handed writer a crumpled up pack of (brand of cigarettes) with no cigarettes inside. Pt states he didn't flush them, he had gotten them from saving them and that nobody gave them to him. Will cont to monitor for behaviors as pt is having difficulty w (with) new times and policy. Of note, R1 continues to have smoking material on him within the facility, when staff are to be supervising his smoking times, maintaining and holding onto his smoking materials. On 5/6/20 at 2:58 PM, R1's Nurses Note, states in part: was observed smoking outside indep (independent) at 1120 (11:20 AM). Pt denied this but eventually admitted to smoking a butt of a shorted cigarette. Pt reluctant to any education and further stated I hate it here. Will cont. to monitor. Of note, R1 continues to have a wanderguard on at this time, yet he was able to be get outside without staff's knowledge. R1's wanderguard should have set off the alarm if it was functioning properly to alert staff that R1 was outside. There is no indication in R1's chart if the alarm was sounding or how R1 was able to get outside without supervision. 15 minute check sheets completed for R1 on 5/10/20 and 5/11/20. On 5/13/20 at 12:46 PM, R1's Nurses Note, states in part: CNA reported resident smoking in his room. Resident denied smoking cigarettes. Reported to DON and Administrator. On 5/14/20 at 6:13 PM, R1's Nurses note, states in part: CNA reported cigarette smell in resident's room. Resident denied smoking cigarettes. Reported to Social Worker. On 5/18/20 at 3:09 PM, R1's Nurses note, states in part: .CNA reported she went into residents room and smelled smoke, writer asked resident if he was smoking in his room and he said yes in my bathroom. Writer asked why and resident stated I don't know why reported to Administrator and (Nurse Practitioner). Of note, there is no indication in R1's record of how R1 had smoking materials in his room, if staff are to be maintaining and distributing his smoking materials. There is no indication of a new smoking assessment being completed or new interventions being put in place to ensure that R1 does not have smoking materials on him while in the facility. R1's May 2020 TAR (Treatment Administration Record) states in part: 5/1/20, 15 min checks and check L (left) ankle every shift for wanderguard. 5/21/20 check wanderguard placement daily Q (every) shift. 5/21/20 Check wanderguard functioning on NOC (night) shift. Of note,there is no evidence of documentation between 5/1 and 5/21 that R1's wanderguard was checked for functioning. On 5/21/20 at 9:30 AM, Surveyor observed the smoking area off of the Birch hallway. CNA J was outside at this time with three different residents, none of which were R1. No cigarette butts observed on the ground at this time and ash tray receptacles were visible. On 5/21/20 at 10:50 AM, Surveyor was informed by NHA A that there are no recent elopements and that R1 went out for a walk and came back. NHA A indicated that is not considered an elopement due to being purposeful and he returned. On 5/21/20 at 12:00 PM, Surveyor interviewed RN K (Registered Nurse) regarding R1. RN K indicated that she has worked down Cedar Hall a few times and a CNA reported smelling smoke in a resident room. RN K indicated she went down and did not find any cigarettes in the room. RN K indicated she does not remember who the CNA was. On 5/21/20 at 12:05 PM, Surveyor interviewed LPN I regarding R1. LPN I indicated that R1 gets 5 (five) cigarettes a day and a CNA walks him out. LPN I indicated there is not a lighter in his box or in the cart. Surveyor observed LPN I check R1's left ankle at this time and observed R1's wanderguard to be in place. On 5/21/20 at 12:10 PM, Surveyor interviewed LPN E regarding R1 and smoking. LPN E indicated if a resident is in danger of walking away, shown behavior or talked about wandering then the resident has a wanderguard. LPN E indicated the wanderguard has to be on the person and not on the wheelchair or walker. LPN E indicated the WG (wanderguard) will set off the door and staff respond to the alarm. LPN E indicated they have a wander booklet and that R1 just transferred from Birch. LPN E indicated that a wanderguard was placed on R1 because he walks to the gas station to buy cigarettes and lighters. LPN E indicated that R1 has not gone to the gas station since his WG was placed and on lock down due to COVID 19. LPN E indicated that none of the residents are allowed to go across the street especially Milwaukee Street. LPN E indicated that R1 is not in the wander book on Cedar and she believes Birch has their own. LPN E indicated that R1 has had a WG for about 2 to 3 weeks. LPN E indicated protectively placed residents or residents with a Guardian are not allowed to leave unless permission to do so and referred Surveyor to Social Worker (SW). LPN E indicated whoever was available, goes out with residents to smoke due to knowing times. LPN E indicated the smoking area is by the NHA A's office. LPN E indicated that smoking materials are kept in the medication carts and staff dispense them as residents come up to you and staff hand them (cigarettes) out to them. LPN E indicated that R1 will get cigarettes from nursing and she does not think he has a lighter. LPN E indicated she thinks the person who goes out will light everyone's cigarettes. On 5/21/20 at 12:20 PM, Surveyor interviewed NHA A regarding R1. NHA A indicated that she thought they discontinued R1's wanderguard and that is why R1 is not in the wanderguard book. NHA A indicated that R1 was not in the Birch hall book for wanderers. On 5/21/20 at 1:03 PM, Surveyor interviewed PTD G (Physical Therapy Director) regarding R1. PTD G indicated that R1 is pretty safe and low blood sugars seem to be his only barrier. PTD G indicated R1's balance is normal for him, but from a cognitive perspective he is not aware of his safety. PTD G indicated R1 was deemed safe to smoke, but cognitively he shouldn't be leaving due to mentation and due to his fragile diabetes. PTD G indicated she is unware if a full cognitive assessment was completed for R1. On 5/21/20 at 1:40 PM Surveyor interviewed NHA A regarding R1. NHA A indicated she spoke with the DON (Director of Nursing) regarding R1, prior to R1 wandering and that R1 was deemed safe. NHA A indicated that R1 went outside and would come back. NHA A indicated that R1's Guardian does not want him leaving the building without staff. NHA A indicated that R1's wanderguard has been charted on and functioning since 5/1/20 when it was placed on R1. Surveyor asked NHA A if the wanderguard alarm sounded when R1 left the building. NHA A stated based on what is charted on 5/4/20 progress note, you're not able to tell if the wanderguard alarm was sounding. NHA A indicated that R1 is no longer on 15 minute checks as they were only done initially due to staff being worried he would take the wanderguard off. NHA A indicated that the nurse keeps his smoking material as R1's guardian only allows him to a certain amount of cigarettes per day. NHA A indicated that the nurses give out R1's cigarettes and that the nurse should be checking in with R1 and taking smoking materials back at the end of the smoke breaks. NHA A indicated she is not sure how R1 had smoking materials in his room. NHA A believes he may have been saving them or picking the items up. Surveyor asked NHA A regarding why the wanderguard palcement did not occur prior to 5/1/20. NHA A indicated this was the first time R1's guardian was angry regarding R1 going outside and does not want him to leave. NHA A A indicated that R1 can smoke independently and that an independent smoker means they're able to hold a cigarette, ash a cigarette and light their own cigarette and that staff just monitor their materials. NHA A indicated that laundry staff check for holes in clothing as well as regular staff on the units. On 5/21/20 at 2:09 PM, Surveyor interviewed SW C regarding R1. SW C indicated that R1's guardian has a concern with him leaving because he's a brittle diabetic and has a habit of getting items that raise his blood sugars. SW C indicated there have been a few incidents where he has went to the gas station unannounced and concerns with smoking materials. SW C indicated that R1 goes out to smoke when he's not supposed to and that R1 picks up cigarette butts off the ground and is sharing butts with others. SW C indicated a couple situations have occurred regarding going to the gas station. SW C indicated that they r (TRUNCATED)

Based on observation, interview and record review, the facility did not ensure a resident with a [DIAGNOSES REDACTED]. R2, who did not like getting up early, was awakened at 5:45 AM to be given a shower. R2 became combative prior to the shower and CNA F (Certified Nursing Assistant) did not stop and continued to give R2 a shower, while protecting herself by blocking R2's punches with her arms. CNA F indicated R2 continued striking out during the shower. CNA F did not stop, nor report this behavior to the nurse or ask for assistance, as R2 was striking out. R2 received multiple large bruises including a huge hematoma and was seen by her MD L (Medical Doctor) that morning. Evidenced by: The facility's policy, Behavioral Health, dated (YEAR), includes, in part: Residents who display, or are diagnosed with [REDACTED]. Procedure: 4. Residents with behaviors and those on any [MEDICAL CONDITION] medication will have their behavior monitored daily. This will be documented on the Behavior Tracking tool. 5. Specific individualized, interventions will be put in place to aide in behavior management that includes non - pharmacological modalities. 6. A behavior IDT (Interdisciplinary Team) will meet at least monthly to review and discuss the following: a. specific resident behaviors b. Appropriateness and effectiveness of interventions c. Current medications - including pharmacy recommendations related to [MEDICAL CONDITION] medications. 7. Resident behavior health needs will be addressed on the resident's person centered plan of care. R2 was admitted , on 3/23/16, with [DIAGNOSES REDACTED]. R2's Health Care Power of Attorney (HCPOA) is activated. R2's Quarterly MDS (Minimum Data Set), dated 9/7/19, indicated a BIMS (Brief Interview for Mental Status) score of 99, indicating R2 has severe cognitive impairment. R2 requires extensive assistance with 1 physical assist for bed mobility, transfers, personal hygiene and bathing. R2 is unable to ambulate. R2's Comprehensive Care Plan, Alteration in cognition d/t (due to) [MEDICAL CONDITION], dated 4/13/19, with a revision date of 3/19/18, includes, in part: Goal - staff to meet needs. Interventions- 1: 1 (one-to-one) visits for support and reassurance as needed, revised 8/1/19. Encourage participation in activity programs. If a resident is resistive to cares, maintain resident safety then re - approach, dated 9/17/19. Monitor changes in mood and cognition, revised 8/1/19. Resident is combative with showers and prefers bed baths or washing up at the sink on shower days. Washing at home sink was a personal preference for [AGE] years prior to admission at the facility, dated 9/17/19. (Note: The latter is information that the facility added to the care plan on 9/17/19 but is information that could have been obtained at admission.) R2's Comprehensive Care Plan, Potential for alteration in mood due to [DIAGNOSES REDACTED]. Interventions - Monitor mood and behaviors for seven days and notify MD if there is increase in crying tearfulness, agitation and changes in appetite, dated 4/3/19, revised 8/1/19. R2's CNA Care Card, dated 9/18/19, includes, in part: Safety and Special Needs - If resident becomes combative, maintain resident safety and reapproach. Report to nurse. ADL's (Activities of Daily Living) - 1 assist. No showers, offer to have sponge bath at sink per her routine or bed bath. These interventions are highlighted yellow and were added to the CNA Care Card on 9/17/19 per DON B (Director of Nursing). Surveyor requested the previous Care Cards for R2. DON B indicated the Care Cards are disposed of daily and did not provide Surveyor with previous Care Cards. Nursing Notes, dated 9/17/19 at 7:06 AM, include, in part: CNA F brought R2 to the Nurse and Case Manager to report a large bruise that R2 obtained during her shower this AM. CNA F said R2 became combative and swinging her arms at her while in the shower chair. MD on-call called and would like R2 seen today at the clinic. Nurse to call after 8 AM to set up appointment. R2 unable to tell Nurse what happened but did want her daughter to come in. Family arrived at 7:15 AM and wanted R2 checked for a UTI (urinary tract infection). On 9/19/19 at 3:25 PM, Surveyor interviewed CNA F regarding R2 and the shower given on 9/17/19. CNA F indicated that she was working a double shift and was the only CNA on the Cedar Hallway. CNA F indicated she woke R2 up at 5:45 AM to give her a shower. CNA F indicated she has given R2 showers in the past and at times R2 is not combative. CNA F indicated R2 was real fussy before the shower. R2 was throwing fighter punches prior to the shower. Surveyor asked if CNA F notified the nurse. CNA F said, no. CNA F said she had to block the punches. Surveyor asked how CNA F blocked the punch. CNA F indicated with her arms held across her body, she would lean in and block R2's arms. CNA F said she told R2 to stop hitting her. CNA F indicated that CNA G came in to help her with R2. Surveyor asked if CNA G assisted with R2's shower. CNA F indicated no and said CNA G helped transfer R2 from the shower chair to the w/c in R2's room. Surveyor asked CNA F how R2 developed the bruises. CNA F indicated she thinks R2 obtained the bruises prior to the shower being given or they could have been caused by her blocking the punches with her arms. CNA F indicated she was trying to stop R2 from hitting her. Surveyor asked CNA F if she remembers grabbing R2's right wrist. CNA F indicated she could not remember. CNA F indicated after she had R2 dressed, she showed R2's bruises to RN J and RN D. Surveyor asked CNA F if she reported to the nurse when R2 was combative with her. CNA F indicated no and she should have. Surveyor asked if R2 is combative often. CNA F indicated that R2 has occasional behaviors but not every day. CNA F stated R2 does not like getting up in the morning. CNA F indicated she was the only CNA on the hall and was trying to do everything in a timely matter. Surveyor asked CNA F if she had any bruises on her arms from R2 punching her. CNA F indicated no. On 9/19/19 at 4:00 PM, Surveyor interviewed CNA G regarding R2 and the bruises that occurred with the shower given by CNA F. CNA G indicated CNA F gave R2 a shower as she, CNA G, was working on another unit. CNA F told CNA G that R2 was combative. CNA F mentioned that R2 had an abrasion on her arm. CNA G indicated R2 had her shirt on at the time she came to help CNA F transfer R2. CNA G indicated she never saw the bruises. CNA G indicated she brought the EZ stand to assist with transferring R2 out of the shower chair into the w/c. Surveyor asked CNA G if CNA F called her to help with the shower. CNA G said no. CNA G said R2 was trying to punch and kick CNA F during the transfer. R2 was telling CNA F to get away from her. Surveyor asked CNA G if R2 is combative with showers. CNA G indicated she has not given R2 a shower. Surveyor asked CNA G if she saw CNA F try to block a punch from R2. CNA G said yes. Surveyor asked CNA G to demonstrate what that looked like. CNA G put her right arm out in front of her holding it parallel. CNA G asked Surveyor to pretend to throw a punch at her. CNA G holding her right arm parallel lunged at Surveyor with force making contact with Surveyors forearm trying to block the punch. Review of MD L's Progress Note, dated 9/17/19 at 9:00 AM, includes, in part: R2 is a [AGE] year old female who presents today. 1. Agitation and Bruising. Left arm bruising was noted this AM by nursing staff at facility. Reportedly was showering this AM when she got combative and the CNA showering her had to protect herself from R2 striking her. Did not reportedly fall. Bruised up quickly over left forearm and other areas. CNA reported this to nursing staff right away who alerted the nursing director as well as the MD on call who recommended an OV (office visit) today. Daughter notified and came to appointment. General appearance: alert, cooperative, no distress. Chronic dementia with limited verbal response to only answer direct questions. Not oriented to person, place, nor time. Mentation appears at baseline. Chest: mild sternal tenderness with palpation that makes R2 jump. No ecchymosis (bruising) on back or buttocks. Bruising: Left forearm - diffuse bruising over the dorsum forearm with chicken egg sized hematoma in the mid forearm. Sternum - 2 cm small ecchymosis that is tender over mid sternum. Left medical calf - 2 x (by) 3 cm ecchymosis Right wrist - with distal bruising noted in finger grip pattern 2 x 5 cm in dimension. Impression: Soft tissue with no acute fracture Diagnosis: [REDACTED]. On 9/19/19 at 8:45 AM, Surveyor observed R2's cares with CNA H. Surveyor observed R2 to have dark purple bruising surrounding her entire left forearm elbow to wrist. Surveyor observed a dark purple raised area (hematoma) on the anterior aspect of R2's left arm. R2's entire right wrist is purple without hematoma. Surveyor observed a purple colored area that is approximately the size of a cherry tomato on R2's right lower chin. Surveyor observed a dark reddened area on R2's mid sternum that was approximately 2 cm (centimeter) long. Surveyor pointed to the bruised area on R2's left arm and asked R2 if she was having any pain. R2 rubbed her left arm and said no. Nursing Notes, dated 9/17/19 at 11:15 AM, include, in part: DON B met with R2 and family to discuss the previous incident. Daughter shared that R2 used to give herself a sponge bath at the kitchen sink for the past [AGE] years prior to admission. Daughter and son-in-law agree to care plan to have bed baths. Staff educated on how to reapproach. On 9/19/19 at 1:57 PM, Surveyor interviewed RN J (Registered Nurse) regarding the incident with R2 on 9/17/19. RN J indicated she was sitting with a group of nurses getting report. RN J indicated she saw CNA F take R2 to the shower room. R2 did not appear to be combative at 6:00 AM. RN J indicated she was counting medications on the cart and heard CNA F say are you still my nurse and I said yes. I did not hear anything else. CNA F brought R2 to the med cart. R2 was wearing a long sleeved top and slacks at the time. CNA F pulled up R2's sleeve on her left arm. Surveyor asked RN J what the bruise looked like. RN J indicated it was really bruised and had a blood blister. RN J asked CNA F how this happened. CNA F said R2 was combative in the shower once she put water on her. CNA F said R2 was hitting her. RN D asked CNA F to write a statement. Surveyor asked RN J if she could hear R2 from the shower room. RN J indicated if R2 was screaming she would be able to hear that. RN J indicated she tried to get R2 to say what happened. And R2 couldn't say. RN J indicated the bruise didn't look good and called the family right away. RN J indicated she called the on-call MD next. RN J indicated she wrote a report and reported this to DON B and NHA [NAME] RN J indicated the on-call MD said to call the clinic at 8:00 AM. Surveyor asked RN J if she measured the bruises. RN J indicated she did not measure the bruises. RN J indicated she spoke to R2's daughter and told her about the bruises. RN J indicated she asked RN D to measure because I didn't have a tape measure. It looked like 12 cm by 8 cm and a huge hematoma. RN J indicated she saw bruises on R2's right hand. RN J indicated they sent CNA F into the nurse's station to write a statement .R2 was really bruised, and it looked like a large blood blister. Surveyor asked RN J if CNA F ever reported to her that R2 was striking out or being combative. RN J indicated no. On 9/19/19 at 2:18 PM, Surveyor interviewed RN D regarding the shower given to R2 by CNA F. RN D indicated CNA F gave R2 a shower. CNA F came up to us when counting narcotics. R2 was dressed. CNA F said R2 had a bruise to her arm that she wanted to report that was noted in the shower room. CNA D said she started the shower and R2 became agitated. R2 hit CNA F twice. Surveyor asked RN D if CNA F indicated she had to protect herself from R2. RN D indicated CNA F did not say she was trying to protect herself. RN D indicated R2 had a large bruise on her left wrist all the way up to middle of elbow and there was a very large hematoma noted that was tender to the touch. R2 complained that it hurts when touched. RN D felt an x- ray would be needed. R2 bruises easily. I didn't see any finger print marks. RN D indicated she didn't see another bruise. RN D indicated CNA F was told to stay away from R2. RN D indicated she and RN J interviewed R2. We asked what happened. R2 has Alzheimer's and couldn't tell us what happened. We called her daughter. CNA F was helping other residents get up on another hall. CNA F finished out her shift. DON B and NHA A were notified. RN J and RN D asked staff if any other residents don't like a shower. On 9/19/19 at 5:22 PM, Surveyor interviewed DON B and NHA A regarding R2 and the bruising that occurred. DON B indicated she was contacted, at 6:22 AM on 9/17/19, and was told CNA F gave a shower to R2 and R2 had behaviors. CNA F put her arms up in defense and maintained R2's safety. DON B indicated she did provide education to CNA F to maintain safety of resident while in the shower chair. Surveyor asked DON B if the facility teaches the staff to block if a resident is throwing a punch. DON B indicated the facility does not teach the staff to block. Surveyor asked DON B when she first saw the bruises on R2. DON B indicated between 9:30 - 11:14 AM. R2 was woken up and given a shower at 5:45 AM. Surveyor showed DON B R2's body diagram that documents the bruised areas of R2's left arm with a huge blood filled hematoma, right wrist, sternum, right chin and left calf. Surveyor noted there were no measurements of the bruised areas. Surveyor asked DON B if these areas should have been measured. DON B indicated yes. Review of R2's TAR indicates: Monitor bruises to left forearm, right hand, for signs / symptoms of changes, pain, discomfort, monitoring every shift. Report changes to PCP (Primary Care Provider), dated 9/17/19. Surveyor observed initials on the AM and PM shift on 9/17 and only on the AM shift on 9/18 and 9/19. Surveyor asked DON B if the staff should be initialing this off after the bruises are checked. DON B indicated yes. Surveyor asked DON B if R2 has behaviors. DON B indicated yes. Surveyor asked if these behaviors should be tracked. DON B indicated yes. Surveyor showed DON B and NHA A the Behavior Tracking requested for (MONTH) and (MONTH) 2019. The Behavior Tracking Sheet indicates the behavior being tracked is for Not eating for (MONTH) and September. Surveyor showed DON B and NHA A the Behavior Tracking that was added per Social Worker, 9/17/19. The behavior that is being tracked now is Refusal of care / Combative of care. There is no documentation to show this behavior is being tracked. Surveyor asked DON B if the behavior should be tracked and documented. DON B said yes. Surveyor asked DON B if it was appropriate to wake R2 and take her to the shower at 5:45 AM. DON B indicated she was not sure of R2's wake time. Surveyor asked DON B, if R2 is throwing punches at staff, should staff have stopped what they are doing and report it to the nurse. DON B said yes. NHA A indicated the facility called CNA F after she was done working the full day on the Cedar Hall to tell her she was not to come to work because now the facility felt they needed to do a self - report. CNA F worked all day on the same hall where R2 lives. NHA A indicated they did not take her off the schedule as the facility did not feel abuse occurred. NHA A indicated, once the facility had more information, they suspended CNA F after she had left for the day. Surveyor asked DON B if R2 had any Dementia care training at the facility. DON B could not locate any training in CNA F's employee file. On 9/19/19 at 7:30 PM, The facility gave Surveyor a copy of CNA F's Dementia training via computer, dated 1/29/19, and a sign-in sheet from an education fair at the facility that was held on 6/19. The facility did not have documentation of the Dementia education provided except for a Trifold display that was brought into the room.This display includes: Topics such as Sun downing - Behaviors, confusion, anxiety, agitation, aggressiveness, restlessness, panic . On 9/20/19 at 9:30 AM, Surveyor interviewed MD L regarding R2's bruising obtained in the shower on 9/17/19. MD L indicated, based on the extensive bruises and the huge blood filled hematoma, she felt this did not fit with a defense maneuver. MD L indicated this was more consistent with a traumatic event. MD L indicated it was too early in the morning to be giving R2 a shower and R2 did not like showers to begin with. MD L indicated R2 flinched when she touched the area of bruising on R2's sternum and it was very tender. MD L indicated the x-rays were negative for fracture. MD L indicated the facility needs to work on Dementia care training.

