Every finding on record at Maple Ridge Health Services

Based on observation, interview, and record review, the facility did not ensure 3 (R20, R67, R37) of 6 residents reviewed for accidents had adequate supervision to prevent accidents. *R20 fell out of the wheelchair while staff was pushing the wheelchair and sustained multiple right knee fractures. *R67 was assessed to require two staff to assist with bed mobility tasks and sustained a fall out of bed when being assisted by one staff member. *R37 is a smoker and did not have evidence of smoking assessments. Findings include: The facility policy titled Fall Prevention and Management Guidelines with revised date 7/18/24 documents: . Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. The facility utilizes a standardized risk assessment for determining a resident's fall risk. Upon admission, the nurse will complete a fall risk assessment. Review the resident's medical record for any diagnosis that may contribute to an increase in fall risk. The nurse will initiate interventions to help prevent falls on the resident's baseline care plan. Suggested standard interventions may include: implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: a clear pathway to the bathroom and bedroom doors; bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed; call light and frequently used items are within reach; adequate lighting; wheelchairs and assistive devices are in good repair . implement routine rounding schedule; monitor for changes in resident's cognition, gait, ability to rise/sit, and balance; encourage residents to wear shoes or slippers with non-slip soles when ambulating; complete a fall risk assessment quarterly, post-fall, and as with a significant change of condition. each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care . interventions will be monitored for effectiveness . the plan of care will be revised as needed and should be communicated to the staff, resident, and resident's family/responsible party. R20 was admitted to facility on 10/14/25 with diagnoses including polyneuropathy, vascular dementia, lymphedema, and type 1 diabetes mellitus. R20's admission fall risk assessment dated [DATE] documented R20 was not at risk for falls. R20's functional abilities Care Area Assessment (CAA) dated 10/20/25 documented resident has impaired functional ability in self-care and mobility; staff assists with these areas. R20's falls CAA dated 10/20/25 documented falls triggered secondary to resident taking antidepressant medications, staff to monitor for side effects, including falls, to prevent injury. R20's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated R20 is cognitively intact; R20 did not exhibit any behavior concerns; R20 was independent with wheeling a manual wheelchair 50 feet, and R20 was dependent on staff for wheeling a manual wheelchair 150 feet. R20's MDS documented R20 did not have any falls since the prior MDS assessment. R20's care plan for focus area activities of daily living (ADL) self-care deficit with initiated date 10/17/25 and revised date 10/24/25 documented the following intervention: -Ambulation/locomotion: wheelchair. Surveyor noted R20's care plan did not specify the level of assistance R20 required for mobilizing in the wheelchair. R20's care plan for focus area at risk for falls with initiated date 10/17/25 and revised date 10/24/25 documented the following interventions: -Bed in low position -Encourage to transfer and change positions slowly -Have commonly used articles within easy reach -Reinforce need to call for assistance Surveyor reviewed R20's electronic health record (EHR) and located a nurse's progress note dated 8/5/26 at 15:40 (3:40 pm), which documented resident was being transported down hallway in wheelchair, and the resident planted feet on the ground and fell forward out of the chair. R20's witnessed fall document dated 8/5/26 documented incident location: hallway; nursing description: resident was being transported down hallway in wheelchair. Resident planted feet on the ground and fell forward out of chair; resident description: resident said I planted my feet on the floor and fell forward; was this incident witnessed: Y (yes); description: fall team called to assist. Vital signs obtained. Range of motion (ROM) of extremities, right lower extremity painful and unable to perform ROM. No new skin issues noted except bloody nose, neuro check completed and negative, resident reports 10 out of 10 pain, Tylenol administered. Nurse Practitioner (NP) notified and order to send to emergency department (ED) for evaluation and treatment given, ambulance called; injuries observed at time of incident: injury location: right knee (front); level of pain: numerical: 10, level of consciousness: alert, mobility: wheelchair bound; other info: resident does not use foot pedals as she chooses to normally self-propel wheelchair. Pedals would hinder resident's right to self-propel; Statements: certified nursing assistant (CNA)-F: I was pushing the resident down the hallway when she planted her feet on the ground. When she did this, she fell out of her wheelchair and landed on her knees and hit her face. R20's interdisciplinary (IDT) clinical review note dated 8/6/26 documented resident was being pushed down the hallway by a staff member when she planted her feet on the ground causing her to fall out of her wheelchair onto her knees. The resident then fell forward onto her face causing a bloody nose. The root cause of the fall was the resident put her feet down while being pushed in her wheelchair. The immediate intervention is to ensure foot pedals are put on her wheelchair when she is being pushed around the building. On 8/11/26 at 9:51 AM, Surveyor requested medical records from R20's ED visit on 8/5/26. On 8/11/25 at 1:35 PM, Surveyor received the requested medical records. R20's x-ray report of the right knee dated 8/5/26 at 1744 (5:44 PM) documented impression: there is an avulsion fracture identified of the medial distal right femur; there is a transverse fracture identified of the proximal right tibia; there is a probable medial tibial plateau fracture; there is a transverse fracture identified of the proximal right fibula. R20's medical decision making and ED course documented R20 presented to ED for evaluation of injuries after falling forward out of the wheelchair. X-ray of the knee showed multiple fractures including proximal tibia, proximal fibula, avulsion fracture of the distal femur, and a probable medial tibial plateau fracture as well. Spoke with on-call orthopedics, who stated this could be dealt with as an outpatient, did speak to care staff to confirm that they would be able to accommodate her care while being nonweightbearing. Patient will be discharged back to her facility and prescribed pain medication. On 8/12/26 at 3:27 PM, Surveyor interviewed CNA-F who confirmed they were working on 8/5/26. CNA-F stated there were two residents outside who wanted to be brought back inside so CNA-F assisted another resident while CNA-H pushed R20 in the wheelchair. CNA-F stated CNA-H asked to switch residents as requested by R20. CNA-F stated as they were about to turn the corner in the hallway, R20 put her feet down without warning and fell out of the wheelchair. CNA-F stated R20 did not have foot pedals on the wheelchair at the time of the fall. CNA-F stated they were told by CNA-H that R20 declined having the foot pedals put on the wheelchair. On 8/13/26 at 11:43 AM, Surveyor asked Director of Nursing (DON)-B if there were any additional witness statements obtained from R20's fall on 8/5/26. On 8/13/26 at 12:27 PM, Surveyor was provided with an additional statement from CNA-H. CNA-H's statement dated 8/5/26 documented CNA-H was called by resident to help her outside. I asked if she wanted to go outside to the courtyard because it was closer and she said no. I informed her that going to the front was a far ride without foot pedals. She wanted to sit at the front of the building. I set a 15-minute alarm to go out and check on her, during the second alarm, she said she was ready to come inside. I brought the resident inside the building, and we got halfway down the hallway until she asked me to give her to CNA-F. I took another resident down to the unit, and when I made a turn, I heard a boom and a loud noise. On 8/13/26 at 9:59 AM, Surveyor interviewed CNA-H who confirmed they were working on 8/5/26. CNA-H stated R20 was self-propelling the wheelchair down the hallway past the main dining room when she saw CNA-H coming and asked to be pushed outside. CNA-H stated they told R20 there were no foot pedals on the wheelchair and R20 said she did not need them. CNA-H stated they brought R20 outside and set an alarm to check on R20 every 15 minutes. CNA-H stated the second alarm went off and R20 wanted to come back inside, so CNA-H brought R20 back in. CNA-H stated after pushing R20 a little way, R20 asked to have CNA-F push the wheelchair because they were stronger. CNA-H stated by the time they were about to turn down the hallway, they heard a scream and R20 must have fallen out of the wheelchair. CNA-H stated R20 did have foot pedals for the wheelchair and staff put them on when R20 had appointments outside the facility. R20's post event observation dated 8/6/26 at 9:00 AM documented R20 was having severe/extreme pain to the right lower extremity, 10 out of 10, crying and yelling out in her room. PRN APAP (as needed acetaminophen) ineffective at this time, resident stated I cannot take the pain. NP updated and assessed resident. New order received to send to ED for evaluation and treatment and request to have surgical/orthopedics consult done in ED due to the multiple new fractures. Sent to the ED at 9:30 AM. On 8/12/26 at 1:17 PM, Surveyor interviewed CNA-L who stated R20 was very particular about cares and would sometimes refuse cares. CNA-L stated R20 required a mechanical lift for transfers with two-person assistance and would self-propel the wheelchair in her room. CNA-L stated when R20 was tired, she would ask to be pushed in the wheelchair by staff. On 8/12/26 at 1:22 PM, Surveyor interviewed CNA-J who stated R20 was particular about cares. CNA-J stated R20 used the wheelchair and could wheel herself short distances but would ask to be pushed by staff for long distances. CNA-J stated R20 had foot pedals for the wheelchair but did not like them. On 8/12/26 at 3:11 PM, Surveyor interviewed CNA-K who stated R20 would get pushed by staff in the wheelchair for longer distances or when she was tired, otherwise could mobilize in the wheelchair by herself for short distances. CNA-K stated R20 only used the foot pedals on the wheelchair for appointments. On 8/13/26 at 10:04 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-M who confirmed they were working 8/5/26 when R20 fell. ADON-M stated R20 was being transported in the wheelchair, planted her feet and fell out of the wheelchair onto her knees and then forward onto her face. ADON-M stated R20 had a bloody nose and was complaining of right knee pain but did not have any complaints of head or face pain and was intact neurologically. ADON-M stated R20 was sent to the hospital due to knee pain and diagnosed with right knee fractures. ADON-M stated at baseline, R20 was able to independently move short distances in the wheelchair, but for long distances, staff would assist in pushing the wheelchair. ADON-M stated R20 was picky with the foot pedals and did not want them on the day of the fall. ADON-M stated education was provided to R20 after the fall that the foot pedals should be on the wheelchair. On 8/13/26 at 11:43 AM, Surveyor interviewed DON-B, who stated staff complete yearly competencies which covers safe wheelchair transportation and mobility. DON-B stated at baseline, R20 would self-propel in the wheelchair using her feet but would ask for staff to push her long distances. DON-B stated R20 did not like using the foot pedals on the wheelchair when in the building but would have them put on the wheelchair when leaving the facility, such as for appointments. DON-B stated R20 did not have the foot pedals on the wheelchair the day of the fall and R20 was being pushed by staff in the wheelchair when she fell. Surveyor asked DON-B if any alternative interventions were implemented when being pushed by staff in the wheelchair for long distances prior to R20's fall out of the wheelchair, and DON-B stated they would look into it and the therapy department may have more information. On 8/13/26 at 10:01 AM, Business Office Assistant (BOA)-C provided Surveyor with a document titled Skills and Techniques Evaluation which they stated is utilized to assess staff competency. The evaluation documented under restorative services: wheelchair mobility: positioning, assistive devices. On 8/13/26 at 1:16 PM, Surveyor interviewed Director of Rehabilitation (DOR)-V who stated R20 did work with therapy on wheelchair mobility and strengthening. DOR-V stated R20 did not like the foot pedals on the wheelchair and worked on self-propelling the wheelchair in physical therapy (PT) and occupational therapy (OT). DOR-V stated R20 could propel herself in the wheelchair short distances without the foot pedals. On 8/13/26 at 1:24 PM, Surveyor was provided with PT and OT visit notes. R20's PT visit note dated 3/3/26 documented R20 self-propelled the wheelchair with bilateral upper extremities and lower extremities for 50 feet, 25 feet, and an additional 50 feet; response to treatment: compliant with skilled interventions and compliant with trained techniques. R20's PT recert, progress report and updated therapy plan dated 3/3/26 documented R20 self-propels 50-75 feet with bilateral upper extremities and lower extremities at supervision level. The functional skills assessment section documented wheelchair mobility: wheel 150 feet not attempted due to medical conditions or safety concerns, able to do 75 feet with one rest break at supervision level. R20's OT visit note dated 3/4/26 documented wheelchair mobility task performed propelling self with education on use of feet; response to treatment: compliant with skilled interventions. Surveyor noted the PT and OT visit notes did not include any documentation regarding any education provided to R20 about the use of the wheelchair foot pedals, or any documentation regarding alternative interventions to using the foot pedals for longer distances. On 8/13/26 at 1:29 PM, Surveyor shared concern with DON-B and Nursing Home Administrator (NHA)-A that R20 sustained a fall resulting in multiple right knee fractures when being pushed by staff in the wheelchair without foot pedals on, and there was no evidence any alternative interventions were implemented to accommodate R20's preference of not using the foot pedals on the wheelchair. NHA-A stated the facility does not have a policy related to wheelchair mobility and pushing residents in wheelchairs. 2) R67's diagnosis include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. R67's (activities daily living) ADL self-care deficit care plan initiated 9/20/25 includes an intervention for bed mobility: Assist of 2. Initiated 9/20/25. R67's at risk for falls care plan initiated 9/20/25 & revised 9/24/25 documents the following interventions: *Encourage to transfer and change position slowly. Initiated 9/24/25. *Have commonly used articles within easy reach. Initiated 9/24/25. *Provide assist to transfer and ambulate as needed. Initiated 9/24/25. The falls CAA (care area assessment) for R67's admission MDS (minimum data set) dated 9/26/25 did not trigger. R67's quarterly MDS with an assessment reference date of 3/16/26 has a BIMS (brief interview mental status) score of 00 which indicates severe cognitive impairment. R67 is assessed as being dependent on staff for toileting hygiene, rolling left and right, chair/bed to chair transfer, and lying to sitting on bedside. R67 is frequently incontinent of urine and occasionally incontinent of bowel. R67 has had no falls since prior assessment period. R67's nurses note dated 3/25/26, at 5:30 a.m., documents while CNA (Certified Nursing Assistant) was changing resident he fell out of bed. Writer assessed resident, he had a nosebleed. No other injuries noted. Resident was still hooked up to his IV as well. Resident is nonverbal but showed no signs of pain or discomfort. Resident's vitals were stable. Resident was hoyered back into bed by CNAs. [Medical group name] was contacted and NP (nurse practitioner) agreed that he should be sent out. POA (power of attorney) notified. R67's nurses note dated 3/25/26 at 06:33 (6:33 a.m.), documents The writer was notified that the resident had a witnessed fall from his bed while being changed by his CNA. The resident is unable to state what happened. The CNA states she turned the resident and he became (sic) to slide off the side of the bed falling on the floor onto his face. The CNA called for the resident's nurse who completed a neuro check. Neuro check negative. The resident did sustain a bloody nose during the fall. ROM (range of motion) of all extremities without new deficiencies. The resident has contractures to his left leg at baseline. No new skin issues noted. The resident does not show any signs of pain. No grimacing or guarding of his body. The resident was assisted into bed with 2 and a Hoyer. [Name of provider] and the resident's POA-[Name] notified of the fall. The resident was sent to [hospital initials] for evaluation and treatment post fall. All fall intervention in place at the time of the fall. R67's nurses note dated 3/25/26, at 10:37 a.m., documents Background: Resident A & O x 1 (alert and orientated times one), able to make needs known by answering yes or no questions by shaking his head, requires maximum assistance with ADLs (activities daily living). On 3/25/26 the resident had a witnessed fall from his bed. The resident was being changed by his CNA and due to his contractures can be difficult to turn. When the CNA turned the resident, the resident was on the side of the bed and slide off onto the floor. The root cause of the fall is the resident has an air mattress and is unable to assist in turning in his bed. The immediate intervention is for the resident to be an assist of 2 with all cares to prevent further falls. Nurse assessment completed, ROM (range of motion) performed with no new deficits, and neuro (neurological) assessment completed. All interventions in place at the time of the incident. MD and family were notified. Surveyor noted there should have been two staff in with R67 as R67 was assessed to require an assist of two for bed mobility as of 9/20/25. R67's at risk for falls care plan was revised with an intervention of assist of 2 for all cares on 3/25/26. Licensed Practical Nurse (LPN)-P's statement for R67's fall on 3/25/26 documents At about 4:30 a.m. I was changing the resident in rm [number] he leaned forward to reach his arm to the wall and he flipped off the bed onto the floor between the wall and bed near heater. I yelled for the nurse [Name] and she came running to help get him up. On 8/13/26, at 2:40 p.m., surveyor asked Director of Nursing (DON)-B when R67 fell on 3/25/26 why weren't there two staff there. DON-B informed surveyor she thinks she changed R67's care plan to assist of 2 after R67's fall. Surveyor informed DON-B R67's ADL self-care deficient care plan has an intervention for bed mobility of assist of 2 which was initiated on 9/20/25. Surveyor asked DON-B if the staff member should have had someone with her. DON-B replied yes if two person. 3) The Facilities policy, titled Smoking Policy, last revised 9/10/2024, indicates that all residents will be asked about tobacco/nicotine use during the admission process, during each quarterly or comprehensive Minimum Data Set (MDS) assessment process .residents who smoke or use nicotine or electronic (e)-cigarettes will be further assessed . R37 was admitted to the facility on [DATE], with diagnoses including paraplegia. R37 Significant Change Minimum Data Set, dated [DATE], indicates R37 has a Brief Interview for Mental Status score of 15 indicating being cognitively intact, does not have any behavior concerns, has impairment in upper and lower extremities on one side and requires set up assistance with eating. A progress note dated 7/25/2026, at 7:56 PM, indicates R37 spoke with Unit Manager (UM)-N regarding the use of an electronic vape for smoking. It was emphasized that the facility's policy strictly prohibits smoking any substance on the premises. R37's electronic vape was confiscated due to the possibility of containing illegal substances, and R37 was educated on the Facility policy. On 08/10/2026, at 10:32 AM, Surveyor observed an electronic vape in R37's room, on the bedside table. R37 expressed needing assistance sometimes to plug in the electronic vape to be charged and will go outside to use the electronic vape. Surveyor reviewed R37's Nicotine Assessment, dated 2/16/2024, and noted R37 was assessed to not currently smoke or use smokeless tobacco or other device containing nicotine, which prompts to skip to section I, indicating no care plan would be initiated. Surveyor noted R37 had no other smoking assessments that were provided by the Facility. On 08/10/2026, at 3:12 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated R37 was caught with an electronic vape and indicated the electronic vape had marijuana components, per R37. The electronic vape was taken from R37 and disposed of. LPN-D indicated R37 has visitors coming in that have brought alcohol and other inappropriate things. Surveyor reviewed R37's care plan and noted there is no care plan addressing R37's smoking, alcohol use or outsiders potentially bringing illegal substances into the Facility for R37. On 08/13/2026, at 8:56 AM, Surveyor interviewed Social Services-E who indicated she was not directly involved during the incidents but recalls speaking with R37 regarding the incidents and offering services. Social Services-E informed Surveyor she did not add R37's drinking or smoking to the care plan and will be doing that now. On 08/13/2026, at 9:52 AM, Surveyor informed the Facility of the concerns, no further information was provided at time of write up.

Based on observation, interviews and policy review, the facility failed to ensure kitchen staff covered exposed hair with a hair net while plating food to serve to residents for one of one kitchen with the potential to affect 70 out of 73 census residents consuming food out of the kitchen. This failure had the potential to cause unsanitary food to be served to residents. Findings include: Observation of the kitchen tray line on 07/14/26 at 4:28 PM, 4:35 PM, and 4:45 PM revealed [NAME] 1 was plating food and there was no hair net covering a ponytail and exposed hair at the back middle area of her head. During an interview with the Dietary Supervisor (DS) and the Dietary District Manager (DDM) on 07/16/26 at 8:55 AM, they confirmed all of [NAME] 1's hair should have been covered with a hair net while plating food. Review of the facility's policy titled, Staff Attire, revised 01/25, revealed Procedures.a. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Based on record review and interviews, the facility failed to ensure physician ordered medication was provided for two of five residents (Resident (R) 6 and R3) reviewed for medication administration of 15 sample residents. This failure had the potential to cause medical complications and a decline in condition. Findings include: 1. Review of R6's admission Record under the Profile tab in the electronic medical record (EMR) revealed he was originally admitted to the facility on [DATE] with a diagnosis of cerebrovascular accident (stroke.) Review of the Progress Notes under the Progress Notes tab in the EMR revealed a provider progress note, dated 04/02/26, which indicated EGD (upper endoscopy [the tube from the throat to the stomach is visualized through a scope]) 10/08/2025 LA Grade [Los Angeles Classification System used to grade the severity of erosive esophagitis] esophagitis D [severe sores that cover 75% or more of the esophagus's circumference] with suspected underlying [NAME] esophagus [tissue lining the esophagus is damaged by chronic acid reflux (GERD – gastroesophageal reflux disease) . Review of the Clinical Care Plan Detail under the Care Plan tab in the EMR, revealed GI [gastrointestinal] distress r/t [related to] GERD . Administer meds [medications] as ordered . Review of the Order Summary Report under the Orders tab in the EMR, revealed Omeprazole Magnesium Oral Packet 10 MG (milligrams) . Give 4 packet via G-Tube [gastrostomy tube] two times a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITH ESOPHAGITIS .Order Date 12/11/2025. Review of the Medication Administration Record (MAR), dated April 2026 under the Orders tab of the EMR, revealed on 04/02/26 and 04/07/26, R6 did not receive omeprazole as ordered. The administration times on 04/02/26 and 04/07/26 indicated 9 with staff initials. The Chart Codes on the MAR indicated 9=Other/See Progress Notes. Further review of the Progress Notes under the Progress Notes tab in the EMR revealed nursing notes on 04/02/26 at 8:49 AM and 10:02 PM and 04/07/26 at 1:30 PM indicated, Omeprazole Magnesium Oral Packet 10 MG . on order. In an interview with Licensed Practical Nurse (LPN) 5 on 07/16/26 at 2:29 PM, she stated for R6 she documented 9 on 04/02/26 at 8:49 AM because the omeprazole wasn't here. In an interview with the Director of Nursing (DON) on 07/16/26 at 11:10 AM, she confirmed R6's omeprazole was not administered as ordered by the physician on 04/02/26 at 8:00 AM and 8:00 PM and on 04/07/26 at 8:00 AM. 2. Review of R3's admission Record under the Profile tab in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type two and discharged on 03/11/26. Review of the Order Summary Report under the Orders tab in the EMR revealed, Ozempic (0.25 or 0.5 MG [milligram]/DOSE) Subcutaneous Solution Pen-Injector 2 MG/3ML Inject 0.5 mg subcutaneously one time a day every Mon [Monday] for DM [diabetes mellitus] . Order Date . 02/10/2026. Review of the Medication Administration Record (MAR) dated February 2026 under the Orders tab in the EMR revealed on 02/09/26 and 02/16/26, 9 was documented, and on 02/23/26, 2 was documented. The Chart Codes indicated 2=Drug Refused and 9=Other/See Progress Notes. Review of the Progress Notes under the Progress Notes tab of the EMR, revealed a nursing note, dated 02/16/26 at 10:57 AM, which indicated Med is not available. In an interview with Licensed Practical Nurse (LPN) 1 on 07/15/26 at 1:40 PM, she stated R3 didn't like to take it and refused the Ozempic on 02/23/26. In an interview with LPN4 on 07/15/26 at 2:00 PM, she stated on 02/16/26 she documented Med [medication] is not available because We didn't have it. LPN4 stated that when the resident's medication isn't in the medication cart, she looks for it and if she can't find it, she calls the pharmacy to see if it was delivered. In an interview with LPN3 on 07/15/26 at 2:57 PM, she stated on 02/09/26 she documented 9 because It wasn't here. In an interview with the Director of Nursing (DON) on 07/15/26 at 5:00 PM she stated the shipping manifest from the contracted pharmacy provider, dated 02/07/26 and timed 4:24 PM, indicated Ozempic 0.25 – 0.5 mg/dose pen, quantity three was delivered for R3 and signed for by LPN7. In a phone interview with LPN7 on 07/15/26 at 5:05 PM, she stated her normal process when the pharmacy delivered medications was to open the boxes and check the medications off with the list of medications from the pharmacy and reconcile them and then she signed. She stated, I usually do it. When asked if she ever did not do that, she did not answer. LPN7 stated after she received the medications from the pharmacy, she put them away in the medication cart or in the refrigerator. When asked if there was any reason to think that she didn't follow her usual process on 02/07/26 when R3's Ozempic was delivered with other medications she stated, I don't recall. She confirmed she took care of R3 while she was at the facility and when asked if the Ozempic was available to administer, she stated, I don't recall. In a phone interview with the facility's Contractor Pharmerica Staff (CPS) 1 on 07/16/26 at 1:32 PM, CPS1 stated R3's Ozempic was delivered on 02/07/26 at 10:50 PM. CPS1 stated four doses were delivered which was a 28-day supply.

Based on interviews, record review, and policy review, the facility failed to follow their grievance process and file a grievance after a concern was brought to the attention of staff for one of three residents (Resident (R) 5) reviewed for grievances of 15 sample residents. This had the potential to affect all residents in the facility who had concerns. Findings include: Review of R5's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted to the facility on [DATE] with diagnosis which included unspecified dementia. Review of R5's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/20/26 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident as not having a Brief Interview for Mental Status (BIMS) assessment completed. A review of the facility's Grievance log for the last 12 months, provided by the facility, revealed no grievances filed for R5 related to concerns about the cleanliness of the resident's shared bathroom. A review of R5's Care Conference Summary, dated 03/03/26 and located under the Assessments tab of the EMR, revealed the resident and responsible party (RP) were in attendance. Further revealed there were no concerns or issues. During an interview on 07/16/26 at 3:42 PM the Social Services Director (SSD) revealed R5's responsible party informed the staff in attendance of the resident's care conference about the concerns related to R5's bathroom not being cleaned on several occasions. She stated when she looked in R5's bathroom that day it was clean and therefore she did not document anything about the care. However, she stated any concerns that were brought up during a care conference were documented in the conference notes and a grievance form was completed. She was unable to answer why she did not document any concerns during the conference or why a grievance form was not completed. But she agreed one should have been completed. During an interview on 07/16/26 at 4:15 PM the Director of Nursing (DON) stated anytime there was a concern brought to staff's attention a grievance form should be completed. She stated she was aware there were concerns by R5's RP and that a grievance should have been completed. Review of the facility's policy titled, Grievance Policy, revised 07/22, revealed The facility will seek to resolve concerns, complaints or grievances and provide residents, responsible parties, staff and others feedback and resolution in a timely manner per $483.10 (J)(l), The resident has a right to voice grievances without fear of retaliation. When a Complaint/Grievance Report is initiated: A copy of the initiated concern form will be placed in the Grievance Notebook as a reminder that the Grievance is still being investigated and resolved. The original form will then be forwarded to the department head for which the Grievance pertains to (i.e., Dietary Manager for food and dining related issues, DON for any nursing or clinical related issues, Laundry Supervisor for missing clothing issues etc.) The Department Head that is assigned the concern form is responsible for investigating the issue and following up to provide a resolution to the issue within 72 hours of being assigned the grievance. Once resolution of the grievance is achieved, the Grievance Officer will ensure that follow up with the concerned party, explanation of the investigation and the resolution and documentation of the concerned party's response to the resolution take place.

Based on observations, interviews, record review, and policy review, the facility failed to ensure personal protective equipment for enhanced barrier precautions were in place during high contact care for two of three residents (Resident (R) 6 and R14) reviewed for enhanced barrier precautions (EBP's) of 15 sample residents These failures had the potential to cause the spread of infection. Findings include: 1. Review of R6's admission Record under the Profile tab in the electronic medical record (EMR) revealed he was originally admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), dysphagia (inability to swallow), and esophageal (tube from the mouth to the stomach) obstruction. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/26 and located under the MDS tab of the EMR, revealed R6 had a feeding tube. During an observation on 07/15/26 from 8:50 AM to 9:11 AM, Licensed Practical Nurse (LPN) 1 administered medications to R6 via his gastrostomy (feeding) tube. There was a sign posted by the resident's door which indicated R6 was on EBP's. LPN1 prepared R6's medications and entered the room without a gown. LPN1 disconnected the tube feeding from R6's gastrostomy tube, manipulating the flange of the tube against the resident's skin, flushing the tube, and administered the medications, going back and forth between the bed and the sink, and leaning against the side of the resident's bed. In an interview with LPN1 after exiting R6's room, on 07/15/26 at 9:12 AM, when asked what personal protective equipment (PPE) staff were supposed to use when administering medications through the gastrostomy tube to R6, LPN1 stated, I didn't wear a gown. We're supposed to wear gowns. 2. Review of R14's admission Record under the Profile tab in the EMR revealed he was admitted to the facility on [DATE] with a diagnosis of heart failure. Review of R14's quarterly MDS with an ARD of 07/07/26, revealed R14 had an indwelling catheter and a multi-drug-resistant organism (MDRO). During an observation on 07/15/26 from 9:30 AM to 9:48 AM, Physical Therapy Assistant (PTA) 1 was observed in R14's room at the bedside, providing therapy exercises. PTA1 was assisting R14 and leaning against the side of the bed. There was a sign by R14's door indicating he was on EBP's. In an interview with PTA1 immediately after she exited R14's room on 07/15/26 at 9:48 AM, she confirmed she did not wear a gown while assisting R14 with therapy exercises in his room. She stated she saw the PPE on the one side of the door but did not see the sign on the other side of the door and she didn't realize she was supposed to wear a gown. In an interview with the Infection Preventionist (IP) on 07/16/26 at 3:20 PM, she stated staff were supposed to wear gowns while providing high contact care to residents on EBP's. The IP stated LPN1 should have worn a gown while providing care and administering medications through the gastrostomy tube to R6, and PTA1 should have worn a gown while providing therapy exercises to R14 at the bedside. Review of the facility's policy titled, Enhanced Barrier Precautions, date reviewed/revised on 08/08/24, revealed Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs) . Definitions: 'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . 3. Implementation of Enhanced Barrier Precautions . b. PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities (described below) and may not need to be donned prior to entering the resident's room . 4. High-contact resident care activities include . g. Device care or use . (. feeding tubes .) . 5. Enhanced barrier precautions should be followed outside the resident's room when performing transfers . and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with . mobility .

Based on record reviews and interviews, the facility failed to ensure resident's weights were obtained according to the physician's orders for one of three residents (Resident (R) 1) reviewed for quality of care of 15 sample residents. This failure had the potential for R1 to have an unassessed change in weight which could cause a decline in condition. Findings include: Review of R1's admission Record under the Profile tab in the electronic medical record (EMR) revealed she was readmitted to the facility on [DATE] with diagnoses including a compression fracture of the first lumbar vertebra (spinal bone), heart failure, weakness, dementia, and protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/25 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 12 of 15, indicating moderate cognitive impairment. Review of the Order Summary under the Orders tab in the EMR revealed an order, dated 10/10/25 indicating, WEIGHT on admit, daily x2 [times two], weekly x3 [times three], monthly.Obtain reweight if change of 5 lbs [pounds] since last weight. Review of the Care Plan under the Care Plan tab in the EMR revealed R1 was at risk for nutritional status change and to record R1's weight according to physician's orders. Review of R1's Weight Summary under the WTS/VITALS tab in the EMR revealed R1 was weighed on 10/10/25 (date of readmission), 10/15/25, 10/29/25, 11/01/25, and 11/02/25. R1 was not weighed daily or weekly as ordered. During an interview on 07/16/26 at 10:48 AM, the Director of Nursing (DON) confirmed R1 was not weighed according to physician's orders.