Based on observation, interview, and record review, the facility did not ensure that a resident who entered the facility without a pressure injury does not develop pressure injuries and a resident who has a pressure injury receives the necessary treatment and services to promote healing, prevent infection, and prevent new pressure injuries from developing, for 2 of 11 sampled residents (R1 and R5). R1 was admitted to the facility without a Pressure Injury (PI) and was identified to be at risk for PI development. R1 was known to occasionally refuse to be repositioned and developed numerous areas of shearing to the coccyx and buttocks which placed R1 at increased risk for PI development. The facility failed to implement more aggressive interventions to prevent R1 from developing a PI. R1 developed a facility acquired unstageable PI. R5 developed a pressure injury due to pressure from foley catheter tubing. This is evidenced by the following: The facility's Pressure Injury/Skin Integrity/Wound Management Policy dated 11/16 includes in part, a system in place for the prevention, identification, treatment, and documentation of PI and non-PI wounds. Avoidable - Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice. Monitor and evaluate the impact of the interventions and/or revise the interventions as appropriate. On 5/2/17 at 10:30 AM Surveyor interviewed Registered Nurse (RN) K who was identified as the facility wound care certified (WCC) nurse. Surveyor asked RN K what Standard of Practice (SOP) she follows for PI's and RN K indicated that she follows the National Pressure Ulcer Advisory Panel (NPUAP) for wound care. According to the National Pressure Ulcer Advisory Panel (NPUAP) skin care and treatment of [REDACTED]. Use of supportive offloading surfaces: Proper positioning, transfer, and turning techniques to minimize skin injury due to friction and shear; accurately document skin risk assessment, prevention strategies as well as resident response. Example 1 R1 was admitted on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. R1's Braden (skin assessment) scores are as follows: 3/27/17 and 4/4/17 scored a 13 indicating R1 was at moderate risk for PI development. 4/11/17 scored a 12 indicating R1 was at high risk for PI development. R1's quarterly Minimum Data Set ((MDS) dated [DATE] (prior to R1 developing a PI) indicates: Section M0150 - R1 is at risk for developing a PI. Section M0210 - R1 does not have any unhealed PI. Section M1200 Skin Treatments: Z is checked indicating no measures put in place. Section G0110, Activities of Daily Living (ADL's) indicates R1 requires 1 staff and extensive assistance for bed mobility and Total Dependence for transfer. A Care Area Assessment (CAA) worksheet dated 9/22/16 states in part; Triggering Conditions: Bed mobility - total dependence, always incontinent of bowel and bladder and at risk of developing a PI. Extrinsic risk factors: pressure - requires staff assistance to move sufficiently to relieve pressure over any one site confined to a bed or chair most of the time, requires pressure reducing mattress or seat cushion and requires regular schedule of turning. [MEDICATION NAME] Factors: Immobility - altered mental status and cognitive loss. [DIAGNOSES REDACTED]. Treatments and other factors: Newly admitted / readmitted and functional limitation in range of motion. Description of Problem: This area is left blank. Care plan: Yes, avoid complications. Review of R1's Certified nursing Assistant (CNA) Care Plan, undated, includes in part; encourage to use tilt in space (recline wheel chair) after meals to decrease pressure. Float heels in bed. Encourage repositioning while in bed. Bowel and bladder - check and change every 2 hours. Wedge under right trunk, hip, and knee, pillows between knees, and under right shoulder. Blue boots in bed. Right palm protector at all times. Diabetic - daily foot checks with cares for breakdown. Alert nurse. R1's Comprehensive Care Plan Potential for impaired skin integrity secondary to impaired mobility with high muscle tone and potential for contractures, incontinence of bowel and bladder, and effects of diabetes dated 8/11/05 includes in part; Goal - will have no further skin breakdown - target date 3/30/17. Interventions: Blue boots to keep heels off bed. Daily foot checks for skin breakdown. Document R1's refusal to reposition to side. Encourage R1 to reposition every 2 hours. Encourage tilt in space feature on wheelchair for pressure relief. Low air loss mattress, wheelchair cushion. Treatment as ordered. It should be noted that R1 does not have a specialized pressure reduction cushion in his wheelchair. R1's wheelchair cushion is a custom fitted cushion for his wheelchair and was approximately 7 years old. R1's nursing notes, dated 3/25/17 at 9:57 AM by LPN M, includes in part; CNA brings to writer's attention numerous areas of shearing on coccyx and right side and right buttock, all in areas of scarring. Had discussion with R1 regarding importance of turning but he states, We'll see. Message to NP N with above information and if she prefers different orders to call on Monday. Of note - There was no documentation with the risks/benefits of not repositioning given to R1 or R1's legal guardian. It should be noted that R1 was demonstrating evidence of shearing on 3/25/17 which increases the risk for PI development. According to http://www.npuap.org/wp-content/uploads/2012/02/Shear_slides.pdf. Although sheer is understood to be a major contributor to the formation of pressure ulcers the measurement of shear and how shear contributes to formation of pressure ulcers have not been fully established. The facility failed to recognize the shear as an increased risk for PI development and failed to implement more aggressive interventions to prevent R1 from developing a PI. There were no changes to the care plan to address this increased risk. Review of R1's Pressure Ulcer Weekly Skin Assessment sheet dated 4/3/17 states skin intact / areas dry. There is not an indication of where the dry areas are located. Review of R1's SBAR (situation, background, assessment, and request), dated 4/10/17 at 7:18 PM by Licensed Practical Nurse (LPN) I, includes in part; wound right buttock / crease 3.2 x 1.8 x 0.3. This started on 4/10/17. Has wound that needs to be evaluated by wound nurse. Family notified and message left for Nurse Practitioner (NP) N. R1's nursing notes, dated 4/11/17 at 2:27 PM by LPN I, includes in part; late entry for 4/10/17. Wound had no foul odor but did have minimal -moderate amount of greenish drainage and bed of wound was greenish grayish in color. See SBAR dated 4/10/17. R1's nursing notes, dated 4/11/17 at 5:03 PM by LPN I, includes in part; New order for wound treatment to right buttock/thigh crease as follows: clean with NS (normal saline), apply skin prep to periwound, calcium alginate to wound bed f/b (followed by) [MEDICATION NAME] 2 x daily. RN K aware. R1's nursing notes, dated 4/11/17 at 9:26 PM by LPN I, includes in part; Treatment to wound right buttocks/crease. RN K to do wound rounds tomorrow and evaluate the wound. Review of R1's Right Ischium Wounds Evaluation Flow Sheet marked in-house acquired, states in part; 4/11/17 - 4.0 centimeters (cm) x 2.8 cm x <0.1 cm. Color - yellow, tan thick. Stage - 3. Granulation 25%, Slough 75%. Wound Evaluation Flow Sheet, dated 4/11/17, states R1 was on a pressure redistribution mattress. (Of note this was prior to the wound on R1's R ischium). Surveyor asked for the manufacturer's recommendations for the mattress. Surveyor was given information on the Primary Care mattress which is indicated for prevention and treatment of [REDACTED]. Director of Nursing (DON) B indicated that the entire facility changed to this type of mattress 15 months ago. Surveyor observed the Millennium Plus Stage 4 air mattress on R1's bariatric bed. Review of the invoice indicated it was delivered on 4/12/17. Manufacturer's guidelines indicate it is used for stage 4 PI and has direct low air loss. Of note, R1 was on a low air loss mattress. The facility implemented an alternating low air loss mattress after R1 developed an unstageable PI. Review of R1's Pressure Ulcer Weekly Skin Assessment sheet, dated 4/11/17, - Treatment: as ordered. [MEDICATION NAME] (dressing) intact with a line drawn to the coccyx and wound pointing to right lower buttock. R1's nursing notes, dated 4/12/17 at 2:19 PM by LPN I, includes in part; Family member called back from the message that was left two days ago. Family member updated on the open area to R1's right buttock, the treatment and that R1 will be getting a low air loss mattress tomorrow and will be repositioning him every 2 hours. R1's nursing notes, dated 4/12/17 at 7:09 PM by LPN I, includes in part; received new orders from NP N to check vital signs every shift for 72 hours and to have wound nurse assess wound. Note placed in RN K's mailbox. Low air loss mattress delivered and staff will attempt to reposition every two hours as resident is resistant to this. Review of R1's Treatment Administration Record (TAR), dated 4/12/17, includes in part; encourage every 2 hours positioning side to side and document, AM, PM, NOC (day, evening and night shift). R1's nursing notes, dated 4/14/17 at 2:46 PM by LPN I, includes in part; call placed to NP N requesting changing treatment to [MEDICATION NAME] Ag for dressing changes. Also requested Foley placement for wound healing due to R1 is incontinent and location of wound. R1's nursing notes, dated 4/14/17 at 6:44 PM by LPN K, includes in part; R1 repositioned to left side nearly flat, HOB (head of bed) elevated slightly. Vital signs stable. Dressing change done as ordered. Wound greenish center loosening. R1 cooperative with repositioning side to side. It should be noted on 4/18/17 - R1 was in the hospital. Review of R1's hospital discharge summary, dated 4/21/17, includes in part; Pressure ulcer stage 2. R1 was noted to have PI's and a foley catheter was placed at his facility to help promote his soft tissue healing. R1's initial Nursing Care Plan, dated 4/21/17, includes in part; Potential or Actual alteration in skin integrity. R/T: Diabetes, Incontinence, History of PI, Open area right buttocks thigh. To be noted there are no interventions checked for this care planned problem. Review of R1's Right Ischium Wounds Evaluation Flow Sheet marked in-house acquired dated 4/24/17 - Re-admission: 1.5 cm x 2.5 cm x 0.8 cm. Color- left blank. Unstageable. Slough 100%. Review of R1's Pressure Ulcer Weekly Skin Assessment sheet, dated 4/25/17, - Right Ischial wound. Wound treatment as prescribed. Areas of dryness. No documentation to indicate where the dry areas are noted. R1's nursing notes, dated 4/25/17 at 5:16 AM by LPN Q, includes in part; R1 has been repositioned on right and left side with pillows at side, however R1 ends up lying on his back. To be noted the care plan calls for a wedge to be used with repositioning. R1's Skin/Wound note, dated 4/25/17 at 2:33 PM by Physical Therapy Director (PTD) J, includes in part; R1 was readmitted on [DATE] with a stage 3 right Ischial ulcer and now presents as an unstageable. Braden score indicates high risk for skin breakdown. Interventions include: low air loss mattress, ROHO (air filled) cushion in wheelchair; of note - R1 does not have a ROHO cushion. Tilt in space electric wheelchair, encourage and assist with repositioning every two hours as R1 allows (R1 does not always cooperate with getting on his sides), moisture barrier cream, daily foot checks. Review of R1's Right Ischium Wounds Evaluation Flow Sheet marked in-house acquired dated 5/2/17 states in part - 2.5 cm x 2.75 cm x 0.7 cm. Color left blank. Unstageable. Granulation 20%, Slough 80%. Skin /Wound notes, dated 5/3/17 at 10:53 AM by RN K, includes in part; R1's unstageable PI has increased in size from 1.5 x 2.5 to 2.5 x 2.75. Wound bed has changed from 100% slough to 80% slough with 20% granulation tissue. On 5/3/17 at 2:30 PM Surveyor interviewed Occupational Therapist (OT) P regarding R1's electric wheelchair cushion. OT P indicated that the cushion is custom made and came with the wheelchair. OT P indicated that the electric wheel chair is approximately 8 years old and so is the cushion. OT P indicated she did a screen when R1 was readmitted from the hospital. OT P indicated she sent the request in to get approval for a new wheel chair and custom made cushion. OT P indicated that R1 does not fit well in the chair. OT P indicated that once an electric wheelchair is 6-7 years old, it usually is not repaired. OT P indicated that due to R1's changing position in the wheelchair due to body shape, deformities and weight. A new seating system has been requested due to the above changes identified prior to the hospital stay. Due to R1's custom molded back and seat, an alternative cushion is not appropriate. Recommend when R1 is up in the wheelchair to use the tilt feature to provide pressure relief. On 5/2/17 at 9:45 AM Surveyor observed R1 lying in bed with the head of bed (HOB) up 45 degrees. Of note - R1 is at increased risk for shearing and PI with the HOB elevated greater than 30 degrees. On 5/2/17 at 1:00 PM Surveyor observed R1 lying in bed with the HOB up 45 degrees. Surveyor observed the air mattress set at low air loss. R1 was repositioned by two CNA's to his left side. On 5/2/17 at 3:40 PM Surveyor observed R1 lying in bed. Air mattress set at low air loss. Surveyor observed LPN I remove the dressing on R1's right ischium. Surveyor asked LPN I to describe the wound. LPN I indicated that the wound was yellow and tan in color with 80% slough and 20% granulation tissue. On 5/3/17 at 7:55 AM Surveyor observed R1 lying in bed semi positioned on his right side. Surveyor observed the air mattress to be reading system alarm. Not low air loss. On 5/3/17 at 8:00AM Surveyor asked LPN S to come to R1's room. Surveyor asked LPN S what R1's air mattress is set at. LPN S looked at the setting and indicated it might be 472 but she was not sure what that means as it says system alarm. LPN S indicated she would need some training on the air mattress and would check with someone. R1's comprehensive care plan directed staff to Document R1's refusal to reposition to side. On 5/4/17 Surveyor observed the CNA book and reviewed R1's documents. Surveyor observed progress notes to document refusal of care which include in part; 2/1/17 - refusing cares, asking for soda. 5/3/17 - R1 got up at 11:00 AM for lunch. Asked R1 to lie down at 1:15 PM, R1 refused. Tilt encouraged. 5/3/17- went to bed around 8:15 PM, played bingo until it ended. On 5/4/17 at 10:30 AM Surveyor observed RN V complete R1's wound treatment. Wound bed observed to be sero - sang and slough 75-80%. Surveyor asked RN V what stage the wound is. RN V indicated it was a stage 3. R1 complained of pain during the treatment and RN V indicated she was sorry it hurt. R1 indicated 'you say you're sorry but you keep doing it'. RN V indicated that she was almost done. RN V asked R1 if he wanted some pain medication when the treatment was completed. R1 indicated he would appreciate that. RN V asked R1 if he was doing ok. R1 indicated, 'No, I'm not doing ok'. RN V indicated she would go and get some pain medication. On 5/4/17 at 12:30 PM RN K gave Surveyor a timeline for R1's wounds. RN K, DON B and RN Corp T asked Surveyor to meet and review the timeline. RN K indicated that R1 was always compromised. DON B and RN K indicated that R1 was brewing something and the facility did not have any indication for the skin breakdown. To be noted - R1 was at risk for skin breakdown based on the Braden score. RN K indicated that the facility was using the same interventions since his admission in 2005. DON B indicated that R1's wedge was not working and the facility is talking with therapy about it. On 5/4/17 at 3:50 PM DON B, RN K, RN Corp T, and PTD J wanted to meet with the survey team. DON B indicated that the facility does not feel they caused the PI. DON B indicated the facility had many items in place for a long time. DON B indicated the facility is following the care plan as best as they can. DON B indicated that R1 refusals are not always documented. DON B indicated that R1 was on an air mattress owned by the facility before the PI occurred. Surveyor indicated that she was told R1 was on a pressure redistribution mattress and that was documented on R1's wound sheet when the PI was noted on 4/11/17. DON B indicated that R1 was on a low air loss mattress (without a motor) and the facility went to an alternating low air loss mattress (with a motor) with alternating pressure. DON B indicated R1 did not have any PI since admit 2005. Of note - R1 did have skin breakdown and was using [MEDICATION NAME] dressing in March 2017. RN K indicated that all facility mattresses were replaced 15 months ago during the renovation. Surveyor asked what else the facility did if R1 was not compliant with repositioning. DON B indicated that she can't see how things could change as R1 had been non-compliant for a long time, while this was long standing. DON B indicated nothing has changed leading up to the wound. DON B indicated that the facility has had the same care plan and there were no signs or symptoms leading up to this. Of note - the initial care plan on R1 readmission did not include any interventions or new interventions as the care plan should be updated when changes occur. PT J indicated that in 1/17 Therapy was pursuing a better seating system to prevent PI, further contractures and pain in bed so we were working on that. Of note - the facility was aware at this time better seating for R1 is needed. PT J indicated that R1's right ischium issue is not a bed issue, it is a chair issue and R1 is almost always tilted when he is in it. Of note - the therapy department noted a concern with the wheelchair cushion in 1/17. PT J indicated that R1's weight has decreased and provided more room in the wheelchair. PT J indicated that there were no changes to his pressure points. PT J indicated that R1 has less surface with his body posture and contours. PT J indicated that R1 was in the best chair. Of note - OT P has been working on getting R1 a new wheelchair and cushion as his wheelchair is 6-7 years old and with his weight loss his pressure points could have shifted. PT J also indicated that therapy has been working with R1 for a new seating system since 1/17. RN K indicated something was going on at that time. The facility saw changes but we didn't know what was going on. Of note R1 was showing changes as evidenced by numerous areas of shear on March 25, 2017 and the facility did not implement aggressive measures at this time to prevent PI development. R1 developed an unstageable PI. Example 2 R5 [DIAGNOSES REDACTED]. R5's most recent Minimum Data Set ((MDS) dated [DATE] measures R5 as being dependent on staff for bed mobility, transfers, and toileting. R5 has an indwelling foley catheter related to the pressure injuries. R5's Braden Scale for Predicting Pressure Sore Risk on 2/10/17 is 13 for moderate risk for pressure injuries. R5's care plan dated 10/4/16 directs for the resident to be out of bed for meals only. R5's undated nurse aide care card directs nurse aide staff to leave brief open when in bed to prevent cath tubing pressure. On 2/21/17 R5's wound measurements include a Week 1 measurement on the left lateral leg-5.5 centimeters (cm) by 1.2 cm by <.1cm. It is marked that the wound was acquired in house. No cause of injury is noted. On 4/21/17, Physical Therapy Director (PTD) J writes in the progress notes: Left upper leg lateral aspect: Stage 2 pressure ulcer-mechanism of injury is the catheter tubing . On 5/4/17 at 10:05 A.M., Surveyor spoke to PTD J. PTD J she did not remember when the pressure injury started on R5's leg. PTD J said nursing found the injury and it was caused by the foley catheter tubing.

Based on record review and interview, in 5 of 7 total residents reviewed for abuse (Residents 1, 2, 3, 4 and 7) the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures, have evidence that all alleged violations were thoroughly investigated and that steps were taken to prevent further potential abuse while an investigation was in progress. This had the potential to affect all facility residents. Resident 1 was assessed to be cognitively intact. On 5/28/16, Certified Nursing Assistant (CNA) D asked Resident 1 to shut the window in her room, as the facility had the air conditioning on, Resident 1 declined. CNA D then asked CNA E to approach Resident 1 to shut her window. Resident 1 again declined to have staff shut her window. CNA D stated to CNA E, There is no reason why the rest of us should have to suffer because she does not want to shut her window. CNA D entered Resident 1's room and shut Resident 1's window despite Resident 1 wanting her window left open. Resident 1 became angry and verbally disruptive toward CNA D for shutting her window. According to the resident, CNA D proceeded to stick her tongue out and throw her middle finger up at Resident 1. Resident 1 became so angered by CNA D's actions that Resident 1 displayed verbal and physically aggression towards CNA D and causing physical harm to CNA D. The Licensed Practical Nurse (LPN) G who was on duty was aware of Resident 1's allegation of CNA D bullying her however did not initiate an investigation into the incident. The facility did not immediately initiate an investigation and did not report the allegation to the state agency. The facility did not implement appropriate interventions to prevent reoccurrence. The facility did not conduct an analysis to determine the cause of facility system breakdown in reporting. CNA D continued to work with vulnerable residents for 7 shifts after the alleged abuse occurred. The facility did not take steps to prevent further potential abuse when the abuse was first reported. Lack of immediate action to report, thoroughly investigate and to prevent further potential abuse created an Immediate Jeopardy, which began on 5/28/16. The Nursing Home Administrator (NHA) was informed of this finding on 6/16/16 at 4:28 PM and the Immediate Jeopardy was removed on 6/16/16. The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) as evidenced by the following. The facility did not thoroughly investigate an allegation of abuse when Resident 4 reported that Resident 2 touched her breast. Nursing Home Administrator (NHA) A indicated that Resident 2 was to be put on 15 minute checks and not be left alone in the lounge. These interventions were not added to Resident 2's care plan. The 15 minute checks were only done 6/2, 6/3 & 6/5/16 thus the protection plan was not continued as it should have been. Resident 3 hit Resident 7 on 3 different days and the facility did not have effective measures in place to protect Resident 7 or others. This is evidenced by: On 6/16/16 at approximately 11:52 AM, Surveyor spoke with Nursing Home Administrator (NHA) A regarding the investigation process in the facility. NHA A stated when an allegation of abuse occurs it is the staff's responsibility to ensure he and the Director of Nursing (DON) B are immediately notified and an investigation should immediately begin into the incident. NHA A stated the accused person, if a staff member, is suspended pending investigation. NHA A stated the Social Service department also assists with investigations but the responsibility lies on the NHA. Example 1 Resident 1 was admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITIONS] Disorder and [MEDICAL CONDITION], Visual Hallucinations and Anxiety. Of note Resident 1 is [AGE] years old. Resident 1 had a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/6/16. Resident 1 had a Brief Interview of Mental Status (BIMS) score of 13 indicating Resident 1 is cognitively intact. Section E0200 Behavioral Symptoms indicates Resident 1 had no physical behaviors directed toward others and no verbal behaviors directed toward others. Section D0200 indicates Resident 1 had no mood indicators. Section G0110 indicates Resident 1 was independently able to transfer and ambulate. Resident 1's plan of care Potential for alteration in cognition and mood dated 4/14/16 states in part: Goal: Will be free of depressive symptoms. Interventions: Allow resident time to respond; approach in calm, unhurried manner; monitor for changes in cognition and mood. Resident 1's Behavior Intervention sheet for May 2016 indicates the facility was monitoring Resident 1 for increased agitation and yelling. Resident 1 had no behaviors documented for the month of May. Resident 1's nursing note dated 5/28/16 5:00 PM (late entry) states in part; CNA closed resident's window as air conditioning running. Resident started yelling, cursing, and telling CNA F*** you B****. Writer able to calm resident and CNA moved to another wing. At 5:30 PM resident saw same CNA and just started cursing and yelling at all staff where visitors were present; writer again able to calm resident. A witness statement from CNA D written on 5/28/16 (no time) states in part; I explained to Resident 1 that the air was on in the facility. I noticed her window was open, I explained to her that it needed to be shut to prevent hot air from coming in. I thought she said it was okay to shut the window. When I did close it she flipped out on me. She said she was going to beat my white fat a** called me a B**** and W****. Then the nurse walked in and explained it to her as well about the window. Resident 1 still didn't want it closed. Resident 1 came out of the room and called someone by the time clock saw me and started cussing at me and threatening me in front of residents, staff and family. Resident 1's nursing note dated 5/28/16 at 9:00 PM states in part; writer could hear a person yelling help me. Writer ran down the hall and entered nurse's office to find patient beating on CNA and had phone in her hand and was hitting CNA with the phone. Writer grabbed patient arm and stated (Resident 1's name) stop and come talk with me. Writer raised voice louder and repeated and patient stopped. CNA was crouched down trying to cover head and protect it from being beaten. Writer noted CNA with marks on face and bleeding at forehead. Writer ambulated down hall with patient and had patient talk to writer about what happened. Patient much calmer now and told writer that CNA had shut her window in her room and patient did not want it shut. Patient reported that she re-opened the window and the CNA was giving her the finger and calling her names afterwards. Patient became angry telling CNA To go ahead and beat the crap out of me. CNA did not say anything and did not touch patient but the patient then began beating on the CNA and was hitting CNA with the phone. CNA was trying to protect her head and was yelling for help. Police came and reports were made and patient was then charged with battery and received a citation. Writer did speak with Registered Nurse (RN) H and informed RN H of what happened. RN H informed writer to remove roommate and temporarily do 15 minute checks on Resident 1. Call placed to DON B and left message. CNA D was moved off wing to avoid seeing Resident 1. A witness statement from CNA D dated 5/28/16 (no time) states in part; after the window issue Resident 1 saw me in the nurses station came up behind me and pushed me then started beating me up with closed fist, open hand just hitting me. Resident 1 beat me with the phone over my head and was slapping and hitting my head and face. I was screaming for help. Resident 1 said You need back-up B****. LPN G came in and somehow got Resident 1 to her room. On 6/20/16 at 6:54 PM Surveyor interviewed CNA D regarding the incident between CNA D and Resident 1. CNA D stated that she went into Resident 1's room to shut her window early on the PM shift and Resident 1 declined to have her window shut. CNA D stated she wanted to close the window as the air conditioning was on and she was concerned that Resident 1's roommate was to warm. CNA D stated she asked Resident 1 if she could shut her door and Resident 1 declined to have her door shut. Surveyor asked CNA D if she asked CNA E to approach Resident 1 about shutting her window CNA D stated she did not but Resident 1 called CNA E names as well. CNA D stated I did go over and close her window. CNA D stated this was about 4:30 PM. CNA D stated that after she closed Resident 1's window Resident 1 starting calling her racial slurs and yelling. CNA D stated that LPN F heard Resident 1 yelling and told me to stay away from Resident 1 which I did. CNA D stated about a half hour to an hour later Resident 1 was on the phone by the time clock. CNA D stated Resident 1 saw her and Resident 1 stated to CNA D I'm going to F*** you up. CNA D stated after that incident LPN F moved me to a different wing. CNA D stated I should have been moved right away. Surveyor asked CNA D how long she continued to work on Resident 1's unit after the incident occurred CNA D stated about an hour. CNA D stated LPN F should have let me go home after I shut Resident 1's windows Resident 1 was calling me names after I shut her window. Surveyor asked CNA D if she stuck her tongue out, threw up her middle finger or called Resident 1 names. CNA D stated I heard that someone was concerned I had done those things but I did not do any of those things. I am not sure where that came from. CNA D stated I went to get water for a resident and Resident 1 approached me in the nursing station and started beating me up. She was hitting me with her fists, scratching me and hitting me with the phone. I was yelling for someone to help me and LPN G finally heard me and was able to get Resident 1 to stop hitting me. Resident 1 was calling me F***ing B**** and telling me I was going to need back-up. Surveyor asked CNA D what she thought may have provoked Resident 1 into having such a catastrophic response. CNA D stated I guess when I shut her window. Surveyor asked CNA D if she had ever received training on how to handle a resident that may have a catastrophic response CNA D stated she has not been trained on working with residents with catastrophic reactions. On 6/16/16 at 9:41 AM Surveyor interviewed CNA E regarding the incident on 5/28/16 between Resident 1 and CNA D. CNA E stated CNA D approached her and asked her if she would ask Resident 1 to shut her window. CNA D told CNA E she had already approached Resident 1 and Resident 1 did not want her window closed. CNA E stated she went into Resident 1's room and asked if she could close the window as the air conditioning was on and Resident 1 stated; No. CNA E stated she left Resident 1's room and did not shut the window CNA E stated she told CNA D Resident 1 did not want the window shut. CNA E stated she told CNA D Resident 1 did not want her window shut. CNA D stated to CNA E we should not have to suffer because Resident 1 does not want her window shut. CNA E stated CNA D went into Resident 1's room and shut the window. CNA E stated this upset Resident 1 she got up and re-opened the window and began yelling and calling CNA D names. CNA E stated she left the area and went to the dining room and CNA D remained in the hallway where Resident 1 resides. CNA E stated that Resident 1 alleged after CNA D closed her window CNA D walked by her room and stuck out her tongue, put up her middle finger and called Resident 1 a bully, trying to get Resident 1 Wound up. Surveyor asked CNA E if she witnessed CNA D doing any of the things Resident 1 alleges. CNA E stated she did not witness any of the things Resident 1 alleged as she was in the dining room with residents, but it seems like something CNA D would do. CNA E stated Resident 1 told LPN F that CNA D was bullying her. CNA E stated she told LPN F and LPN G the night the incident occurred that Resident 1 was alleging CNA D was sticking out her tongue, calling her names and stick her middle finger up at her. CNA E stated it did not seem like the nurses wanted to do anything. CNA E stated after the altercation between Resident 1 and CNA D, CNA E called the police and another unnamed CNA called DON B regarding the incident. Surveyor asked CNA E if she has ever received training on how to work with residents that have catastrophic reactions such as Resident 1's CNA E stated she has not had any training on how to deal with catastrophic reactions. On 6/6/16 at 10:23 AM Surveyor interviewed LPN F regarding the incident on 5/28/16 between Resident 1 and CNA D. LPN F stated around the dinner hour about 5:00 PM she heard Resident 1 yelling. I came out of a resident's room and saw CNA D coming out of Resident 1's room at the same time. I walked into Resident 1's room and asked her what was wrong. Resident 1 stated that B**** wants to shut my window. LPN F stated she told Resident 1 they would leave the window open. LPN F stated she told CNA D to leave the window open and to keep the Resident 1 calm. LPN F stated CNA D stated did you hear what she was saying to me. LPN F stated she told CNA D she did hear what Resident 1 said and advised CNA D to ignore it. LPN F stated every time CNA D would go by Resident 1's room Resident 1 would escalate so LPN F decided to remove CNA D from the unit. Surveyor asked LPN F what time CNA D was removed from the unit. LPN F stated around 5:45 to 6:00 PM. Surveyor stated CNA D may have worked on the unit for about an hour after the incident occurred. LPN F stated her shift ended at 6:00 PM and she was not present when the incident occurred between Resident 1 and CNA D. Surveyor asked LPN F if she was aware of any allegations Resident 1 made regarding CNA D. LPN F stated when she returned to work the next day she was informed that Resident 1 alleged that CNA D was calling her names, sticking her tongue out at her and giving her the finger. LPN F stated she did not witness any of the things Resident 1 alleged. Surveyor asked LPN F if she reported the allegations to anyone. LPN F stated she did not as everyone was aware of the allegations and incident and she thought management was aware. Surveyor asked LPN F if she has been trained on how to work with residents that have catastrophic reactions such as Resident 1 had on 5/28/16. LPN F stated she has not received training on catastrophic reactions. A witness statement from LPN F dated 6/16/16 (no time) states in part; I did not hear anything about CNA D rolling eyes until Sunday night at 6:00 PM. I thought administration and the DON had full report. A witness statement from LPN G dated 5/28/16 at 11:00 PM states in part; Patient reported that she re-opened the window and the CNA was giving her the finger and calling her names afterwards. Patient became angry telling CNA To go ahead and beat the crap out of me, I'm going to whoop your ass. CNA did not say anything and did not touch patient but the patient then began beating on the CNA and was hitting CNA with the phone. CNA was trying to protect her head and was yelling for help. Police came and reports were made and patient was then charged with battery and received a citation. Writer did speak with Registered Nurse (RN) H and informed RN H of what happened. RN H informed writer to remove roommate and temporarily do 15 minute checks on Resident 1. Call placed to DON B and left message. CNA D was moved off wing to avoid seeing Resident 1. On 6/22/16 at 5:20 PM Surveyor interviewed LPN G regarding the incident between CNA D and Resident 1. LPN G stated she heard someone yelling for help and found CNA D in the nurse's station being hit by Resident 1. Resident 1 was hitting her with her hands and the phone. LPN G stated she grabbed Resident 1 by the arm and asked her to stop. LPN G stated she had to raise her voice and ask Resident 1 to stop and Resident 1 stopped. LPN G stated she found it unreal that Resident 1 was upset over a closed window so she asked her what happened. LPN G stated Resident 1 stated the CNA D was sticking her tongue out at her, calling her names and shut her window. LPN G stated Resident 1 was calm and she left her in her room. LPN G stated she spoke with CNA D and told her she needed to stay on another hall the rest of the shift this was about 6:30 PM. LPN G stated she made it very clear to CNA D she was not to come off the unit until the end of her shift as not to agitate Resident 1. Surveyor asked LPN G if CNA D had been on Resident 1's hall until 6:30 PM and LPN G stated I think she was moved a little earlier but I did not want her off the unit now. Surveyor asked LPN G if she reported Resident 1's allegations to anyone. LPN G stated I documented it in the nursing notes. Surveyor asked if she spoke to anyone about the allegations. LPN G stated she called RN H and reported the incident between CNA D and Resident 1 and left a message on the phone with DON B regarding the incident. LPN G stated she did not speak to anyone about Resident 1's allegations. LPN G stated I do not think CNA D provoked Resident 1. I think CNA D closed her window and Resident 1 got mad and she decided to corner CNA D and beat her up. Surveyor asked LPN G if Resident 1 had a history of [REDACTED]. Surveyor asked LPN G if she has received education on abuse. LPN G stated she receives education at least 2 times per year. Surveyor asked LPN G about the facility's policy for reporting abuse allegations. LPN G stated we are to report allegations of abuse to the chain of command. Surveyor asked LPN G if she reported Resident 1's allegations of CNA D sticking out her tongue and calling Resident 1 names. LPN G stated she did not report it to anyone but she documented it in the nursing notes. LPN G stated she should have reported the allegations to RN H when she spoke with her on the phone . Surveyor asked LPN G if she has received education on how to deal with a resident who has catastrophic reactions such as Resident 1's. LPN G stated she has not but it would have been useful in this situation. A (City Name) police report dated 5/28/16 states in part; Reported date: 5/28/16 at 6:25 PM. Interview with Resident 1: Resident 1 stated she became upset today when CNA D rushed in my room to close the window. Resident 1 stated CNA D slammed the window shut out of nowhere. Resident 1 stated that CNA D stood outside Resident 1's room door and was sticking her tongue out at Resident 1. Resident 1 stated to the PO J she closed my window. I was bullying her back like she tried to bully me. Resident 1 stated the CNA's here are very unprofessional. Resident 1 states that CNA D left her room and Resident 1 used a phone to call Resident 1's daughter so that her daughter could call the NHA. Resident 1 stated she was making this phone call from the time clock room which is across from the nurse's station. Resident 1 stated that CNA D was in the nurse's station and CNA D was sticking her tongue out and throwing up her middle finger at Resident 1. Resident 1 stated CNA D was responsible for starting everything because CNA D was sticking her tongue out at Resident 1. Resident 1 told PO J a little while later she went into the nurse's station and was pushing CNA D. Resident 1 stated the pushing was mutual and lasted approximately 1 minute. Resident 1 stated she was pushing CNA D because her sister was on the nurse's station phone and Resident 1 wanted to talk to her sister. Resident 1 stated the pushing was with hands and did not involve punching or other motions. PO J asked Resident 1 if she was trying to hurt CNA D Resident 1 stated she was mad. PO J asked Resident 1 to clarify if she was trying to hurt CNA D Resident 1 stated probably so and when you mad, yeah. Resident 1 stated the disturbance did not involve any swinging of arms or hands and Resident 1 did not use the phone to hit CNA D. On 6/14/16, at 12:50 PM, Surveyor spoke with Resident 1. Resident 1 stated CNA D and CNA E came to her room and stood in the doorway. CNA D went to the window and slammed it shut and stated to Resident 1 you are not the only one here. CNA D would just stand in the doorway and look at Resident 1. Resident 1 stated she felt CNA D was bullying her. Resident 1 then went up the hall to call her daughter and CNA D stated you run up on me! Resident 1 went to her room and when she came out again is when the incident occurred with CNA D. Resident 1 was going to the phone and CNA D put her middle finger up at her and said B**** this and B****that. Resident 1 stated she did hit CNA D but CNA D was hitting her back and the facility did not do anything about it. Resident 1 stated she told multiple staff that CNA D hit her and had been bullying her. Resident 1 stated DON B was also told when Resident 1 was discharging from the building that CNA D had been provoking her and had hit her during the altercation. On 6/16/16 at 11:52 AM Surveyor interviewed NHA A and DON B regarding the incident between Resident 1 and CNA D. NHA A stated that CNA D upon instruction from the nurse went into Resident 1's room to shut her window as the air conditioning was on in the building. Resident 1 did not respond when CNA D asked if she could shut the window and CNA D took this as a yes and shut the window. Later Resident 1 beat up CNA D and the police were called. Surveyor asked NHA A if he completed an investigation into the incident. NHA A stated he did not report the incident as it was a staff member that was injured not a resident. NHA A provided Surveyor with a soft file of the incident this file included witness statements from LPN G, LPN F, CNA D, CNA E, statements from residents and photographs of CNA D's injuries. There was no statement from Resident 1. Surveyor asked NHA A and DON B if they were aware of the allegation Resident 1 made toward CNA D. NHA A and DON B stated they were unaware that Resident 1 voiced an allegation toward CNA D. Surveyor reviewed the nursing notes dated 5/28/16 at 9:00 PM which state in part; patient much calmer now and told writer that CNA had shut her window in her room and patient did not want it shut. Patient reported that she re-opened the window and the CNA was giving her the finger and calling her names afterwards. Patient became angry telling CNA To go ahead and beat the crap out of me. NHA A and DON B stated they were unaware of this allegation. Surveyor asked NHA A and DON B if they would expect LPN F, the author of the nursing note, to immediately report such an allegation. NHA A stated, Yes, of course. NHA A was reviewing the soft file on this incident and stated to DON B It's documented in here, it is all right here. Surveyor asked DON B if she reviews the nursing notes DON B stated she does review the nursing notes. DON B stated I must have missed it, if it is documented in the soft file we missed it. NHA A stated I did not have this allegation reported to me. Surveyor stated should you have known. NHA A stated Yes, it should have been reported to me. I have it here in the file. Had I known I would have filed a report and completed an investigation into the incident. Surveyor asked NHA A if you would have had prior knowledge of this incident tell me how you would have proceeded? NHA A stated CNA D would have been removed from duty pending investigation. Surveyor asked DON B and NHA A if CNA D has continued to work since 5/28/16? DON B stated yes she has continued to be scheduled. Surveyor reviewed the nursing schedule from 5/28/16 through 6/16/16. The facility has 5 halls and 1 float position. CNA D worked the following shifts on the following halls. 5/28/16 - CNA D was moved off Resident 1's hall approximately 1 hour after verbal altercation with Resident 1. 6/1/16 - CNA D floated 6/6/16 - CNA D worked hall S.L. 6/8/16 - CNA D worked hall H 6/9/16 - CNA D floated 6/12/16 - CNA D worked hall P 6/13/16 - CNA D worked hall P 6/15/16 - CNA D worked hall G CNA D floated and worked 4 out of the 5 halls after the incident on 5/28/16. Surveyor reviewed CNA D's personnel file. CNA D was re-hired by the facility on 4/15/16. On 4/19/16, just 4 days after CNA D was re-hired, CNA D received an Employee Counseling from DON B. The counseling record states in part; Description of Problem: When assisting another CNA with a Hoyer transfer, resident was complaining that it was too uncomfortable and was causing pain. Resident was lifted back up and tried again to sit in shower chair; became confrontational with residents daughter and asked if she was a CNA and then said just let us do our job. Corrective Action: You NEVER become confrontational with a resident or their family. You were suspended from the 19th to the 22nd. This is a final warning and if anything like this occurs again it will be termination. Of note, just 4 days after re-hire CNA D received a final written warning for poor customer service. On 6/16/16 at 1:10 PM Surveyor met with and NHA A, DON B and Corporate Registered Nurse (RN) I regarding the incident and investigation into the incident between Resident 1 and CNA D. RN I stated to Surveyor I understand from NHA A and DON B that you have some concerns regarding the investigation into the incident with CNA D and Resident 1. RN I stated we acknowledge that we should have reviewed the nursing notes regarding Resident 1's allegation and NHA A and DON B have been educated however we did complete a thorough investigation into this incident. Surveyor stated to NHA A, DON B and RN I help me to understand your investigation process. RN I stated we interviewed other residents and witnesses to the incident. Surveyor asked NHA A if Resident 1 was interviewed. NHA A stated he met with Resident 1 on 5/31/16 and asked if everything was okay and she did not report an allegation she stated everything was okay she had ample opportunity to report an allegation on 5/31/16. Surveyor asked NHA A if he documented the meeting with Resident 1. NHA A stated he did not document the meeting. Surveyor asked NHA A did you interview Resident 1 regarding the events on 5/28/16 and what may have caused Resident 1 to get into a verbal and physical altercation with Resident 1? NHA A stated shutting the window provoked Resident 1. NHA A stated I did not review the incident with Resident 1. I did not want to increase her agitation. Surveyor asked NHA A typically when completing a thorough investigation would you interview all parties. NHA A stated normally follow up is completed by the Social Worker. We had 28 room changes to complete, I am not making excuses. RN I stated we are not making excuses we thought we did a thorough job. NHA A stated I guess I was distracted by CNA D being attacked by Resident 1. DON B stated CNA D is very volatile she uses foul language mostly when on the phone with her son. We have had to ask her lower her voice when speaking with her son. Surveyor stated to NHA A and DON B regarding CNA D's personnel record and the final written warning. Surveyor asked NHA A if you had been informed of Resident 1's allegation on 5/28/16 and knowing CNA D had a final written warning in her personnel file for customer service how would you have proceeded? Would this incident warrant termination for CNA D? NHA A stated good question; if I would have known about the allegation CNA D would have been suspended. RN I interjected and stated only corporate has the authority to terminate an employee. RN I further stated I do not think shutting a window is abuse. We have re-educated the staff on working with residents with behaviors and we teach re-approaching residents; no indication other residents were at harm. We are starting an investigation today and CNA D has been suspended pending further investigation. A witness statement dated 6/16/16 from NHA A states in part; when the incident occurred that was reported to me concerning CNA D being assaulted by Resident 1. I instinctually asked if Resident 1 was provoked, in anyway by CNA D I was told no by LPN F who reported to me. Nursing notes dated 5/31/16 (no time) state in part; received call from place Resident 1 will be discharged to will pick Resident 1 up at 2:00 PM. Call placed for discharge orders. On 6/16/16 at 4:46 PM Surveyor interviewed DON B regarding 5/31/16 when Resident 1 discharged from the facility. Surveyor asked DON B if Resident 1 had spoken to her prior to discharge regarding the altercation between Resident 1 and CNA D. DON B stated as Resident 1 was going out the door Resident 1 stated CNA D started it. DON B stated she did not think anything of it. Resident 1 alleged CNA D was sticking her tongue out at her, throwing her middle finger up at her and calling her names. This allegation was not immediately reported to the NHA thus the investigation was not thorough and complete and no measures taken to prevent further potential abuse as CNA D continued to work with residents. The failure to fully investigate and to take actions to prevent further potential abuse created a situation of immediate jeopardy. The facility removed the Immediate Jeopardy on 6/16/16 when: 1. Resident 1 was discharged on [DATE]. 2. CNA D was suspended on 6/16/16 pending further investigation. 3. All alert residents were interviewed to see if any employee has provoked them to the point they were upset. 4. All employees involved in the incident with Resident 1 were re-interviewed to see if Resident 1 was provoked to get upset. 5. LPN G was re-educated on the facility's policy on abuse, neglect and misappropriation that includes the need to immediately report, investigate, and protect resident. 6. Department heads including NHA and DON were educated on the facility's policy on abuse, neglect and misappropriation including immediate reporting all allegations, thoroughly investigating and assuring residents are protected. 7. Before working their next shift, all staff will be educated on the facility's policy on abuse, neglect and misappropriation including the need to immediately report complete a thorough investigation and protecting the resident. 8. Resident interviews will be conducted 3 times per week, allegation audits will be conducted after each allegation to ensure that they are thoroughly investigated. Cross reference 223 and 226 The deficient practice continues at scope/severity of F (potential for harm that is not immediate jeopardy/widespread) as evidenced by the following: Example 2 Registered Nurse (RN) C reported to NHA A that Resident 4 reported to her that Resident 2 touched her breast. Resident 4 wrote the following statement: Resident 4 reported to me that she was in the TV room when Resident 2 started talking to her, as they were talking resident reported that Resident 2 touched her breast. The facility self reported this incident, however, they did not interview other residents or other staff members to determine to scope of the abuse. In NHA's notes he noted for Resident 2 to add 15 minute checks and Not alone in lounge. These interventions were not added to the comprehensive care plan or the Certified Nursing Assistant (CNA) care card. The facility documented 15 minute checks for 3 days only. (Please note the 15 minutes checks were supposed to continue for Resident 4's protection plan). On 6/16/16 at 2:45 PM, Surveyor spoke with Director of Nursing (DON) B. Surveyor asked DON B if the above referenced interventions should have been added to Res

Based on interview and record review, the facility did not implement its policies and procedures that prohibit mistreatment, abuse and neglect of residents for 1 of 7 total residents reviewed (Resident 1). Facility staff did not immediately report the allegation, the facility did not immediately investigate the allegation, and the facility did not take steps to prevent further potential abuse as the accused certified nursing assistant (CNA) was allowed to continue working with residents and without increased supervision. This had the potential to affect all residents of the facility. Resident 1 was assessed to be cognitively intact. On 5/28/16, Certified Nursing Assistant (CNA) D asked Resident 1 to shut the window in her room, as the facility had the air conditioning on. Resident 1 declined. CNA D then asked CNA E to approach Resident 1 to shut her window. Resident 1 again declined to have staff shut her window. CNA D stated to CNA E, There is no reason why the rest of us should have to suffer because she does not want to shut her window. CNA D entered Resident 1's room and shut Resident 1's window despite Resident 1 wanting her window left open. Resident 1 became angry and verbally disruptive toward CNA D for shutting her window. Resident 1 alleged that CNA D proceeded to stick her tongue out and throw her middle finger up at Resident 1. Resident 1 became so angered by CNA D's actions that Resident 1 displayed verbal and physical aggression towards CNA D and causing physical harm to CNA D. The Licensed Practical Nurse (LPN) G who was on duty was aware of Resident 1's allegation of CNA D bullying her, however did not immediately contact the admininistrator or initiate an investigation into the incident. The facility did not immediatelyreport the allegation to the state agency. The facility did not implement appropriate interventions to prevent reoccurrence. The facility did not conduct an analysis to determine the cause of facility system breakdown in reporting. CNA D continued to work with vulnerable residents for 7 shifts after the alleged abuse occurred. The facility did not take steps to prevent further potential abuse when the abuse was first reported. The failure to have a system in place to implement the abuse policy and procedure led to the finding of Immediate Jeopardy. Immediate Jeopardy started on 5/28/16. The NHA and DON were notified of the Immediate Jeopardy on 6/16/16 at 4:28 PM. The facility removed the immediate jeopardy on 6/16/16 however, the deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy /widespread) because not all staff has been retrained regarding abuse prevention, reporting, and the protection of residents. Resident 1, who is [AGE] years old, was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident 1 had a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/6/16. Resident 1 had a Brief Interview of Mental Status (BIMS) score of 13 indicating Resident 1 is cognitively intact. Section E0200 Behavioral Symptoms indicates Resident 1 had no physical behaviors directed toward others and no verbal behaviors directed toward others. Section D0200 indicates Resident 1 had no mood indicators. Section G0110 indicates Resident 1 was independently able to transfer and ambulate. Resident 1's plan of care Potential for alteration in cognition and mood dated 4/14/16 states in part: Goal: Will be free of depressive symptoms. Interventions: Allow resident time to respond; approach in calm, unhurried manner; monitor for changes in cognition and mood. Resident 1's Behavior Intervention sheet for May 2016 indicates the facility was monitoring Resident 1 for increased agitation and yelling. Resident 1 had no behaviors documented for the month of May. Resident 1's nursing note dated 5/28/16 5:00 PM (late entry) states in part; CNA closed resident's window as air conditioning running. Resident started yelling, cursing, and telling CNA F*** you B****. Writer able to calm resident and CNA moved to another wing. At 5:30 PM resident saw same CNA and just started cursing and yelling at all staff where visitors were present; writer again able to calm resident. On 6/14/16, at 12:50 PM, Surveyor spoke with Resident 1. Resident 1 stated CNA D and CNA E came to her room and stood in the doorway. CNA D went to the window and slammed it shut and stated to Resident 1 you are not the only one here. CNA D would just stand in the doorway and look at Resident 1. Resident 1 stated she felt CNA D was bullying her. Resident 1 then went up the hall to call her daughter and CNA D stated you run up on me! Resident 1 went to her room and when she came out again is when the incident occurred with CNA D. Resident 1 was going to the phone and CNA D put her middle finger up at her and said B**** this and B****that. Resident 1 stated she did hit CNA D but CNA D was hitting her back and the facility did not do anything about it. Resident 1 stated she told multiple staff that CNA D hit her and had been bullying her. Resident 1 stated DON B was also told when Resident 1 was discharging from the building that CNA D had been provoking her and had hit her during the altercation. A (City Name) police report dated 5/28/16 states in part; Reported date: 5/28/16 at 6:25 PM. Interview with Resident 1: Resident 1 stated she became upset today when CNA D rushed in my room to close the window. Resident 1 stated CNA D slammed the window shut out of nowhere. Resident 1 stated that CNA D stood outside Resident 1's room door and was sticking her tongue out at Resident 1. Resident 1 stated to the PO J she closed my window. I was bullying her back like she tried to bully me. Resident 1 stated the CNA's here are very unprofessional. Resident 1 states that CNA D left her room and Resident 1 used a phone to call Resident 1's daughter so that her daughter could call the NHA. Resident 1 stated she was making this phone call from the time clock room which is across from the nurse's station. Resident 1 stated that CNA D was in the nurse's station and CNA D was sticking her tongue out and throwing up her middle finger at Resident 1. Resident 1 stated CNA D was responsible for starting everything because CNA D was sticking her tongue out at Resident 1. Resident 1 told PO J a little while later she went into the nurse's station and was pushing CNA D. Resident 1 stated the pushing was mutual and lasted approximately 1 minute. Resident 1 stated she was pushing CNA D because her sister was on the nurse's station phone and Resident 1 wanted to talk to her sister. Resident 1 stated the pushing was with hands and did not involve punching or other motions. PO J asked Resident 1 if she was trying to hurt CNA D Resident 1 stated she was mad. PO J asked Resident 1 to clarify if she was trying to hurt CNA D Resident 1 stated probably so and when you mad, yeah. Resident 1 stated the disturbance did not involve any swinging of arms or hands and Resident 1 did not use the phone to hit CNA D. A witness statement from CNA D written on 5/28/16 (no time) states in part; I explained to Resident 1 that the air was on in the facility. I noticed her window was open, I explained to her that it needed to be shut to prevent hot air from coming in. I thought she said it was okay to shut the window. When I did close it she flipped out on me. She said she was going to beat my white fat a** called me a B**** and W****. Then the nurse walked in and explained it to her as well about the window. Resident 1 still didn't want it closed. Resident 1 came out of the room and called someone by the time clock saw me and started cussing at me and threatening me in front of residents, staff and family. Resident 1's nursing note dated 5/28/16 at 9:00 PM states in part; writer could hear a person yelling help me. Writer ran down the hall and entered nurse's office to find patient beating on CNA and had phone in her hand and was hitting CNA with the phone. Writer grabbed patient arm and stated (Resident 1's name) stop and come talk with me. Writer raised voice louder and repeated and patient stopped. CNA was crouched down trying to cover head and protect it from being beaten. Writer noted CNA with marks on face and bleeding at forehead. Writer ambulated down hall with patient and had patient talk to writer about what happened. Patient much calmer now and told writer that CNA had shut her window in her room and patient did not want it shut. Patient reported that she re-opened the window and the CNA was giving her the finger and calling her names afterwards. Patient became angry telling CNA To go ahead and beat the crap out of me. CNA did not say anything and did not touch patient but the patient then began beating on the CNA and was hitting CNA with the phone. CNA was trying to protect her head and was yelling for help. Police came and reports were made and patient was then charged with battery and received a citation. Writer did speak with Registered Nurse (RN) H and informed RN H of what happened. RN H informed writer to remove roommate and temporarily do 15 minute checks on Resident 1. Call placed to DON B and left message. CNA D was moved off wing to avoid seeing Resident 1. A witness statement from CNA D dated 5/28/16 (no time) states in part; after the window issue Resident 1 saw me in the nurses station came up behind me and pushed me then started beating me up with closed fist, open hand just hitting me. Resident 1 beat me with the phone over my head and was slapping and hitting my head and face. I was screaming for help. Resident 1 said You need back-up B****. LPN G came in and somehow got Resident 1 to her room. On 6/20/16 at 6:54 PM Surveyor interviewed CNA D regarding the incident between CNA D and Resident 1. CNA D stated that she went into Resident 1's room to shut her window early on the PM shift and Resident 1 declined to have her window shut. CNA D stated she wanted to close the window as the air conditioning was on and she was concerned that Resident 1's roommate was to warm. CNA D stated she asked Resident 1 if she could shut her door and Resident 1 declined to have her door shut. Surveyor asked CNA D if she asked CNA E to approach Resident 1 about shutting her window CNA D stated she did not but Resident 1 called CNA E names as well. CNA D stated I did go over and close her window. CNA D stated this was about 4:30 PM. CNA D stated that after she closed Resident 1's window Resident 1 starting calling her racial slurs and yelling. CNA D stated that LPN F heard Resident 1 yelling and told me to stay away from Resident 1 which I did. CNA D stated about a half hour to an hour later Resident 1 was on the phone by the time clock. CNA D stated Resident 1 saw her and Resident 1 stated to CNA D I'm going to F*** you up. CNA D stated after that incident LPN F moved me to a different wing. CNA D stated I should have been moved right away. Surveyor asked CNA D how long she continued to work on Resident 1's unit after the incident occurred CNA D stated about an hour. CNA D stated LPN F should have let me go home after I shut Resident 1's windows Resident 1 was calling me names after I shut her window. Surveyor asked CNA D if she stuck her tongue out, threw up her middle finger or called Resident 1 names. CNA D stated I heard that someone was concerned I had done those things but I did not do any of those things. I am not sure where that came from. CNA D stated I went to get water for a resident and Resident 1 approached me in the nursing station and started beating me up. She was hitting me with her fists, scratching me and hitting me with the phone. I was yelling for someone to help me and LPN G finally heard me and was able to get Resident 1 to stop hitting me. Resident 1 was calling me F***ing B**** and telling me I was going to need back-up. Surveyor asked CNA D what she thought may have provoked Resident 1 into having such a catastrophic response. CNA D stated I guess when I shut her window. Surveyor asked CNA D if she had ever received training on how to handle a resident that may have a catastrophic response CNA D stated she has not been trained on working with residents with catastrophic reactions. On 6/16/16 at 9:41 AM Surveyor interviewed CNA E regarding the incident on 5/28/16 between Resident 1 and CNA D. CNA E stated CNA D approached her and asked her if she would ask Resident 1 to shut her window. CNA D told CNA E she had already approached Resident 1 and Resident 1 did not want her window closed. CNA E stated she went into Resident 1's room and asked if she could close the window as the air conditioning was on and Resident 1 stated; No. CNA E stated she left Resident 1's room and did not shut the window CNA E stated she told CNA D Resident 1 did not want the window shut. CNA E stated she told CNA D Resident 1 did not want her window shut. CNA D stated to CNA E we should not have to suffer because Resident 1 does not want her window shut. CNA E stated CNA D went into Resident 1's room and shut the window. CNA E stated this upset Resident 1 she got up and re-opened the window and began yelling and calling CNA D names. CNA E stated she left the area and went to the dining room and CNA D remained in the hallway where Resident 1 resides. CNA E stated that Resident 1 alleged after CNA D closed her window CNA D walked by her room and stuck out her tongue, put up her middle finger and called Resident 1 a bully, trying to get Resident 1 Wound up. Surveyor asked CNA E if she witnessed CNA D doing any of the things Resident 1 alleges. CNA E stated she did not witness any of the things Resident 1 alleged as she was in the dining room with residents, but it seems like something CNA D would do. CNA E stated Resident 1 told LPN F that CNA D was bullying her. CNA E stated she told LPN F and LPN G the night the incident occurred that Resident 1 was alleging CNA D was sticking out her tongue, calling her names and stick her middle finger up at her. CNA E stated it did not seem like the nurses wanted to do anything. CNA E stated after the altercation between Resident 1 and CNA D, CNA E called the police and another unnamed CNA called DON B regarding the incident. Surveyor asked CNA E if she has ever received training on how to work with residents that have catastrophic reactions such as Resident 1's CNA E stated she has not had any training on how to deal with catastrophic reactions. On 6/6/16 at 10:23 AM Surveyor interviewed LPN F regarding the incident on 5/28/16 between Resident 1 and CNA D. LPN F stated around the dinner hour about 5:00 PM she heard Resident 1 yelling. I came out of a resident's room and saw CNA D coming out of Resident 1's room at the same time. I walked into Resident 1's room and asked her what was wrong. Resident 1 stated that B**** wants to shut my window. LPN F stated she told Resident 1 they would leave the window open. LPN F stated she told CNA D to leave the window open and to keep the Resident 1 calm. LPN F stated CNA D stated did you hear what she was saying to me. LPN F stated she told CNA D she did hear what Resident 1 said and advised CNA D to ignore it. LPN F stated every time CNA D would go by Resident 1's room Resident 1 would escalate so LPN F decided to remove CNA D from the unit. Surveyor asked LPN F what time CNA D was removed from the unit. LPN F stated around 5:45 to 6:00 PM. Surveyor stated CNA D may have worked on the unit for about an hour after the incident occurred. LPN F stated her shift ended at 6:00 PM and she was not present when the incident occurred between Resident 1 and CNA D. Surveyor asked LPN F if she was aware of any allegations Resident 1 made regarding CNA D. LPN F stated when she returned to work the next day she was informed that Resident 1 alleged that CNA D was calling her names, sticking her tongue out at her and giving her the finger. LPN F stated she did not witness any of the things Resident 1 alleged. Surveyor asked LPN F if she reported the allegations to anyone. LPN F stated she did not as everyone was aware of the allegations and incident and she thought management was aware. Surveyor asked LPN F if she has been trained on how to work with residents that have catastrophic reactions such as Resident 1 had on 5/28/16. LPN F stated she has not received training on catastrophic reactions. A witness statement from LPN F dated 6/16/16 (no time) states in part; I did not hear anything about CNA D rolling eyes until Sunday night at 6:00 PM. I thought administration and the DON had full report. A witness statement from LPN G dated 5/28/16 at 11:00 PM states in part; Patient reported that she re-opened the window and the CNA was giving her the finger and calling her names afterwards. Patient became angry telling CNA To go ahead and beat the crap out of me, I'm going to whoop your ass. CNA did not say anything and did not touch patient but the patient then began beating on the CNA and was hitting CNA with the phone. CNA was trying to protect her head and was yelling for help. Police came and reports were made and patient was then charged with battery and received a citation. Writer did speak with Registered Nurse (RN) H and informed RN H of what happened. RN H informed writer to remove roommate and temporarily do 15 minute checks on Resident 1. Call placed to DON B and left message. CNA D was moved off wing to avoid seeing Resident 1. On 6/22/16 at 5:20 PM Surveyor interviewed LPN G regarding the incident between CNA D and Resident 1. LPN G stated she heard someone yelling for help and found CNA D in the nurse's station being hit by Resident 1. Resident 1 was hitting her with her hands and the phone. LPN G stated she grabbed Resident 1 by the arm and asked her to stop. LPN G stated she had to raise her voice and ask Resident 1 to stop and Resident 1 stopped. LPN G stated she found it unreal that Resident 1 was upset over a closed window so she asked her what happened. LPN G stated Resident 1 stated the CNA D was sticking her tongue out at her, calling her names and shut her window. LPN G stated Resident 1 was calm and she left her in her room. LPN G stated she spoke with CNA D and told her she needed to stay on another hall the rest of the shift this was about 6:30 PM. LPN G stated she made it very clear to CNA D she was not to come off the unit until the end of her shift as not to agitate Resident 1. Surveyor asked LPN G if CNA D had been on Resident 1's hall until 6:30 PM and LPN G stated I think she was moved a little earlier but I did not want her off the unit now. Surveyor asked LPN G if she reported Resident 1's allegations to anyone. LPN G stated I documented it in the nursing notes. Surveyor asked if she spoke to anyone about the allegations. LPN G stated she called RN H and reported the incident between CNA D and Resident 1 and left a message on the phone with DON B regarding the incident. LPN G stated she did not speak to anyone about Resident 1's allegations. LPN G stated I do not think CNA D provoked Resident 1. I think CNA D closed her window and Resident 1 got mad and she decided to corner CNA D and beat her up. Surveyor asked LPN G if Resident 1 had a history of [REDACTED]. Surveyor asked LPN G if she has received education on abuse. LPN G stated she receives education at least 2 times per year. Surveyor asked LPN G about the facility's policy for reporting abuse allegations. LPN G stated we are to report allegations of abuse to the chain of command. Surveyor asked LPN G if she reported Resident 1's allegations of CNA D sticking out her tongue and calling Resident 1 names. LPN G stated she did not report it to anyone but she documented it in the nursing notes. LPN G stated she should have reported the allegations to RN H when she spoke with her on the phone . Surveyor asked LPN G if she has received education on how to deal with a resident who has catastrophic reactions such as Resident 1's. LPN G stated she has not but it would have been useful in this situation. On 6/16/16 at 11:52 AM Surveyor interviewed NHA A and DON B regarding the incident between Resident 1 and CNA D. NHA A stated that CNA D upon instruction from the nurse went into Resident 1's room to shut her window as the air conditioning was on in the building. Resident 1 did not respond when CNA D asked if she could shut the window and CNA D took this as a yes and shut the window. Later Resident 1 beat up CNA D and the police were called. Surveyor asked NHA A if he completed an investigation into the incident. NHA A stated he did not report the incident as it was a staff member that was injured not a resident. NHA A provided Surveyor with a soft file of the incident this file included witness statements from LPN G, LPN F, CNA D, CNA E, statements from residents and photographs of CNA D's injuries. There was no statement from Resident 1. Surveyor asked NHA A and DON B if they were aware of the allegation Resident 1 made toward CNA D. NHA A and DON B stated they were unaware that Resident 1 voiced an allegation toward CNA D. Surveyor reviewed the nursing notes dated 5/28/16 at 9:00 PM which state in part; patient much calmer now and told writer that CNA had shut her window in her room and patient did not want it shut. Patient reported that she re-opened the window and the CNA was giving her the finger and calling her names afterwards. Patient became angry telling CNA To go ahead and beat the crap out of me. NHA A and DON B stated they were unaware of this allegation. Surveyor asked NHA A and DON B if they would expect LPN F, the author of the nursing note, to immediately report such an allegation. NHA A stated, Yes, of course. NHA A was reviewing the soft file on this incident and stated to DON B It's documented in here, it is all right here. Surveyor asked DON B if she reviews the nursing notes DON B stated she does review the nursing notes. DON B stated I must have missed it, if it is documented in the soft file we missed it. NHA A stated I did not have this allegation reported to me. Surveyor stated should you have known. NHA A stated Yes, it should have been reported to me. I have it here in the file. Had I known I would have filed a report and completed an investigation into the incident. Surveyor asked NHA A if you would have had prior knowledge of this incident tell me how you would have proceeded? NHA A stated CNA D would have been removed from duty pending investigation. Surveyor asked DON B and NHA A if CNA D has continued to work since 5/28/16? DON B stated yes she has continued to be scheduled. Surveyor reviewed the nursing schedule from 5/28/16 through 6/16/16. The facility has 5 halls and 1 float position. CNA D worked the following shifts on the following halls. 5/28/16 - CNA D was moved off Resident 1's hall approximately 1 hour after verbal altercation with Resident 1. 6/1/16 - CNA D floated 6/6/16 - CNA D worked hall S.L. 6/8/16 - CNA D worked hall H 6/9/16 - CNA D floated 6/12/16 - CNA D worked hall P 6/13/16 - CNA D worked hall P 6/15/16 - CNA D worked hall G CNA D floated and worked 4 out of the 5 halls after the incident on 5/28/16. Surveyor reviewed CNA D's personnel file. CNA D was re-hired by the facility on 4/15/16. On 4/19/16, just 4 days after CNA D was re-hired, CNA D received an Employee Counseling from DON B. The counseling record states in part; Description of Problem: When assisting another CNA with a Hoyer transfer, resident was complaining that it was too uncomfortable and was causing pain. Resident was lifted back up and tried again to sit in shower chair; became confrontational with residents daughter and asked if she was a CNA and then said just let us do our job. Corrective Action: You NEVER become confrontational with a resident or their family. You were suspended from the 19th to the 22nd. This is a final warning and if anything like this occurs again it will be termination. Of note, just 4 days after re-hire CNA D received a final written warning for poor customer service. On 6/16/16 at 1:10 PM Surveyor met with and NHA A, DON B and Corporate Registered Nurse (RN) I regarding the incident and investigation into the incident between Resident 1 and CNA D. RN I stated to Surveyor I understand from NHA A and DON B that you have some concerns regarding the investigation into the incident with CNA D and Resident 1. RN I stated we acknowledge that we should have reviewed the nursing notes regarding Resident 1's allegation and NHA A and DON B have been educated however we did complete a thorough investigation into this incident. Surveyor stated to NHA A, DON B and RN I help me to understand your investigation process. RN I stated we interviewed other residents and witnesses to the incident. Surveyor asked NHA A if Resident 1 was interviewed. NHA A stated he met with Resident 1 on 5/31/16 and asked if everything was okay and she did not report an allegation she stated everything was okay she had ample opportunity to report an allegation on 5/31/16. Surveyor asked NHA A if he documented the meeting with Resident 1. NHA A stated he did not document the meeting. Surveyor asked NHA A did you interview Resident 1 regarding the events on 5/28/16 and what may have caused Resident 1 to get into a verbal and physical altercation with Resident 1? NHA A stated shutting the window provoked Resident 1. NHA A stated I did not review the incident with Resident 1. I did not want to increase her agitation. Surveyor asked NHA A typically when completing a thorough investigation would you interview all parties. NHA A stated normally follow up is completed by the Social Worker. We had 28 room changes to complete, I am not making excuses. RN I stated we are not making excuses we thought we did a thorough job. NHA A stated I guess I was distracted by CNA D being attacked by Resident 1. DON B stated CNA D is very volatile she uses foul language mostly when on the phone with her son. We have had to ask her lower her voice when speaking with her son. Surveyor stated to NHA A and DON B regarding CNA D's personnel record and the final written warning. Surveyor asked NHA A if you had been informed of Resident 1's allegation on 5/28/16 and knowing CNA D had a final written warning in her personnel file for customer service how would you have proceeded? Would this incident warrant termination for CNA D? NHA A stated good question; if I would have known about the allegation CNA D would have been suspended. RN I interjected and stated only corporate has the authority to terminate an employee. RN I further stated I do not think shutting a window is abuse. We have re-educated the staff on working with residents with behaviors and we teach re-approaching residents; no indication other residents were at harm. We are starting an investigation today and CNA D has been suspended pending further investigation. A witness statement dated 6/16/16 from NHA A states in part; when the incident occurred that was reported to me concerning CNA D being assaulted by Resident 1. I instinctually asked if Resident 1 was provoked, in anyway by CNA D I was told no by LPN F who reported to me. Nursing notes dated 5/31/16 (no time) state in part; received call from place Resident 1 will be discharged to will pick Resident 1 up at 2:00 PM. Call placed for discharge orders. On 6/16/16 at 4:46 PM Surveyor interviewed DON B regarding 5/31/16 when Resident 1 discharged from the facility. Surveyor asked DON B if Resident 1 had spoken to her prior to discharge regarding the altercation between Resident 1 and CNA D. DON B stated as Resident 1 was going out the door Resident 1 stated CNA D started it. DON B stated she did not think anything of it. Resident 1 alleged CNA D was sticking her tongue out at her, throwing her middle finger up at her and calling her names. This allegation was not immediately reported to the NHA thus the investigation was not thorough and complete and no measures taken to prevent further potential abuse as CNA D continued to work with residents. The failure to fully investigate and to take actions to prevent further potential abuse created a situation of immediate jeopardy. The facility removed the Immediate Jeopardy on 6/16/16 when: 1. Resident 1 was discharged on [DATE]. 2. CNA D was suspended on 6/16/16 pending further investigation. 3. All alert residents were interviewed to see if any employee has provoked them to the point they were upset. 4. All employees involved in the incident with Resident 1 were re-interviewed to see if Resident 1 was provoked to get upset. 5. LPN G was re-educated on the facility's policy on abuse, neglect and misappropriation that includes the need to immediately report, investigate, and protect resident. 6. Department heads including NHA and DON were educated on the facility's policy on abuse, neglect and misappropriation including immediate reporting all allegations, thoroughly investigating and assuring residents are protected. 7. Before working their next shift, all staff will be educated on the facility's policy on abuse, neglect and misappropriation including the need to immediately report complete a thorough investigation and protecting the resident. 8. Resident interviews will be conducted 3 times per week, allegation audits will be conducted after each allegation to ensure that they are thoroughly investigated. Cross reference F223 and F225.