Based on interview, record review, and facility policy review, the facility failed to ensure two staff members transferred a resident which resulted in an injury for one of 11 residents (Resident (R) 1) reviewed for accidents. This had the potential to cause injuries during improper transfers. Findings include: Review of the facility policy titled Safe Resident Handling and Transfers revised 08/05/22 revealed, .Resident lifting and transferring will be performed according to the resident's individual plan of care .Review of R1's admission Record located in the Electronic Medical Record (EMR) under the Admission tab indicated that she was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/25 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that she was cognitively intact. R1 was noted to have impairment on one side for upper extremities and lower extremities and was dependent on staff for all transfers. Review of R1's Care Plan provided by the facility and initiated on 11/06/24 included ADL (activities of daily living) self-care deficit as evidenced by: weakness related to : Hx (history) of CVA (stroke), emphysema, COPD (chronic obstructive pulmonary disease), asthma .Transfer: Assist of 2 with gait belt and pivot . Review of R1's Kardex provided by the facility initiated 05/01/25 indicated that R1 should be transferred with assistance from one staff member with gait belt and walker. Review of R1's Progress Notes located in the EMR under the Progress Notes tab dated 05/21/25 revealed R1 was being transferred by a sit to stand lift to a shower chair. R1 slipped out of the sling and fell to the floor. CNA (Certified Nursing Assistant) 1 yelled for help, myself and other staff responded to resident on the floor. Resident was responsive speech was clear. Resident had complaint of pain on the back of head .A lump was on the right back side of patient head. The ambulance was called for patient to be sent out for further evaluation. Review of the Facility Reported Incident (FRI) provided by the facility and dated 05/21/25 indicated that The CNA reported the resident fell while transferring the resident with a sit to stand lift without the assistance of 2 (two staff). The resident reports she hit her head when she fell. However, she does not complain of pain or any injuries. The resident was sent to the emergency room for evaluation. The resident returned to the facility with no noted injuries. An MRI (magnetic resonance imaging) of the resident's head was completed and is negative . The CNA was unavailable for an interview. During an interview on 07/01/25 at 2:10 PM with the Director of Nursing (DON) stated that she recalled R1 sustaining a fall while being transferred with a sit to stand mechanical lift. CNA1 was trying to hurry to transfer her from the bed to the shower chair and chose to use the sit to stand lift. To her knowledge, no staff had previously used the lift for R1's transfer and it was not determined why CNA1 chose to use it that day because her Kardex and Care Plan both indicated R1 was a two person lift using stand/pivot technique. The DON stated that CNA1 had worked at the facility for over 10 years and it was a surprise that she had chosen to transfer the resident using this technique. It was her expectation that staff review the Kardex/Care Plan prior to transfers. During an interview on 07/01/25 at 2:26 PM with Licensed Practical Nurse (LPN)1 stated on 05/21/25 she heard CNA1 yelling for help, she immediately went to R1's room where she witnessed R1 on the floor. R1 stated she hit her head. CNA1 stated that she was trying to transfer R1 with the sit to stand mechanical lift when R1 slid out of the lift onto the floor. It was determined that R1 was not strapped into the lift and she fell while being transferred. LPN1 assessed R1 and then sent her to the hospital for evaluation and treatment. She was noted with a lump to the back of her head and when she returned it was confirmed that she had no internal damage/bleeding per MRI evaluation.

Based on observation, record review and interview, the facility did not ensure that 2 (R43 & R33) of 5 residents reviewed received care, consistent with professional standards of practice, to prevent pressure injuries and ensure that residents do not develop pressure injuries. *R43 is at risk for the development of pressure injuries and was observed to have their heels resting against a surface and not offloaded to prevent pressure injury development. * R33 is at risk for the development of pressure injuries and was observed to have their heels resting against a surface and not offloaded to prevent pressure injury development. Findings include: The facility's policy and procedure titled Pressure Injuries and Non pressure injuries dated 8/2/2021, documents: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. 1.) R43 was admitted to the facility on [DATE] with hypertension (high blood pressure) and stage 3 pressure injuries on buttock and coccyx. R43's Quarterly minimum data set (MDS) assessment dated [DATE] documents that R43 has no current pressure injuries and is at risk of developing a pressure injury. R43 is assessed as dependent on staff for bed mobility and is non-ambulatory. R43 is assessed for a 10 on the Brief Interview of Mental Status (BIMS), which suggests moderate cognitive impairment. R43's Certified Nursing Assistant (CNA) Care Plan dated 4/30/2025, documents: Encourage resident to float heels while lying in bed. R43's plan of care (POC) dated 9/23/22 for skin integrity related to impaired mobility, incontinence, obesity, picking at scabs. documents under the Goal section: Resident will not develop pressure related tissue injury, through next care plan review, date of 5/21/25. Under the Interventions section it documents: - Encourage resident to float heels in bed; initiated 1/22/24. On 4/28/25, at 9:14 AM, Surveyor observed R43 in bed with R43's exposed from the bed covers. R43's heels were resting against the air mattress. R43 heels were not positioned for pressure relief. On 4/29/25, at 7:18 AM, Surveyor observed R43 in bed with R43's exposed from the bed covers. R43's heels were resting against the air mattress. R43 heels were not positioned for pressure relief. Surveyor asked R43 about off-loading their heels. R43 stated that R43 did not like to wear boots (pressure relief boots) and staff sometimes will float their heels with pillows. On 4/29/25, at 1:12 PM, Surveyor observed R43 in bed with R43's exposed from the bed covers. R43's heels were resting against the air mattress. R43 heels were not positioned for pressure relief. On 5/01/25, at 8:08 AM, Surveyor observed R43 in bed with R43's exposed from the bed covers. R43's heels were resting against the air mattress. R43 heels were not positioned for pressure relief. On 5/01/25, at 8:13 AM, Surveyor interviewed Assistant Director of Nursing (ADON)- C. Surveyor shared the observations of R43's heels resting on the mattress and not off loaded to prevent pressure injuries. ADON-C stated they (the facility) did not know why (R43's heels are not offloaded) and maybe R43 refuses off-loading their heels. Surveyor informed ADON-C that Surveyor could not locate any documentation in R43's medical record that R43 was offered or refused to wear off-loading heel boots. ADON-C stated They will review education with staff for off-loading heels. On 5/1/24, at 2:00 PM, Surveyor shared the concerns with R43 with Nursing Home Administrator (NHA)- A. 2.) R33 was admitted on [DATE] with diagnosis of cardiac (heart) disease. R33's Quarterly minimum data set (MDS) completed 3/21/25 documents that R33 is assessed to have physical impairments to both lower extremities. The MDS documents that R33 requires partial/moderate assist for bed mobility and that R33 is assessed for a risk for pressure injury and that R33 does not have current pressure injuries. R33's Brief Interview for Mental status (BIMS) is a 9 for moderate cognitive impairment. R33's Certified Nursing Assistant (CNA) Care Plan dated 4/30/2025 documents: Encourage resident to float heels while lying in bed and Encourage to wear Prevalon boots in bed. R33's plan of care (POC) dated 6/7/24 for skin integrity related to impaired mobility, incontinence and diabetes mellitus. documents under the Goal section: Skin will remain intact, free from erythema, breakdown, excoriation, or bruising until next review, date of 6/12/25. Under the Interventions section it documents: - Encourage resident to float heels in bed. on 6/14/24. - Encourage resident to wear Prevalon boots in bed. on 6/14/24. On 4/28/25, at 9:32 AM, Surveyor observed R33 in bed. R33 heels were resting against the mattress and not offloaded to prevent pressure injuries On 4/29/25, at 1:15 PM, Surveyor observed, R33 in their bed. R33's right leg was fully extended with R33's right heel resting against the mattress. R33's left leg was flexed inward with R33's ankle resting against the mattress. R33 stated, They (staff) sometimes float my (R33) heels and that R33 does not know anything about Prevalon boots. On 5/01/25, at 8:13 AM, Surveyor and Assistant Director of Nursing (ADON) -C observed R33's feet in their bed. R33's left foot is flexed upwards with R33's outer ankle resting against a pillow. R33's right heel is resting on the mattress. Surveyor observed a one green colored pressure off-loading boot in R33's room above the closet. ADON-C stated, They did not know why the Prevalon boot(s) were not used and thought maybe Resident refused. Surveyor shared that R33's medical records do not contain documentation of refusal of off-loading heels. ADON-C stated, They will review education with staff for off-loading heels. On 5/1/24, at 2:00 PM, Surveyor shared the concerns with R33 with Nursing Home Administrator (NHA)- A.

Based on interview and record review, the facility did not ensure 1 (R20) of 18 residents reviewed had a comprehensive care plan developed and implemented so that residents can attain their highest practicable physical, mental and psychosocial well-being. * R20 started receiving dialysis on December 7, 2024. R20's comprehensive care plan does not address the need for dialysis and the care and treatment of R20's dialysis site. Findings include: 1.) R20 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, morbid obesity, and chronic kidney disease. R20's medical record indicates that on 12/7/2024, R20 began receiving dialysis treatments. R20 has a perma cath (central venous catheter for dialysis access) to the right chest that is to be used during dialysis. R20's physician orders indicate R20 receives dialysis twice a week and the order is for staff to monitor the perma cath site for any signs and symptoms of infection. Surveyor reviewed R20 care plan did not find a comprehensive care plan that addresses R20 dialysis and care and treatment of perma cath site. On 4/29/25 at 3:00 p.m., during the daily exit meeting ,Surveyor informed DON-B and NHA-A of the above findings. Surveyor explained that R20 doesn't have a care plan that addresses R20's dialysis treatments and care and or care of R20's perma cath. DON-B stated she would look into it. On 4/30/25 at 9:30 a.m., DON-B informed Surveyor that there should be a care plan for R20's dialysis treatments and perma cath care. DON-B informed Surveyor that DON-B is not sure why there is not a comprehensive care plan developed for R20's dialysis services and perma cath site care. No additional information was provided as to why R20 did not have a comprehensive care plan developed for dialysis services or perma cath care.