Based on record review and interview the facility did not ensure that each resident was free from physical, verbal and mental abuse for 1 of 7 sampled residents. Resident 1 was assessed to be cognitively intact. On 5/28/16, Certified Nursing Assistant (CNA) D asked Resident 1 to shut the window in her room, as the facility had the air conditioning on. Resident 1 declined. CNA D then asked CNA E to approach Resident 1 to shut her window. Resident 1 again declined to shut her window. CNA D stated to CNA E there is no reason why the rest of us should have to suffer because she does not want to shut her window. CNA D entered Resident 1's room and shut Resident 1's window despite Resident 1 wanting her window left open. Resident 1 became angry and verbally disruptive toward CNA D for shutting her window. CNA D proceeded to stick her tongue out and throw her middle finger up at Resident 1. Resident 1 became so angered by CNA D's actions that Resident 1 displayed verbal and physically aggression towards CNA D and caused physical harm to CNA D. This is evidenced by: The facility's policy entitled Abuse Prevention/Resident Treatment dated 4/1/08 defines abuse as: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal Abuse: is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident or their families or within hearing distance . Mental Abuse: includes but is not limited to humiliation, harassment, and threats of punishment or deprivation. Resident 1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Of note Resident 1 is [AGE] years old. Resident 1 had a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/6/16. Resident 1 had a Brief Interview of Mental Status (BIMS) score of 13 indicating Resident 1 is cognitively intact. Section E0200 Behavioral Symptoms indicates Resident 1 had no physical behaviors directed toward others and no verbal behaviors directed toward others. Section D0200 indicates Resident 1 had no mood indicators. Section G0110 indicates Resident 1 was independently able to transfer and ambulate. Resident 1's plan of care Potential for alteration in cognition and mood dated 4/14/16 states in part: Goal: Will be free of depressive symptoms. Interventions: Allow resident time to respond; approach in calm, unhurried manner; monitor for changes in cognition and mood. Of note, there was no indication in Resident 1's plan of care that Resident 1 displayed behaviors. In addition, Resident 1's plan of care did not indicate individualized interventions to prevent or decrease Resident 1's behaviors. Resident 1's Behavior Intervention sheet for May 2016 indicates the facility was monitoring Resident 1 for increased agitation and yelling. Resident 1 had no behaviors documented for the month of May. Nursing notes dated 3/31/16 at 8:30 PM state in part; pleasant and cooperative. Nursing notes dated 4/1/16 at 8:45 AM state in part; in good spirits. Nursing notes dated 4/1/16 at 9:00 PM state in part; mood was good and behavior remained appropriate. Nursing notes dated 4/2/16 at 9:15 AM state in part; pleasant and cooperative. Nursing notes dated 4/18/16 at 3:30 PM state in part; discontinue [MEDICATION NAME] (antianxiety/[MEDICAL CONDITION] disorders) 0.5 milligrams (mg) 1 by mouth four times a day. Nursing notes dated 4/29/16 at 9:00 PM states in part; returned from appointment. Started back on [MEDICATION NAME] 0.5 daily for 2 weeks then 0.25 mg daily for 2 weeks then discontinue. [MEDICATION NAME] (antidepressant) increased to 100 mg daily. Resident 1's (Clinic Name) After Visit Summary dated 4/29/16 states in part; reason for visit today: psychiatric problem; Diagnosis: [REDACTED]. Patient Instructions: Increase [MEDICATION NAME] to 100 mg once daily for anxiety. Take [MEDICATION NAME] 0.5 mg daily for 2 weeks at night then reduce dose to 0.25 mg for 2 weeks at night then stop. Nursing notes dated 5/6/16 at 9:45 PM state in part; pleasant without complaint. Resident 1's nursing note dated 5/28/16 5:00 PM (late entry) states in part: CNA closed resident's window as air conditioning running. Resident started yelling, cursing, and telling CNA F*** you B****. Writer able to calm resident and CNA moved to another wing. At 5:30 PM resident saw same CNA and just started cursing and yelling at all staff where visitors were present; writer again able to calm resident. Resident 1's nursing note dated 5/28/16 at 9:00 PM states in part; writer could hear a person yelling help me. Writer ran down the hall and entered nurse's office to find patient beating on CNA and had phone in her hand and was hitting CNA with the phone. Writer grabbed patient arm and stated (Resident 1's name) stop and come talk with me. Writer raised voice louder and repeated and patient stopped. CNA was crouched down trying to cover head and protect it from being beaten. Writer noted CNA with marks on face and bleeding at forehead. Writer ambulated down hall with patient and had patient talk to writer about what happened. Patient much calmer now and told writer that CNA had shut her window in her room and patient did not want it shut. Patient reported that she re-opened the window and the CNA was giving her the finger and calling her names afterwards. Patient became angry telling CNA To go ahead and beat the crap out of me. CNA did not say anything and did not touch patient but the patient then began beating on the CNA and was hitting CNA with the phone. CNA was trying to protect her head and was yelling for help. Police came and reports were made and patient was then charged with battery and received a citation. Writer did speak with Registered Nurse (RN) H and informed RN H of what happened. RN H informed writer to remove roommate and temporarily do 15 minute checks on Resident 1. Call placed to DON B and left message. CNA D was moved off wing to avoid seeing Resident 1. Resident 1 On 6/14/16, at 12:50 PM, Surveyor spoke with Resident 1. Resident 1 stated CNA D and CNA E came to her room and stood in the doorway. CNA D went to the window and slammed it shut and stated to Resident 1 you are not the only one here. CNA D would just stand in the doorway and look at Resident 1. Resident 1 stated she felt CNA D was bullying her. Resident 1 then went up the hall to call her daughter and CNA D stated you run up on me! Resident 1 went to her room and when she came out again is when the incident occurred with CNA D. Resident 1 was going to the phone and CNA D put her middle finger up at her and said B**** this and B****that. Resident 1 stated she did hit CNA D but CNA D was hitting her back and the facility did not do anything about it. Resident 1 stated she told multiple staff that CNA D hit her and had been bullying her. Resident 1 stated DON B was also told when Resident 1 was discharging from the building that CNA D had been provoking her and had hit her during the altercation. A (City Name) police report dated 5/28/16 states in part; Reported date: 5/28/16 at 6:25 PM. Interview with Resident 1: Resident 1 stated she became upset today when CNA D rushed in my room to close the window. Resident 1 stated CNA D slammed the window shut out of nowhere. Resident 1 stated that CNA D stood outside Resident 1's room door and was sticking her tongue out at Resident 1. Resident 1 stated to the PO J she closed my window. I was bullying her back like she tried to bully me. Resident 1 stated the CNA's here are very unprofessional. Resident 1 states that CNA D left her room and Resident 1 used a phone to call Resident 1's daughter so that her daughter could call the NHA. Resident 1 stated she was making this phone call from the time clock room which is across from the nurse's station. Resident 1 stated that CNA D was in the nurse's station and CNA D was sticking her tongue out and throwing up her middle finger at Resident 1. Resident 1 stated CNA D was responsible for starting everything because CNA D was sticking her tongue out at Resident 1. Resident 1 told PO J a little while later she went into the nurse's station and was pushing CNA D. Resident 1 stated the pushing was mutual and lasted approximately 1 minute. Resident 1 stated she was pushing CNA D because her sister was on the nurse's station phone and Resident 1 wanted to talk to her sister. Resident 1 stated the pushing was with hands and did not involve punching or other motions. PO J asked Resident 1 if she was trying to hurt CNA D Resident 1 stated she was mad. PO J asked Resident 1 to clarify if she was trying to hurt CNA D Resident 1 stated probably so and when you mad, yeah. Resident 1 stated the disturbance did not involve any swinging of arms or hands and Resident 1 did not use the phone to hit CNA D. CNA D A witness statement from CNA D written on 5/28/16 (no time) states in part; I explained to Resident 1 that the air was on in the facility. I noticed her window was open, I explained to her that it needed to be shut to prevent hot air from coming in. I thought she said it was okay to shut the window. When I did close it she flipped out on me. She said she was going to beat my white fat a** called me a B**** and W****. Then the nurse walked in and explained it to her as well about the window. Resident 1 still didn't want it closed. Resident 1 came out of the room and called someone by the time clock saw me and started cussing at me and threatening me in front of residents, staff and family. A witness statement from CNA D dated 5/28/16 (no time) states in part; after the window issue Resident 1 saw me in the nurses station came up behind me and pushed me then started beating me up with closed fist, open hand just hitting me. Resident 1 beat me with the phone over my head and was slapping and hitting my head and face. I was screaming for help. Resident 1 said You need back-up B****. LPN G came in and somehow got Resident 1 to her room. On 6/20/16 at 6:54 PM Surveyor interviewed CNA D regarding the incident between CNA D and Resident 1. CNA D stated that she went into Resident 1's room to shut her window early on the PM shift and Resident 1 declined to have her window shut. CNA D stated she wanted to close the window as the air conditioning was on and she was concerned that Resident 1's roommate was to warm. CNA D stated she asked Resident 1 if she could shut her door and Resident 1 declined to have her door shut. Surveyor asked CNA D if she asked CNA E to approach Resident 1 about shutting her window CNA D stated she did not but Resident 1 called CNA E names as well. CNA D stated I did go over and close her window. CNA D stated this was about 4:30 PM. CNA D stated that after she closed Resident 1's window Resident 1 starting calling her racial slurs and yelling. CNA D stated that LPN F heard Resident 1 yelling and told me to stay away from Resident 1 which I did. CNA D stated about a half hour to an hour later Resident 1 was on the phone by the time clock. CNA D stated Resident 1 saw her and Resident 1 stated to CNA D I'm going to F*** you up. CNA D stated after that incident LPN F moved me to a different wing. CNA D stated I should have been moved right away. Surveyor asked CNA D how long she continued to work on Resident 1's unit after the incident occurred CNA D stated about an hour. CNA D stated LPN F should have let me go home after I shut Resident 1's windows Resident 1 was calling me names after I shut her window. Surveyor asked CNA D if she stuck her tongue out, threw up her middle finger or called Resident 1 names. CNA D stated I heard that someone was concerned I had done those things but I did not do any of those things I am not sure where that came from. CNA D stated I went to get water for a resident and Resident 1 approached me in the nursing station and started beating me up she was hitting me with her fists, scratching me and hitting me with the phone. I was yelling for someone to help me and LPN G finally heard me and was able to get Resident 1 to stop hitting me. Resident 1 was calling me F***ing B**** and telling me I was going to need back-up. Surveyor asked CNA D what she thought may have provoked Resident 1 into having such a catastrophic response. CNA D stated I guess when I shut her window. Surveyor asked CNA D if she had ever received training on how to handle a resident that may have a catastrophic response CNA D stated she has not been trained on working with residents with catastrophic reactions. A (City Name) police report dated 5/28/16 states in part: Reported date: 5/28/16 at 6:25 PM. Interview with CNA D: CNA D told the police officer (PO) J that the incident in question began at approximately 2:00 PM on 5/28/16. At 2:00 PM CNA D went into Resident 1's room and told Resident 1 she needed to close the windows in the bedroom because the air conditioning was on in the facility. CNA D stated that Resident 1 knew what the rules of the facility were that if the air conditioning was on the windows needed to be closed. CNA D stated this lead to about a 2 minute long argument that was verbal in nature because Resident 1 did not want to close the window. CNA D stated this argument caused Resident 1 to become extremely upset which led to Resident 1 yelling. CNA D could not recall anything in specific that Resident 1 was yelling at the time. CNA D stated the next incident in question began after supper which was at approximately 5:00 PM. CNA D told PO J she was in the nurse's station at this time. The nurse's station is a separate room near the front entrance of the facility that is down the hallway from Resident 1's room. CNA D told PO J that LPN G told CNA G that CNA G would not be working in the corridor which Resident 1 resides for the rest of the night. CNA D stated that LPN G made this change so that Resident 1 would not escalate any further. CNA D told PO J that Resident 1 was on the phone in the room CNA D identified as the time clock room which is diagonal to the nurse's station. There is a corded landline telephone in the time clock room which Resident 1 was using to speak with her sister. CNA D stated she could see Resident 1 stretching the cord of the phone so that Resident 1 was able to stand outside of the room area and yell at CNA D. These 2 rooms are approximately 30 feet apart. CNA D told the PO J she was seated in the nurse's station when Resident 1 began yelling at her from the time clock room. CNA D said that Resident 1 yelled you B****, I'm talking to you. CNA D stated that Resident 1 continued to yell at her for several minutes and Resident 1 stated when I find you on the streets, I'm going to beat your fat white a**. CNA D stated that Resident 1 was screaming loudly and also stated I'm going to kill you. CNA D stated the incident did not escalate from here and CNA D thought Resident 1 went back to her room. CNA D denied yelling or doing anything back to Resident 1 when Resident 1 yelled. CNA D stated the next incident began at approximately 6:00 PM. CNA D stated she was getting ice for a resident in the nurse's station. Resident 1 then came up behind her and pushed her from behind with both hands. CNA D stated Resident 1 pushed her head into the wall. CNA D stated Resident 1 began hitting her a lot with both closed and open hands. CNA D stated the physical attack lasted for 2 minutes. CNA D stated that Resident 1's sister was calling on the phone in the nurse's station when this incident began. CNA D stated Resident 1 took the corded landline from CNA D and began hitting her with the phone. CNA D stated that Resident 1 stated You need back-up you little B****. CNA D stated she did not strike back at Resident 1 while Resident 1 was attacking her and she did not hit Resident 1 at any point during the incident. A witness statement /questionnaire dated 6/17/16 from CNA D states the following: Have there been or were there any prior negative interactions with Resident 1? CNA D replied no, we always got along she never swore at me never said anything negative or mean to me. Relationship with Resident 1: CNA D replied my relationship with Resident 1 was good we got along great. Everything changed once I shut her window. I feel it changed because the weather was hot and humid people/residents were hot. At any time did you taunt, make vulgar gestures or swear at Resident 1? CNA D replied I did not taunt Resident1. I did not make vulgar gestures towards her. I did swear at her when she was hitting me. When I shut the window the nurse was outside the door. From then on someone was always with me. Until I was alone in the nurses station; that was the only time I was alone. She came to find me and beat me up. CNA K added that Resident 1 knows what going on and is very aware of what is right and wrong and that it does not take any provocation for Resident 1 to take her anger out. She was very aggressive anything that didn't or couldn't go her way she takes out on the ones around her. CNA E A witness statement from CNA E dated 5/28/16 (no time) states in part; CNA D and CNA E were passing supper and CNA D explained to Resident 1 that we have the air conditioning on and with her window open she's letting the heat in and it's causing the wing to be hot. CNA E thought Resident 1 agreed to have the window closed, but CNA E stated Resident 1 became very upset and started calling CNA D B****. I went into the dining room and thought everything was over but I heard Resident 1 say she was going to whoop CNA D's a** and calling her a stupid B****. Resident 1 went into the time clock room and made her phone call. On 6/16/16 at 9:41 AM Surveyor interviewed CNA E regarding the incident on 5/28/16 between Resident 1 and CNA D. CNA E stated CNA D approached her and asked her if she would ask Resident 1 to shut her window. CNA D told CNA E she had already approached Resident 1 and Resident 1 did not want her window closed. CNA E stated she went into Resident 1's room and asked if she could close the window as the air conditioning was on and Resident 1 stated; No. CNA E stated she left Resident 1's room and did not shut the window CNA E stated she told CNA D Resident 1 did not want the window shut. CNA E stated she told CNA D Resident 1 did not want her window shut. CNA D stated to CNA E we should not have to suffer because Resident 1 does not want her window shut. CNA E stated CNA D went into Resident 1's room and shut the window. CNA E stated this upset Resident 1 she got up and re-opened the window and began yelling and calling CNA D names. CNA E stated she left the area and went to the dining room and CNA D remained in the hallway where Resident 1 resides. CNA E stated that Resident 1 alleged after CNA D closed her window CNA D walked by her room and stuck out her tongue, put up her middle finger and called Resident 1 a bully. CNA E stated trying to get Resident 1 Wound up. Surveyor asked CNA E if she witnessed CNA D doing any of the things Resident 1 alleges. CNA E stated she did not witness any of the things Resident 1 alleged as she was in the dining room with residents but it seems like something CNA D would do. CNA E stated Resident 1 told LPN F that CNA D was bullying her. CNA E stated she told LPN F and LPN G the night the incident occurred that Resident 1 was alleging CNA D was sticking out her tongue, calling her names and stick her middle finger up at her. CNA D stated it did not seem like the nurses wanted to do anything. CNA D stated after the altercation between Resident 1 and CNA D CNA E called the police and another unnamed CNA called DON B regarding the incident. Surveyor asked CNA E if she has ever received training on how to work with residents that have catastrophic reactions such as Resident 1's CNA E stated she has not had any training on how to deal with catastrophic reactions. A (City Name) police report dated 5/28/16 states in part; Reported date: 5/28/16 at 6:25 PM. Interview with CNA E states in part; CNA E told PO J that she was in Resident 1's room with CNA D when CNA D closed Resident 1's window. Resident 1 stated to CNA D B****, I asked you not to do that. CNA E stated Resident 1 was yelling at CNA D when CNA D was trying to close the window. CNA D and CNA E then left Resident 1's room and believed Resident 1 was on the phone with her sister. CNA E stated at 5:50 PM Resident 1 was yelling at CNA D and Resident 1 stated you are going to get your ass beat. Resident 1 was in the hallway heading to the time clock room to use the phone when Resident 1 stated this to CNA D. CNA E stated Resident 1 stated these b****es think they rule something. CNA E stated Resident 1 also stated she was going to call her three grown daughters to whoop my ass. CNA E stated Resident 1 was making a pushing motion toward her with her hands and this occurred in the hallway by the area that CNA E identified as the Occupational Therapy gym. CNA E stated an unnamed CNA escorted Resident 1 back to her room. CNA E stated she was worried but not disturbed by Resident 1's comments. CNA E stated this was not the first time that Resident 1 attacked a CNA. CNA E stated Resident 1 is always verbally abusive to us. LPN F A witness statement from LPN F dated 5/28/16 at 5:00 PM states in part; Resident 1 screaming at CNA D W**** and B**** don't look at me B****. CNA D states she shut Resident 1's window because the air conditioning was on. At 5:30 PM Resident 1 came out of phone room and started cursing at CNA D and 2 other CNA's in front of residents and their families. Able to get Resident 1 to stop cursing and she went to finish her phone conversation. Informed DON B. CNA D switched wings. On 6/6/16 at 10:23 AM Surveyor interviewed LPN F regarding the incident on 5/28/16 between Resident 1 and CNA D. LPN F stated around the dinner hour about 5:00 PM she heard Resident 1 yelling. I came out of a resident's room and saw CNA D coming out of Resident 1's room at the same time. I walked into Resident 1's room and asked her what was wrong. Resident 1 stated that B**** wants to shut my window. LPN F stated she told Resident 1 they would leave the window open. LPN F stated she told CNA D to leave the window open and to keep the Resident 1 calm. LPN F stated CNA D stated did you hear what she was saying to me. LPN F stated she told CNA D she did hear what Resident 1 said and advised CNA D to ignore it. LPN F stated every time CNA D would go by Resident 1's room Resident 1 would escalate so LPN F decided to remove CNA D from the unit. Surveyor asked LPN F what time CNA D was removed from the unit. LPN F stated around 5:45 to 6:00 PM. Surveyor stated CNA D may have worked on the unit for about an hour after the incident occurred. LPN F stated her shift ended at 6:00 PM and she was not present when the incident occurred between Resident 1 and CNA D. Surveyor asked LPN F if she was aware of any allegations Resident 1 made regarding CNA D. LPN F stated when she returned to work the next day she was informed that Resident 1 alleged that CNA D was calling her names, sticking her tongue out at her and giving her the finger. LPN F stated she did not witness any of the things Resident 1 alleged. Surveyor asked LPN F if she reported the allegations to anyone LPN F stated she did not as everyone was aware of the allegations and incident and she thought management was aware. Surveyor asked LPN F if she has been trained on how to work with residents that have catastrophic reactions such as Resident 1 had on 5/28/16. LPN F stated she has not received training on catastrophic reactions. A witness statement from LPN F dated 6/16/16 (no time) states in part; I did not hear anything about CNA D rolling eyes until Sunday night at 6:00 PM. I thought administration and the DON had full report. LPN G A witness statement from LPN G dated 5/28/16 at 11:00 PM states in part; writer could hear a person yelling help me. Writer ran down the hall and entered nurse's office to find patient beating on CNA and had phone in her hand and was hitting CNA with the phone. Writer grabbed patient arm and stated (Resident 1's name) stop and come talk with me. Writer raised voice louder and repeated and patient stopped. CNA was crouched down trying to cover head and protect it from being beaten. Writer noted CNA with marks on face and bleeding at forehead. Writer told CNA that it was her choice to call police and press charges. Police were called. Writer ambulated down hall with patient and had patient talk to writer about what happened. Patient much calmer now and told writer that CNA had shut her window in her room and patient did not want it shut. Patient reported that she re-opened the window and the CNA was giving her the finger and calling her names afterwards. Patient became angry telling CNA To go ahead and beat the crap out of me, I'm going to whoop your ass. CNA did not say anything and did not touch patient but the patient then began beating on the CNA and was hitting CNA with the phone. CNA was trying to protect her head and was yelling for help. Police came and reports were made and patient was then charged with battery and received a citation. Writer did speak with Registered Nurse (RN) H and informed RN H of what happened. RN H informed writer to remove roommate and temporarily do 15 minute checks on Resident 1. Call placed to DON B and left message. CNA D was moved off wing to avoid seeing Resident 1. On 6/22/16 at 5:20 PM Surveyor interviewed LPN G regarding the incident between CNA D and Resident 1. LPN G stated she heard someone yelling for help and found CNA D in the nurse's station being hit by Resident 1. Resident 1 was hitting her with her hands and the phone. LPN G stated she grabbed Resident 1 by the arm and asked her to stop. LPN G stated she had to raise her voice and ask Resident 1 to stop and Resident 1 stopped. LPN G stated she found it unreal that Resident 1 was upset over a closed window so she asked her what happened. LPN G stated Resident 1 stated the CNA G was sticking her tongue out at her, calling her names and shut her window. LPN G stated Resident 1 was calm and she left her in her room. LPN G stated she spoke with CNA D and told her she needed to stay on another hall the rest of the shift this was about 6:30 PM. LPN G stated she made it very clear to CNA D she was not to come off the unit until the end of her shift as not to agitate Resident 1. Surveyor asked LPN G if CNA D had been on Resident 1's hall until 6:30 PM and LPN G stated I think she was moved a little earlier but I did not want her off the unit now. Surveyor asked LPN G if she reported Resident 1's allegations to anyone. LPN G stated I documented it in the nursing notes. Surveyor asked if she spoke to anyone about the allegations LPN G stated she called RN H and reported the incident between CNA D and Resident 1 and left a message on the phone with DON B regarding the incident. LPN G stated she did not speak to anyone about Resident 1's allegations. LPN G stated I do not think CNA D provoked Resident 1. I think CNA D closed her window and Resident 1 got mad and she decided to corner CNA D and beat her up. Surveyor asked LPN G if Resident 1 had a history of [REDACTED]. Surveyor asked LPN G if she has received education on abuse. LPN G stated she receives education at least 2 times per year. Surveyor asked LPN G if she has received education on how to deal with a resident who has catastrophic reactions such as Resident 1's. LPN G stated she has not but it would have been useful in this situation. A (City Name) police report dated 5/28/16 states in part: Reported date: 5/28/16 at 6:25 PM. Interview with LPN G states in part; LPN G told the police officer she could hear CNA D screaming for help and she responded and found Resident 1 trying to hit CNA D. LPN G stated she touched Resident 1 on the arm and said calm down we will talk about it and was able to get Resident 1 to leave the nurse's station and return to Resident 1's room. LPN G told the police officer that Resident 1 told LPN G that she was pissed because CNA D had closed a window in her room and was making remarks to Resident 1 throughout the day. In summary, Resident 1 alleged CNA D shut her window after she requested the window remain open. Resident 1 alleges CNA D was sticking her tongue out at her, throwing her middle finger up at her and calling her names. Resident 1 was so angered and psychosocially/mentally distressed by CNA D's actions that Resident 1 verbally and physically accosted CNA D causing physical harm to CNA D. The facility failed to recognize this mental abuse and failed to protect Resident 1 from the mental abuse. Cross Reference: 225 and 226

Based on observation, interview, and record review, the facility did not ensure that a resident having pressure ulcers receives the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 6 of 9 residents reviewed for treatment and prevention of pressure ulcers (Residents 4, 5, 1,7, 8, and 9). *On 4/18/16 Resident 4 was diagnosed with [REDACTED]. Resident 4 was diagnosed with [REDACTED]. The stage 3 pressure ulcer to Resident 4's right ischium and Stage 2 pressure ulcer to Resident 4's right buttock were avoidable pressure ulcers that the facility failed to identify, assess, measure and implement interventions promptly. The stage 3 pressure ulcer to Resident 4's right ischum was not identified by the facility, the wound clinic identified the pressure ulcer on his appointment on 4/18/16. On 4/11/16 the facility identified a secondary wound noted in (Resident 4's) right buttock crease. The facility did not measure this pressure ulcer until after Resident 4 returned from the emergency roiagnom on [DATE] (3 days later). The facility also did not put any interventions in place for this pressure ulcer. The first example rises to a level of actual harm and the remaining examples are at a level of no actual harm. *Resident 5 was admitted with a Stage 4 pressure ulcer on her sacrum. On two occasions the facility went longer than 7 days in between measurements and the pressure ulcer worsened. Resident 5 was admitted to the hospital on [DATE], re-admitted to the facility on [DATE], and no measurements were done upon re-admission to the facility. The facility did not reassess and measure the pressure ulcer until 3/14/16, 3 days after being readmitted . Resident 5's bilateral lower extremities were not floated per her Physician order [REDACTED]. *Resident 1 was assessed by the facility to be a high risk for pressure ulcers and has the intervention to float his heels as tolerated on his care plan. During observation staff did not offer to float his heels. *Resident 7's heels were observed to not be floated off the mattress surface while lying in bed, when they should have been. *Resident 8's weekly skin checks and foot assessment for 3/5/16 and 4/5/16 were incomplete. *Facility failed to update Resident 9's care plan to reflect Resident 9 had a RBKA (right below knee amputation) on 1/25/16. Resident 9's weekly skin assessments were inaccurate and incomplete from 2/2/16 thru 3/22/16. Evidenced by: The facility policy entitled Pressure Ulcer/Skin Integrity/Wound Management - HDGR, dated 9/13/11, states as follows: Policy: A system is in place for the prevention, identification, treatment, and documentation of pressure and non-pressure wounds. Definitions: Definitions are provided to clarify clinical terms related to pressure ulcers and their symptoms and treatment. Pressure ulcer: A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primarily causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. Avoidable/Unavoidable Pressure Ulcers. Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: Evaluate the resident's clinical condition and pressure ulcer risk factors; Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; Monitor and evaluate the impact of the interventions; and/or revise the interventions as appropriate. Unavoidable means that the resident developed a pressure ulcer even though the facility had: Evaluated the resident's clinical condition and pressure ulcer risk factors; Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; Monitored and evaluated the impact of the interventions; Revised the approaches as appropriate. The definitions for the stages of pressure ulcers identified below are from the NPUAP (National Pressure Ulcer Advisory Panel): Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. a Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. The facilities Procedure for wound Assessment a. Upon admission - i. A head to toe skin assessment will be conducted by a licensed nurse. It is recommended that this assessment is completed within the shift that the resident was admitted ; however, it must be completed within 24 hours of admission. d. Re-admission or Significant Change in Condition per MDS: i. Follow process for admission, and complete all admission assessments. 2. Assessment and Treatment: It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that may have influenced its development, the potential for development of additional ulcers, or for the deterioration of the pressure ulcer(s) be recognized, assessed, and addressed as follows: a. Differentiate the type of ulcer (pressure-related versus non-pressure related) because interventions may vary depending on the specific type of ulcer; b. Determine the ulcer's stage; c. Describe and monitor the ulcers characteristics; d. Monitor the progress toward healing and for potential complications; Determine if infection is present; and g. Monitor dressings and treatments. Example 1 Resident 4 was admitted to the facility on [DATE]. Resident 4's [DIAGNOSES REDACTED]. Resident 4's quarterly Minimum Data Set (MDS) from 2/18/16 for cognition indicates a Brief Interview for Mental Status (BIMS) of 15, indicating he is cognitively intact. This MDS also indicates that Resident 4 requires extensive assist of 1 for bed mobility. Resident 1 has a catheter and an ostomy. Resident 4's comprehensive care plan for Skin Integrity 12/9/11 states as follows: Focus: Ulceration or interference with structural integrity of layers of skin caused by immobility, lack of sensation (buttocks). Resident is often non-compliant with recommendations to limit time in wheelchair. Goal: Pressure ulcer will continue progress toward healing (dated 12/9/15). Interventions: Dietician evaluation to optimize nutrition to promote wound healing, Encourage resident to limit his time up in wheelchair, Tilt in space wheelchair (9/24/15), Air mattress (9/26/15), Encourage resident to reposition self q (every) 2 hours and PRN (as needed), Ensure pressure reduction mattress is in place and in working order, Encourage resident to only be up ordered amount of time (12/9/15), Follow up with plastic surgery MD (Medical Doctor) as scheduled, Monitor labs PRN per MD orders, Pressure relief cushion in wheelchair for pressure reduction (contoured gel cushion) (11/6/15), Remind resident to use tilt-in-space in lieu of lying down (tilt all the way back for 10-15 minutes), Remove hoyer pad when up in w/c (wheelchair), Report any changes in wound such as increased drainage, size, pain or odor to MD, Resident noncompliant with recommended limited time up in wheelchair, Treatment to buttock and scrotum as ordered, Encourage resident to be up for only 3 hours per day (4/12/16). The facility completed the Braden Scale for Predicting Pressure Sore Risk on 3/10/16 (score16) and 4/4/16 (score 15). An assessment of 15 or 16 indicates low risk for developing pressure ulcers. Resident 4 developed three facility acquired pressure ulcers. Resident 4 was diagnosed with [REDACTED]. The Wound Evaluation Flow Sheet for Resident 4's L (left) scrotum indicates the following 4 measurements. These are the only measurements for Resident 4's scrotum prior to being sent to the emergency roiagnom on [DATE]. All four assessments and measurements were completed by Registered Nurse (RN) D, who is Wound Care Certified (WCC). 1. 4/4/16: 0.5 x 0.1 x 0.1 centimeters (cm) - Color: None, Consistency: None, Amount: None, Odor: None Stage/Type: MASD; Tissue Type: [MEDICATION NAME] 100%, Wound margins: Moist, Surrounding Tissue: Intact, Current Treatment: Barrier Cream 2. 4/6/16: 1.0 x 0.4 x 0.2 cm - Color: Tan, Consistency: Thin, Amount: Moderate, Odor: None, Stage/Type: MASD, Tissue Type: [MEDICATION NAME] 100%, Wound margins: Moist, Surrounding Tissue: Intact Current Treatment: (illegible) 3. 4/11/16: 1.0 x 0.4 x 0.2 cm - Color: Tan, Consistency: Thin, Amount: Moderate, Odor: None, Stage/Type: MASD, Tissue Type: [MEDICATION NAME] 100%, Wound margins: Intact, Surrounding Tissue: Intact, Current Treatment: [MEDICATION NAME] 4. 4/12/16: 6.0 x 4.2 x 2.0 cm - Color: Tan, Consistency: Thin, Amount: Moderate to Heavy, Odor: (Left blank), Stage/Type: Presents as a stage 3, Tissue Type: Granulation 75% and Slough 75%, Wound margins: Uneven Pink, Surrounding Tissue: Pink moist Treatment: (Left blank) On 4/13/16 at 9:00 AM, Surveyor went over the roster matrix for the 500 hall with RN D and conducted a tour of the 500 wing. The matrix did not identify any pressure ulcers for Resident 4. After going over the triggered areas for all the residents on the 500 wing, including Resident 4, who was not marked for pressure ulcers, Surveyor asked RN D if there were any other residents on the 500 wing with pressure ulcers or skin issues that we had not already discussed. RN D replied, No. It is important to note that RN D documented that Resident 4 had a Stage 3 pressure ulcer the day before on 4/12/16. The Resident Census and Condition provided by the facility did not identify any pressure ulcers or facility acquired pressure ulcers for Resident 4. On 4/11/16 at 10:00 PM, a Nurses Note states the following: Scrotal area wound larger/deeper with increased drainage. A CNA (Certified Nursing Assistant) reported increased odor. Secondary wound right buttock crease [MEDICATION NAME] applied to both wounds. Voicemail left on RN D and Wound RN (ADON) V's voicemail. On 4/12/16 at 10:50 AM, a Nurses Note entered by RN D states as follows: Wound to L (left) scrotal area assessed at 10:10 AM. Area measures 6.4 x 4.2 x 2.0 cm (centimeters) with large amount of tan, odorous drainage. Message left for Physician Assistant (PA) AA at (managed care). Resident wishing to see Physician Assistant (PA) BB at Wound Care Clinic. Education given to resident and staff that resident should not be up in chair greater than 3 hours per day. Resident acknowledged understanding that increased time up in chair causes greater risk for skin breakdown. Awaiting return call. It is important to note that RN D did not assess or measure the secondary wound right buttock crease that was documented on 4/11/16 at 10:00 PM. This pressure ulcer was not measured by the facility until 4/14/16 at 11:45 AM. On 4/12/16 at 3:15 PM, a Nurses Note entered by RN D states as follows: PA AA returned call. Orders received for wound to L (left) scrotal area. See T.O. (Telephone order) PA AA will be here 4/14/16 to examine the wound. Resident notified of changes. Will continue to ensure and document resident's compliance with staying in bed and only getting up for 3 hours per day as recommended by this writer. On 4/14/16 at 7:00 AM, a Nurses Note states as follows: Resident's scrotum wound has excessive green/yellowish drainage noted with foul smell also the buttocks on right side has new open wound with bright red blood. Resident 4 was sent to Hospital emergency room . On 4/15/16 at 9:13 AM, the Hospital emergency room MD documented the following history and physical for Resident 4: Resident 4 is a [AGE] year old male who presents with a pressure ulcer. Patient has a history of [DIAGNOSES REDACTED] and is confined to a wheelchair. He has had extensive problems with pressure ulcers. He reports that as of one month ago they were all healed. Two weeks ago he suffered an abrasion to the area of the sacrum and has since developed a gradually worsening lesion. He has no fever or chills. He has no sensation in the area and has had no pain. Patient is requesting a wound care evaluation. He does not want to see a (hospital name) doctor. The Hospital emergency room MD documented the following note for resident 4's back: There are 2 open [MEDICAL CONDITION] that are full-thickness with minimal drainage. No Tracts noted. The midline wound is about 5cm in greatest length and 2 cm in greatest width. The right-sided wound is about 3cm x 2 cm. There is no local redness and warmth without tenderness. It is important to note that no staff member assessed or measured the secondary wound right buttock crease that was documented on 4/11/16 at 10:00 PM until after Resident 4 was sent out to Hospital emergency roiagnom on [DATE]. This pressure ulcer was not measured by the facility until 4/14/16 at 11:45 AM when Resident 4 returned from the Hospital emergency room . The Admission Skin Check documents the right buttock measurement as 2.5 x 1.0 x 0.1 cm. On 4/19/16 at 1:15 PM, Surveyor spoke with RN D and ADON V. Surveyor showed RN D the note from the hospital on [DATE] at 9:13 AM and asked her to clarify the location of the wounds they are describing. RN D stated the midline wound described above is the scrotum/sacrum and the right-sided wound is the right buttock. RN D and ADON V stated that because of Resident 4's [DIAGNOSES REDACTED], his anatomy is not typical. Resident 4 had an appointment with Wound Care Clinic on 4/18/16. Resident 4 was seen by Advanced Practice Nurse Prescriber (APNP) Z. APNP Z notes the following. History and Physical: Resident 4 presents for evaluation of pressure ulcer to sacrum, Stage 3, pressure ulcer to right ischium stage 3, and pressure ulcer to right buttock, stage 2. Wound location: Right ischium, sacrum, right buttock Duration/Onset: 2 weeks, patient has history of multiple previous pressure ulcers that have healed or have had surgical intervention. Seen in wound clinic since: 4/18/16 - first visit Severity: Wounds have been worsening . Wound Exam: Wound Site #1 Location: Right ischium Etiology: Pressure Ulcer Length (cm): 1.0 Width (cm): 3.5 Depth (cm): 1.0 Tunneling (cm): 0 Undermining (cm): 0 Square Area (cm): 3.5 Color: Pink Drainage Present: Mild, serosanguinous Odor Present: None [DIAGNOSES REDACTED]: None Induration: No Wound Bed Description: Granulated; [MEDICATION NAME] Adherence: firmly adherent Wound Margins: Hyperkeratotic; epibolized Surrounding Skin: viable Debrided: No Treatment: [MEDICATION NAME] flex/[MEDICATION NAME]/[MEDICATION NAME] border Wound Site #2 Location: Sacral Etiology: Pressure Ulcer Length (cm): 4.0 Width (cm): 6.0 Depth (cm): 1.0 Tunneling (cm): 1.0 Tunneling Location: 1 O'clock Undermining (cm): 0 Square Area (cm): 24 Color: Pink; Yellow Drainage Present: Mild, serosanguinous Odor: None [DIAGNOSES REDACTED]: Mild Induration: No Wound Bed Description: Granulated; biofilm; [MEDICATION NAME] Adherence: Firmly adherent Wound Margins: Pink Surrounding Skin: Viable Debrided: No Treatment: [MEDICATION NAME] flex, [MEDICATION NAME] border dressing Wound Site #3 Location: Right buttock Etiology: Pressure Ulcer Length (cm): 1.0 Width (cm): 1.0 Depth (cm): 0.1 Tunneling (cm): 0 Undermining (cm): 0 Square Area (cm): 1 Color: Pink Drainage Present: Scant; Serosanguinous Odor: None [DIAGNOSES REDACTED]: None Induration: No Wound Bed Description: Clean, non-granulating Adherence: Firmly adherent Wound Margins: Viable; pink Surrounding Skin: Viable Debrided?: No Treatment: [MEDICATION NAME] flex, [MEDICATION NAME] border Barriers to wound healing: immobility, diabetes, tissue quality - previous surgeries and scarring Other recommendations: Nursing home staff to perform dressing changes every other day and as needed, need to restrict time in chair/sitting, limit to meals only, schedule joint visits with MDs. APNP Z documented her face to face minutes for evaluation, dressing application, and education of Resident 4 regarding plan of care was 40 minutes. On 4/19/16 at 12:25, Surveyor visualized the 3 dressing in place per APNP Z's orders. Surveyor requested multiple times to observe wound treatments for Resident 4, however, due to Resident 4 being sent out to the emergency roiagnom on [DATE] and then being sent to Wound Clinic on 4/18/16, his dressing was not due to be changed while Surveyor was in the building. On 4/19/16 at 1:10 PM, Surveyor spoke with Assistant Director of Nursing (ADON) V. Surveyor asked ADON V if she was aware of Resident 4's stage 3 pressure ulcer to his right ischium prior to Resident 4 going out to Wound Care Clinic on 4/18/16. ADON V replied No. Surveyor asked ADON V if she was aware of or has ever assessed the Stage 2 pressure ulcer to Resident 4's right buttock. ADON V stated, No. ADON V stated she just started two days prior to us entering the facility for their annual recertification and the wound care has not been officially turned over to her yet. ADON V stated that RN D is responsible for wound care until it is transitioned to her after she comes back from vacation in about 1 1 /2 weeks. ADON V stated that she looked at Resident 4's scrotum the morning of 4/14/16 before he was sent to the emergency room and it looked like MASD. ADON V had no concern with the appearance of Resident 4's scrotum. Because LPN U was concerned and RN D was concerned due to the increased drainage, increased size, and odor of the pressure ulcer, RN D had Resident 4 sent to the emergency room to be evaluated. The emergency room documented the scrotum and right buttock as full thickness pressure ulcers. On 4/19/16 at 1:15 PM, Surveyor spoke with RN D. Surveyor asked RN to help me understand what happened between 4/11 and 4/12 that may have caused Resident 4's scrotal pressure ulcer to increase drastically in size. RN D stated, I have no idea what caused the dramatic jump. RN D stated it started as moisture and then turned like this, as she snapped her fingers. At the time we were talking in the nurse's station, Licensed Practical Nurse (LPN) U entered the nurse's station. LPN U was working on 4/14, the morning that Resident 4 was sent to the emergency room . Surveyor asked LPN U if she had any idea what caused Resident 4's pressure ulcer to increase in size and worsen between 4/11 and 4/12. LPN U stated, The wound was wet and had so much drainage coming out of it. LPN U stated the excessive drainage is what caused the pressure ulcer to worsen. Surveyor asked RN D if she was aware of Resident 4's stage 3 pressure ulcer to his right ischium prior to Resident 4 going out to the Wound Care Clinic on 4/18/16. RN D replied No. Surveyor asked RN D if she was aware of or has ever assessed the Stage 2 pressure ulcer to Resident 4's right buttock. ADON V stated, No. RN D stated that she has not seen Resident 4 for a while because wound care has been turned over to ADON V since last Wednesday or Thursday (4/13/16 or 4/14/16). Surveyor asked RN D what is the process when a staff member finds a skin issue or pressure ulcer. RN D stated that the nurse on duty should document a change in condition, complete a pink form, measure the wound, notify the MD, Notify myself, ADON V or Director of Nursing (DON) B. RN D then stated she is the person responsible for wound care and she delegates things to ADON V until the wound care is officially transitioned over to ADON V. As RN D and I were talking, ADON V entered the conversation and stated it is so frustrating to her that the hospital emergency room s and wound care clinics call everything pressure. ADON V stated she had no concerns regarding Resident 4's open areas, which she calls MASD, despite the fact that hospital emergency room diagnosed them as pressure ulcers on 4/14/16 and the wound clinic diagnosed them as pressure ulcers on 4/18/16. On 4/19/16 at 4:20 PM, Surveyor spoke with DON B. Surveyor asked DON B if a staff member notes a skin issue or pressure ulcer what should they do? DON B stated the nurse should measure it, note a description, call the MD, Notify the Wound Care Nurse. DON B stated they can contact her, RN D or ADON V. If staff note a pressure ulcer to be worsening they should notify Wound Care nurses in the building (DON B, RN D, or ADON V). DON B agreed that Resident 4's stage 3 pressure ulcer on his right ischium should have been identified in house prior to Resident 4 being sent to Wound Clinic. DON B agreed that a skin assessment should be done when a resident returns to the facility from the hospital. DON agrees that when a pressure ulcer is noted in house it should immediately be assessed and measured. Example 2 Resident 5 was admitted to the facility on [DATE]. Resident 5's [DIAGNOSES REDACTED]. Resident 5 underwent surgery to amputate bilateral lower limbs. Resident 5's Admission Minimum Data Set (MDS) from 1/5/16 for cognition indicates a Brief Interview for Mental Status (BIMS) of 15, indicating she is cognitively intact. This MDS also indicates that Resident 4 requires extensive assist of 1 for bed mobility. Resident 5's comprehensive care plan for Skin Integrity upon admit states as follows: Potential for impaired skin integrity secondary to impaired mobility, sacral pressure ulcer, bilateral foot necrosis. Goal: Will have no further breakdown, Will have no s/sx (signs and symptoms) of infection. Interventions: Air mattress (in place upon initial admission), Complete treatment as ordered and complete weekly measurements and assessment of open areas, Keep skin clean and dry, Monitor s/sx of infection i.e. purulent drainage, elevated temperature, redness, Roho cushion in wheelchair, Weekly skin assessment, Wound vac change Monday, Wednesday, Friday and PRN to sacral ulcer (discontinued entry 1/29/16), Elevate BLE stumps when in bed (1/29/16) Resident 5's Physician order [REDACTED]. Resident 5 was admitted with a Stage 4 pressure ulcer on her sacrum. On two occasions the facility went longer than 7 days in between measurements and the pressure ulcer worsened. The pressure ulcer measurments on 2/1/16 are 2.5 x 0.7 x 0.5. The next pressure ulcer measurements were done on 2/10/16 is 4.0 x 4.0 x 0.1. The facility went 9 days in between measurements and the pressure ulcer measurements were larger. The pressure ulcer measurements on 3/2/16 are 1.5 x 2.2. The next pressure ulcer measurements were done on 3/14/16 is 2.5 x 3.0 x less than 0.1. The facility went 12 days between measurements and the pressure ulcer measurements were larger. Resident 5 was admitted to the hospital on [DATE], re-admitted to the facility on [DATE], and no measurements were done upon re-admission to the facility. The facility did not reassess and measure the pressure ulcer until 3/14/16, 3 days after Resident 5 was readmitted to the facility. On 4/14/16 at approximately 9:00 AM, Surveyor observed Licensed Practical Nurse (LPN) U change Resident 5's dressing on her sacrum. Resident 5's bilateral lower extremities (BLE) were not floated per her Physician order [REDACTED]. floated when we entered Resident 5's room. LPN U replied, No. LPN U looked around the room for a pillow to float Resident 5's BLE's and located an extra pillow on the top shelf of Resident 5's closet. LPN U stated Resident 5's BLE's should have been floated. On 4/19/16 at 4:20 PM, Surveyor spoke with DON B. Surveyor asked DON B how often a pressure ulcer should be measured. DON B stated pressure ulcers should be measured weekly (every 7 days). Surveyor asked DON B if a full skin assessment should be done when a resident returns to the facility after being hospitalized . DON B stated, Yes. Surveyor asked DON B how soon this measurement should be done. DON B stated, immediately upon the resident's return to the facility. Surveyor asked DON B if she expects staff to follow care plans. DON B stated, Yes. Surveyor asked DON B if a resident has a Care Plan and Physician order [REDACTED]. DON B replied, Yes. Example 3 Resident 1's Norton Plus Pressure Ulcer Scale completed 3/15/16 shows his score was 8 which means he is a high risk for pressure ulcers. His Minimum Data Set completed 3/10/16 indicates he had moderate cognitive impairment. His Care Plan reviewed 3/13/16 includes the intervention to float heels when in bed as tolerated. This is also on the care sheet the CNAs carry dated 4/11/16. On 4/13/16 at 1:22 PM Surveyor observed CNA F and CNA R assist Resident 1 into his bed after lunch. Upon leaving his room they did not offer to float his heels per his care plan. Resident 1's heels were pressed onto his mattress. On 4/19/16 at 10:19 AM Surveyor interviewed Director of Nursing B who stated she would expect that staff offer to float resident's heels and document if they refuse. Example 4 Resident 7 was readmitted to the facility on [DATE] following a hospital stay for treatment of [REDACTED]. Resident 7's Braden scale score was 16 on 2/16/16 and initial MDS (Minimum Data Set) dated 2/18/16, indicates that Resident 7 is at risk for developing pressure ulcers. Resident 7's CAA (Care Area Assessment) for pressure ulcers dated 2/18/16 indicates that Resident 7 requires extensive assistance with bed mobility. Resident 7's care plan dated 2/17/16 includes in part Focus-Self-care deficit related to dementia, cognitive loss, Goal-Resident will remain free of skin breakdown during the next 90 days. Intervention-Assist of 1 to transfer .Focus-Pain related to [MEDICAL CONDITION], Goal- reduced pain, Intervention Tubi- grips to lower extremities as ordered. On 4/13/16 at 1:30 PM Surveyor observed Resident 7 lying in bed with Tubi- grips on (per orders) and both of her heels in direct contact with surface of her mattress. On 4/13/16 at 4:00 PM Surveyor observed Resident 7 lying in bed with both of her heels in direct contact with surface of her mattress. On 4/18/16 at 7:45 AM Surveyor observed Resident 7 lying in bed with both of her heels in direct contact with surface of her mattress. On 4/18/16 at 7:50 AM Surveyor interviewed CNA (Certified Nursing Assistant) J about Resident 7, asking if Resident 7's heels should be floated off the surface of the mattress when she is in bed, CNA J stated that Resident 7's heels should be floated with pillows when she is in bed. CNA J then went into the room, communicated with Resident 7 and placed pillows under her legs to float her heels. On 4/19/16 at 7:30 AM Surveyor interviewed DON B about Resident 7's cares asking if she would expect staff to float Resident 7's considering her risk factors, DON B stated that she did expect staff to assure Resident 7's heels were floated when she was in bed, and they did not. Example 5 Resident 8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 8's care plan dated 2/23/15 includes in part: Focus-Potential for impaired skin integrity, Goal-will have no skin breakdown, Interventions-Keep skin clean and dry .Weekly skin checks. Record review for Resident 8 notes the form entitled Weekly Skin Check for 3/8/16 and 4/5/16 which also includes Foot Assessment was not completed and left blank except for the nurses' signature and date on the bottom of the page. On 4/14/16 at 1:45 PM Surveyor interviewed RN (Registered Nurse) G and reviewed Resident 8's nursing documentation including weekly skin and foot assessments. Surveyor asked RN G if these assessments should have been completed, RN G stated that Resident 8's skin checks and foot assessments were not complete and should have been. Example 6 Resident 9 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Resident 9 had a right [MEDICAL CONDITION] (RBKA) on 1/25/2016. Resident 9 is her own person and is a full body lift for transfers. On 4/13/16, Surveyor , received Resident 9's care plan, with target date of 5/9/16, states in part Focus -Resident has a LAKA, R (right) foot wound, open areas. Severe [MEDICAL CONDITION] with poor wound healing. and 1/28/16 RBKA. Interventions include: 12/3/15 Cont. (continue) order for wound care Prevalon boot to R (right) foot 12/13/15 12-15-15 Skin prep R heel BID (twice a day) 12/23/15 no (change) in orders 12/30/15 no (change) in orders 01/06/16 no (change) in orders 1/13/16 no longer measurable upcoming amputation 1/28/16 .Immobilizer as ordered Please note that Resident 9 had a right [MEDICAL CONDITION] on 1/25/16. The CNAs (Certified Nursing Assistants) care sheet dated 4/11/2016, indicates Knee immobilizer on at all times for Resident 9. Orthopedic after visit summary dated 2/22/2016 states in part no need for knee immobilizer any longer On 4/18/2016, at 1:10PM, Surveyor , interviewed DON B, and RN Consultant C regarding Resident 9's care plan. DON B indicated that the CNA care sheet and Resident 9's care plan should have been updated to reflect accurate information related to Resident 9's RBKA. Resident 9's Minimum Data Set (MDS) assessment, dated 2/4/16 indicates Resident 9 is at risk for pressure sores, and had one unhealed stage 2 pressure sore. Resident 9's MDS assessment, dated 3/25/16 indicates Resident 9 is at risk for pressure sores. On 4/19/2016, at 4:05PM, Surveyor reviewed Resident 9's skin checks with RN G, who indicated to Surveyor , while looking at skin checks, that the nurses generally assess, but CNA's are responsible for skin checks and if any issues identified then a skin assessment is done by a nurse. RN G also indicated that CNA's fill out the weekly skin check by marking the appropriate areas, and if skin issues then the nurses are to go back and look at any areas marked on the skin check. (Of note Resident 9 has a Right [MEDICAL CONDITION] and a Left above the Knee Amputation). Weekly skin check dated 2/2/16 and signed by a nurse and CNA on 2/2/16 indicates Resident 9's toenails were trimmed and heels are intact (please note Resident 9 has a Right [MEDICAL CONDITION] and a Left above the Knee Amputation). On 4/19/16, at 4:10PM, Surveyor , Interviewed RN (Registered Nurse) G, who indicated skin check on 2/2/16, was not accurate. Weekly skin check, has no patient name or date, and signed by a nurse and CNA on 2/9/16 indicates toenails are short and trimmed, and that Resident 9's heels are intact. On 4/19/16, at 4:11PM, Surveyor , Interviewed RN (Registered Nurse) G, who indicated skin check on 2/9/16, was not accura

Based on observation, interview and record review the facility did not ensure each resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 9 residents (Residents 1, 2, 12, and 14) reviewed for falls, 5 of 15 residents (Residents 2, 10, 12, 23, and 24) that reside on the memory care/300 wing, and 1 of 1 residents (Resident 2) observed for swallow concerns. *Resident 14 had two falls at the facility on 8/22/15. Resident 14's first fall occurred at 11:50 AM. The facility added a new intervention of Continuous monitoring of resident to keep her safe from falls. An x-ray revealed a possible fracture of the lateral aspect of her acetabulum (hip). Resident 14 had second fall that same day at 10:00 PM. Resident 14 was sent to the emergency room where she was diagnosed with [REDACTED]. The facility did not provide continuous monitoring to keep Resident 14 from having additional falls and fractures after her first fall on the morning of /22/16. The facility did not add a new fall intervention(s) after Resident 14 returned to the facility after sustaining multiple fractures from falls. Resident 14 fell on [DATE]. The fall investigation indicates that Resident 14's call light was on the floor and her tab alarm was found on her over the bed table and not turned on. The facility does not have evidence of what they did to address Resident 14's safety and interventions not in place. The first example rises to a level of actual harm and the remaining examples are no actual harm *Resident 1 fell on [DATE] and the facility identified a new intervention to be put in place to keep him safe. The facility did not ensure the new intervention was added to his care plan. *Resident 2 has a [DIAGNOSES REDACTED]. His care plan and dietary ticket stated he should receive honey thick liquids. Resident 2 had a fall 11/26/15 and the facility identified the need to complete a Bowel and Bladder (B&B) diary to evaluate the root cause. The facility had no evidence of the B&B diary completed or other intervention put in place to keep him safe. *On the 300 wing when staff is assisting residents in their rooms, other residents with dementia were left with no supervision on 4/18/16. Resident 12 was observed standing, his wheelchair alarm not sounding, and no staff were supervising the lounge. Resident 12 fell on [DATE] and the facilty did not assess the safety device that was in place or put intervention into place after the fall. Evidenced by: The facility policy titled Accidents/Falls-HDGR revised Feb. 2014 states: Any episode of a fall or other incident/accident should be documented on the incident accident report. Each incident/accident or fall must be investigated and/or assessed to determine the cause of the episode to prevent any further injury. A post-fall assessment will be conducted following any fall episode within 24 hours post fall. Once the post-fall assessment is completed by nursing, the director of nurses (DON) or designee will seek additional input from the interdisciplinary team (IDT) and other staff. DON/IDT Review Portion will be completed timely. The resident's individualized care plan is to be updated with any changes or new interventions post fall/incident/accident, communicated to appropriate staff, and implemented. Example 1 Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 14's quarterly Brief Interview for Mental Status (BIMS) score for cognition is 15, indicating she is cognitively intact. However, Resident 14 is noted to be having delirium symptoms on 8/21/16 and was started on Haldol for 7 days only. The facility documents this is for short term management only due to [DIAGNOSES REDACTED]. Resident 14's Falls Risk Assessment-HDGR was completed on 6/22/15, the day of Resident 14's admission. The assessment indicates that Resident 14 fell ,[DATE] times in the last 3 months prior to her admission. Underlying Diseases or Conditions indicate: Changes in orthostatic blood pressure or hypotension, psychiatric or cognitive conditions, cardiac [DIAGNOSES REDACTED]. Does the resident use any assistive devices/adaptive equipment?: Four wheeled walker/wheelchair. Is the resident able to toilet themselves?: 1 assist. Based on the information you have collected/assessed, do you believe this resident is or is not at a greater risk for falls?: Yes box is checked; Resident has had episode of dizziness with standing and falls. Resident 14's comprehensive care plan states a Problem: Risk for fall secondary to weakness, dementia; Goal: Will not sustain serious injury from fall; Interventions: 1 assist for transfers, assist resident to and from destinations, bed and chair alarms, observe for changes in level of consciousness, refer to therapy screen as needed, and therapies to treat to improve strength, mobility, safety. It is important to note that the facility did not add a new fall intervention(s) after Resident 14 returned to the facility after sustaining multiple fractures from falls. On 8/21/15 at 4:00 PM, a Nurses Note states, Resident is very confused, whispering that there is a funeral going on. Also trying to stand up from her wheelchair. It important to note that a staff member is documenting the day before Resident 14 fell that she observed Resident 14 standing up on her own. There is no assessment or interventions put in place when she was observed trying to stand on own. On 8/21/15 at 4:30 PM, a Nurses Note states, Haldol 2mg (milligrams) administered, helped or was effective. Will continue to monitor. Resident 14 fell at the facility on 8/22/15 at 11:50 AM. The facility completed a Falls Risk Post-Fall Assessment-HDGR and Investigation/Root Cause Analysis. The facility's reports indicate that Resident 14 had been in the dayroom watching TV while sitting in her wheelchair. A Licensed Practical Nurse heard the alarm sounding and entered the room to find Resident 14 on the floor. The investigation notes that Resident 14 began to complain of hip pain later in the day and an x-ray was done and was negative. (Note: the x-ray report indicates a possible fracture.) Facility noted to continue alarms. The facility noted that her, Fall seems to be related to delirium and confusion which has recently been addressed. Continue behavior tracking and frequent checks. On the fall investigation, to summarize post-fall findings indicates, Resident must continue to be monitored due to problem with judgment. The Interventions to be implemented as a result of the assessment indicated the following: Continuous monitoring of resident to keep her safe from fall. On 4/19/16 at 4:20 PM, Surveyor spoke with Director of Nursing (DON) B. Surveyor asked DON B what it means when a fall intervention states: Continuous monitoring of resident to keep her safe from falls. DON B stated, To me it would mean someone is with her constantly. Surveyor discussed Resident 14's 2 falls that occurred on 8/22/15, and DON B stated according to the intervention of continuous monitoring, she would expect someone to be with Resident 14 constantly. Instead of continuous monitoring, the facility documented behavior tracking every hour with a brief description of what Resident 14 was doing at the time. On 8/22/15 at 6:20 PM, a Nurses Note states resident c/o (complaining of) hip pain - she is able to flex and extend extremity but still c/o pain. MD called, x-ray right hip ordered. Mobile x-ray results as follows: The impression states as follows: 1. there are degenerative changes of the hip and sacroiliac joints. A non-displaced fracture of the superior lateral aspect of the acetabulum cannot be excluded. If further evaluation is desired, a CT should be considered. 2. There is a probable hip joint effusion, and a superficial contusion overlying the greater trochanter. The facility's documented behavior tracking indicated Resident 14 was sleeping at 9:00 PM. On 8/22/15 at 9:45 PM, the facility noted the x-ray report, called the MD, and stated. MD called, transfer to hospital, transfer to hospital. POA (Power of Attorney) aware, Resident aware, emergency room called and informed of above. Ryan Brothers called, DON (previous) and message left. On 8/22/15 at 9:50 PM, the facility wrote a Telephone Order (T.O.) to transfer Resident 14 to emergency room . The facility's documented behavior tracking at 10:00 PM indicates Up OOB (out of bed) fell . On 8/22/15 at 10:00 PM, the Nurses Note notes: Resident found on the floor on L (left) side - goose egg bump on L side of head. VS 97.8 (temp), BP (blood pressure) 106/80, 02 (oxygen saturation) 95%, resident confused and not sure how she fell . Ice pack applied to head. Does not appear to understand that she fell . Resident 14 fell at the facility on 8/22/15 at 10:00 PM. The facility completed a Falls Risk Post-Fall Assessment-HDGR and Investigation/Root Cause Analysis. The facility's reports indicate that Resident 14's alarm was heard going off in Resident 14's room. Resident 14 was found in her room laying on her left side near her bed. Injury noted: Goose-egg bump left side of head (temple area). Was the source of the injury observed by anyone: No When and where did you last see the resident: In bed at 2100hr (9:00 PM). What were they doing?: Sleeping It is important to note, that if the facility documents at 9:45 PM that Resident 14 is aware, she would be awake at this time, 5 minutes prior to her documented fall, which was unwitnessed. If staff was providing Continuous monitoring of resident to keep her safe from falls per the care plan intervention added earlier in the day on 8/22, after Resident 14's first fall, they would likely have been able to prevent her second fall, which caused greater injury. Resident was sent to Hospital emergency room . A CT of Resident 14's right hip was done. The findings indicate the following: There is a non-displaced intra-articular fracture line extending along the anterior, medial and superior right acetabulum. There is also a fracture of the superior rim of the acetabulum. An associated hematoma is noted in the adjacent pelvis. No-intra-articular fracture fragments are present. There is a joint effusion of the right hip. The femoral head is situated within the acetabulum. No fracture of the femoral head, femoral neck or greater trochanter is appreciated. Degenerative changes of the pubic symphysis are present. There is also a comminuted minimally displaced fracture of the right inferior pubic ramus. There is diffuse osteopenia. Atherosclerotic disease of the right common femoral artery. The urinary bladder is unremarkable. The imaged large bowel demonstrates scattered areas of [DIAGNOSES REDACTED] without Diverticulitis. There is a mild amount of stranding within the mesenteric fat within the pelvis. There is a contusion in the soft tissues overlying the right greater trochanter. Impression: 1. Fractures extending along the superior, medial and anterior aspects of the right acetabulum with associated joint effusion and hematoma. No intra-articular fracture fragment identified. 2. Comminuted minimally displaced fracture of the right inferior pubic ramus. Resident 14 fell again on 9/5/15 at 1:45 AM. The fall Investigation Summary stated the following: 9/5/15 at 0145 staff nurse heard scraping sound while in med room across hall. Found resident on floor between doorway and bathroom. Lying on L (left) side with knees bent. I want to go to the bathroom. No injury. Assist by staff with EZ stand. Resident had been checked at 2400 rounds, sleeping at the time. Alarm did not sound. 