Based on interview and record review, the facility did not ensure residents received treatment and care consistent with N6 Wisconsin Nurse Practice Act for 2 (R3 & R1) of 4 residents reviewed. R3 was admitted to the facility on [DATE]. During the night of [DATE], R3 experienced a change of condition including having shortness of breath, increased pulse and respirations, and oxygen (O2) saturations of 65% (as obtained by Licensed Practical Nurse (LPN)-N. LPN-N sought out Registered Nurse (RN)-L for a second opinion. LPN-N and RN-L had a miscommunication as RN-L believed R3's O2 sats were 85%. RN-L listened to R3's lung sounds but did not complete a comprehensive assessment of R3's change of condition. LPN-N obtained an order to transfer R3 to the hospital and called a private ambulance service. Upon EMS arrival, they found R3 to be in severe respiratory distress and unresponsive. R3 passed away in the ambulance while still at the facility. The facility's failure to have effective communication of R1's medical status between RN-L and LPN-N, the failure to complete a comprehensive assessment of R3's status by RN-L, the failure to recognize the acute change in condition to include hypoxia, and the delay in providing emergency medical care to R3 by not calling 911 when R3's oxygen saturation was 65% created a finding of Immediate Jeopardy (IJ) which began on [DATE]. NHA (Nursing Home Administrator)- A, DON (Director of Nursing)-B, & [NAME] President of Success-Q were notified of the immediate jeopardy on [DATE] at 2:03 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of D (potential for harm/isolated) related to the example involving R1 and as the facility continues to implement its action plan. *R1 was observed without the right lower extremity tubi grip on [DATE] & [DATE]. Findings include: The facility's policy titled, Change in Condition of the Resident and reviewed/revised [DATE] under Policy documents: A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). According to the State of Wisconsin Nurse Practice Act: N 6.03 - Standards of practice for registered nurses. (1) General nursing procedures. An R.N. 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. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. According to https://www.yalemedicine.org People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia, a condition in which not enough oxygen reaches the body's tissues. If blood oxygen saturation levels fall to 88% or lower, seek immediate medical attention. R3 is an [AGE] year-old male admitted to the facility on [DATE]. R3 was hospitalized from [DATE] to [DATE] following a fall in the bathroom. R3 presented to the ED (emergency department) in A Fib (Atrial Fibrillation) with rapid venticular response, concern for ST (sinus tachycardia), and troponin elevation. R3 received heparin during hospitalization but was transitioned to low dose Eliquis. R3's diagnoses include non-sinus tachycardia myocardial infarction, syncope and collapse, chronic kidney disease with heart failure, diabetes mellitus, depressive disorder, atrial fibrillation, and presence of left artificial hip joint. R3 was his own person and did not have an activated power of attorney for health care. The nurses note dated [DATE], at 17:05 (5:05 p.m.), documents: Resident is on follow up for: New Admission. The current status is Resident arrived facility at 1500 (3:00 p.m.) from [hospital initials]. Resident was in hospital after a fall at home. Resident has complaints of mild pain in both hips and lower back. Resident uses urinal in bed and is a check and change for BM (bowel movement) due to weakness until evaluated by therapy. Active bowel sounds in all four quads (quadrants), Lungs clear. Hospital states resident would be a candidate for sit to stand but it was never attempted in hospital. Resident is A&Ox3 (alert and orientated times three) sometimes a bit confused but easily redirected. Resident has a friend [first name] that is very involved and visits often. This nurses note was written by LPN (Licensed Practical Nurse)-T. The nurses note dated [DATE], at 00:38 (12:38 a.m.), documents: Resident is on follow up for: New Admission. The current status is Resident in bed resting with eyes closed at this time. Follow up, new admit. Resident adjusting well to facility. No c/o (complaint of) pain or discomfort. No sob (shortness of breath) or respiratory distress noted. All cares provided by staff PPOC (per plan of care). Will monitor. This nurses note was written by LPN-U. The nurses note dated [DATE], at 08:29 (8:29 a.m.), documents: Resident is a new admit who went into hospital after a fall at home. Resident has complaints of mild pain in both hips and lower back. Resident uses urinal in bed and is a check and change for BM due to weakness until evaluated by therapy. Active bowel sounds in all four quads, Lung clear. Hospital states resident would be a candidate for sit to stand but it was never attempted in hospital. Resident is A&Ox3 some confused at times but easily redirected. We will cont. (continue) ppoc. This nurses note was written by LPN-M. The nurses note dated [DATE], at 19:25 (7:25 p.m.), documents: Resident is on follow up for: New Admission. The current status is Follow up, new admit after a fall at home. Resident adjusting well to facility. No c/o pain or discomfort. No sob (shortness of breath) or respiratory distress noted. All cares provided by staff PPOC. Resident here post fall at home, resident here for weakness and strengthening. This nurses note was written by LPN-T. Review of R3's oxygen saturation under the weight/vitals tab reveals the following: [DATE], at 1543 (3:43 p.m.) 95% on room air. [DATE], at 0445 (4:45 a.m.) 93% on room air. [DATE], at 1132 (11:32 a.m.) 95% on room air. [DATE], at 1632 (4:32 p.m.) 96% on room air. [DATE], at 0131 (1:31 a.m.) 65% on room air. Review of R3's pulse under the weight/vitals tab reveals the following: [DATE] at 1543 (3:43 p.m.) 74 bpm (beats per minute). [DATE] at 0445 (4:45 a.m.) 65 bpm. [DATE] at 1132 (11:32 a.m.) 80 bpm. [DATE] at 1632 (4:32 p.m ) 60 bpm. [DATE] at 0131 (1:31 a.m.) 97 bpm. Review of R3's respirations under the weight/vitals tab reveals the following: [DATE] at 1543 (3:43 p.m.) 22 breaths per minute. [DATE] at 0445 (4:45 a.m.) 20 breaths per minute. [DATE] at 1132 (11:32 a.m.) 18 breaths per minute. [DATE] at 1632 (4:32 p.m ) 18 breaths per minute. [DATE] at 0131 (1:31 a.m.) 28 breaths per minute. Review of R3's Electronic Medical Record (EMR) indicates R3 experienced an acute change in condition on [DATE]. After receiving an oxygen saturation of 65% on [DATE], LPN-N left R3 to obtain oxygen and seek out Registered Nurse (RN)-L on a different unit for a 2nd opinion on R3's status. RN-L stated during interviews, she listened to R3's lung sounds but did not confirm/verify the information gathered by LPN-N or complete a comprehensive assessment of R3's change in condition. RN-L stated after listening to R3's lungs she agreed something was going on with R3. Both nurses left R3's room, LPN-N proceeded to call R3's physician/nurse practitioner's office to obtain an order to send R3 to the hospital for further evaluation (physician's office was called at 1:18am.) LPN-N obtained the order to transfer R3 to the hospital and called a private ambulance service (not 911) at 1:31am that arrived at the facility without lights and sirens. RN-L left R3 to get paperwork ready for R3's transfer to the hospital and was then called back to her assigned unit. During interviews with RN-L she shared she thought LPN-N said the pulse ox level was 85% not 65%. RN-L shared had she known that she would have immediately sent R3 out. When RN-L went back to check on LPN-N EMS (Emergency Medical Services) was already in R3's room. Upon EMS arrival to R3's room (at 1:38am) they were informed by facility staff R3 had exhibited severe lethargy and unusually slow respiratory pattern for approximately 30 minutes prior to EMS activation. BLS (Basic Life Support) EMS assessed R3 to be in severe respiratory distress, periodic breathing-Cheyne-Stokes breathing, unresponsive, no blood pressure, weak pulse at 56, blood glucose of 222, and agonal breathing at 70% O2 saturation on room air. BLS EMS used a BVM (Bag Valve Mask) and 15 liters of oxygen to assist R3 with breathing. ALS (Advanced Life Support) EMS arrived at the facility at 1:48am with lights and sirens to provided BLS EMS assistance. R3 was transferred into the ALS ambulance and was found to be in asystole and CPR was implemented. R3 was pronounced deceased in the ALS ambulance while still at the facility. On [DATE], at 6:30 a.m., Surveyor interviewed LPN-N, who was assigned to care for R3 and was the charge nurse for her shift on [DATE]. Surveyor asked LPN-N to walk Surveyor through what happened on [DATE] with R3. LPN-N informed Surveyor R3 was basically a new patient, he was doing fine, on report for new admission. LPN-N informed Surveyor she doesn't know the exact time, probably around 1:50 a.m. to 2:00 a.m., R3 had his call light on. LPN-N informed Surveyor she answered the light because the CNA was on break. LPN-N informed Surveyor she went into R3's room and he was having a hard time breathing so I asked him if this just started. LPN-N informed Surveyor she went to grab all her vital sign things, blood pressure cuff, pulse ox, thermometer. LPN-N informed Surveyor R3's SPO2 was 65%, R3 said this just started and she went to go look for oxygen and to get the other nurse. LPN-N then stated, I think I called her because I wanted to get the O2 (oxygen). LPN-N informed Surveyor she went back to R3 and thinks started the oxygen at 2 liters. LPN-N informed Surveyor R3's pulse ox was not going up, so she put a mask on him & increased the oxygen to 3 liters then the RN [RN-L's first name] was in assessing R3 as I wanted her to be a 2nd person. Surveyor asked if R3's oxygen saturations increased. LPN-N informed Surveyor it stayed at 65%. We listened to R3's lungs, could hear trach congestion and wheezing. LPN-N informed Surveyor they ended up calling [name of medical group] and the NP said okay to send to [hospital name]. LPN-N informed Surveyor she called the ambulance, emergency contact, and called in report to the RN at the hospital. LPN-N informed Surveyor a little while later, [name] ambulance came in and told her R3 had expired, and the protocol is for the cops to come so they will be talking with us. Surveyor asked who called the ambulance. LPN-N replied, I believe I did. Surveyor asked who she called. LPN-N stated [Name] of ambulance company. Surveyor asked LPN-N why she didn't call 911. LPN-N replied, the nurse practitioner didn't specify to call 911. LPN-N informed Surveyor she was conferring with the RN and asked if they should call 911 before. Surveyor asked LPN-N what assessments RN-L did. LPN-N informed Surveyor RN-L was listening to R3's lungs and asking him questions like how long he has felt like this, when did it start, did he want to go to the hospital. R3 said yes. That's all I believe I can recall. Surveyor asked LPN-N if she told RN-L what R3's oxygen saturation was. LPN-N replied yes. Surveyor asked LPN-N when she obtained an oxygen saturation of 65% for R3 why didn't she send R3 out to the hospital. LPN-N replied because I had to call the doctor. Usually, we have to get an order to send him out. Surveyor asked LPN-N if she was in R3's room prior to him placing on the call light. LPN-N replied, just to peek in. Surveyor asked LPN-N what she meant by peeking in. LPN-N informed Surveyor she checks to make sure the resident is not at the edge of the bed, positioning is good, bed is low, call light, things like that. Surveyor asked prior to R3 putting on his call light, had she taken R3's vital signs. LPN-N replied, I did not. Surveyor asked from the time she called for the ambulance, how long was it until they arrived. LPN-N replied 15 maybe 20 minutes seemed like they came pretty fast. Surveyor asked LPN-N who was the charge nurse this night. LPN-N replied I believe it was me but not positive. Surveyor asked who documents the assessments. LPN-N replied usually the RN puts their own note in. Surveyor asked if RN-L documented. LPN-N replied, I don't believe she did, no. Surveyor asked LPN-N if RN-L gave her any information to include in her note. LPN-N replied no, not that I'm aware of. Surveyor asked LPN-N after she received an oxygen sat for R3 of 65% how long was it until RN-L came to the unit. LPN-N replied maybe 5 minutes. Surveyor asked LPN-N if there was anything else she wanted Surveyor to know. LPN-N informed Surveyor she tried to put everything in her note. LPN-N's nurses note is dated [DATE], at 02:12 (2:12 a.m.), documents Patient C/O (complained of) SOB (shortness of breath). TPR (temperature, pulse, respirations) 98.4, 97, 28. BP (blood pressure) ,d+[DATE]. SPO2 65%, RA (room air). O2 (oxygen) started at 2L (liters) and SPO2 remained at 65% so increased to 3L (liters) per NC (nasal cannula)/mask. Congested cough with tracheal congestion noted. LS (lung sounds) course with expiratory wheezes. HOB (head of bed) elevated. LPN (Licensed Practical Nurse) and RN (Registered Nurse) assessed. NP (Nurse Practitioner) notified and ok to send to [hospital initials] ER (emergency room ) for evaluation. [Name] ambulance called. Emergency contact notified. [Name] ambulance here to transport to [hospital initials] ER. Report called to ER RN [Name]. This nurses note was written by LPN-N. LPN-N also had a nurses note dated [DATE], at 02:19 (2:19 a.m.) which documents: Blood sugar 222. Surveyor notes LPN-N was calling the NP, responsible party, ambulance company, and giving report to the receiving hospital while RN-L was gathering the necessary paperwork for R3's transfer, however, RN-L was called back to her assigned unit, leaving CNA-V with R3 who continued to experience a more severe change in condition as noted by BLS EMS's assessment of R3 upon their arrival. On [DATE], at 2:34 p.m., Surveyor interviewed RN (Registered Nurse)-L regarding R3. RN-L informed Surveyor she works the back half which consists of the 200 & 300 units. RN-L informed Surveyor R3 was having trouble breathing and [first name of LPN-N] asked her to give a 2nd opinion. RN-L stated his lungs were not sounding great. RN-L informed Surveyor when she went in, he was alert and talking with both of them, stated he was having trouble breathing and his O2 (oxygen) was mid to high 80s. RN-L informed Surveyor she couldn't remember the exact number. Surveyor asked RN-L if she did any assessment. RN-L informed Surveyor she listened to R3's lungs, they weren't clear and wasn't sure if they were coarse. RN-L informed Surveyor she told LPN-N, you're right something is going on. Surveyor asked RN-L if LPN-N told her what R3's oxygen saturation was. RN-L stated, she (LPN-N) got, like I said, mid to high 80s. Surveyor informed RN-L R3's oxygen saturation was 65%. RN-L replied, Sh*t I didn't know it was that low thought 85, 88. Surveyor then read LPN-N's [DATE] note which documented R3's oxygen at 65%. RN-L replied, Sh*t I would have called [name of medical group] if it was 65 and sent R3 out. RN-L informed Surveyor O2 at 85 (%) she's worried but at 65 (%) she's panicking. Surveyor asked who called [name of medical group]. RN-L informed Surveyor she doesn't remember. RN-L informed Surveyor she was trying to get the paperwork ready but was having trouble with the printer. Surveyor asked RN-L if she remembers what time LPN-N came to get her. RN-L informed Surveyor she doesn't remember any of the times. Surveyor asked RN-L if she documented her assessment. RN-L informed Surveyor usually she has a notebook in her pocket so she can write things down and tear it out. Surveyor asked RN-L if she gave LPN-N any information. RN-L informed Surveyor she assumes she did but can't swear she did. Surveyor asked RN-L if she was the supervisor this night. RN-L replied no they have not made me charge nurse and explained usually, the nurse on the 100 unit is the charge nurse, who was LPN-N, was the charge nurse. Surveyor asked who would document an assessment. RN-L informed Surveyor the nurse who has the resident. RN-L informed Surveyor the nurse who has the resident would do the change of condition, call [name of medical group] and all that stuff. Surveyor asked who documented on R3. RN-L replied just the LPN and stated she was getting everything ready. RN-L informed Surveyor while she was with LPN-N she got called back to her unit and when she went back to check on LPN-N, EMS (emergency medical services) was already in the room ready to load R3 up. Surveyor asked RN-L prior to LPN-N getting her, had she been told anything about R3. RN-L replied no, explaining she is usually on unit 3 and didn't know anything about R3. RN-L informed Surveyor when LPN-N came to get her she was charting at the nurses' station on her unit and asked her if she could borrow her. RN-L informed Surveyor she checked R3's breathing. Surveyor asked RN-L who determined to place 2 liters of oxygen on R3. RN-L replied she did. RN-L informed Surveyor they were partners in assessing if that makes sense. Surveyor asked RN-L again if she knew R3's oxygen was 65. RN-L replied, I didn't realize it was that low, thought she said 85, I must have misheard. 85 is worrying & 65 is panic and I panic. Did not know it was 65. According to https://my.clevlandclinic.org, Hypoxia can be life-threatening and if you are experiencing symptoms of hypoxia, call 911. Surveyor notes LPN-N's evaluation of R3 was miscommunicated and/or misunderstood by RN-L. RN-L did not complete and document an assessment of R3. BLS Ambulance Crew arrived at the facility and assessed R3 to be experiencing a more severe change in condition as they were unable to get blood pressure, a weak carotid bradycardic regularly irregular pulse at 58, SPO2 was approximately 70% on room air, bradypneic at approximately 8 for irregularly irregular respiration rate. Crew used BVM (Bag valve mask) with oxygen at 15 liters per min (minute). Surveyor reviewed the private ambulance Patient Care Report, dated [DATE], which documents: Disp (dispatch) notified: 01:31(AM), [DATE] Recvd (received): 01:31 (AM), [DATE] En route: 01:31 (AM), [DATE] At scene: 01:37 (AM), [DATE] At patient: 01:38 (AM), [DATE] [NAME] (Transition of care): 01:45 (AM), [DATE] Crew 1 level: EMT-Basic Nature of the call: Respiratory Distress Unit type: BLS (Basic Life Support) Chief Complaint: Respiratory-Severe Distress (Primary) Primary Symptoms: Periodic Breathing; or Cheyne-Stokes Breathing (periods of shallow breathing alternating with periods of deeper, rapid breathing. The deep, rapid breathing may be followed by a pause before breathing begins again.); Abnormal breathing pattern. Assessment: [DATE], at 01:39 (AM), B/P (blood pressure) no; Pulse: 58, weak, regular; Respiratory: Weak, Agonal, irregularly irregular; SPO2 (oxygen saturation): 70% on room air. -Skin Temp-Cool; Skin color: Pale; Skin moisture: Clammy -Level of consciousness: Unresponsive, Arm Movement: Left-None, Right-None; Leg - Movement: Left-None, Right-none Treatment Summary: Time: 01:40 (AM): Oxygen -Device: Adult BVM (Bag Valve Mask) -Dosage Unites: Liters per Minute -Rate: 15 LPM (Liters per Minute) -Indication: Respiratory Failure -Response: Improved -Successful: Yes Time: 01:42 (AM) Indication: Respiratory Distress Response: Unchanged SpO2: 85% Time: 01:46 (AM) -Blood Glucose Measurement: 222 -Response: Unchanged Narrative: [Name of Ambulance Company] dispatched no lights and sirens to address above (address of the Facility) for [AGE] year-old male patient for respiratory distress.Upon arrival crew was directed to patient room. Crew did not receive paperwork from health care staff, when brought up health care professional states staff was getting the paperwork now. Upon arrival patient was found in bed unconscious, crew obtaining vitals. Crew unable to get blood pressure. Crew obtained a weak carotid bradycardic regularly irregular pulse at 58. SPO2 was approximately 70% on room air. Patient was bradypneic at approximately 8 for irregularly irregular respiration rate. Crew used BVM with oxygen at 15 liters per min (minute). Crew was unable to get a [sic] adequate seal on the patients mouth due to the patient's bariatric status. Crew tried to get a summary of what happened. Healthcare professional that guided crew to patient stated she was not the person that took care of the patient and didn't know what was going on. Crew asked the healthcare professional to get the person that has information about the patient. Crew monitored patients SPO2 and heart rate. SPO2 improved with BVM and 15 liters of oxygen up to approximately 80%. Crew obtained blood glucose measurement at 222. ALS (Advanced Live Support/EMS) arrived on scene with healthcare professional in charge of patient. Crew transferred care to ALS. Crew assisted ALS due to poor seal of the BVM. ALS provided crew with CPAP (continuous positive air-way pressure) mask to put on patient as well. Crew assisted ALS with 12 lead. When put on patient was asystole (A condition where the heart's electrical and mechanical activity completely stops, resulting in a lack of a heartbeat.). Crew assisted ALS by providing chest compressions and breathing for patient with BVM at 15 liters per minute. Crew alternated positions to maintain adequate depth and speed for compressions. Crew proceeded to do CPR until instructed by ALS to stop due to med (medical) control pronouncing patient deceased . ALS (Advance Life Support) Ambulance Narrative, dated [DATE]: Assessment at 1:48 (AM): -Breathing: Absent: agonal -Level of consciousness: unresponsive -Circulation: Pulses- Carotid-weak -Mental Status: Unresponsive [Name of private ambulance company] responded w/ (with) lights and sirens to the above location for respiratory distress. Crew arrived to discover an 85-y/o (year old) male PT (Patient) lying supine in bed assisted by SNF (Skilled Nursing Facility) staff, and [name of ambulance company number of BLS (Basic Life Support) crew] had been on the scene for a few minutes prior to (ALS)'s arrival, and immediately reported to crew that pt was in hypoxic shock due to inadequate ventilation PT had reportedly had severe bradynea at rate of ,d+[DATE] BPM on their arrival w/ thready pulses centrally and SPO2 measured ~60% on conventional device. Crew noted that pts skin was pale, cool, and dry. [BLS] had intervened immediately w/ BVM ventilation but were otherwise unable to intervene prior to [ALS]'s arrival. Staff indicated that PT had arrived [DATE] for rehabilitation of a recent procedure on the left hip. PT had reportedly exhibited severe lethargy and usually slow respiratory pattern approx. (approximately) 30 min (minutes) prior to EMS activation. PT's paperwork indicated PMH (Primary Medical History) of AKI (Acute Kidney Injury), primary hypertension, and Type 2 diabetes, w/ multiple antihypertensive and anticoagulants listed on the chart. Assessment was performed on scene. PT was found totally unresponsive/weak pulses noted in the carotid artery at ~30 BPM. Assessment from vitals was unsuccessful, as no numerical measurements were appreciable at [BLS] assessment. [DATE], at 01:57 (AM), Initial CPR: Attempted ventilation and initiated Chest Compressions. On [DATE], at 8:33 a.m., Surveyor called [name of medical group] to inquire who was the NP facility staff had contacted on [DATE]. NP-W informed Surveyor it was NP-Y and NP-W can email her as she doesn't have her phone number. On [DATE], at 9:02 a.m., Surveyor called [name of medical group] to try to speak with MD (Medical Doctor)-X. NP-W informed Surveyor MD-X is out on leave. Surveyor asked NP-W if she received a call from the facility telling her there is a new admission with oxygen sats at 65% what would she tell the nurse to do. NP-W replied call 911. NP-W informed Surveyor NP-Y works part time and wasn't working this day but could read Surveyor NP-Y's note. NP-W read to Surveyor NP-Y's note which read, nursing call request order ED for evaluation due to respiratory distress. Pt pulse ox 65% on 3L inspirations and expirations wheezing using accessory muscles. Nursing orders given. NP-W informed Surveyor NP-Y's note doesn't say to call 911. NP-W informed Surveyor this note was created on [DATE] at 2:16 a.m. On [DATE], at 9:15 a.m., Surveyor spoke with NP-W on the telephone along with Director of Operations-Z from [name of medical group] to inquire if NP-Y spoke with the facility when they called or if she had to call them back. Surveyor was informed the call from the facility came in at 1:18 a.m., the patient order given was time stamped at 2:16 a.m. for when it was created in the chart, but they don't know if NP-Y spoke to the facility at 1:18 a.m. or she had to call back. On [DATE], at 10:38 a.m., Surveyor spoke with DON (Director of Nursing)-B to inquire what the night shift staffing is. DON-B informed Surveyor there are 2 nurses and 3 to 4 CNAs. One nurse is on the 100 unit and the other nurses takes 2 & 3. Surveyor asked if there is a charge nurse. DON-B informed Surveyor the charge nurse is working on the 100 unit. Surveyor asked what happens when a resident has a change of condition. DON-B informed Surveyor they typically wait for an order if it's an emergency the nurse could use their judgement and send them out. Surveyor asked about oxygen orders. DON-B informed Surveyor there is a standard nursing order for 2 liters and then call the doctor if it needs to go up. Surveyor asked if an LPN is working the unit, and a resident has a change of condition what should be done. DON-B informed Surveyor the LPN should observe the findings what they see, call the RN in the building, the RN can assess, and if it's an emergency send them out. Surveyor asked about R3. DON-B informed Surveyor LPN-N came into the room to answer the call light, R3 was SOB, she called RN-L who came and assessed. DON-B informed Surveyor he was responsive, his O2 was 85, respirations were high, they called [name of medical group] and gave an order. Once the ambulance came, they took over. Surveyor asked DON-B if the RN does their own vital signs. DON-B replied, she said they were doing vitals together. Surveyor asked DON-B if a resident has O2 sats of 65 what would you expect staff to do. DON-B replied hope they called for ambulance and prepare for code. DON-B informed Surveyor personally she would have cranked up the oxygen. Surveyor asked DON-B if she was aware when LPN-N took R3's oxygen sats it was 65. DON-B replied no, not until I looked at the progress note. RN-L told me 85. Surveyor asked DON-B if the NP doesn't specifically say to call 911 could the nurse call 911. DON-B replied, I don't know what our policy is I'll have to get back to you. On [DATE], at 3:07 PM, Surveyor interviewed Deputy Director of Operations for the EMS ambulance company (DDO)-AA who stated BLS did report to ALS R3 was in hypoxic shock upon their arrival. The facility's failure to ensure R3 received appropriate care and treatment when R3 experienced a change in condition including shortness of breath, increased pulse and respirations, and low oxygen sats led to a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility implemented the following action plan: * Director of Nursing completed an audit of residents requiring transfer from facility to higher level of care within the last 14 days, to verify appropriate provider notification and Emergency Medical Services activation. [DATE] * Facility Licensed Nursing staff reeducated by Director of Nursing or designee on Change of Condition of the Resident policy starting [DATE] and will be completed prior to next scheduled shift. This re-education included information on assessing (done by the RN if available) or data gathering (done by the LPN) and reporting findings requiring immediate notification to the medical provider. Re-education includes use of the INTERACT 4.5 Change in Condition Guidelines for when to immediately notify the physician/provider. Reeducation also includes when to activate Emergency medical services by calling 911 for residents requiring emergency intervention. * The Director of Nursing, Executive Director, and [NAME] President of Success reviewed established Change in condition of resident policy. No changes were necessary to this policy. [DATE]. * Director of Nursing or Designee will review facility charting daily to identify resident change in condition, to ensure proper documentation of change of condition and notification of provider including method of transfer and if 911 contacted or ambulance service contacted. These audits will be completed daily 2 weeks, then with morning clinical 5 days per week for 10 weeks or until substantial compliance is maintained. Results of these audits will be brought to QAPI (quality assurance performance improvement) for review and recommendation. * ADHOC QAPI review of this plan was completed with Medical Director, VP (Vice President) of Success, Director of Nursing, and Executive Director. [DATE] The deficient practice continues at a scope/severity of D (harm/isolated) as evidenced by the following example with R1. 2.) R1's diagnoses includes atherosclerotic heart disease, chronic kidney disease, and hypertension. The physician

Based on record review and staff interview, the facility did not ensure 1 Resident (R2) of 3 sampled Residents were treated with dignity and respect. *The facility sent R2 to a chemotherapy appointment covered in emesis. Findings Include: R2 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy, Malignant Neoplasm of Colon, Chronic Obstructive Pulmonary Disease, Legal Blindness, and Essential Hypertension. R2 has an activated Health Care Power of Attorney (HCPOA). R2's Quarterly Minimum Data Set (MDS) completed 9/12/24 documents R2's Brief Interview for Mental Status (BIMS) score to be 4, indicating R2 demonstrates severely impaired skills for daily decision making. R2 is documented as having no mood or behavior issues. R2's MDS also documents R2 is independent with eating, has range of motion impairment on both sides of lower extremity, requires substantial/maximum assistance for showers and upper dressing. Partial/moderate assistance for lower dressing, mobility and transfers. R2's MDS documents R2 to always be incontinent of bladder and frequently incontinent of bowel. On 10/9/24, at 10:29 AM, Surveyor interviewed Receptionist at the Cancer Center (REC)-C via telephone. REC-C reported the van driver who transported R2 was appalled at the condition of R2. In particular, the day R2 was covered with emesis all down the front of R2. The nurse at the Cancer Clinic (RN)-D reported that RN-D noticed on several occasions R2 has been wet from urine. R2 has had R2's mask filled with food. RN-D confirmed R2 arrived covered in emesis to the clinic. RN-D stated R2's tubing was filled with emesis and that it had hardened and smelled so bad. On 10/9/24, at 11:25 AM, Medical Records (MR)-E confirmed that MR-E is responsible for scheduling of appointments and arranging transportation for the residents. On 10/9/24, at 11:42 AM, Surveyor interviewed via telephone Office Manager (OM)-F of the transportation company. OM-F informed Surveyor OM-F recalls the incident with R2. OM-F stated the van driver informed OM-F that when the van driver picked up R2 from the facility, R2 was covered in dried emesis. The van driver informed the person at the desk (of the Facility), who acted like they didn't care. OM-F stated the person at the desk would not take R2 to get changed before leaving the facility to go to the Cancer Center for chemotherapy. OM-F stated OM-F called the facility and reported the details to MR-E. OM-F informed Surveyor the incident occurred on 9/19/24. On 10/9/24, at 12:04 PM, Surveyor spoke with the Van Driver (VD)-G. VD-G informed Surveyor R2 was completely full of emesis the day VD-G picked up R2 to transport to the Cancer Clinic. VD-G stated that was the first time VD-G transported R2. VD-G stated R2 was brought up front late, a little over 20 minutes VD-G waited for R2. VD-G talked with the nurse at the Cancer Clinic about it and the nurse stated R2 has been soaked in urine at times. On 10/9/24, at 2:01 PM, MR-E denies receiving any phone calls from OM-F in regards to R2. On 10/10/24, at 11:06 AM, Director of Social Services (DSS)-K stated R2 is gone for R2's chemotherapy appointment for about 5 hours and about 30 minutes the second day to get R2's port out. On 10/10/24, at 11:25 AM, Surveyor shared the concern with Director of Nursing (DON)-B that R2 arrived to the Cancer Center covered in emesis, compromising R2's dignity. No further information was provided by the facility at this time.

Based on observation and interview, the facility did not ensure a clean, comfortable, and homelike environment which had the potential to affect 2 (R1 and R2) of 3 wheelchairs observed during the survey process. *R1's wheelchair was observed to be dirty during the survey. *R2's wheelchair was observed to be dirty, and the arm rests in need of repair during the survey. Findings Include: R2 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy, Malignant Neoplasm of Colon, Chronic Obstructive Pulmonary Disease, Legal Blindness, and Essential Hypertension. R2 has an activated Health Care Power of Attorney (HCPOA). R2's Quarterly Minimum Data Set (MDS) completed 9/12/24 documents R2's Brief Interview for Mental Status (BIMS) score to be 4, indicating R2 demonstrates severely impaired skills for daily decision making. R2 is documented as having no mood or behavior issues. R2's MDS also documents R2 is independent with eating, has range of motion impairment on both sides of lower extremity, requires substantial/maximum assistance for showers and upper dressing. Partial/moderate assistance for lower dressing, mobility and transfers. R2's MDS documents R2 to always be incontinent of bladder and frequently incontinent of bowel. On 10/9/24, at 11:04 AM, Surveyor observed R2's wheelchair. Both arm rests are missing the leather covering the foam. The right arm rest foam is mostly exposed with very little leather covering the arm rest. Surveyor observed dried food on the center of the wheelchair on both sides under the seat of the wheelchair. The wheels are dirty and dusty. R2's wheelchair brakes are covered with dried food crumbs. On 10/9/24, at 11:28 AM, Surveyor interviewed Maintenance Director (MD)-R. MD-R stated 3rd shift staff completes the task of cleaning the wheelchairs. MD-R stated they rely on staff communicating to MD-R if a wheelchair needs to be repaired. On 10/9/24, at 3:03 PM, Director of Nursing (DON)-B stated that wheelchairs are cleaned on the night shift on shower days and as needed. On 10/10/24, at 7:42 AM, Surveyor notes R2 was to have a shower on 10/9/24, which means that R2's wheelchair should have been cleaned on night shift on 10/9/24. On 10/10/24, at 8:15 AM, Surveyor observed R2's wheelchair continued to be dirty as observed on 10/9/24, evident of R2's wheelchair not being cleaned on R2's shower day. R2's arm rests remain in poor condition and in need or repair with exposed foam. On 10/10/24, at 10:33 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H. CNA-H stated wheelchairs are cleaned on 3rd shift and should be in the CNA assignment book as a task. On 10/10/24, at 10:34 AM, CNA-J informed Surveyor that 3rd shift washes the wheelchairs. CNA-J stated if CNA-J observed anything needing to be fixed on a wheelchair, CNA-J would let the maintenance department know. On 10/10/24, at 11:25 AM, Director of Nursing (DON)-B and Surveyor both observed R2's wheelchair together. DON-B agreed R2's wheelchair was filthy and both arm rests needed to be replaced with new ones. DON-B stated she understands Surveyor's concern with the dirty wheelchair. DON-B confirmed 3rd shift should be cleaning wheelchairs and is part of the CNA assignment. DON-B stated that wheelchairs can be cleaned as needed. No further information was provided by the facility at this time. 20483 2.) On 10/9/24, at 8:52 a.m., Surveyor observed under R1's roho wheelchair cushion there are multiple small food crumbs and debris throughout the wheelchair seat. On 10/10/24, at 8:03 a.m., Surveyor observed under R1's roho cushion there are multiple small food crumbs and debris throughout the wheelchair seat. On the front edge of the wheelchair seat there is dried food. On 10/10/24, at 11:25 AM, a Surveyor interviewed Director of Nursing (DON)-B in regards to the procedure for washing wheelchairs. DON-B explained that wheelchairs are expected to be cleaned on 3rd shift as part of the CNA assignment and as needed on the Residents' shower day when staff see the wheelchair needs to be cleaned. DON-B was informed of the observation of R1's dirty wheelchair.

Based on interview and record review, the facility did not thoroughly investigate 1 of 2 Facility Reported Incidents (FRI) reviewed for alleged abuse. R1 and R2 were found in R1's room and R2 was fondling R1's breasts. An investigation was opened and FRI submitted to the State Agency. The staff member who found the residents, Licensed Practical Nurse (LPN)-F, was not interviewed by the management preparing the investigation. No residents were interviewed to rule out the extent of R2's behavior or if others witnessed or had knowledge of potential inappropriate contact between R1 and R2. Findings include: Surveyor reviewed the facility's Abuse, Neglect and Exploitation policy with a revision date of 7/15/2022. Documented was: .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g not destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s); 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation . R1 was admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Cognitive Communication Deficit, Anxiety and Symptoms and Signs Involving Cognitive Function and Awareness. Surveyor reviewed R1's MDS (Minimum Data Set) Assessment with an assessment reference date of 1/31/24. Documented under Cognition was a BIMS (brief interview mental status) score of 10 which indicated moderate cognitive impairment. R2 was admitted to the facility on [DATE] with diagnoses that included Orthostatic Hypotension, Dementia, Anxiety and Alcohol Induced Amnestic Disorder. Surveyor reviewed R2's MDS Assessment with an assessment reference date of 4/19/24. Documented under Cognition was a BIMS score of 10 which indicated moderate cognitive impairment. Surveyor reviewed the FRI submitted to the state agency on 4/25/24. Included with the Misconduct Incident Report was an Investigation Summary, Face Sheets for both residents, staff questionnaire sheets and Appendix 1 - Recommendations for Addressing Resident Relationships Intimacy & Sexuality History. Surveyor noted there were no interviews with other residents asking if R2 had any concerns with R2's behavior towards them or if they had witnessed any potentially inappropriate contact between R1 and R2. There were also no witness statements or an interview with LPN-F who witnessed the incident. Documented under Investigation Summary was: .Description of Incident: .On 4/20/2024, [LPN-F], was completing her rounds and observed [R2] in [R1's] room. [LPN-F] stated [R1] had her breasts exposed and [R2] was touching her breasts. She removed [R2] from [R1's] room and notified [Nursing Home Administrator (NHA)-A] immediately. Investigation protocol was initiated, and the investigation was started immediately . [Assistant Executive Director/Social Services Director (SSD)-C) and [Social Services Coordinator (SSC)-G] interviewed [R1] and [R2]. The State of Wisconsin's Board on Aging and Long-Term Care's presentation on Balancing Rights and Protection: Inclusive Relationships, Sexuality and Consent was used as a guide to interview both Residents. [R1] denied the above allegation, stating she and [R2] were just watching TV. She denied that he touched her in any way and expressed she was aware of her rights to maintain a relationship with [R2] should she wish. She acknowledged her awareness of her right to say no if she felt uncomfortable with any interactions with [R2] however denied any concerns at this time. She said she is not interested in pursuing anything beyond friendship with [R2] and enjoys spending time with him, as they have a lot in common. She denied any concerns and verbalized she feels safe and comfortable at [the facility]. [R2] also denied the above allegations. He stated that he and [R1] are very good friends and he feels thankful to have met someone he can share companionship with. He stated he is not interested in pursuing anything but friendship with [R1]. He expressed awareness of his rights to pursue relationships and his right to say no if he felt uncomfortable with any interactions. He denied any concerns and stated he feels safe and comfortable at [the facility]. Both [R2] and [R1's] activated POA's (Power of Attorney) were notified of the interaction. Neither voiced any concerns and both stated they were happy their loved ones had found companionship in each other. [R1] and [R2] had increased monitoring post interaction. Skin assessments were completed with no evidence of trauma. [R1] and [R2] were noted to be watching TV in the common area and chatting per usual. No behaviors or complications noted as a result of the interaction . On 5/6/24, at 12:17 PM, Surveyor interviewed SSD-C and Social Service Coordinator (SSC)-G. Surveyor asked what happened on the day of the incident. SSD-C stated LPN-F found R2 fondling R1's breasts in R1's room. LPN-F removed R2 from R1's room and called Nursing Home Administrator (NHA)-A. SSD-C stated she and SSC-G came to the facility and started interviewing. They interviewed R1 and R2 and the staff that was available at the time. Surveyor asked if any other residents were interviewed. SSD-C stated no, only the 2 involved in the incident. Surveyor asked if LPN-F was interviewed. SSD-C stated she was interviewed by NHA-A. On 5/6/24, at 1:30 PM, Surveyor interviewed NHA-A. Surveyor asked about the interview with LPN-F. NHA-A stated she did not interview LPN-F. NHA-A stated when the incident occurred, LPN-F called the on-call manager. That day it was Scheduler-E. Scheduler-E then called her and reported what happened. She called SSD-C and reported what LPN-F had said to Scheduler-E. Surveyor noted that SSD-C stated she had taken LPN-F's statement, which meant no one interviewed LPN-F as the main witness. Surveyor also note no other residents besides R1 and R2 were interviewed. NHA-A stated SSD-C was new to the Assistant Executive Director role and still learning how to do FRI's. Surveyor expressed concerns that a thorough investigation did not occur and asked for any other documentation of interviews being completed. No other documentation was provided.