3 day bowel and bladder to be done. Check and change. The Incident Report for the 9/5/15 fall states the following: Was the call light on? Was the call light within reach? Call light cord was on floor next to fall mat. Was alarm sounding? No; If not, why? Tabs alarm found on over the bed table. The facility did not follow up to ensure Resident 14's interventions were in place and did not follow up to educate staff regarding fall interventions not in place. On 4/19/16 at 4:20 PM, Surveyor spoke with Director of Nursing (DON) B. Surveyor asked DON B if a resident is to have alarms (bed and chair) per her care plan would you expect those interventions to be in place. DON B stated, Yes. Surveyor asked DON B if resident call lights should be within reach for residents to access. DON B stated, Yes, absolutely. DON B agreed that Resident 14's call light should have been within reach and her alarm should have been on per her care plan when she fell on [DATE]. Surveyor asked DON B if she could find what the facility did in response to the fall, such as staff education, etc. The facility did not provide any further information. DON B agreed that a fall intervention should have been added to Resident 14's care plan when she returned from the hospital. Example 2 Resident 1 has [DIAGNOSES REDACTED]. His fall assessment completed 12/9/15 indicates he is at risk for falls and has interventions of a sensor alarm in bed, and tab alarm in his wheelchair. The facility Fall Risk Post Fall Assessment completed for Resident 1 on 3/13/16 states he fell /slid out of bed while eating breakfast. The facility indicated to add a new intervention to place the resident in the middle of the bed before he eats his meal in bed. Upon review of his care plan for falls in the medical record with review date of 3/13/16 it was not added to his care plan and was not on the care sheet dated 4/11/16 that the CNAs follow. On 4/18/16 at 4:27 PM Surveyor interviewed Director of Nursing B who stated she does expect interventions to be put in place after falls and to be placed on the residents care plan as well. Example 3 Resident 2's Minimum Data set completed 3/10/16 indicates he has severe cognitive impairment. Resident 2's Fall Risk Assessment completed on 10/11/15 states that he remains a fall risk due to dementia and he has bed and chair alarms and continues to self-transfer. Resident 2's Fall Risk Post Fall Assessment completed 11/26/15 states the he was trying to get out of bed and fell . The Investigation Summary states, Resident (2) is unable to indicate what he was attempting to do. Will initiate a bowel and bladder diary to evaluate needs and perhaps toileting needs as root cause is difficult to determine without more evaluation. Surveyor requested the Bowel and Bladder that was completed after this fall or other interventions that were identified. None was provided by the facility. Resident 2's only Bowel and Bladder evaluation after 11/26/15 was completed on 3/8/16. On 4/18/16 at 4:27 PM Surveyor interviewed Director of Nursing B who stated she does expect interventions to be put in place after falls and to be placed on the residents care plan. Resident 2 has a [DIAGNOSES REDACTED]. The care sheet the CNAs carry to follow for resident care also indicates he requires honey thick liquids. Resident 2's food ticket from the kitchen for breakfast 4/14/16 states for Special Diets: Thick Fluids - Honey. On 4/14/16 at 7:54 AM Surveyor observed that he received thickened juice and unthickened milk. Surveyor questioned CNA E who was assisting Resident 2 if his milk was honey thick. CNA E picked up the glass that was ¼ full and stated that it was not thickened. She removed it and stated that resident drinks come from the kitchen thickened. CNA E agreed Resident 2 should not have been given the unthickened milk. Example 4 Residents 2, 10, 12, 23, and 24 reside on the memory care/300 wing. Resident 2 was indicated to have severe cognitive impairment on his most recent Minimum Data Set (MDS) completed on 3/9/16. Resident 10 was indicated to have severe cognitive impairment on her most recent MDS completed on 3/14/16. Resident 12 was indicated to have severe cognitive impairment on his most recent MDS completed on 4/1/16. Resident 23 was indicated to have severe cognitive impairment on her most recent MDS completed on 4/1/16. Resident 24 was indicated to have severe cognitive impairment on her most recent MDS completed on 2/1/16. On 4/13/16 at 10:43 AM Surveyor was going with CNA F and CNA R to assist a resident to bed on the 300 wing. An alarm sounded in the dining room and CNA R ran to the dining room to assist a resident. CNA F said, It would be nice to have someone down there (in the dining room) watching them (the residents). On 4/18/16 from 7:06 AM to 9:00 AM Surveyor made observations on the memory care/300 wing where 15 residents reside. There is a lounge/dining room on the unit and closed doors that separate the wing from the rest of the facility. During this time there were 3 staff on the unit. CNA K, CNA I, and RN G were getting residents up and then assisting residents after breakfast. At 7:06 AM Residents 12, 23, and 24 were present in the 300 wing dining room/lounge with no staff in the room until 7:20 AM. At 7:20 AM CNA I brought Resident 2 to the dining room and then she left. At 7:24 AM Nursing Home Administrator A entered the dining room , staff brought more residents to the dining room and they all left by 7:26 AM leaving a total of now 6 residents unattended in the dining room including Resident 10. At 7:28 AM CNA I assisted Resident 10 into the dining room. Surveyor observed meals then at 9:00 AM the unit staff had left the dining room to assist residents leaving 9 residents alone in the dining room. Surveyor interviewed CNA I who stated that the 300 wing usually is assigned 2 CNAs and 2 nurses split the residents on the 300 wing so there are many times when a nurse is not on the unit. On 4/18/16 just after 1:13 PM Surveyor was passing the 300 lounge after observing care for Resident 2. Surveyor saw Resident 12 unsteadily standing at one of the tables in the lounge with no staff in the room and no alarm was sounding. Surveyor asked CNA I who was by the shower room, not in view of the dining room, if Resident 12 was able to stand independently. CNA I immediately rushed to Resident 12's side and stated his alarm had not sounded yet. She moved his wheelchair that was directly behind him and the alarm sounded. On 4/18/16 at 4:03 PM Surveyor interviewed Director of Nursing (DON) B and RN Consultant C. DON B explained that there are 2 CNAs assigned to the 300 wing and 2 nurses cover the wing. On 4/19/16 at 10:00 AM DON B further explained that they are planning to assign 300 wing a nurse who can stay on the unit to increase supervision in the dining room/lounge when residents are in it. Example 5 Resident 12 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Resident 12's Quarterly MDS dated [DATE] indicates his cognitive pattern is severely impaired. On 4/18/2016, Surveyor , Received Resident 12's care plan, with target date of 6/14/16, states in part: Risk for falls secondary to weakness, dementia. Interventions include ambulation with walker 1 assist Encourage to ask for assist as needed Monitor gait for unsteadiness Observe for changes in level of consciousness Refer for therapy screen as needed Remind Resident to slow down while ambulating Tabs alarms bed and wheelchair Wheelchair with roll back brakes Anti 10/14/15 In AM (after) morning cares set up (with) snack or simple activity to provide distraction 2/22/15 - initiate B (and) B bowel and bladder No other intervention indicated or dated after 2/22/15. On 4/18/2016, at 3:20PM, Surveyor received a copy of Resident 12's Incident Report dated 4/16/16. Resident 12's incident report indicated Resident 12 stood up from his wheel chair, fell , and hit his head on 4/16/16, at 11:20AM. The IDT INCIDENT SUMMARY (capitol letters used on report) states in part: Res (resident) stood up out of chair it rolled back, alarm sound, but res (resident) fell hitting his head signed by nurse on 4/16/16. No new interventions indicated on incident report or an assessment of current fall interventions. On 4/18/2016, at 4:20PM, Surveyor interviewed DON B and RN Consultant C regarding what is expected of staff after a resident falls. RN Consultant C indicated the nurse needs to look at why the resident fell , and do something immediately, until IDT (interdisciplinary team) review. RN Consultant C indicated fall assessments done at the time of fall are review/looked at in standup/IDT review. Asked if they had reviewed Resident 12's fall yet, both DON B and RN Consultant C indicated they had not and will be reviewing it today. Surveyor , DON B and RN Consultant C reviewed Resident 12's fall care plan at this time. DON B stated yes indicating she expects a temporary intervention to be put into place after a fall. Surveyor asked if there was a temporary or new intervention indicated on Resident 12's fall care plan, DON B indicated No. On 4/19/2016, at 2:51PM, Surveyor , Interviewed RN O regarding how Resident 12's anti roll back brakes worked. Surveyor , observed RN O go over to Resident 12 while Resident 12 was sitting in his wheelchair in the 300wing lounge and began moving a black lever connected to the anti-roll back brakes, located on the back of Resident 12's wheelchair. RN O moved the black lever up and down while moving Resident 12's wheelchair forward and back. Resident 12's wheel chair was still able to move with black lever in the up and down position. RN O stated I'm guessing this lever is not working and indicated the lever usually would tighten it if moved, referring to anti-roll back brakes. RN O then stated, I'm not sure it's working. Surveyor asked RN O if it made a difference that Resident 12 was sitting in the chair. RN O then asked CNA K to assist her. Surveyor , Observed RN O and CNA K assist resident to a standing position, RN O was still able to move Resident 12's chair back and forth. Surveyor , asked RN O and CNA K if it was working properly, RN O stated, No, it needs to be fixed, and indicated she was going to place it in the maintenance book. CNA K also indicated Resident 12's anti-roll back brakes were not working properly. On 4/19/2016, at 3:10PM, Surveyor notified DON B and MDS RN D that Resident 12's anti-roll back brakes on wheelchair were not working. Surveyor , asked DON B and MDS RN D, if they were aware that Resident 12's incident report states he stood up out of chair it rolled back. Surveyor , observed DON B tell staff who just came into her office to get maintenance right away, to fix them. No indication was given that the facility had assessed Resident 12's anti-roll back brakes after his fall on 4/16/16.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer for 3 of 4 residents (Resident 1, 3 and 4). Resident 1 was admitted to the facility without a pressure ulcer (PU) and was identified to be at risk for PU development. Interventions were not put into place to prevent Resident 1 from developing a PU. Resident 1 developed an avoidable, facility acquired Deep Tissue Injury (DTI) that worsened to a Stage IV PU to the right heel and developed a DTI that worsened to an unstageable PU to the left heel. Subsequently, Resident 1 developed osteo[DIAGNOSES REDACTED] in the right heel and amputation of the right lower extremity has been recommended. Resident 3 was admitted to the facility without a pressure ulcer (PU) and was not identified to be at risk for PU development per the Braden scale, but was documented as at risk per the Minimum Data Set. Interventions were not put into place to prevent Resident 3 from developing a PU. Resident 3 developed an avoidable; facility acquired unstageable PU to the right ischial tuberosity. Resident 4 developed an unstagable wound to her right lower extremity while in the facility. Documentation states this wound was caused by a bolster used to elevate Resident 4's heels, instead of a pillow as per the physician's orders [REDACTED]. This is evidenced by the following: According to http://emedicine.medscape.com/article/ 2-overview#a0156 <http://emedicine.medscape.com/article/ 2-overview>, 15% (of diabetics) develop a foot ulcer, and 12-24% of individuals with a foot ulcer require amputation. Indeed, diabetes is the leading cause of nontraumatic lower extremity amputations in the United States. (Diabetics account for 3% of the US population and for over half of all nontraumatic lower leg amputations.) Similarly, the American Family Physician notes, The risk of lower extremity amputation is 15 to 46 times higher in diabetics than in persons who do not have diabetes mellitus . The vast majority of diabetic foot complications resulting in amputation begin with the formation of skin ulcers. <http://www.aafp.org/afp/1998/0315/p1325.html>. Failure to properly prevent a pressure ulcer can lead to other serious complications as well. According to the Mayo Clinic ' s website, Complications of pressure ulcers include: ¿ Sepsis.[MEDICAL CONDITION] occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure. ¿ [MEDICAL CONDITION]. [MEDICAL CONDITION] is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. [MEDICAL CONDITION] can lead to life-threatening complications. ¿ Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteo[DIAGNOSES REDACTED]) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications. <http://www.mayoclinic.org/diseases-conditions/bedsores/basics/risk-factors/con- 848> The Quick Reference Guide entitled Pressure Ulcer Prevention published by the National Pressure Ulcer Advisory Panel (NPUAP) in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Ensure the heels are free of the surface of the bed. Using a pillow under the calves so the heels are elevated (i.e., floating) will accomplish reduction of pressure on heels. The facility's policy entitled Pressure Ulcer/Skin Integrity/Wound Management revised 9/13/11 states in part; Procedure: a. Upon admission: i. a head to toe skin assessment will be conducted by a licensed nurse. Assessment information should identify specific factors that might increase the risk of PU development or affect healing of a PU. ii. All residents are preventatively placed on pressure reduction mattresses and cushions in w/c's based on the skin assessment. Appropriate turning and repositioning schedules will also be put in place per assessment. An initial/immediate care plan will be initiated. 2. Assessment and Treatment: a. Residents with risk for or who have a loss of skin integrity will receive the appropriate treatment/services, and residents who are determined to be at risk for or who have loss of skin integrity will receive the appropriate treatment/services which may include: ii. pressure relieving equipment; iii. Repositioning or off-loading as per resident assessment and care plan; b. all interventions and treatment should be evaluated for efficacy and modified/changed as needed. 4. Documentation a. Assessment: i. assessment information should identify specific factors that might increase the risk of PU development or affect healing of a PU such as: 1. Decreased mobility; 2. Cognitive impairment 3. Significant weight loss in a resident who also has mobility/positioning concerns; 10. History of PU and 11. Any decline in clinical status or co-morbid [DIAGNOSES REDACTED]. b. Care Planning: 1. For new admission/readmissions, an immediate plan of care will be developed to address the immediate interventions to preserve and/or treat skin integrity issues. 2. For a resident at risk for developing a PU or who has a PU and individualized care plan will be developed. 3. The care plan should address prevention of any skin breakdown; including sheering or friction; repositioning or off-loading; pressure relief equipment. The facility uses either a Panacea mattress as their standard mattress. According to manufacturer's recommendation the mattress used in the facility is rated for pressure reduction and redistribution and may be appropriate through Stage 2 PU. On 12/15/15, at 2:57 PM Surveyor interviewed Director of Nursing (DON) B regarding the facility skin care policy. DON B stated a head to toe assessment is completed on admission. A Norton skin assessment is completed followed by a Braden assessment. Based on the clinical findings of these assessments the facility implements preventative interventions to prevent impaired skin integrity. DON B stated clinical factors such as diabetes mellitus and incontinence could increase risk factors. DON stated basic interventions include weekly skin assessments on shower day and daily skin monitoring by Certified Nursing Assistants (CNA's). Surveyor asked DON B what individualized care plan interventions the facility initially put in place for Resident 1. Surveyor handed DON B Resident 1's initial care plan dated 6/1/15. DON B stated Resident 1 had a therapy evaluation and the Dietician reviewed his nutrition. Of note, these are routine assessments completed for all new admissions. DON B further stated when the blisters developed we implemented measures including heels off of bed, elevate the heels with a cushion and pillows, Profor boots when up in wheelchair (w/c) and skin prep to the blisters to the heels. Surveyor asked DON B if the facility offloads resident's heels as a preventative measure for all residents at risk for impaired skin integrity. DON B stated the facility does not implement routine heel offloading for residents at risk all care plans are individualized. On 12/16/15 at 7:40 AM Surveyor interviewed DON B regarding Resident 1's PU's. DON B stated she is wound care certified along with 2 other dayshift nurses. Example 1 Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Of note, Resident 1 had a history of [REDACTED]. Resident 1's Admission Skin Check dated 5/22/15 indicates Resident 1's heels were intact. Resident 1's admission Braden assessment, dated 5/22/15, indicates Resident 1 scored an 18 indicating Resident 1 was at risk for PU development. The facility's Braden risk score indications are as follows: At Risk: 15 -18, Moderate Risk: 13-14, High Risk: 10-12, Very High Risk: 9 or below. The Braden assessment indicating the following Sensory Perception: slightly limited indicating responds to verbal commands, but cannot always communicate discomfort of the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. Mobility: makes frequent though slight changes in body or extremity position independently. Friction or sheer: moves feebly or requires minimal assistance. During a move skin probably slides to some extent against sheets, chair .Maintains relatively good position in chair or bed most of the time but occasionally slides down. Resident 1's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/29/15, indicates A Brief Interview for Mental Status (BIMS) was completed with Resident 1 scoring a 13 indicating Resident 1 is cognitively intact. Section M0150 of the MDS indicates Resident 1 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 1 requires 1 staff and extensive assistance for bed mobility and 2 staff and extensive assistance for transfers. A Care Area Assessment (CAA) worksheet states in part; Triggering conditions: ADL assistance for bed mobility was needed ; Bed mobility : extensive assistance; Weight loss in absence of physician prescribed regimen loss of 5% or more in last month or 10% or more in the last 6 months. Resident is at risk for developing a PU. Analysis of findings: Nature of problem/condition: triggers CAA due to decline in ADL's related to recent hospitalization for wound dehiscence following cholecystostomy placement. Requires extensive assistance with ADL's alert and oriented times 3. Continent of bowel and bladder has ostomy and [MEDICATION NAME]. Has surgical wound with wound care. Extrinsic risk factors: needs special mattress or seat cushion to reduce or relieve pressure; requires regular schedule of turning. [MEDICATION NAME] risk factors: immobility, altered mental status, cognitive loss, and poor nutrition. [DIAGNOSES REDACTED]. Treatments and other factors that cause complications or increase risk: newly admitted . Resident 1 has a comprehensive care plan entitled Potential for impaired skin integrity secondary to impaired mobility dated 6/1/15. An intervention to this comprehensive plan of care states in part; keep skin clean and dry, weekly skin assessments. Nursing notes dated 5/22/15 at 6:00 PM state in part; needs assist with transfers and turning in bed; skin warm, dry and intact. Nursing notes dated 5/23/15 at 9:50 AM states in part; alert and oriented x's 3 able to make needs known. Nursing notes dated 5/28/15 at 8:15 PM states in part; is a one person extensive assist for all ADL's Nursing notes dated 6/2/15 at 4:30 PM states in part; one assist with care and 2 assist with transfers. Nursing notes dated 6/3/15 at 11:00 AM states in part; returned from podiatry appointment. No new orders. Nursing notes dated 6/5/15 at 11:00 AM state in part; resident with DTI to bilateral heels; right greater than left; both intact and purple/dark in color. Both heels treated with skin prep and elevated on heels off cushion. Profor boots provided for when up in w/c. Per interview heels were intact yesterday with no skin issues except dryness. The facility's Wound Evaluation Flow Sheet dated 6/5/15 indicates the following: Right heel: Measurements: 5.5 centimeters (cm) x 8.0 cm Stage: DTI Wound Bed: 100% eschar; Treatment: skin prep Left heel: Measurements: 6.5 cm x 4.0 cm Stage: DTI Wound Bed: 100% eschar; Treatment: skin prep Resident 1's comprehensive care plan entitled Impaired skin integrity secondary to impaired mobility dated 6/5/15. An intervention to this comprehensive plan of care states in part; keep skin clean and dry, weekly skin assessments, heels off cushion in bed; [MEDICATION NAME] boots bilaterally to feet when in w/c; lotion to bilateral lower extremities daily and as needed; treatment to bilateral heels as ordered. Nursing notes dated 6/6/15 at 9:15 AM states in part; dark colored blisters noted on both heels. Nursing notes dated 6/7/15 at 9:00 PM state in part; blisters to both heels intact; color dark purple. Heels up when in bed. Nursing notes dated 6/11/15 at 9:45 PM states in part; Right heel dark black with slightly lighter color periwound. Left heel skin intact with slightly darkened area in the center. The facility's Wound Evaluation Flow Sheet dated 6/12/15 indicates the following: Right heel: Measurements: 6.0 centimeters (cm) x 8.0 cm Stage: is blank; Wound Bed: 100% eschar; Treatment: skin prep Left heel: Measurements: 6.0 cm x 5.5 cm Stage: DTI Wound Bed: 100% eschar; Treatment: skin prep Nursing notes dated 6/14/15 at 10:05 AM states in part; skin prep applied to heels; necrotic heels. Of note, on 6/15/15 the facility notes 2 open areas on the anterior right foot - these are not considered PU. Nursing notes dated 6/17/15 at 1:00 PM states in part; left heel black area intact and soft, right heel black area intact and hard to the touch. Nursing notes dated 6/1915 at 4:00 AM states in part; skin prep applied to necrotic heels. Nursing notes dated 6/22/15 at 4:20 AM states in part; heel areas dark, firm and no [DIAGNOSES REDACTED] (redness). Of note, the facility initiated a low air loss mattress on 6/24/15. The facility's Wound Evaluation Flow Sheet dated 6/30/15 indicates the following: Right heel: Measurements: 5.8 centimeters (cm) x 7.5 cm Stage: is blank; Wound Bed: intact eschar; Treatment: skin prep Left heel: Measurements: 5.0 cm x 7.5 cm Stage: is blank; Wound Bed: 100% eschar; wound margins attached; Treatment: skin prep Nursing notes dated 6/30/15 at 11:00 AM states in part; request to see secondary to concern about progression of necrotic area to the anterior foot. Of note, this is not a PU. On 7/3/15 Resident 1 is admitted to the hospital related to the progression of the ulcerations (non-PU) of the anterior foot. Hospital wound care notes dated 7/3/15 state in part; Right heel unstageable PU measures 7.0 cm x 8.0 cm with black/dry eschar; Left heel unstageable PU measures 5.5 cm x 5.5 cm with black/dry dry eschar. Hospital wound care notes dated 7/6/15 states in part; Assessment bilateral heels with black dry eschar. Impression: bilateral heel ulcers unstageable PU's. Of note during this hospitalization a right lower extremity (RLE) angiogram was completed which showed posterior tibial artery long segmental distal occlusion. It is important to note Resident 1 was diagnosed with [REDACTED]. Of note, Resident 1 returned to the facility on [DATE]. Infection Disease Progress note dated 7/30/15 states in part; Wound Care at {Agency Name}. Wound Clinic notes dated 9/11/15 heel eschars stable and decreasing in size. Do not allow heels to get wet. Paint heels with [MEDICATION NAME] daily. Allow to air dry then cover with gauze wrap. Plastic Surgery notes dated 9/15/15 state in part; right heel PU Stage IV clean with dry eschar. Start [MEDICATION NAME] twice daily be generous with [MEDICATION NAME] both heel ulcers. May shower daily and get soap and water on heels and feet. Nursing notes dated 9/16/15 at 11:30 AM state in part; call to plastic surgeon {Dr. Name} office to review wound orders. Request rationale for disturbing/macerating dry stable eschar to heels in a diabetic using [MEDICATION NAME]. Also updated wound clinic as it was noted on 9/11/15 that the eschar was stable and healing nicely. Nursing notes dated 9/21/15 at 1:00 PM state call placed to Wound Clinic again to request assistance with treatment orders to wounds on feet. Order for [MEDICATION NAME] is not an appropriate treatment for [REDACTED]. Medical Director contacted regarding concern. Of note: No further information was found regarding the Medical Director contact except to continue with the ordered treatments. Nursing notes dated 9/24/15 at 12:00 PM Wound Team met to discuss current wound care. [MEDICATION NAME] to be initiated per plastic's order secondary to wound clinic declines to make any recommendations. Wound Clinic Progress notes dated 9/30/15 state in part; right heel still with thick eschar. Some of the left heel eschar debrided. Plastic Surgeon progress notes dated 10/20/15 state in part; heel PU eschars well demarcated, no evidence of infection or [MEDICAL CONDITION]. Continue with twice daily dressing change with [MEDICATION NAME] over heels eschars. Wound Clinic notes dated 10/28/15 state in part; intense odor to right heel today. Heavy drainage was also noted. Debridement was performed right heel wound. Obtain x-ray and labs. Placed on antibiotic [MEDICATION NAME] 500 milligrams (mg) 1 capsule by mouth 4 times daily for 10 days. Infectious Disease note dated 10/29/15 states in part; right calcaneus (heel) osteo[DIAGNOSES REDACTED]. Resident 1 refuses intravenous (IV) antibiotics. Plan: [MEDICATION NAME] and [MEDICATION NAME] discontinue [MEDICATION NAME]. Infectious Disease progress note dated 11/3/15 right heel still with odor. Still refusing IV antibiotics Infectious Disease progress note dated 11/12/15 right heel infected wound positive osteo[DIAGNOSES REDACTED] on [MEDICATION NAME] and [MEDICATION NAME]. Plan discontinue [MEDICATION NAME] and [MEDICATION NAME]. Start Ertapenem (antibiotic) IV 1 gram every 24 hours. Wound Clinic notes dated 11/13/15 right heel with wet, eschar and bogginess. Strong malaodor, moderate serous drainage. Unable to probe to bone. Left heel necrotic. Telephone order 11/13/15 states in part; right heel [MEDICATION NAME] 500 mg tab crush 1 tab and apply to right heel wound under Dakins soaked gauze daily. Discontinue [MEDICATION NAME]. Left heel: Use Santyl to the right foot and left heel wounds daily. Infectious Disease Progress note dated 11/17/15 states in part; right heel eschar had recently become weeping and malodorous, although without exposed bone. A radiograph (x-ray) on 10/28/15 was concerning for osteo[DIAGNOSES REDACTED] of the posterior right calcaneus (heel). The left calcaneus was negative for osteo[DIAGNOSES REDACTED]. A wound culture on the day of 10/28/15 grew a pansensitive Proteus mirabilis. The right heel shows a large infected soft eschar with a foul smell. It is starting to separate from the surrounding soft tissue. Bilateral foot wounds an infected right calcaneus eschar with underlying osteo[DIAGNOSES REDACTED]. The prognosis for salvage of the foot appears guarded. It is likely that this infection will result in an above the knee amputation. This was discussed with the patient in unambiguous terms. He is completely opposed to any form of surgery of the foot. Hospital emergency department note dated 11/28/15 at 10:53 AM states in part; Assessment: admission with shortness of breath, weakness, tremulous, [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) [MEDICAL CONDITION]. Final Diagnostic Impression: pneumonia and osteo[DIAGNOSES REDACTED]. Wound Care Progress notes dated 12/3/15 at 12:19 states in part; the bilateral heels continue to have devitalized deep tissue and eschar. There is exposed bone on the right heel. Paliative Care hospital progress note dated at 12:59 PM 12/7/15 states in part; x-ray right calcaneus 10/28/15 indication unspecified heel, stage 4. Estimated Prognosis : Poor given VRE bacteremia, calcaneous osteo[DIAGNOSES REDACTED] not responsive to antibiotics, bilateral pneumonia with [MEDICAL CONDITION]. Impression: progressive advanced weakness due to poor oral intake, [MEDICAL CONDITION] and [MEDICATION NAME] Resistant bactermia, calcaneous osteo[DIAGNOSES REDACTED] not responsive to antibiotics and pneumonia; difficult situation where amputation is needed to cure osteo[DIAGNOSES REDACTED] of right foot but not good surgical candidate. He appears to be in the dying process and does not have good options to prolong life. Hospital progress notes dated 12/9/15 at 1:48 PM states in part; Assessment: the bilateral heels continue to have devitalized deep tissue, slough, and eschar. There is exposed bone on the right heel. Of note Resident 1 returned to the facility on [DATE] with hospice. On 12/15/15 at 8:30 AM Surveyor observed Certified Nursing Assistant (CNA) G reposition pillows under Resident 1's feet. Resident 1's bilateral heels were resting on the pillows that were placed under his legs thus his heels were not free floating. Surveyor asked CNA G if Resident 1's heels were touching the pillow CNA G stated I am going to get the nurse his dressing is coming off. On 12/15/15 at 8:35 AM Surveyor interviewed Resident 1 regarding the PU's to his bilateral heels. Resident 1 stated the heel ulcers started at the facility shortly after he was admitted . Resident 1 stated that he developed pus sacs to his heels because the staff did not turn him frequently enough. Surveyor asked Resident 1 if the facility elevated his heels off the bed upon admission. Resident 1 stated not until after he developed the sores on his heels. Surveyor asked Resident 1 regarding his air mattress. Resident 1 stated he received that after his heel ulcers developed. On 12/15/15 at 10:15 AM Surveyor observed wound care for Resident 1 being provided by Registered Nurse (RN) C and RN D. RN C removed the dressing to the right heel which revealed a large ulcer which was slightly smaller than a bar. The wound bed had approximately 80 % eschar with an area of white material within the large heel PU which appeared to be bone. RN C removed the dressing to the left heel that revealed an unstageable PU with 100% black eschar that appeared to be the size of a 50 cent piece. At approximately 10:50 AM upon completion of the dressing change Surveyor interviewed RN C regarding Resident 1's PU's. Surveyor asked RN C about the PU's. RN C stated the PU's developed at the facility shortly after Resident 1 was admitted . RN C stated the right heel is about the size of a small orange with 75% slough. RN C stated the ulcer was caused by pressure and is unstageable. RN C stated the left PU is the size of a 50 cent piece with 100 % eschar and is unstageable. Surveyor asked RN C if the heels should be offloaded at all times. RN C stated the heels should be off the mattress with the heel cushion and pillows at all times when Resident 1 is in bed. Surveyor informed RN C of the observation of Resident 1's heels touching the pillows and not completed offloaded. Resident 1 stated now that I have returned from the hospital they reposition me a lot more frequently now. On 12/15/15 at 2:57 PM Surveyor interviewed DON B regarding Resident 1's PU's. DON B stated that the ulcers to Resident 1's feet are considered diabetic ulcers not PU. Surveyor asked DON B what standard of practice the facility follows for wound care. DON B stated the National Pressure Ulcer Advisory Panel (NPUAP). Surveyor asked DON B why the facility is considering the ulcers diabetic versus pressure ulcers. DON B stated that per the NPUAP a ulcer on the foot of a diabetic is considered a diabetic ulcer and that there would be no change in Resident 1's plan of care if the ulcer was a PU or a diabetic ulcer. Surveyor asked DON B if Resident 1 was at risk for PU development upon admission. DON B stated Resident 1 was at risk but not at high risk. DON B stated Resident 1 could move his feet and could move in bed. Surveyor reviewed nursing documentation and the MDS with DON B and stated per nursing notes and the MDS assessment it appears Resident 1 required extensive assistance for bed mobility. On 12/15/15 at 4:30 PM surveyor interviewed Dr. E regarding Resident 1's PU's. Surveyor asked Dr. E regarding the ulcerations. Dr. E stated that Resident 1 has had a long history of leg ulcers and uncontrolled diabetes and has very poor vascularization with ischemia. Dr. E stated Resident 1 has had poor self care and many of his problems are related to inability to follow medical recommendations. Surveyor asked Dr. E if he felt the ulcers to Resident 1's heels were related to ischemia versus pressure. Dr. E stated the slighest bit of pressure could cause an ulceration due to Resident 1's ischemia. I cannot say that pressure did not start then the ulcers developed. Surveyor asked DON B what the facility had in place to prevent Resident 1 from developing a PU. Surveyor asked DON B what individualized care plan interventions the facility initially put in place for Resident 1 to prevent PU development. Surveyor handed DON B Resident 1's initial care plan dated 6/1/15. DON B stated Resident 1 had a therapy evaluation and the Dietician reviewed his nutrition. Of note, these are routine assessments completed for all new admissions. DON B further stated when the blisters developed we implemented measures including heels off of bed, elevate the heels with a cushion and pillows, Profor boots when up in wheelchair (w/c) and skin prep to the blisters to the heels. Surveyor asked DON B if the facility offloads resident's heels as a preventative measure for all residents at risk for impaired skin integrity. DON B stated the facility does not implement routine heel offloading for residents at risk all care plans are individualized. Resident 1 developed an avoidable facility acquired DTI to the right heel that worsened to a Stage IV PU and an unavoidable facility acquired unstageable PU to the left heel. Resident 1 was identified as at risk for PU development upon admit evidenced by [DIAGNOSES REDACTED]. Example 2 Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>[MEDICAL CONDITIONS]/ Urinary Tract Infection [MEDICAL CONDITIONS] with Foley Catheter, Dementia, and Rhabdomyolysis. Resident 3's admission Braden assessment, dated 10/27/15, indicates Resident 3 scored a 23 indicating Resident 3 was not at risk for PU development. The facility's Braden risk score indications are as follows: At Risk: 15 -18, Moderate Risk: 13-14, High Risk: 10-12, Very High Risk: 9 or below. Of note, per the Braden scale Resident 3 was not at risk for PU development. Development of a PU in a low risk resident is of greater concern than an expected at risk resident. Of note although the Braden score indicated a low risk Resident 3 was determined at risk per Minimum Data Set. Resident 3's Admission Skin Check dated 10/27/15 indicated Resident 3's skin was intact. Resident 3's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/3/15, indicates A Brief Interview for Mental Status (BIMS) was completed with Resident 3 scoring a 15 indicating Resident 3 is cognitively intact. Section M0150 of the MDS indicates Resident 3 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 3 requires 2 staff and extensive assistance for bed mobility and transfers. A Care Area Assessment (CAA) worksheet states in part; Triggering conditions: ADL assistance for bed mobility was needed and bed mobility: extensive assistance; Resident is at risk for developing a PU. Analysis of findings: Nature of problem/condition: triggers CAA due to at risk for PU's related to decline in mobility, requires extensive assistance and has [MEDICAL CONDITION] (MS). Extrinsic risk factors: requires staff to assist to move sufficiently to relieve pressure over any one site; confined to bed or chair all or most of time; needs special mattress or seat cushion to reduce or relieve pressure; requires regular schedule of turning. [MEDICATION NAME] risk factors: immobility, altered mental status, cognitive loss. [DIAGNOSES REDACTED]. Treatments and other factors that cause complications or increase risk: newly admitted . Resident 3 has a comprehensive care plan entitled Potential for impaired skin integrity secondary to impaired mobility dated 11/10/15. An intervention to this comprehensive plan of care states in part; keep skin clean and dry, weekly skin assessments. Nursing notes dated 10/27/15 at 1:00 PM state in part; transferred with two staff assist with pivot transfer unable to stand straight up and very difficult to move both feet. Nursing notes dated 10/28/15 at 1:00 PM state in part; no open areas; two assist with pivot transfers. Nursing notes dated 10/29/15 at 10:15 AM states in part; needs assist of 1 with ADL's and transfers. Nursing notes dated11/17/15 at 10:00 PM states in part; likes to sit in w/c and watch TV; no skin issues. Nursing notes dated 11/21/15 at 9:00 PM states in part; resident in room throughout the shift watching TV; transfers with one assist. Nursing notes dated 11/22/15 at 9:50 AM state in part; CNA noticed and open area on the residents right gluteal fold 0.9 cm x 0.6 cm. Wound was cleansed with normal saline and covered with Allevyn border dressing for protection. Dr. {physician name} called and left message. Resident 3's comprehensive care plan entitled Potential for impaired skin integrity secondary to impaired mobility unstageable PU to right tuberosity dated 11/23/15. An intervention to this comprehensive plan of care states in part; keep skin clean and dry, weekly skin assessments, w/c cushion; pressure reduction air mattress, position off right hip, reposition every 2 hours in bed and w/c. Of note, these interventions were not added to Resident 3's plan of care until after a PU developed. In addition, there is no pressure reduction air mattress on Resident 3's bed. The facility's Wound Evaluation Flow Sheet dated 11/23/15 indicates the following: Right ischial tuberosity Measurements: 1.5 centimeters (cm) x 2.7 cm Stage: unstageable Wound Bed: 100% slough; Treatment: Allevyn Nursing notes dated 11/22/15 at 11:30 AM state in part; Dr. {physician name} called back on resident open area on the gluteal fold and stated it is okay to carry on with the wound treatment as initiated in the facility. Physical therapy notes dated 11/23/15 wheelchair cushion adjusted to patients comfort. Nursing notes dated 11/25/15 at 1:00 PM state in part; open area right buttock continues; very large amount of brownish drainage on old dressing. The facility's Wound Evaluation Flow Sheet dated 12/2/15 indicates the following: Right ischial tuberosity Measurements: 0.7 centimeters (cm) x 1.0 cm Stage: unstageable Wound Bed: 50% slough; 50% granulation; Treatment: Allevyn Nursing notes dated 12/8/15 at 12:00 PM state in part; left gluteal wound dressing changed with small amount of serous drainage on old dressing; wound is closing up. The facility's Wound Evaluation Flow Sheet dated 12/8/15 indicates the following: Right ischial tuberosity - Now 2 small open areas Measurements: 0.4 centimeters (cm) x 0.4 cm and 1.0cm x 0.4 cm; Stage: appears as Stage 2 Wound Bed: 100% granulation; Treatment: Allevyn

Based on observation, interview and record review the facility did not ensure the resident environment remained as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 9 residents and 3 supplemental residents (Resident 1, 11, 22, 23, 24 and 9) Resident 1 was identified as being at risk for falls and had fallen prior to admission and had sustained a fractured hip. He had 4 falls within 25 days of admission, one leading to sutures of his forehead. The facility did not thoroughly investigate these falls to determine the root cause in order to implement effective measures to prevent Resident 1 from additional falls. Additionally, during survey, Resident 1 was observed without care-planned fall interventions in place. Failure to ensure Resident 1 received adequate supervision and assistance devices to prevent accidents created a finding of immediate jeopardy. The immediate jeopardy began on 1/20/12. The NHA was notified of the immediate jeopardy on 2/29/12 at 4:30 PM. The facility removed the immediate jeopardy on 2/29/12, however the deficient practice continues at scope/severity E (potential for harm that is not immediate jeopardy/pattern) as evidenced below: Residents 1, 11, 22, 23 and 24 all utilized chair sensor alarms to alert staff of attempts to self transfer. The alarms were not utilized according to manufactures' recommendations. Resident 9 had a fall while being transported without his foot rests on his wheel chair, he lowered his legs, placing his feet on the floor and fell to the floor. His care plan "Risk for falls", indicates he is to have wheel chair foot rests put on his wheel chair when being pushed to help to prevent injury to feet. Resident 9 was observed without his foot rests on his wheel chair as he was being pushed down the hall by staff. This is evidenced by the following: The facility's "Accident/Falls" policy, dated 4/1/08, indicates the following: 1. For all residents, a fall risk assessment will be conducted upon admission, readmission from the hospital, quarterly and with any significant change to the resident's status which puts them at greater risk for falls. 6. ...Each incident/accident or fall must be investigated and/or assessed to determine the cause of the episode to prevent any further injury. 9. The resident's individualized care plan is to be updated with any changes or new interventions post fall/incident/accident, communicated to appropriate staff and implemented. The manufacturer's instructions for the Secure Personal Accident Deterrent System (PADS) states: (chair alarm) 2. Place PADS Chair Sensor in center of chair seat directly under buttocks of user. If chair cushion is used sensor pad must be placed on top of chair cushion directly under buttocks of user. 7. When staff removes user from pad for whatever reason the alarm will sound. Example 1 Resident 1 was admitted to the facility on [DATE] following a fall with a hip fracture and [DIAGNOSES REDACTED]. Resident 1's admission fall assessment completed on 1/10/12 indicates Resident 1 has had 3 or more falls in the past 6 months and Resident 1 had impaired mobility due to left hip fracture. The summary indicates Resident 1 is at risk for falls. Resident 1's care plan, initiated 1/13/12, identifies the focus area of "Risk for falls secondary to confusion, non weight bearing on fractured hip r/t (related to) h/o (history of) falls with hip fracture. Interventions include: Use alarms to alert staff, if necessary, physical therapy evaluation and treatment, and keep in common area when up to monitor for attempts to self transfer. On 1/11/12, Resident 1's care plan was updated to a Hoyer lift transfer and non-ambulatory. Resident 1's care plan was updated on 1/18/12 when non-ambulatory was discontinued and Resident 1's transfers were changed to assist of 2 with EZ Stand and weight bearing as tolerated. Resident 1's nursing notes indicate the following: -1/12/12 at 12:00 PM, indicate Resident 1 is up in geri chair with alarm. -1/19/12 AM (no time indicated) "Heard a resident yelling down hall. Several nurses responded and noticed (Resident 1) lying on R (right) side on the floor. Received small skin tear on L (left) elbow...physician notified. Resident 1's "Falls Risk Post-Fall Assessment", dated 1/19/12, indicates the fall occurred at 9:00 AM, in the doorway of another resident's room. The report indicates Resident 1 was sitting in chair by resident's room. Skin tear to left elbow. The report asked the following questions with answers: --Fall interventions currently being used: In sight of nurse and CNA (Certified Nursing Assistant) with working chair alarm. --Review the information completed above and summarize the post-fall findings: Resident (1) feeling better, wants to get up and walk. Continues to work with therapy. --Interventions to be implemented as a result of the assessment: working chair alarm. Resident 1's "Incident Report" for 1/19/12, indicates Resident 1 was in the hall sitting in his wheelchair. Resident 1 got up and walked then fell on floor in doorway of another resident. There is no investigation into whether Resident 1 was supposed to have an alarm in place at the time of the fall and if so was it sounding or if Resident 1 was in a common area as indicated on the care plan. There were no changes made to Resident 1's plan of care. Physical Therapy notes, dated 1/20/12, indicate Resident 1 seen in therapy changed cushion wedge/roho; Resident 1 looks good with posture and positioning. This was not added to Resident 1's care plan. Resident 1's nursing notes on 1/20/12, at 1:30 PM, indicate "Resident (1) was in day room having lunch, Res (Resident 1) was seen by staff standing, wheelchair alarm functioning properly, staff was unable to get to res (Resident 1) in time. (Resident 1) fell on r (right) side of forehead, received a 1 1/2-2 inch laceration..." Resident 1's "Falls Risk Post-Fall Assessment", dated 1/20/12, indicates the following: Resident 1 was in the Activity Room eating lunch at the time of the fall. --Fall interventions currently being used: chair alarm, bed alarm. --Review the information completed above and summarize the post-fall findings: Resident 1 was unattended, alarm sounded and staff was unable to get to Resident 1 prior to fall. --Resident 1 sent to the emergency room , will assess needs upon return to facility. Resident 1's "Incident Report" for 1/20/12, includes the following statement by a Certified Nursing Assistant: I was by the wing rotunda, I heard an alarm going off, I saw Resident 1 getting up out of his wheelchair the chair started to move and he fell on the floor hitting his head hard... Resident 1's hospital notes indicate Resident 1 received sutures in his forehead and remained in the hospital for evaluation to ensure Resident 1's hip was not refractured. Resident 1 was also evaluated for new fractures, all were negative. Resident 1's Falls Risk Assessment, dated 1/23/12, indicates Resident 1 is at high risk for falls and therapy is working with resident on safety. Resident 1's nursing notes indicate on 1/23/12 that Resident 1 was readmitted to the facility and a Velcro lap buddy was put into place. Resident 1's care plan was updated with the use of the Velcro lap buddy. Resident 1's "Restraint Free Care" assessment, dated 1/23/12, indicates Resident 1 can easily remove the lap buddy and it is not a restraint. The assessment indicates Resident 1 was placed in a tilted cardiac chair with a Velcro lap buddy which decreased the forward hip thrust. Facility 24 hour report for 1/23/12, indicates Resident 1 has a Broda chair with lap buddy but he takes it off himself. Resident 1's care plan was updated on 1/23/12 to include: Moderate assist of 1/stand by assist of 1 with gait belt with transfers, Velcro lap buddy in place in wheelchair. Resident 1's nursing notes indicate: 1/25/12-a floor mat is in place by Resident 1's bed 2/5/12- Bed alarm and floor mat in place 2/5/12-Extremely restless when up in chair. Had to be put back to bed immediately after supper meal due to safety issues. Keeps tearing off lap buddy. Very agitated. 2/11/12-9:00 PM, Up in wheelchair for 1 hour over supper and constantly trying to stand up. Very restless. Settles down when in bed. 2/13/12-AM (no time) Upon return from doctor appointment Resident 1 was very agitated and attempting to get out of wheelchair. Resident 1 removed the lap buddy, alarm went off, by the time CNA/nurse had reached Resident 1 he had already fallen. A moderate amount of blood noted coming from left elbow skin tear... Resident 1's "Falls Risk Post-Fall Assessment", dated 2/13/12 at 12:00 PM, indicates Resident 1 was sitting in chair. --Fall interventions currently being used: Lap buddy, fall mat, bed and wheelchair alarm. --Review the information and summarize the post fall findings: Resident 1 has difficulties with judgment and safety so is unaware that it is unsafe for him to ambulate independently. --Interventions to be implemented as a result of the assessment: Walking program. Attempted to ambulate Resident 1. Works with therapy after fall to use up energy and allow him chance to walk. Resident 1 was noted to be agitated and able to remove the lap buddy prior to the fall. The facility knew the intervention was ineffective at that time. The facility also should have known the alarms were ineffective as Resident 1 had previously fallen with the alarm in place and staff were unable to respond in time. There is no evidence of a walking program or that CNA staff ambulated with Resident 1 outside of therapy. Resident 1's "Incident Report" for 2/13/12 at 12:00 PM, indicates Resident 1 got out of wheelchair, removing lap buddy and then fell to the floor on wing after doctor appointment. --Closely monitor. Resident 1's nursing notes indicate: 2/13/12- PM (no time), Resident was found on floor of room laying next to bed on floor mat. It was noted that Resident 1 had a new skin tear related to this fall. DON (Director of Nursing) notified and working with Resident 1 with therapy. 2/13/12-Resident 1's nurse practitioner called back and ordered Trazadone 25 mg (milligrams) every 6 hours as needed for agitation and a urine dip. Therapy placed safety belt on Resident 1's wheelchair that is self releasable. The urine dip was negative. Resident 1's "Falls Risk Post-Fall Assessment", dated 2/13/12 at 2:30 PM indicates: --Fall interventions currently being used: chair alarm, lap buddy, floor mat and bed alarm. --Review information and summarize the post fall findings: Resident found lying on floor beside his bed. Sustained skin tear to left elbow. Again Resident 1 very anxious and restless. Attempted to ambulate after fall due to restlessness. Resident 1 stood well but did not ambulate. --Interventions to be implemented: Resident 1 moved to Memory Care unit to engage in activities and increase supervision. There is no evidence how Resident 1 was "closely monitored." The Memory Care Unit, on 2/27/12, had 14 residents and 2 CNAs. There is no nurse on the unit from 12:00-2:30 PM. There are doors to the unit that remain closed at all times. On 2/27/12 during the initial facility tour, Surveyor was informed by Registered Nurse AA that most of the residents on the unit require total assistance and 2 staff for cares. When 1 CNA left the unit for break that left only one staff member on the unit. Resident 1's "Restraint Free Care", dated 2/13/12, indicates a seat belt was put into place and Resident 1 is unable to remove the seat belt. Resident 1's physical therapy notes, dated 2/22/12, indicate Resident 1 seen, right foot boot loose, seatbelt undone and cushion sliding off. Notified nurse as need to keep seatbelt on to control sliding out. On 2/27/12, at 1:43 PM, Surveyor observed Resident 1 in bed. There was a sensor pad alarm in place and the box was tucked into Resident 1's nightstand out of reach of Resident 1. On 2/28/12, at 7:20 AM, Surveyor observed DON B assist Resident 1 with his meal. DON B unbuckled Resident 1's seat belt. At 8:05 AM, DON B left the dining room, other staff was present and Resident 1's seat belt remained unfastened. At 8:28 AM, CNA E left the dining room to take another resident back to their room and there were no staff present in the dining room for approximately 45 seconds. Then CNA E returned to the dining room. CNA E backed Resident 1 away from the table and noted the seat belt was unfastened. CNA E told Surveyor that she was unaware that Resident 1's seat belt was not fastened. On 2/28/12, at 8:55 AM, Surveyor observed CNA E and CNA H assist Resident 1. CNA E and CNA H stood Resident 1 up with a gait belt and Resident 1 took a step before the chair alarm sounded. Surveyor noted the sensor pad was located under Resident 1's alternating air cushion. Resident 1 was assisted into bed and neither CNA E nor CNA H checked for the placement of a bed alarm. Note there was no bed alarm in place. On 2/28/12, at 12:45 PM, Surveyor observed Resident 1 in bed. There was a sensor pad alarm in place on Resident 1's bed. On 2/29/12, at 7:05 AM, Surveyor and CNA H checked Resident 1's bed. There was a bed sensor pad alarm in place. On 2/29/12, at 7:45 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated Resident 1 had a chair alarm on 1/13/12 but not a bed alarm and the care plan should specify the type of alarm in use. DON B stated the facility only uses sensor alarms not tab/pull alarms. DON B stated indicating "if necessary" on the care plan is not appropriate. Surveyor asked what "keep in common area when up to monitor for attempts to self transfer" meant. DON B stated Resident 1 should be where people could see him and they are to monitor him as much as possible. DON B stated the care plan should state to monitor as much as possible. DON B was unable to clarify definitively what "as much as possible" meant. DON B then stated Resident 1 did not have a chair alarm until after the fall on 1/19/12 because on 1/19/12 the staff heard Resident 1 yelling. DON B stated interventions were in place on 1/19/12 and 1/20/12 but staff could not get to Resident 1 in time. DON B stated when Resident 1 returned to the facility on [DATE] a lap buddy was put into place. Surveyor asked about the use of an alarm on Resident 1's bed. DON B stated Resident 1 did not have a bed alarm until she put the bed alarm on Resident 1's bed the prior afternoon (1/28/12). On 2/29/12, at 2:30 PM, Surveyor interviewed DON B. DON B stated she assisted Resident 1 on 2/28/12 with breakfast. DON B stated she removed the seat belt because she was right with Resident 1. DON B stated she told the staff the seat belt was unfastened before leaving the dining room. The facility removed the immediate jeopardy on 2/29/12, after they implemented the following: Resident 1 was reassessed for fall risk, the Interdisciplinary team met and discussed previous falls, interventions, and reviewed the new fall assessment to identify the root cause of the falls. Due to this reassessment the team implemented hourly checks for 24 hours to ensure resident safety, during the hourly checks Resident 1's behaviors and activities will be logged to identify any potential pattern, the cushion pad alarm was discontinued and an alarming seatbelt was added, a walking program was initiated, and dementia specific activities will be offered to Resident 1 as he tolerates. All staff was trained on Resident 1's new plan and all oncoming staff will be educated on the plan for Resident 1, the policy and procedure for accident and incident review, and how to determine the root cause of a fall prior to starting their next tour of duty. The deficient practice continues at a scope/severity level E (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following: Example 2 On 2/29/12, at 4:30 PM, Surveyor observed Resident 1, Resident 11, Resident 22, Resident 23 and Resident 24 in their wheelchairs. All the residents had a sensor pad alarms that were positioned under a cushion in their wheelchairs not directly under their buttocks as per the manufacturer's instructions. Example 3 The nurses notes on 12/3/11 at 1:30 am indicates Resident 9 placed his feet on the floor while being transported in the wheel chair without his foot rests causing a sudden forward shift in momentum, causing him to fall out of the wheel chair onto the floor on his knees. He received a superficial abrasion on his right knee with complaints of discomfort. Resident 9's care plan, Risk for falls, dated 2/25/12 indicates he is to have his wheel chair foot rests put on his wheel chair when being pushed to help prevent injury to feet. On 2/27/12, at 5:00 pm Surveyor observed CNA (Certified Nursing Assistant) J pushing Resident 9 to the dining room in his wheel chair without his foot rests on. CNA J told Resident 9 to hold his feet up while he transported him to the dining room. Resident 9's care plan was not followed when transporting him to the dining room creating a potential that he would fall out of his wheel chair, causing injury. On 2/29/12, at 3:30 pm Surveyor asked LPN (Licensed Practical Nurse) K if Resident 9 uses his foot rests. He said Resident 9 is to use his foot pedals with ambulation since he doesn't lift his legs. On 2/29/12, at 3:50 pm Surveyor asked DON (Director of Nursing) B what her expectation was for following Resident 9 care plan for falls and CNA J transporting Resident 9 in the hall without his foot rests when his care plan for falls indicates he is to use them. She said he should have had his foot pedals on as his care plan states.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 2 of 8 residents (Resident 1 and 3). Resident 1 was at risk for pressure ulcers upon admission; the facility did not properly assess Resident 1's skin on admission and readmission. When Resident 1 developed pressure ulcers the facility did not properly assess and document the pressure ulcers and did not float Resident 1's heels in bed per current standards of practice. Resident 3 developed a pressure ulcer on his right heel after admission to the facility. The facility did not properly assess and document the the wound. The facility did not document weekly assessments per the facility policy. This is evidenced by the following: A Quick Reference Guide entitled "Pressure Ulcer Prevention" published by the National Pressure Ulcer Advisory Panel in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Using a pillow under the calves so the heels are elevated (i.e., "floating") will accomplish reduction of pressure on heels. The facility's policy "Pressure Ulcers/Skin Integrity/Wound Management," revision date 9/13/11, includes the following: 1. Wound Assessment a. Upon Admission: i. A head to toe skin assessment will be conducted by a licensed nurse. It is recommended that this assessment is completed within the shift the resident was admitted ; however, it must be completed per state requirements and/or facility policy within 24 hours of admission...A Norton or Braden skin assessment will also be completed upon admission. ii. All residents are preventatively placed on pressure reduction mattresses and cushions in wheelchairs based on the skin assessments. Those residents who represent a high risk will have further preventative interventions put in place. Appropriate turning and repositioning schedules will also be put in place per assessment. b. A weekly skin check will be conducted and documented for at-risk residents. d. Re-admission or Significant Change in Condition per MDS: i. Follow process for admission, and complete all admission assessments. 2. Assessment and Treatment. It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that may have influenced its development, the potential for development of additional ulcers, or for the deterioration of the pressure ulcer(s) be recognized, assessed and addressed as follows: a. Differentiate the type of ulcer (pressure related versus non-pressure related) b. Determine the ulcer's stage c. Describe and monitor the ulcers characteristics... 4. Documentation a. Assessment: i. Assessment information should identify specific factors that might increase the risk of pressure ulcer development or affect healing of a pressure ulcer such as: (1) Decreased mobility (2) Cognitive Impairment (4) Use of restraints (11) Any decline in clinical status or co-morbid [DIAGNOSES REDACTED]. ii. For a resident who was admitted with a pressure ulcer or who developed one within one or tow days, the admission documentation should include at least the following: (1) Ulcer site and characteristics at the time of admission, including measurements. (3) Skin condition on and within a day of admission if suspected deep tissue injury. The skin was purple, discolored, or maroon in color. Any blood-filled blisters present or tissue that is painful, mush, boggy, or warmer or cooler compared to adjacent tissue. c. Routine/Ongoing Documentation iii. At least weekly, an evaluation of the pressure ulcer wound should be documented...At a minimum, documentation should include the date the ulcer or wound was observed and: (1) Location and staging (2) Size... Example 1 Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's "Admission Skin Assessment," dated 1/10/12, indicates a "5 cm (centimeter) redness c (with) superficial oas (open areas) along coccyx." "Heels intact." Resident 1's admission Braden Scale was completed on 1/10/12 indicating redness on the coccyx. The scale is completed however not totaled. Resident 1's risk score would be 8 indicating a "Very High Risk." Resident 1's care plan was developed on 1/13/12 and identified the "Focus" area of "Alteration in Mobility r/t (related to) hip fx (fracture)." Interventions include: Turn and reposition in bed every two hours with two staff. The care plan does not indicate to float heels or any further preventative interventions for skin integrity or a skin integrity care plan. Resident 1's nursing notes indicate the following: 1/10/12-Coccyx area with 5 cm very red area with several superficial open areas along coccyx line. Will apply barrier cream. Heels floated. 1/11/12-Heels intact. Coccyx red. 1/13/12-Scattered redness to sacral coccygeal area. Order obtained for [MEDICATION NAME] as preventative. Area is blanchable but does not resolve with pressure relief. Order also for Med Pass Supplement to provide calories and protein. Note written by Director of Nursing (DON) B who is part of the wound team. A "Wound Evaluation Flow Sheet" was not started to monitor the coccyx area. Other than on 1/10/12 there are no measurements to indicate the size of the reddened area. On 1/20/12 Resident 1 was discharged to the hospital following a fall per the nursing notes. Resident 1's nursing notes indicate Resident 1 was readmitted to the facility on [DATE]. Skin check completed and noted an open area and redness on coccyx which was covered by [MEDICATION NAME]. See skin sheet. Resident 1's "Admission Skin Assessment," dated 1/23/12, has the coccyx circled and indicates "redness/open covered c (with) [MEDICATION NAME]." The heels are noted to be intact. The skin assessment was completed by Licensed Practical Nurse/Wound Nurse (LPN) W. There are no measurements of the area. Resident 1's care plan was updated on 1/23/12 to include the use of an alternating pressure air mattress and a Velcro lap buddy was put into place. On 1/24/12 the care plan was updated to include a 2 inch foam cushion in the cardiac wheelchair. Resident 1's nursing notes, written by DON B on 1/25/12, indicate Resident 1 with large DTI (Deep Tissue Injury) to sacral area. Center appears moist macerated with surrounding redness. [MEDICATION NAME] appears to be causing too much moisture. Order changed to Polymem secured with [MEDICATION NAME]. A telephone order was obtained for Resident 1 on 1/25/12 indicating to discontinue the [MEDICATION NAME] to the coccyx and apply Polymem Secured with [MEDICATION NAME] to sacral area. Resident 1's nursing notes on 1/26/12 indicate "Has a flat dry blister on L (left) heel. Skin prep applied." There is no physician's order for the skin prep or indication the physician or wound team was updated on the dry blister. Resident 1's nursing notes, 1/28/12, indicate treatment on coccyx intact. The facility was unable to locate Resident 1's weekly skin check that should have been completed on 1/29/12. Resident 1's physical therapy notes on 2/2/12 indicate Right heel float boot obtained, open area on right back of heel. New cushion obtained for Resident 1, higher in the front. This cushion will hopefully prevent scooting forward in chair and decrease sacral wound sheering and prevent Resident 1's heel from rubbing on the footrest. Resident 1's nursing notes on 2/2/12 indicate physical therapy put a splint boot on Resident 1's right foot due to an open area. Resident 1's care plan was updated on 2/2/12 to indicate the use of the pressure relief boot on the right foot due to an open area. Resident 1's nursing notes on 2/3/12 and 2/4/12 indicate the treatment to the right heel is intact, but there is no indication what the treatment is. Resident 1's physician orders indicate an order for [REDACTED]. Resident 1's Treatment Record indicates the heel treatment of [REDACTED]. There is no indication of any other treatment for [REDACTED]. On 2/2/12 "Wound Evaluation Flow Sheets" were initiated for Resident 1's right heel and sacrum. Right Heel--The wound sheet for Resident 1's right heel does not indicate the type of wound, where it was acquired, date of origination or the stage of the wound. -2/2/12 the measurements indicate the wound is 2 cm by 2 cm with a moderate amount of thin serous drainage. The wound bed is 100% pink granulation tissue. The treatment is Polymem and a boot. (Note: order was not obtained until 2/5/12) -2/8/12 the measurements indicate the wound is 1.5 cm by 1.8 cm with 100% slough. There is no stage indicated for the wound. The treatment was changed to [MEDICATION NAME] Blue. -2/18/12 the measurements indicate the wound is 1 cm by 1 cm with no drainage and is scabbed/dry. There was no change to the treatment. -2/23/12 the measurements indicate the wound is 1 cm by 1 cm with a scant amount of thin serous drainage. The wound bed is 100% pink granulation tissue. Sacrum Wound--The wound sheet for Resident 1's sacrum does not indicate the type of wound, where it was acquired, date of origination or the stage of the wound. -2/2/12 the measurements indicate the wound is 3 cm by 3.5 cm with a moderate amount of thin serous drainage. The wound bed is 100% yellow slough with the surrounding tissue red. The treatment includes Polymem, a cushion and positioning. -2/8/12 the measurements indicate the wound is 2.2 cm by 1.5 cm with a scant amount of thin serous drainage. The wound bed is yellow slough. The treatment is changed to [MEDICATION NAME] Blue and a roho cushion and air mattress. -2/18/12 the measurements indicate the wound is 1 cm by 1 cm with a scant amount of thin serous drainage. The wound bed is 100% yellow slough. -2/23/12 the measurements indicate the wound is .5 cm by .5 cm with a scant amount of thin serous drainage. The wound bed is 100% yellow slough. Resident 1's care plan for skin integrity was initiated on 2/8/12 and updated on 2/15/12 to include a walking pressure relieving boot on right lower extremity when in wheelchair and a blue boot on when in bed. The care plan was also updated on 2/16/12 with the use of an alternating pressure air cushion in the wheelchair.--Note the care plan does not address floating heels when in bed. The facility was only able to locate the weekly skin check completed on 2/21/12 which indicates a "decubitus" on the coccyx and right heel. Weekly skin assessments should have been documented on 2/6/12 and 2/13/12. On 2/27/12, at 1:43 PM, Surveyor observed Resident 1 in bed. Resident 1 was wearing the blue boot on the right foot. Resident 1's feet were not floated off the mattress. On 2/28/12, at 8:55 AM, Surveyor observed Certified Nursing Assistant (CNA) E and CNA H assist Resident 1 into bed. CNA E and CNA H placed the blue boot on and used a pillow from the empty bed to float Resident 1's feet. On 2/28/12, at 12:45 PM, Surveyor observed Resident 1 in bed. Resident 1 was wearing a blue boot on the right foot. Resident 1's feet were not floated and the left ankle was directly on the mattress. On 2/28/12, at 1:20 PM, Surveyor interviewed DON B. DON B stated when Resident 1 was readmitted from the hospital on [DATE] he had a pinpoint open area on the coccyx. DON B stated she looked at the area on 1/25/12 and did not note an open area and felt it was a deep tissue injury. DON B confirmed she did not measure the area or document what the area looked like to confirm a possible deep tissue injury. DON B stated Resident 1's coccyx is an unstageable pressure ulcer that presented as a deep tissue injury. DON B stated when Resident came in it was a stage 1 then it got worse but it is now getting better. DON B stated Resident 1's heel is a stage 2 with a pink wound bed. Surveyor asked about current interventions related to skin integrity. DON B stated Resident 1 uses an air mattress and air cushion and has a blue boot to float his right heel. Surveyor asked about the left heel. DON B stated the left heel is in tact so it does not need to be floated and the air mattress has some pressure relief. On 2/29/12, at 7:45 AM, Surveyor again interviewed DON B. DON B stated Resident 1 was admitted originally on 1/10/12 with a reddened buttock with a superficial open area on the coccyx. DON B stated she assessed the area on 1/13/12 and it was not opened but still red. DON B stated she would expect the admitting nurse to take the [MEDICATION NAME] off and assess the area including measurements on admission. DON B confirmed the skin assessment completed on 1/23/12 was completed by LPN W and should have been co-signed by a Registered Nurse. DON B stated when she assessed Resident 1's coccyx on 1/25/12 it was not open but she suspected a deep tissue injury. DON B stated she did not realize she should measure and describe the area of a possible deep tissue injury. DON B confirmed she was not aware of a dry blister to Resident 1's left heel on 1/26/12 and that the nurse should have updated the physician and obtained an order for [REDACTED]. At 7:45 AM, DON B continued to state that when Resident 1's coccyx opened it was unstageable due to slough and Resident 1's heel opened as a stage 2 with pink granulation. The scab came off today and the area is now unstageable due to 100% slough. DON B stated there should have been stages documented on the wound sheets. Example 2 Resident 3 was admitted to the facility on [DATE] and readmitted after a hospitalization on [DATE] and has [DIAGNOSES REDACTED]. Resident 3 is noted to have a wound to his right heel beginning 2/9/12. The "Wound Evaluation Flow Sheet" for Resident 3 is the tool used to assess the wound and document the appearance, staging, and treatment of [REDACTED]. In the section that asks if the wound is a "Pressure Ulcer" or "Other Wound", neither box is marked. There are two entries for the weekly wound assessments on 2/9/12 and 2/19/12. Assessments are supposed to be done weekly per facility policy, but 10 days had elapsed between assessments. On survey exit date of 2/29/12 there had not been a new assessment noted since the 2/19/12 assessment. This is again 10 days since last assessment. The description of the Right Heel ulcer on the Wound flow sheet is: 2/9/12 - 4 x 5 cm (centimeters), with moderate, serous, thin exudate and 100% granulation tissue. 2/19/12 - 4 x 5 cm, with moderate, serous, thin exudate and 100% granulation tissue. The wound is now noted to have an odor and be painful to the touch. There is a box for each weekly assessment to note the Stage of the Ulcer. Both the 2/9/12 and 2/19/12 boxes for staging are left blank. Staging is an important part of pressure ulcer assessment as wounds of higher staging may require different or more aggressive treatment. It also measures progression of the wound over time (improving or deteriorating). Both the 2/9/12 and 2/19/12 wound assessments are signed by Licensed Practical Nurse (LPN) W, the facility's wound nurse. The entries are not co-signed by an Registered Nurse (RN). On 2/27/12 at 4:45 PM, Surveyor observed LPN K complete a dressing change and wound treatment to Resident 3's heel. Resident 3 was observed to have an ulcer on the lateral aspect of his right heel. At the center of the ulcer is an area of slough approximately 2 cm in diameter. The peri-wound is intact. LPN K cleansed the wound with normal saline, and dressed it with Hydroferra Blue (an antibacterial dressing) covered by [MEDICATION NAME]. This dressing was applied properly per the Physician order. Resident 3's heels were floated after the treatment on a foam wedge per his plan of care.