Based on interview and record review, the facility did not comprehensively assess 2 (R1 and R2) of 4 residents reviewed for alleged abuse. The facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, to have the highest practicable physical, mental, and psychosocial well-being. R1 and R2 were found in R1's room and R2 was fondling R1's breasts. Prior to this incident, R1 and R2 were spending lots of time together including being found holding hands. The residents were not assessed for competency, ability to consent to a sexual relationship or intimacy and sexual history assessment completed. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Cognitive Communication Deficit, Anxiety and Symptoms and Signs Involving Cognitive Function and Awareness. Surveyor reviewed R1's MDS (Minimum Data Set) Assessment with an assessment reference date of 1/31/24. Documented under Cognition was a BIMS (brief interview mental status) score of 10 which indicated moderate cognitive impairment. R2 was admitted to the facility on [DATE] with diagnoses that included Orthostatic Hypotension, Dementia, Anxiety and Alcohol Induced Amnestic Disorder. Surveyor reviewed R2's MDS Assessment with an assessment reference date of 4/19/24. Documented under Cognition was a BIMS score of 10 which indicated moderate cognitive impairment. Surveyor reviewed FRI submitted to the state agency on 4/25/24 prepared by [Assistant Executive Director/Social Services Director (SSD)-C)]. Included with the Misconduct Incident Report were an Investigation Summary, Face Sheets for both residents, staff questionnaire sheets and 2 copies of Appendix 1 - Recommendations for Addressing Resident Relationships Intimacy & Sexuality History that included an attached page of resident specific questions related to the relationship between R1 and R2. One copy had R1's name on the top and 1 copy had R2's name on the top. Both assessments and additional page of questions were blank. 3 of the 17 staff questionnaire sheets noted staff had seen R1 and R2 holding hands prior to the incident on 4/20/24. Documented under Investigation Summary was: .Description of Incident: On 4/20/2024, Licensed Practical Nurse [LPN-F], was completing her rounds and observed [R2] in [R1's] room. [LPN-F] stated [R1] had her breasts exposed and [R2] was touching her breasts. She removed [R2] from [R1's] room and notified [Nursing Home Administrator (NHA)-A] immediately. Investigation protocol was initiated, and the investigation was started immediately. Upon report of the above allegation, the following was initiated: Interview of affected residents Investigation protocol initiated Skin check completed on affected residents Self-report submitted Provider notified for both residents Residents monitored post interaction Police department notified of incident- declined to respond or pursue investigation Notification to [State Ombudsmen-J] Results of Investigation: [SSD-C] and [Social Services Coordinator (SSC)-G] interviewed [R1] and [R2]. The State of Wisconsin's Board on Aging and Long-Term Care's presentation on Balancing Rights and Protection: Inclusive Relationships, Sexuality and Consent was used as a guide to interview both Residents. [R1] denied the above allegation, stating she and [R2] were just watching TV. She denied that [R2] touched her in any way and expressed she was aware of her rights to maintain a relationship with [R2] should she wish. She acknowledged her awareness of her right to say no if she felt uncomfortable with any interactions with [R2] however denied any concerns at this time. She said she is not interested in pursuing anything beyond friendship with [R2] and enjoys spending time with him, as they have a lot in common. She denied any concerns and verbalized that she feels safe and comfortable at [the facility]. [R2] also denied the above allegations. He stated he and [R1] are very good friends and he feels thankful to have met someone he can share companionship with. He stated he is not interested in pursuing anything but friendship with [R1]. [R1] expressed awareness of his rights to pursue relationships and his right to say no if he felt uncomfortable with any interactions. He denied any concerns and stated he feels safe and comfortable at [the facility]. Both [R2] and [R1's] activated POA's (Power of Attorney) were notified of the interaction. Neither voiced any concerns and both stated they were happy their loved ones had found companionship in each other. [R1] and [R2] had increased monitoring post interaction. Skin assessments were completed with no evidence of trauma. [R1] and [R2] were noted to be watching TV in the common area and chatting per usual. No behaviors or complications noted as a result of the interaction . Surveyor reviewed documentation of email correspondence between SSD-C and Ombudsman-J. Documented to Ombudsman-J from SSD-C on 4/22/24, at 4:34 PM, was: We have 2 Residents here that have been pursuing a very close friendship recently. Over the weekend, they were noted to be engaging in some sexual behavior. We did submit a self report right away and interviewed both Residents regarding the incident however they both denied that anything happened. During the interviews, they both made it very clear they were only interested in pursuing a friendship with each other and were not interested in anything further. I was able to refer back to the presentation Balancing Rights and Protection from a few months ago for reference. Just wanted to make [sic] aware and see if you had any recommendations or suggestions on how to handle this moving forward. Thanks! Documented to SSD-C from Ombudsman-J on 4/23/24, at 4:55 PM, was: I have attached some documents about sexuality and intimacy you might find helpful. The important thing, if the residents decide to pursue something beyond friendship, is their ability to understand and give consent to one another. One of the documents attached is a guide in determining the ability to consent. The residents should not be deterred from pursuing a relationship, if they choose, as long as they still have an understanding of intimacy and can consent. Let me know if you have any additional questions. Attached to the email was Balancing Rights and Protection: Inclusive Relationships, Sexuality and Consent PowerPoint, Recommendations for Addressing Resident Relationships, Appendix 1 - Recommendations for Addressing Resident Relationships Intimacy & Sexuality History and Appendix 2 - Recommendations for Addressing Resident Relationship Assessment for Consent to Physical Sexual Expressions. Surveyor reviewed Recommendations for Addressing Resident Relationships. Documented was: This document provides guidance to facilities suggesting what might be included in a Resident Relationships Policy that addresses intimacy and sexuality issues. It does not in any way constitute a regulation, mandate or requirement. Facilities are encouraged to write their own policies related to these issues . Surveyor reviewed Appendix 1 - Recommendations for Addressing Resident Relationships Intimacy & Sexuality History. Documented was: This appendix is not legal advice or mandated, but is intended to be used as a guide for facilities to obtain information about a resident's intimacy and sexuality history. This history is to be completed with the resident, and the information obtained may be helpful overall in assisting residents to feel at home, comfortable and secure. This information may be best gathered once rapport is gained between a resident and staff skilled at interviewing. If additional information is needed, a family member or legal decision maker could be interviewed. It may be helpful to take notes about the resident's statements, as the actual verbal response often reveals a lot about the person's level of understanding of the topic. It should also be understood that the resident has the right to refuse to participate in this conversation, and that refusal should not constitute an inability to consent to an intimate or sexual relationship . Surveyor reviewed Appendix 2 - Recommendations for Addressing Resident Relationship Assessment for Consent to Physical Sexual Expressions. Documented was: Wisconsin has not specifically defined what an individual must understand in order to consent to sexual contact. However, discussion in the Guardianship of Adults (http://www.dhs.wisconsin.gov/publications/P2/p20460.pdf), implies that there may be indications that the following four guidelines could be used as the basis for an assessment to determine a person's ability to consent to sexual contact. Depending on the uniqueness of each situation, additional considerations might be appropriate. Assessment efforts should focus on the resident revealing his/her understanding of the following four guidelines: 1. The person understands the distinctively sexual nature of the conduct. That is, that the acts have a special status as sexual. 2. The person understands that their body is private and they have the right to refuse, or say no. They should also understand the other person should respect their right of refusal. 3. The person understands there may be health risks associated with the sexual act. (pregnancy, STD's, cardiac, other health risks) 4. The person understands there may be negative societal response to the conduct. (Gossip, name calling, social fallout, stigmatized.) . On 5/6/24, at 12:17 PM, Surveyor interviewed Social Service Director (SSD)-C and (Social Service Coordinator) SSC-G. Surveyor asked about the information provided by Ombudsman-J. SSD-C stated that is what they used to determine that both residents could consent and were allowed to have a relationship if they wanted to, but at this time they only wanted a friendship. Surveyor noted the blank copied of Appendix 1 with R1 and R2's names on them. Surveyor asked why the assessments were blank. SSD-C stated both residents refused to answer the questions. Surveyor asked if either resident were assessed prior to the 4/20/24 incident. SSD-C stated no. Surveyor noted that R1 and R2 were observed by staff holding hands and spending lots of time together. Surveyor asked why they were not assessed prior to the incident. SSD-C stated she was not sure. Surveyor asked if either resident was reapproached to answer any of the questions from Appendix 1 after the incident. SSD-C stated no because they were adamant it did not happen and it was just a friendship. Surveyor noted LPN-F had witnessed the incident. SSD-C and SSC-G did not respond. Surveyor asked where the refusal to answer the questions was documented. SSD-C stated it was not. Surveyor asked how they determined R1 and R2 were able to consent. SSD-C stated she asked the two questions, if they understood their rights to have a relationship and if they understood if the other one was reluctant to be in a relationship and the right to say no. Surveyor noted if they were using the information provided by Ombudsman-J, Appendix-J has four specific questions to determine competency. Surveyor asked if they had used Appendix 2. SSD-C stated no. Surveyor asked if either R1 or R2 had been assessed for consent prior to the incident on 4/20/24. SSD-C stated no. SSD-C stated R1 and R2 only want a friendship so consent was not needed. Surveyor asked what would warrant a sexual/intimacy assessment and consent assessment. SSD-C stated a resident wanting to pursue a relationship with someone in the facility. On 5/6/24, at 1:30 PM, Surveyor interviewed (Nursing Home Administrator (NHA)-A. Surveyor explained the concerns with no assessments being completed to determine a residents' ability to consent to a potentially sexual relationship prior to the 4/20/24 incident where R1 and R2 were observed touching each other in a sexual manner. NHA-A stated she was concerned about resident rights issues but understood the concerns about the assessments and they will be completed to avoid this situation.

Based on record review and interview, the facility did not comprehensively assess 2 (R1 and R3) of 3 residents reviewed for trauma informed care and care plan approaches to mitigate any triggers to prevent re-traumatization. ~ R1 was admitted [DATE] and during her admission psychosocial assessment, the facility did not identify R1 as having a history of physical abuse. On 5/1/24 the facility completed Trauma Informed Care Assessments for all high risk residents. R1's past history of physical abuse was then identified. A care plan and approaches to mitigate any triggers to prevent re-traumatization was not put in place after the assessment for R1 had been completed. ~ R3 was admitted on [DATE] and during her admission psychosocial assessment, the facility identified R3 as having a history of physical abuse. This information was not transferred to R3's plan of care. On 5/1/24 the facility completed Trauma Informed Care Assessments for all high risk residents and identified R3 as having a history of physical and sexual abuse. Prior to that R3 had no care plan approaches to mitigate any triggers to prevent re-traumatization. Findings include: Surveyor reviewed the facility's Trauma Informed Care policy with a revision date of 10/18/2022. Documented was: Policy: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Definitions: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to: a. Natural and human caused disasters b. Accidents c. War d. Physical, sexual, mental, and/or emotional abuse (past or present) e. Rape f. Violent crime g. History of imprisonment h. History of homelessness i. Traumatic life events (death of a loved one, personal illness, etc.) Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Policy Explanation and Compliance Guidelines: 1. The facility will work to facilitate the principles of trauma informed care which include: a. Safety - Ensuring residents have a sense of emotional and physical safety. b. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident. c. Peer support and mutual self-help - If practicable, assist the resident in locating and arranging to attend support groups (potentially hosted by the facility) which are organized by qualified professionals. d. Collaboration - an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care. e. Empowerment, voice, and choice - Ensuring that resident's choice and preferences are honored and that residents are empowered to be active participants in their care and decision-making, including recognition of, and building on resident's strengths. 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as reviewing documentation such as the history and physical, consultation notes, or information received from family/responsible party . 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. 5. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to: a. Experiencing a lack of privacy or confinement in a crowded or small space. b. Exposure to loud noises, or bright/flashing lights. c. Certain sights, such as objects that are associated with their abuser. d. Sounds, smells, and physical touch. 6. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. 7. The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified. 8. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. ~ R1 was admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Cognitive Communication Deficit, Anxiety and Symptoms and Signs Involving Cognitive Function and Awareness. Surveyor reviewed R1's MDS (Minimum Data Set) Assessment with an assessment reference date of 1/31/24. Documented under Cognition was a BIMS (brief interview mental status) score of 10 which indicated moderate cognitive impairment. Surveyor reviewed R1's Psychosocial Assessment Admission with an effective date of 1/27/24 prepared by Former Registered Nurse/Case Manager (RN)-I. Documented was Prior Trauma or [history/diagnosis (hx/dx)] of [Post Traumatic Stress Disorder (PTSD)]? c. none of the above. Surveyor noted the assessment did not identify R1's history of physical abuse. Surveyor reviewed R1's Trauma-Informed Care Observation with an effective date of 5/1/24 prepared by Social Services Director (SSD)-C. Documented was: .5. Have you ever experienced, witnessed, learned about a physical assault (e.g. attacked, hit, beaten up, etc.)? b. Personally experienced . Experience 1. Did any of these events bother you? b. Yes 2. Comments on events resident was bothered by: Resident states her ex-husband was physically abusive. He has since passed away. She remarried and stated her most recent husband was the best thing that ever happened to me. States she always has the memories of the abuse she suffered with her first husband however tries to remember the good memories with her second husband . Effects . 2. How much did the event(s) bother you emotionally? d. Much 3. What are the triggers that remind you of the event (e.g, loud noises, confined spaces, bath tubs, hot surfaces, sirens, etc.)? Verbalized no current triggers, just often thinks about the events. Has a close relationship with peer and daughter; states spending time with them helps her forget about negative memories. 4. How do you react when you are reminded of the event(s)? Becomes sad/tearful. Treatment 1. When you are reacting to the event(s), what helps you refocus? Spending time with friend/family, watching tv. Enjoys going for walks, going to group activities, enjoying nice weather, etc . Surveyor reviewed R1's Comprehensive Care Plan. There was no Trauma Informed Care care plan put in place after this assessment was completed. On 5/7/24, at 11:00 AM, Surveyor interviewed SSD-C. Surveyor asked why R1's physical abuse was not identified on her admission psychosocial assessment. SSD-C stated she was not sure and RN-I no longer worked at the facility. Surveyor asked why the Trauma Informed Care assessment was not done until 5/1/24. SSD-C stated R1 had an incident with another resident on 4/20/24 so they decided to assess all the high-risk residents. Surveyor asked who should receive a Trauma Informed Care assessment. SSD-C stated anyone who triggers for trauma on the psychosocial assessment. SSD-C stated she was unsure why R1's assessment did not identify the physical abuse. ~ R3 was admitted to the facility on [DATE] with diagnoses that included a Right Fibula Fracture, Personality Disorder, Anxiety and Schizoaffective Disorder. Surveyor reviewed R3's MDS (Minimum Data Set) Assessment with an assessment reference date of 12/6/23. Documented under Cognition was a BIMS (brief interview mental status) score of 06 which indicated severe cognitive impairment. Surveyor reviewed R3's Psychosocial Assessment Admission with an effective date of 11/30/23 prepared by Former Registered Nurse/Case Manager (RN)-I. Documented was: Social History . 5. Other important relationships: [Sister] - POA for healthcare (not active) Prior Trauma or [history/diagnosis (hx/dx)] of [Post Traumatic Stress Disorder (PTSD)]? a. Prior trauma 5aa. Describe prior trauma Resident states parents were physically abusive D. Care Planning Check all that apply to add care plan 2. Trauma Informed Care Surveyor noted the assessment did not identify R1's history of sexual abuse. Surveyor also noted no Focus, Goals or Interventions were checked under care planning. Surveyor reviewed R3's Comprehensive Care Plan. There was no Trauma Informed Care care plan put in place after this assessment was completed. R3 did have a care plan addressing her behaviors with an initiation date of 12/1/23. Documented was: Focus: At risk for adverse effects [related to (r/t)] use of antipsychotic medication, mood stabilizer Dx schizoaffective disorder, bipolar type anxiety disorder, personality disorder. Goal: - To show minimum side effects of medications taken - Show no signs of hallucinating or delusional thinking - Will have medication dose reduction/elimination as indicated Interventions/Tasks: - AIMS testing per facility guidelines (upon admission, initiation of, change of, every 6 months and [as needed (PRN)] - Evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs - Provide resident teaching of risks and benefits of medications as needed - Psychiatrist consult and follow up as needed - TARGET BEHAVIOR 1: Resident will become paranoid, believe that someone is trying to murder her and her family, someone is going to rape her and as a result can become verbally and physically aggressive. Intervention #1: Offer 1:1 opportunity to express feelings and validate. Intervention #2: Offer to assist in contacting sister. Intervention #3: Allow Resident time to calm and reapproach as needed. Offer to take for a walk to get some fresh air. - TARGET BEHAVIOR 2: Resident will become tearful when feeling depressed. Intervention #1: Offer 1:1 opportunity to express feelings and validate. Intervention #2: Offer to assist in contacting sister. Intervention #3: Offer diversionary activity. Resident enjoys watching tv, 1:1 visits, talking with sister. Surveyor reviewed R3's Trauma-Informed Care Observation with an effective date of 5/1/24 prepared by Nursing Home Administrator (NHA)-A. Documented was: .5. Have you ever experienced, witnessed, learned about a physical assault (e.g. attacked, hit, beaten up, etc.)? b. Personally experienced . 6. Have you ever experienced, witnessed, learned about a sexual assault (e.g. rape, attempted rape, mad perform a sexual act via force or threat of harm, etc.) b. Personally experienced . Experience . 2. Comments on events resident was bothered by: Sexual and physical abuse Effects 1. How long were you bothered by the event(s)? d. Other: 1a. I am still affected by these events. 2. How much did the event(s) bother you emotionally? e. Very much 3. What are the triggers that remind you of the event (e.g. loud noises, confined spaces, bath tubs, hot surfaces, sirens, etc.)? Seeing photos of my family, shows or movies involving abuse, the word abuse. Conversations regarding abusive or sexual situations. 4. How do you react when you are reminded of the event(s)? I cry and scream. Treatment 1. When you are reacting to the event(s), what helps you refocus? Talking to staff, going outside for fresh air, coloring, eating a snack, getting nails done. 2. What type of help have you received to address your response to the event(s)? b. Medications c. Counseling . 4. Additional Observer Info: Resident's trauma recently shared by her sister. Resident does often speak of her hallucinations (auditory and visual) and often talks to the voices in her head. She is redirectable but would benefit from a quiet, small environment. Placement being actively pursued as resident has done well in group home setting and regularly seeing psych services along with taking her medications . On 5/2/24 a Comprehensive Care Plan was put in place for R3 for Trauma Informed Care. Documented was: Focus: At risk for retraumatization of past event or experience where reminders/triggers of event or experience may cause behavioral changes and/or emotional distress per resident history of sexual assault and mental illness. Goal: Reminder/triggering events will be avoided with minimal impact during stay within the facility. Interventions/Tasks: - 1 on 1 care provided - Determine individualized de-escalation preferences; stop talking about current situation that is bothersome. - Monitor for decreased social interaction and explore opportunities to avoid decline. If other residents are engaging in conversation and it appears to be stressful, need to remove resident from situation/environment. - Monitor for increased withdrawal, anger or depressive behaviors and explore opportunities to avoid - Provide choice-making activities - Provide a safe environment - Refer to Psychology as indicated - Remove/Avoid situations that may trigger retraumatization including the word abuse, sexual abuse, pictures of family members. On 5/7/24, at 11:00 AM, Surveyor interviewed Social Service Director (SSD)-C. Surveyor asked why R3's Trauma Informed Care care plan and assessment was not completed until 5/1/24. SSD-C stated after the incident with R1 and R2 they decided to assess all the high-risk residents. Surveyor asked why the sexual abuse trauma was not identified earlier. SSD-C stated they found that information out from her sister/POA who was not involved until recently. Surveyor asked what recently meant. SSD-C stated the last week or two. Surveyor asked who should receive a Trauma Informed Care assessment. SSD-C stated anyone who triggers for trauma on the psychosocial assessment. Surveyor stated that R3's 11/30/23 Psychosocial Assessment triggered for trauma but there was no Trauma Informed Care assessment until this one completed on 5/1/24. SSD-C stated she was unsure why R3 did not have the trauma assessment done. SSD-C stated RN-I did the Psychosocial Assessment and she does not work here anymore so they were unable to ask her. On 5/6/24, at 1:30 PM, Surveyor interviewed NHA-A. Surveyor asked why the sexual abuse trauma for R3 was not identified earlier. NHA-A stated they found that information out from her sister/POA who was not involved until a few weeks ago. Surveyor noted on the 11/30/23 Psychosocial Assessment prepared by RN-I it stated Sister/POA as important person in her life. NHA-A stated she was unaware of that. Surveyor asked why all the Trauma Informed Care assessments were not completed until 5/1/24. NHA-A stated after the incident with R1 and R2 they identified the residents that were at risk for trauma and completed the assessment on them. Surveyor noted R3 did trigger for physical trauma on 11/30/23 and also had a care plan in place with behaviors that she will become paranoid, believe that someone is trying to murder her and her family and someone is going to rape her. NHA-A stated that is part her delusions and psych issues. Surveyor noted could these behaviors possibly be part of past trauma. NHA-A stated she understands the concerns. NHA-A stated R3 is working closely with Psych currently and will be transferred to a Psych group home which is a more appropriate setting for her.