Based on observation, interview, and record review the facility did not ensure that a resident maintains acceptable parameters of nutritional status such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible, and receives a therapeutic diet when there is a nutritional problem for 1 resident out of 8 reviewed (Resident 1). Resident 1 had decreased food and fluid intakes in the month of December. Resident 1 had a 10 pound weight loss in 8 days and a 16 pound weight loss in one month. Resident 1 was ordered a Magic Cup supplement on 12/2/10, the facility has no evidence that the Magic Cup was offered to or received by Resident 1. On 12/13/10 Hormel Plus 2, 60 cc four times a day was ordered, and although the facility added a supplement, it is the only intervention added to slow Resident 1's weight loss. Resident 1 was observed to receive 1% milk when she was to receive whole milk which has added nutritional value. Findings as follows: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Admission Evaluation and Interim Care Plan dated 11/18/10 states that Resident 1's height was 5'4" and her weight is 152 pounds. Resident 1 has no teeth and a swallowing problem with a diet of mechanical soft with thin liquids. Resident 1's comprehensive care plan dated 11/29/10 has a risk for nutritional problems due to [MEDICAL CONDITION](Cardiovascular accident), Alzheimer's with dysphagia. Resident 1 has chewing difficulty, is edentulous (no teeth), pockets food, is an aspiration risk and has variable meal intake. Resident 1's goal is that she will maintain a weight at 140-150#, will tolerate food/fluid intake without choking aspirating, and will exhibit no signs and symptoms of dehydration. Resident 1's interventions included: Puree with family desiring thin liquids, encourage to eat and drink, food pocketing or spitting out food, document meal refusals, monitor weight weekly. Added on 12/2/10-Recommend magic cup, and does not eat beef or pork by history. Resident 1's Nutrition assessment dated [DATE] states that Resident 1's nutritional needs are for 1600 calories and 1600-1920 cc of fluids a day. Resident 1 has variable meal intakes and has a decline in intake since admission. The Dietitian's nutrition interventions are listed as: serve prescribed diet, monitor weights, monitor intakes for adequacy of fluids, solids and assist resident to eat. Goal weight is to be maintained between 140 and 150 pounds for 3 months and be free of signs and symptoms from dehydration for 90 days. Additional comments by the dietitian state, "...Staff noted episodes of swishing solids and fluids in her mouth and spitting them out over the past few days. She is dx'd (diagnosed ) with Alzheimer's with this condition impacting on texture tolerance. She is at nutritional risk secondary to [MEDICAL CONDITION], Alzheimer's and dysphagia. Wt variance has occurred since admission...She is s/p (status [REDACTED]." There is no evidence of any documentation that Resident 1 received the Magic cup as ordered. A review of Resident 1's meal intake sheet for November 19-24th (6 days with 18 meals served) indicates that her average meal intake per day was 61%. The next 6 days November 25 to November 30th indicates that her average meal intake decreased to an average of 35 % intake at each meal. There is no indication that a physician or dietitian was made aware of the decrease in food intake. Resident 1's MAR (medication administration record) dated November 2010 states that her weight on 11/19/10 is 153.6 and on 11/26/10 her weight is documented as 142 then 140 pounds (Rechecked). Resident 1 had a weight on admission of 152 pound and a weight of 142 pounds on 11/26/10 (8 days later) this is a 10 pound loss and a significant 6.5% loss in 8 days. A dietitian note dated 12/2/10 states the following: Met with resident, SW (Social Worker), daughter-in-law this PM, re: meals. The discussion was regarding meats that resident does not eat and maybe that is why she is spitting food out food. The food service director updated her dislikes on her diet. Interest was expressed in getting dentures for Resident 1. An order was written on this day for Magic Cup 4 ounces and daily weights for 3 days to be obtained. Continue NAR (nutrition at risk) tracking. On 12/3/10, 5 days after the dietitian recommendation, the weights were 12/3-144.6, 12/4-145.6, and 12/5-146.0. Also noted, on the PM shift on 12/3/10 a weight is recorded as 151 pounds there is no documentation of this weight as an error. Resident 1's meal intake average for 12/1/10-12/7/109 averaged 40 % of each meal. Resident 1's meal intake average for 12/8/10-12/14/10 averaged 18% of each meal. 15 of 21 opportunities for meal intake state "bites," "refused," or was left blank. Resident 1's December 10th weight was documented as 143 pounds. Resident 1's dietitian note dated 12/13/10 states, "NAR tracking: Diet order puree with thin liquids. She requires texture alteration secondary to advanced [MEDICAL CONDITION], on texture tolerance. She ate 100 % at breakfast on 12/9, bites or refusals at meals 12/8 dinner through 12/ 10 dinner expect for that 1 meal average 1420 cc fluid consumed every meal for 7 days, magic cup 4 ounces offered. Recommend Hormel -2, 60 cc QID ...Continue per NAR." Resident 1's meal intake average for 12/15/10 to 12/21/10 was 4.7% meal consumption of each meal. 15 of 21 meals had a "zero" or "bites" documented on it. Resident 1's December 17 the weight is documented as 142 pounds. Resident 1's meal intake average for 12/22/10 to 12/28/10 was 4.7% meal consumption of each meal. 18 of 21 meals had "zero" or "bites" documented. Resident 1's December 24 the weight is documented as 142 pounds and December 28 the weight is documented as 136 pounds. Resident 1 lost a total of 16 pounds (152-136=16 pounds) in approximately 1 month. Resident 1's appetite decreased to almost no food intake by the end of December. On 1/19/11 Surveyor asked for the physician phone communication as the facility has no documentation that the physician was made aware of Resident 1's significant weight loss since admission. A phone record from Resident 1's physician office dated 12/14/10 at 6:09 PM states, "I called (name of facility) for an update on (Resident 1's name) she was moved there recently after suffering an ischemic stroke.....Spoke with nurse (nurse name) Apparently she's not eating much, mainly liquids and requires nurse assistance..." There is no evidence that the facility made Resident 1's physician aware that she had an actual weight loss. A physician visit on 12/17/10 (not found in Resident 1's record), indicates her vital signs and a weight of 143 at Belmont on 12/10/10. There is no notation of any weight loss or that the MD was made aware of any decrease in weight since admission. The only reference to her eating is that her caretaker believes that the facility is not respecting Resident 1's dietary preferences. On 12/27/10, at 12:30 PM a nursing note stated that resident vomited brown liquid but resident was drinking chocolate milk at the time. At 1:30 PM a call was placed to primary MD office to discuss concerns regarding appetite and participation/progress in therapy. Message left awaiting return call. A telephone encounter from Resident 1's physician dated 12/28/10 at 1:58 PM states, "Nurse has multiple concerns: 1) appetite is poor, weight is slightly declines, never eats more than 15% of meals. 2) has declines in activity, not participating as much. Had to be placed sitting in a recliner chair other than her usual wheelchair. 3) Care giver and staff worried about depression. 4) would you consider [MEDICATION NAME] for this patient?.." Resident 1's primary physician returned the call at 6:01 PM and he acknowledged this concern (depression and medication) could be a possibility but Resident 1 is started on a treatment for [REDACTED]. Will hold off on medication for now. There is no information given to MD as to Resident 1's 16 pound weight loss in a month and that her appetite has been only eating bites to refusals for the last week. A nursing note on 12/28/10 at 6:00 PM states that a call was received from MD stating that he would like to hold off on starting on an antidepressant until her [MEDICAL CONDITION] is regulated and does not want to: "muddy the waters." She has recently started on new [MEDICAL CONDITION] med, caregiver updated..." On 12/29/10 at 9:00 AM Resident 1's nursing note states, "Spoke with (caregiver name) re: decreased appetite, weight loss, and increased lethargy. Discussed current interventions and that dietitian will be seeing today. Reported decrease in weight since admission. Will have dietitian call her after assessment." On 12/29/10 at 10:26 AM a physician phone encounter states, "Spoke to (Caregiver name) She was the caretaker for Resident 1 before going to the Nursing Home. She is very concerned about her weight loss (11/18 152 lbs, 12/3 151 lbs, 12/10 143 lbs, 12/17 142 lbs, 12/24 142 lbs., 12/28 136 lbs). Her mood has been depressed and she is not eating and drinking well. She is aware of the plan worked out between the NH and (MD name) but wanted to make sure he has all the info needed to make his decisions regarding (Resident 1's care)." Please note that this information was called to the physician by the caretaker not the facility. On 12/29/10 a nursing note at 3:00 PM states, "Spoke with dietician and resident is drinking average of 950 cc a day and needs at least 1500 cc a day eating 0% to bites x 1 week, weight 142 # on 12/24 down to 136 on 12/28. Asked by dietitian and case manager to call the MD office to request labs for possible dehydration." On 12/29/10 a physician telephone encounter at 3:08 PM from the facility nurses states, "Resident 1 has only been taking in 950 cc of fluid per day and taking only bites of food at every meal. She has lost weight. (Nurse name) would like to know if labs should be ordered to check for dehydration." A physician telephone encounter on 12/29/10 at 6:42 PM indicates that he called the caregiver and felt that she was frustrated with the facility thinks she and I weren't informed quickly enough about the weight loss, that Resident 1 is receiving 1% milk when she is eating so poorly. On 12/29/10 a nursing note at 7:30 PM, states that the facility received a call from Resident 1's MD and stated it could be a combination of [MEDICAL CONDITION], depression and evolution of her stroke. Will check with caregiver and guardian to discuss treatment plan in AM. Orders reviewed for a CBC, CMP, UA and [MEDICATION NAME] to be drawn in AM. On 12/30/10 at 12:20 PM Resident 1's nursing notes states that she has critical labs: BUN 173 (normal 6-30 mg/dL) and Potassium of 6.9 (normal 3.4-4.8 mg/dL). Creatinine was 4.8 mg/dL (normal 0.5-1.1) Called to MD and received orders to transport to ER. A review of the facility 24 hour boards from 12/17/10 to 12/28/10 note on 12/17/10, 12/22/10, 12/24/10, 12/25/10, 12/27, and 12/28/10 it is indicated that Resident 1 has a poor appetite. The 24 hour board does not indicate a call to the physician, or any new interventions attempted to increase food and fluid consumption. A review of Resident 1's hospital History and Physical dated 12/30/10 states that Resident 1 was admitted for evaluation and treatment of [REDACTED]. Resident 1's abnormal labs were BUN 159 and Creatinine of 5.0, and Potassium 6.0. On 1/3/11 Resident 1's BUN, creatinine, and Potassium were back within normal range. Resident 1 was readmitted to the facility on [DATE] and her re-admit weight was 145#. On 1/5/11 Resident 1's weight was 146 #. On 1/5/11 Resident 1's dietitian note states that Resident 1 was readmitted and at the hospital she was found with altered mental status secondary to acute [MEDICAL CONDITION], UTI, [MEDICAL CONDITION], and dehydration. Conditions did improve with IV antibiotics and IV fluids. Resident 1's weights in January are: 1/7/11-136#, 1/12/11-142, 1/13-139, 1/14-142#, 1/15-145#, 1/16-148#, 1/17-137#, 1/18-139#, and 1/19-139#. From re-admission Resident 1 has lost 6 more pounds. These weights vary and from the 16 th to the 17 th they document an 11 pound loss. There is no documentation or plan in place to attempt to get accurate weights for Resident 1. On 1/19/10 at 7:45 AM, Surveyor observed Resident 1 sitting in a small dining room with one other resident. Resident 1 was watching TV. An RN came in to assist Resident 1 with her meal. Resident 1 was served 1% milk, protein juice, cream of wheat, and tea. On 1/19/11 at 4:00 PM Surveyor interviewed DON B and NHA A regarding Resident 1 receiving 1% milk on her tray. NHA A stated that Resident 1 was to receive whole milk. The facility ran out and was at the store now making sure that whole milk was available. DON B stated that there was no plan in place yet for Resident 1's fluctuating weights in January. DON B also stated that there was no indication that the Magic cup was that was ordered on [DATE] was given. The process for supplement documentation is to get an order and place it on he MAR indicated [REDACTED] The facility did not ensure that Resident 1 met the acceptable parameters of nutritional status and when she continued to decline in intake the facility did not inform the physician timely or add new interventions to slow or stop the progress. In addition Resident 1 was served 1% milk when she was not on a limited diet.

Based on observation, interview, and record review the facility did not ensure that the facility provided each resident with sufficient fluid intake to maintain proper hydration and health for 1 resident out of 8 reviewed (Resident 1). The facility identified Resident 1 at risk for dehydration. Resident 1 was placed on intake and output and staff recorded her outputs every day. Resident 1's outputs did not meet resident 1's estimated fluid needs. December 15-29th Resident 1 had a further decrease in fluids. The facility did not implement interventions to prevent dehydration. Resident 1 was sent to the hospital for abnormal lab results, and was admitted to the hospital with [REDACTED]. Findings as follows: The facilities policy and procedure for "Hydration" no date indicated, includes the following: 2. The interdisciplinary team identified needs and risk factors specific to each resident and develops an appropriate preventative care plan to maintain or restore adequate hydration for each resident. 8. If the fluid and or hydration status in in question, the Dietitian or designee, along with licensed Nursing staff will develop an interdisciplinary care plan that will identify interventions/approaches to utilize including: Identification of a fluid intake goal, clinical conditions and any factors that put the resident at risk for dehydration. Approaches to increase the hydration level are identified to reduce those risk factors and ensure adequate fluid intake. If adequate fluid intake is difficult to maintain, have an alternate treatment approach identified. The procedure continues on to state that residents identified as being at high risk for dehydration will have an individualized care plan including a goal of fluid intake and specific approaches to utilize, as determined by Dietitian/designee. If adequate fluid intake is difficult to maintain alternative treatment approaches should be developed in an attempt to increase fluid intake by the use of popsicles, gelatin, and other similar non-liquid foods. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/18/10 Resident 1's lab results taken at the hospital before admission were as follows: BUN-10, Creatinine-0.8, Potassium-3.7, and Sodium 135. All labs were within normal blood levels. Resident 1's Admission Evaluation and Interim Care Plan dated 11/18/10 states that Resident 1's height was 5'4" and her weight is 152 pounds. Resident 1's hydration assessment dated [DATE] states that Resident 1 is at risk for dehydration and the facility will proceed to notify physician and dietitian. A temporary care plan or updated care plan to include the following recommendations: intake and output, regularly offer fluids, and monitor vital signs. Resident 1's comprehensive care plan dated 11/29/10 has a risk for nutritional problem due to [MEDICAL CONDITION](Cardiovascular accident), Alzheimer's with dysphagia. Resident 1 has chewing difficulty, is edentulous (no teeth) pocketing, aspiration risk and variable meal intake. Resident 1's goal is that she will maintain a weight at 140-150#, will tolerate food/fluid intake without choking aspirating, and will exhibit no signs and symptoms of dehydration. Resident 1's interventions listed included: Puree with family desiring thin liquids, limited/extensive assistance at meals, encourage to eat and drink, food pocketing or spitting out food, document meal refusals, monitor weight weekly. Added on 12/2/10-Recommend magic cup, and does not eat beef or pork by history. Please note that intake and outputs are not on the care plan as an intervention to monitor for dehydration. Resident 1's Nutrition assessment dated [DATE] states that Resident 1's nutritional needs are for 1600 calories and 1600-1920 cc of fluids a day. Resident 1 has variable meal intakes and has a decline in intake since admission. The Dietitian's nutrition interventions are listed as: serve prescribed diet, monitor weights, monitor intake s for adequacy-of fluids, solids and assist resident to eat. Goal weight is to be maintained between 140-150 for 3 months and be free of signs and symptoms from dehydration for 90 days. Additional comments by the Dietitian state, "...Staff noted episodes of swishing solids and fluids in her mouth and spitting them out over the past few days. She is dx'd (diagnosed ) with Alzheimer's with this condition impacting on texture tolerance. She is at nutritional risk secondary to [MEDICAL CONDITION], Alzheimer's and dysphagia. Wt variance has occurred since admission. She is s/p IVF (intravenous fluids) which is a potential factor in weight status recommending daily weight x 3 days and order Magic Cup 4 OZ every day. There is no evidence of any documentation that Resident 1 received the Magic cup as ordered. Resident 1's MAR indicated [REDACTED]. Resident 1's November 2010 grand totals for 24 hour fluid intake ranged from 840 cc to 1710cc per day. This is an average daily intake of 1425cc of fluids documented. Resident 1 did not meet her fluid needs for 9 days out of 12 days reviewed. Resident 1 had a weight on admission of 152 pound and a weight of 142 pounds on 11/26/10 (8 days later) this is a 10 pound loss and a significant 6.5% loss in 8 days. A dietitian note dated 12/2/10 states the following: Met with resident, SW (Social Worker) daughter-in-law this PM, re:meals. The discussion was regarding meats that resident does not eat and maybe that is why she is spitting food out. The food service director updated her dislikes on her diet. Interest was expressed in getting dentures for Resident 1. An order was written on this day for Magic Cup 4 ounces, and daily weights for 3 days to be obtained. Continue NAR (nutrition at risk) tracking. Resident 1's fluid intake from 12/1/10 to 12/16/10 ranged from 860 to 1480 cc a day. Resident 1 had an average of 1,317 cc a day of fluids. Resident 1 did not meet her estimated fluid needs 13 days out of 16 days. Resident 1's dietitian note dated 12/13/10 states, "NAR tracking: Diet order puree with thin liquids. She requires texture alteration secondary to advanced [MEDICAL CONDITION], on texture tolerance. She ate 100 % at breakfast on 12/9, bites or refusals at meals 12/8 dinner through 12/ 10 dinner expect for that 1 meal average 1420 cc fluid consumed every meal for 7 days, magic cup 4 ounces offered. Recommend Hormel =2, 60 cc QID..., Continue per NAR." Resident 1's fluid intake from 12/17/10 to 12/29/10 ranged from 280cc to 1260 cc a day. Resident 1 averaged 882 cc a day. Resident 1 did not meet her daily fluid needs any day from 12/17/10 to 12/29/10. Resident 1's meal intake average for 12/22/10 to 12/28/10 was 4.7% meal consumption of each meal. 18 of 21 meals had "zero" or "bites" documented. Resident 1's December 24 th weight is documented as 142 pounds and December 28 th weight is documented as 136 pounds. Resident 1 lost a total of 16 pounds (152-136=16 pounds) in approximately 1 month. On 1/19/11 Surveyor asked for the physician phone communication as the facility has no documentation that the physician was made aware of Resident 1's significant weight loss since admission. A phone record from Resident 1's physician office dated 12/14/10 at 6:09 PM states, "I called (name of facility) for an update on (Resident 1's name) She was moved there recently after suffering an ischemic stroke.....Spoke with nurse (nurse name) Apparently she's not eating much, mainly liquids and requires nurse assistance..." There is no evidence that the facility made Resident 1's physician aware that she was not taking in her estimated fluid needs on a daily basis. A physician visit on 12/17/10 (not found in Resident 1's record), indicates her vital signs and a weight of 143 at (the facility) on 12/10/10. Resident 1 had a high [MEDICAL CONDITION] test on this visit and started [MEDICATION NAME]. There is no notation of any weight loss or that the MD was made aware of any decrease in weight since admission there is only a weight recorded. The only reference to her eating is that her caretaker believes that the facility is not respecting Resident 1's dietary preferences. There is no documentation in Resident 1's nursing notes regarding her fluid needs except that the 24 hour totals were documented each day by the night shift. On 12/27/10, at 12:30 PM a nursing note stated that resident vomited brown liquid but resident was drinking chocolate milk at the time. At 1:30 PM a call was placed to primary MD office to discuss concerns regarding appetite and participation/progress in therapy. Message left awaiting return call. A telephone encounter from Resident 1's physician office dated 12/28/10 at 1:58 PM states, "Nurse has multiple concerns: 1) appetite is poor, weight is slightly declined, never eats more than 15% of meals. 2) has declines in activity, not participating as much. Had to be placed sitting in a recliner chair other than her usual wheelchair. 3) Care giver and staff worried about depression. 4) would you consider [MEDICATION NAME] for this patient?.." Resident 1's primary physician returned the call at 6:01 PM and he acknowledged this concern (depression and medication) could be a possibly but she is started on a treatment for [REDACTED]. Will hold off on medication for now. There is no information given to MD as to what Resident 1's weight loss is (which is 16 pounds in a month) and that her appetite has been only eating bites to refusals for the last week." A nursing note on 12/28/10 at 6:00 PM states that a call was received from MD stating that he would like to hold off on starting on an antidepressant until her [MEDICAL CONDITION] is regulated and does not want to "muddy the waters." She has recently started on new [MEDICAL CONDITION] med, caregiver updated..." On 12/29/10 at 9:00 AM Resident 1's nursing note states, "Spoke with (caregiver name) re: decreased appetite, weight loss, and increased lethargy. Discussed current interventions and that dietitian will be seeing today. Reported decrease in weight since admission. Will have dietitian call her after assessment." On 12/29/10 at 10:26 AM a physician phone encounter states, "Spoke to (Caregiver name) She was the caretaker for (Resident 1) before going to the Nursing Home. She is very concerned about her weight loss (11/18 152 lbs, 12/3 151 lbs, 12/10 143 lbs, 12/17 142 lbs, 12/24 142 lbs., 12/28 136 lbs) Her mood has been depressed and she is not eating and drinking well. She is aware of the plan worked out between the NH and (MD name) but wanted to make sure he has all the info needed to make his decisions regarding (Resident 1's care)." Please note that this information was called to the physician by the caretaker not the facility. On 12/29/10 a nursing note at 3:00 PM states, "Spoke with dietician and resident is drinking average of 950 cc a day and needs at least 1500 cc a day eating 0% to bites x 1 week, weight 142 # on 12/24 down to 136 on 12/28. Asked by dietitian and case manager to call MD office and request to labs for possible dehydration. On 12/29/10 a physician telephone encounter at 3:08 PM from the facility nurses states, "Resident 1 has only been taking in 950 cc of fluid per day and taking only bites of food at every meal. She has lost weight. (Nurse name) would like to know if labs should be ordered to check for dehydration." A physician telephone encounter on 12/29/10 at 6:42 PM that he called the caregiver and felt that she was frustrated with the facility -thinks she and I weren't informed quickly enough about the weight loss, that she is receiving 1% milk when she is eating so poorly. On 12/29/10 a nursing note at 7:30 PM, states that the facility received a call from resident 1's MD and stated it could be a combination of [MEDICAL CONDITION], depression and evolution of her stroke. Will check with caregiver and guardian to discuss treatment plan in AM. Orders reviewed for a CBC, CMP, UA and [MEDICATION NAME] to be drawn in AM. On 12/30/10 at 12:20 PM Resident 1's nursing notes states that she has critical labs: BUN 173 (normal 6-30 mg/dL) and Potassium of 6.9 (normal 3.4-4.8 mg/dL). Creatinine was 4.8 mg/dL (normal 0.5-1.1) Called to MD and received orders to transport to ER. A review of the facility 24 hour boards from 12/17/10 to 12/28/10 indicate on 12/17/10, 12/22/10, 12/24/10, 12/25/10, 12/27, and 12/28/10 it is indicated that Resident 1 has a poor appetite. The 24 hour board does not indicate a call to the physician, or any new interventions attempted to increase food and fluid consumption. A review of Resident 1's hospital History and Physical dated 12/30/10 states that Resident 1 was admitted for evaluation and treatment of [REDACTED]. Resident 1's abnormal labs were BUN 159 (normal-7-20), Creatinine of 5.0 (normal-0.6-1.3), Sodium 140 (Normal 135-144), and Potassium 6.0 (normal) 3.5-4.8. On 1/3/11 Resident 1's BUN, creatinine, Sodium, and Potassium were back to normal limit range. On 1/5/11 Resident 1's dietitian note states that Resident 1 was readmitted and at the hospital she was found with altered mental status secondary to acute [MEDICAL CONDITION], UTI, [MEDICAL CONDITION], and dehydration. Conditions did improve with IV antibiotics and IV fluids. On 1/19/10 at 10:15 AM, surveyor interviewed DON B regarding documenting fluid intakes. DON B stated that the policy does not give a specific number or how many days of low fluid intakes but the staff nurse should notify the Dietitian, DON, and the Physician if continued low fluid intakes are recorded. I would expect the nursing staff to push fluids in an attempt to get more in her. On 1/19/11 at 4:00 PM Surveyor interviewed DON B and NHA A regarding Resident 1 receiving 1% milk her diet. NHA A stated that she was to receive whole milk. The facility ran out and was at the store now making sure that whole milk was available. DON B stated that there was no plan in place yet for Resident 1's fluctuating weights in January. DON B also stated that there was no indication that the Magic cup was that was ordered on [DATE] was given. The process for supplements documentation is to get an order and place it on he MAR indicated [REDACTED] The facility did not ensure that Resident 1 was provided with sufficient fluid intake to maintain proper hydration and health. The facility documented decreasing daily fluid totals and no new interventions nor a physician call made to discuss a plan of care. Resident 1's caretaker called the physician and made him aware of the actual facts of her situation with low food and fluid intakes.