Based on observation, record review and interview, the facility did not ensure food was prepared safely, for 75 of 75 Residents who eat food prepared in the main kitchen. On 1/23/24, the 2 thermometer probes were not sanitized between taking the temperatures of different food items. Findings: The facility policy, entitled Food Temperatures, revised date of 8/16/2022, states: the temperatures of all food items will be taken and properly recorded prior to service of each meal. On 01/23/24, at 11:19 AM, Surveyor observed Cook-D take temperature of food items. Cook-D opened two thermometers. The first thermometer #1 was placed in the ravioli and the temperature was taken. This thermometer was wiped with an alcohol swab and placed on a clean plate. This thermometer was then taken from the plate and placed in the green beans. The temperature was taken and then placed on the plate without being cleaned with an alcohol swab. This thermometer was then placed in puree veggie, the temperature was taken, and then placed on the plate with no cleaning of the thermometer. The second thermometer #2 was placed in a Salisbury steak and temperature taken. This thermometer was placed on the plate and not cleaned with an alcohol swab. Thermometer #2 was then picked up from the plate and placed into puree meat and temperature taken, it was cleaned with the same wipe as used previously and placed on the plate. Thermometer #2 was then placed in the puree ravioli, temperature was taken and then placed on the plate without cleaning of the thermometer. This process continued where the two thermometers alternated food items. The probes were not cleaned properly after each use or before taking the temperature of a different food item. A total of 10 different food items had their temperature taken and a total of 4 alcohol swabs were used. On 1/23/24, at 12:51 PM, Surveyor interviewed Dietary Manager-E and District Manager-F who explained that the thermometer probe should be cleaned with a wipe after each food item to prevent any cross contamination. Surveyor explained concern with the observation of temperatures being taken and the use of two thermometers and only being wiped occasionally after being in a food item. District Manager-F stated this was not their process and that if 10 food items were tested then there should have been a total of 10 wipes used. District Manager-F stated they would begin conducting an in-service for dietary staff starting with the cooks. On 1/23/24, at 03:10 PM, at the end of the day meeting with Nursing Home Administrator-A, Director of Nursing-B, and Social Worker-C, Surveyor explained concerns with observation of temperatures being taken at the lunch time meal. They expressed that they understood the concern and that food service employees would be educated. No additional information provided.

Based on record review and interview, the facility did not review and revise Comprehensive Care Plans by the interdisciplinary team with resident voice after comprehensive and quarterly assessments for 7 (R13, R7, R14, R47, R22, R24 and R15) of 18 sampled residents. R13, R7, R14, R47, R22, R24, and R15 did not have quarterly care conferences with the Interdisciplinary Team (IDT) and resident or resident representative and did not have documentation of inviting the resident or resident representative and their declination of the invitation. Findings: The facility policy and procedure entitled Comprehensive Care Plan dated 9/23/2022 states: Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS (Minimum Data Set) assessment. Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. 3. The comprehensive care plan will describe, at a minimum, the following: . f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: . e. The resident and the resident's representative, to the extent practicable. Based on record review and interview, the facility did not review and revise Comprehensive Care Plans by the interdisciplinary team with resident voice after comprehensive and quarterly assessments for 7 (R13, R7, R14, R47, R22, R15, and R24) of 18 sampled residents. R13, R7, R14, R47, R22, R15, and R24 did not have quarterly care conferences with the Interdisciplinary Team (IDT) and resident or resident representative and did not have documentation of inviting the resident or resident representative and their declination of the invitation. Findings: The facility policy and procedure entitled Comprehensive Care Plan dated 9/23/2022 states: Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS (Minimum Data Set) assessment. Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. 3. The comprehensive care plan will describe, at a minimum, the following: . f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: . e. The resident and the resident's representative, to the extent practicable. 1. R13 was admitted to the facility on [DATE] with diagnoses of lumbar radiculopathy, chronic obstructive pulmonary disease, morbid obesity, lymphedema, depression, atrial fibrillation, and anxiety. R13's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R13 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R13 did not have an activated Power of Attorney. R13 had an Annual MDS assessment dated [DATE] with a documented Care Conference with the IDT on 7/26/2023. No other Care Conferences were documented. No documentation was found indicating R13 was offered a Care Conference at any time after 7/26/2023 and declined attending. 2. R7 was admitted to the facility on [DATE] with diagnoses of demyelinating disease of the central nervous system, lupus, paraplegia, chronic kidney disease, depression, and osteoporosis. R7's Quarterly MDS assessment dated [DATE] indicated R7 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R7 did not have an activated Power of Attorney. R7 had a Quarterly MDS assessment dated [DATE] with a documented Care Conference with the IDT on 6/26/2023. No other Care Conferences were documented. No documentation was found indicating R7 was offered a Care Conference at any time after 6/26/2023 and declined attending. On 1/22/2024 at 9:57 AM, Surveyor asked R7 if R7 had quarterly Care Conferences to discuss their plan of care and goals. R7 stated they had a Case Manager but did not have any meetings with anyone. 3. R14 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease Stage 4, chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, and fibromyalgia. R14's Quarterly MDS assessment dated [DATE] indicated R14 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R14 did not have an activated Power of Attorney. R14 had a Quarterly MDS assessment dated [DATE]. On 8/3/2023 at 10:29 AM in the progress notes, Social Worker (SW)-C charted R14's AHCPOA (Activated Healthcare Power of Attorney) declined a care conference for R14 and wished R14 to remain a DNR (Do Not Resuscitate). R14's AHCPOA agreed to the psych recommendation for melatonin 3 mg. Surveyor noted R14's Power of Attorney had not been activated. No documentation was found indicating the IDT had a Care Conference for R14 to correlate with the 7/31/2023 Quarterly MDS assessment. R14 elected hospice services on 8/16/2023 with a terminal diagnosis of end stage kidney disease. No documentation was found of a Care Conference including the IDT and the hospice agency. R14 had a Quarterly MDS assessment dated [DATE]. A Psychosocial Assessment was completed on 10/31/2023 by Social Worker (SW)-L. SW-L documented R14 declined scheduling a Care Conference at that time. SW-L charted R14 had a HCPOA in place but R14 is their own decision maker. No documentation was found indicating the IDT had a Care Conference for R14 to correlate with the 10/31/2023 Quarterly MDS assessment or with the hospice agency. R14 had a Significant Change MDS assessment dated [DATE] to capture the election of hospice services in 8/2023. No documentation was found of a Care Conference including the IDT and the hospice agency or documentation R14 was invited to attend the Care Conference and their declination to attend. 4. R47 was admitted to the facility on [DATE] with diagnoses of osteomyelitis of the left ankle and foot, diabetes, depression, anxiety, epilepsy, and peripheral vascular disease. R47's Quarterly MDS assessment dated [DATE] indicated R47 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12. R47 did not have an activated Power of Attorney. On 7/13/2023 on the Care Conference Summary, R47 was invited to the Care Conference and attended along with Social Worker (SW)-l and an Occupational Therapist. R47 declined family to be invited. The purpose of the meeting was to establish a Baseline Care Plan. On 8/18/2023 on the Care Conference Summary, R47 was invited to the Care Conference and attended along with SW-I and an Occupational Therapist. R47 declined family to be invited. The purpose of the meeting was due to readmission to the facility after hospitalization . No documentation was found that R47 had a Care Conference or was invited to attend a Care Conference and the declination of attending after the Care Conference on 8/18/2023. In an interview on 1/24/2024 at 1:21 PM, Surveyor asked Registered Nurse Case Manager (RNCM)-K what the facility process was for Care Conferences. RNCM-K stated when a resident is newly admitted , a Care Conference is held within the first 24-48 hours and the following Care Conferences are dependent on the resident and their discharge goals. RNCM-K stated RNCM-K works with the short-term residents and if a resident is admitted for long term care or hospice, RNCM-K attends the initial Care Conference and then Social Worker (SW)-L takes over for the following Care Conferences. In an interview on 1/24/2024 at 1:31 PM, Surveyor asked SW-L how Care Conferences are scheduled and who attends the Care Conferences for long term care residents. SW-L stated Care Conferences for long term care residents are held quarterly or annually. SW-L stated the resident will be asked if they want to schedule a Care Conference and most times the resident will decline having a Care Conference. SW-L stated when SW-L talks to the resident quarterly to do the BIMS and the PHQ-9 for the MDS, SW-L will verify the code status with the resident and then invite them to a Care Conference. Surveyor asked SW-L if the resident declines the Care Conference, does the IDT meet to discuss the resident and their plan of care with goals. SW-L stated the IDT does not meet. SW-L stated the resident's care plan is reviewed individually by the IDT members. SW-L stated the IDT does touch base in morning meetings and monthly behavior meetings when psychotropic medications are reviewed. SW-L stated it is the resident's right to decline a Care Conference. Surveyor agreed with SW-L that the resident or resident representative does not have to attend the Care Conference, but the Care Plan should have the resident voice which SW-L could bring forward to the Care Conference with the IDT to incorporate into the Care Plan. SW-L stated R13 declined the last couple of Care Conferences and stated SW-L did not schedule a Care Conference for the IDT to meet and review R13's Care Plan to ensure it had R13's voice. SW-L stated R7 usually declines Care Conferences and stated R7 is reviewed in behavior meetings because R7 is on psychotropic medications, so they are being monitored. SW-L stated SW-L did not schedule a Care Conference for the IDT to meet and review R7's Care Plan to ensure it had R7's voice. SW-L stated R14 has an activated Power of Attorney who was invited to a Care Conference which they declined, but the code status was verified and confirmed R14 was to stay long term care. SW-L stated SW-L did not schedule a Care Conference for the IDT to meet and review R14's Care Plan to ensure it had R14's voice. Surveyor asked SW-L if a Care Conference was held when R47 became a long-term care resident with different needs from initially expecting to go home after therapy completed. SW-L stated R47 usually declines Care Conferences and stated R47 is reviewed in behavior meetings because R47 is on psychotropic medications, so they are being monitored. SW-L stated SW-L did not schedule a Care Conference for the IDT to meet and review R47's Care Plan to ensure it had R47's voice. On 1/24/2024 at 2:11 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R13 had not had a Care Conference since 7/26/2023 and the IDT does not meet to review R13's Care Plan to ensure R13's voice is in the Care Plan. Surveyor shared with NHA-A the concern R7 had not had a Care Conference since 6/26/2023 and the IDT does not meet to review R7's Care Plan to ensure R7's voice is in the Care Plan. Surveyor shared with NHA-A the concern no documentation was found indicating R14 has had a Care Conference and the IDT does not meet to review R14's Care Plan to ensure R14's voice is in the Care Plan. Surveyor shared with NHA-A the concern no documentation was found indicating R47 has had a Care Conference and the IDT does not meet to review R47's Care Plan to ensure R47's voice is in the Care Plan. Surveyor shared with NHA-A no documentation was found that the IDT met to discuss R47's Care Plan or goals with R47's wishes being presented and there was no documentation R47 was invited to attend a Care Conference and declined the invitation since the readmission Care Conference on 8/18/2023. NHA-A stated if the resident or family decline to come to a care conference, the IDT still review the Care Plan but do not have a Care Conference. No further information was provided at that time. 46214 5. R22 was admitted on [DATE] with diagnoses that include cerebral palsy, epilepsy, encephalopathy, dementia, heart failure and other developmental disorders of speech and language. R22's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R22 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 and the Activities of Daily Living Care indicate that R22 needs extensive assistance with all cares. R22 does have a Guardian. Surveyor reviewed R22's medical record. A psychosocial note dated 2/23/23 documents, .Writer is trying to schedule a care conference with hospice and family. Another psychosocial note dated 2/2/23 documents, .declined scheduling a care conference as we had one not long ago. Care Conferences documented in R22's medical record occurred on 3/1/23 and 11/21/22. No other documentation was found of quarterly care conference meetings. On 01/23/24, at 03:11 PM, at the daily exit with the facility, Surveyor shared with Nursing home Administrator (NHA)-A, Director of Nursing (DON)-B and Social Worker (SW)-C concern for no care conference meeting documentation could be found since 3/1/23. NHA-A stated they would look for information. 6. R24 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, heart failure, depressive disorder, lymphedema and encephalopathy. R24's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R24 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and the Activities of Daily Living Care indicate that R24 is dependent with most cares. On 1/23/24, Surveyor spoke with R24 about their care conferences. R24 stated that they don't attend care conferences as they usually decline them. Surveyor reviewed R24's medical record. Social services note dated, 9/15/23, documents, .Declines care conference at this time. Surveyor reviewed R24's medical record and was unable to locate any care conferences over the past year. On 01/23/24, at 03:11 PM, at the daily exit with the facility, Surveyor shared with Nursing home Administrator (NHA)-A, Director of Nursing (DON)-B and Social Worker (SW)-C concern for no care conference meeting documentation could be found for R24. NHA-A stated they would look for information. 7. R15 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, major depressive disorder, epilepsy, dyskinesia of esophagus and mild neurocognitive disorder. R15 has an activated Power of Attorney (POA). R15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R15 is moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 and the Activities of Daily Living Care indicate that R15 is dependent with most cares. Surveyor reviewed R15's medical record. A communication with family/POA note dated, 10/10/23, documents, .offer to schedule a care conference .and declined a care conference being scheduled at this time. Surveyor reviewed R15's medical record and care conferences were documented on 8/31/22, 11/3/22 and 3/2/23. Surveyor was unable to locate any care conferences held after 3/2/23. On 01/23/24, at 03:11 PM, at the daily exit with the facility, Surveyor shared with Nursing home Administrator (NHA)-A, Director of Nursing (DON)-B and Social Worker (SW)-C concern for no care conference meeting documentation after 3/2/23 could be found for R15. NHA-A stated they would look for information. On 01/24/24, at 07:38 AM, NHA-A informed Surveyor they could not locate any care conference documentation after 3/1/23 for R22, no care conference for R24 for the past year, and no care conference after 3/2/23 for R15. NHA-A stated that when a resident or power of attorney does not want a care conference, they do not schedule one, however the residents code status is still updated at that time. On 01/24/24, at 01:36 PM, Surveyor interviewed Social Worker-L regarding care conferences. Social Worker-L confirmed when a resident declines to have a care conference the interdisciplinary team does not usually meet. They will still update a resident's code status. Surveyor informed her of the concerns that R22 did not have a care conference since 3/1/23. Surveyor informed her of the concerns that R24 did not have a care conference over the past year. Surveyor informed her of the concerns that R15 did not have a care conference held after 3/2/23. No additional information was provided.

Based on interview and record review the facility did not ensure 1 (R54) of 2 residents reviewed for psychotropic medication were being assessed and monitored appropriately to be free from unnecessary drugs. R54 started Quetiapine/Seroquel (Antipsychotic) and did not have an AIMS (Abnormal involuntary movement scale) completed at the start of the medication. When the AIMS was completed, there was a recommendation for a neurological exam based off of the score indicated. There was no follow up on this recommendation or reassessment of the AIMs score. Finding include: The facility policy, entitled Psychotropic Medications, date revised 10/24/22, states: #8. Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement scale (AIMS) test performed on admission, at least every 6 months, when the antipsychotic medication is changed, and PRN. R54 was admitted to the facility on [DATE] with diagnoses of heart disease with heart failure, unspecified dementia, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, and alcohol abuse with alcohol induced mood disorder. R54's Quarterly MDS (Minimum Data Set) assessment, dated 12/14/23, documents a BIMS (Brief Interview for Mental Status) score of 3, indicating R54 is severely cognitively impaired. It also assesses that R54 is taking antipsychotics and antianxiety medication. Review of R54's medical record documents a physician order that documents, Seroquel, oral tablet, 25 MG (milligram), give 12.5 mg by mouth two times a day for Dementia, with an active date of 12/9/23. Review of R54's Monthly Medication Pharmacy Review dated 10/2/2023 documents recommendations were made which include to check the AIMS. Review of R54's Monthly Medication Pharmacy Review dated 11/6/23 documents recommendations were made which include to check the AIMS. Surveyor was able to locate one AIMS which was completed on 11/16/23. The score on this assessment is 4 which indicates a referral for neurological exam is needed. Surveyor notes that there are no AIMS completed when Seroquel was originally started on 9/25/23. Surveyor is also unable to locate any follow up for this neurological exam or a retake of the AIMS to determine if the score of 4 was a mistake or not. On 01/24/23, at 1:11 PM, Surveyor spoke with Director of Nursing (DON)-B who informed Surveyor that they are new to their role and unsure of who administers the AIMS and how often the AIMS should be completed. DON-B also informed Surveyor that she just recently started taking over reviewing the monthly medication pharmacy reviews and did not know who was responsible for the follow up prior to her. On 01/24/24, at 02:59 PM, at the end of day meeting with Nursing Home Administrator (NHA)-A, DON-B, Social Worker (SW)-C, Surveyor informed them of the concerns regarding a lack of an AIMS upon start of an antipsychotic for R54 and that for two months the monthly pharmacy review recommended an AIMS to be completed and then when it was completed the score indicated that a referral for a neurological exam was needed. Surveyor asked if there was any follow up. They stated they would look. On 01/25/24, at 07:31 AM, NHA-A and SW-C informed Surveyor that R54 was seen on 11/21/23 by neurology for follow up for his stroke. The team felt that this appointment was satisfactory and that a new referral was not made based off of the AIMS assessment. Surveyor reviewed the after-visit paperwork summary from the neurology visit on 11/21/23 and did not find any reference to neurological work up for side effects for antipsychotics as well as did not find Seroquel listed on the current medication list. Surveyor could not find documentation that the neurologist was made aware of the antipsychotic and results of the AIMS and therefore would not even know to be looking for side effects of them. On 01/25/24, at 07:57 AM, NHA-A stated that in review they believe that the initial AIMS completed on 11/16/23 was scored incorrectly and that they redid the AIMS the previous night and got a score of 0. NHA-A explained that they did start education for nurses on how to administer the AIMS and scoring. No additional information was provided.

Based on observation, interview and record review the facility did not ensure its medication error rates are not 5 percent or greater. There were 2 errors in 29 opportunities for an error rate of 6.9% for R3 and R22. * R3 was administered Senna Plus (Docusate Sodium/Sennosides) versus regular Senna as ordered by the Physician. * R22's Medication Administration Record (MAR) documented an order for Atropine 0.01% versus 1% as ordered by the Physician. Findings include: The facility policy titled Medication Administration dated 01/23 documents (in part) . .Medication Preparation 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label. Medication Administration 9. Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is prepared c. Before dose is administered 1. On 1/23/24 at 7:45 AM Surveyor observed Licensed Practical Nurse (LPN)-G prepare R3's medications which consisted of Senna Plus (Docusate Sodium/Sennosides) 50/8.6 mg (milligrams) - 2 tablets, Aspirin EC (enteric coated) 81 mg - 1 tablet, Arnulty Ellipta (Fluticasone) 100 mcg (micrograms) 1 puff daily, Quetiapine Fumarate 50 mg - 1 tablet, Divalproex Sodium DR (delayed release) 250 mg - 1 tablet, Fluoxetine HCL 10 mg - 3 tablets, Metformin HCL ER 750 mg - 1 tablet and Miralax 17 grams mixed with 180 ml (milliliters) of water. Surveyor verified the number of tablets with LPN-G. LPN-G reported Calcium with vitamin D and Laculose was not available and would obtain from contingency/order from pharmacy. LPN-G handed R3 the cup containing the medications and R3 proceeded to swallow the medications with Miralax/water. LPN-G handed R3 the inhaler which she did independently and rinsed her mouth after. R3's current January 2024 MAR documented an order for Senna Oral Tablet (Sennosides) Give 2 tablets by mouth two times a day for laxative - start date 9/28/23. Surveyor noted LPN-G administered Senna Plus versus the Sennosides as ordered. On 1/23/24 at 9:09 AM Surveyor advised LPN-G of the observation Senna Plus versus Senna given. LPN-G advised Surveyor she gave R3 the Calcium and Lactulose. LPN-G reported pharmacy made a delivery last night and the medications were put in the wrong medication cart. Surveyor verified the medications signed out as administered. 2. On 1/23/24 at 9:30 AM Surveyor observed LPN-H prepare medications for R22 which consisted of Atropine 1% eye drops - 2 drops sublingually TID (three times daily), Famotidine 20 mg - 1 tablet and Levetiracetam oral solution 100 mg/ml - 2.5 ml. LPN-H administered the Famotidine and Levetiracetam through R22's gastrostomy tube. Surveyor identified no concerns with procedure. R22 refused the Atropine. LPN-H asked R22 three times, but R22 refused. R22's current January 2024 MAR documented an order for Atropine Sulfate Ophthalmic Solution 0.01 % - Give 2 drops by mouth three times a day for oral secretions - start date 2/20/23. On 1/23/24 at 9:56 AM Surveyor asked LPN-H to view the Atropine bottle together. Surveyor advised LPN-H the label indicates 1%, however the MAR order indicates 0.01%. LPN-H stated: I don't know, I'll have to look into that. Surveyor review of R22's medical record revealed a progress note dated 1/23/24 at 10:59 AM which documented: Writer had Atropine eye drops clarified by NP (Nurse Practitioner) and order rewritten. Family here visiting and updated of patient's condition. Note Text: Atropine Sulfate Ophthalmic Solution 1% - Give 2 drop by mouth three times a day for secretions - Atropine 1% eye drop instill 2 drops sublingually TID. Surveyor noted R22's MAR was corrected to include the order for Atropine 1% versus 0.01%. On 1/24/24 at 9:05 AM Nursing Home Administrator (NHA)-A was advised of the above observations and medication error rate. No additional information was provided.

Based on observation, interview and record review the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 2 of 3 medication carts reviewed in the facility. * Medication carts contained insulin that was not labeled, dated and/or expired. On [DATE] Surveyor observed a Levemir insulin pen which was open and used, but not dated when opened. In addition, there was no label or name on the insulin pen. On [DATE] Surveyor observed R23's Levemir insulin vial was open and used dated wither ,d+[DATE] or [DATE]. Once opened this product expires 42 days after first use or removal from the refrigerator which ever comes first. In addition, the physician's order indicates a discontinued date of [DATE] for Levemir Subcutatneous Solution 100 Unit/ML On [DATE] Surveyor observed R46's Humalog insulin Kwikpen was open and used dated [DATE]. Once opened this product expires 28 days after first uses or removal from the refrigerator, whichever comes first. Findings include: The facility policy titled Medication Storage dated ,d+[DATE] documents (in part) . .Policy Medications and biological's are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures 12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in the refrigerator or at room temperature. Opened insulin pens can be stored at room temperature. (Refer to Section 9.10 - Medications with Shortened Expiration Dates). 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists. The facility policy titled Medication Administration dated ,d+[DATE] documents (in part) . .Medication Administration 8. Check expiration date on package/container. No expired medication will be administered to a resident. a. Drugs dispensed in the manufacturer's original container will be labeled with a manufacturer's expiration date. b. The nurse shall place a date opened sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. c. Certain products or package types such as multi-dose vials and opthalmic drops have specific shortened end-of-use dating, once opened, to ensure medication purity and potency (refer to section 9.10 - Medications With Shortened Expiration Dates). Section 9.10 Appendix of Resources Medications with Shortened Expiration Dates: Levemir vial: Once opened product expires 42 days after first use or removal from refrigerator, whichever comes first. Levemir Flextouch pen: Once opened product expires 42 days after first use or removal from refrigerator, whichever comes first. Humalog kwikpen: Once opened product expires 28 days after first use or removal from refrigerator, whichever comes first. 1. On [DATE] at 1:53 PM Surveyor observed the unit 300 side 2 medication cart. In the top drawer of the cart, Surveyor located a Levemir insulin pen which was open and used, but not dated when opened. In addition, there was no label or name on the insulin pen. Surveyor asked Licensed Practical Nurse (LPN)-H who the insulin pen belonged to. LPN-H stated: I don't know, there's no name on it. 2. Surveyor located a Levemir insulin vial labeled with R23's name, which was open and used, dated [DATE] or [DATE]. Surveyor asked LPN-H if she could clarify the date. LPN-H reported she was not sure which date was written, adding either way it not right. Let me look to see if she even still gets it. LPN-H looked at R23's Medication Administration Record and stated: Yes, she still gets it. I think they switched her to the pen, I'll get rid of this (referring to vial). Surveyor review of R23's Physician's orders documented: Levemir Subcutaneous Solution 100 UNIT/ML (milliliters) Inject 25 unit subcutaneously one time a day for DM (Diabetes Mellitus) start date [DATE] discontinued [DATE]. Levemir FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 25 unit subcutaneously one time a day related to Type 2 DM with hyperglycemia start date [DATE]. 3. On [DATE] at 2:06 PM Surveyor observed unit 200 high end medication cart. In the top drawer, Surveyor located a Humalog insulin kwikpen with R46's name which was open and used, dated [DATE]. Surveyor showed LPN-I the Humalog insulin pen and asked if she knew how long the insulin was good for once opened. LPN-I stated: I'm not sure, I think 3 months. Usually there's a label with a use by date. LPN-I looked at the insulin pen and was unable to find a use by date. LPN-I stated: Just leave it here and I will get rid of it. On [DATE] at 9:00 AM Nursing Home Administrator (NHA)-A was advised of the above observations. No additional information was provided.

Based on interview and record review, the facility did not ensure Residents (R) without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 2 (R18 & R13) of 8 Residents reviewed for pressure injuries. *An unavoidable skin integrity care plan was developed for R18 on 09/02/20, which was R18's admitted . On 07/13/21, R18 was identified with a Stage 3 coccyx pressure injury. On 07/15/21, the facility developed a pressure ulcer actual or at risk care plan. R18's coccyx pressure injury healed on 07/20/21. On 08/18/21, the weekly skin review documents a Stage 2 sacrum pressure injury. On 08/19/21, the pressure injury weekly tracker documents a Stage 3 coccyx pressure injury with measurements of 4.6 x 2.5 x 0.1 The facility did not clarify R18's at risk for unavoidable skin integrity condition or pressure sores intervention of encouraging frequent repositioning in bed and chair when R18 required extensive assistance with one person physical assist for bed mobility. The facility did not revise R18's pressure ulcer actual or at risk care plan after R18 developed the stage 3 coccyx pressure injury. This care plan did not include repositioning until 06/16/22. On 09/07/21, R18's coccyx pressure injury declined to unstageable. There was no revision to either at risk for unavoidable skin integrity condition or pressure sores or pressure ulcer actual or at risk care plan until 05/27/22. On 11/29/21, R18's coccyx pressure injury with measurements of 2 x 2 x 0.4 is identified as a Stage 4. WD (Wound Doctor) R's recommendations of limit sitting to 60 minutes; off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able, were not implemented into R18's plan of care or clarified with WD R and R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. On 11/29/21, WD R ordered treatment of: wash with soap and water, dry, apply Dakins soaked gauze to wound bed, apply bordered gauze, change twice daily and as needed. This pressure injury treatment was not started until 12/02/21, three days later. On 06/06/22, R18's coccyx pressure injury was identified as being infected and Doxycycline (an antibiotic) 100 mg (milligrams) twice daily was ordered. On 06/20/22, WD R recommended R18 be sent out to the ER (emergency room ) for debridement under GA (general anesthesia), due to necrotizing fasciitis. R18 was hospitalized from 06/20/22 to 06/25/22. On 09/15/22 & 09/20/22, Surveyor observed R18 in bed with the air mattress off. The facility's failure to revise R18's skin integrity care plan when R18 developed a Stage 3 coccyx pressure injury on 08/19/22, not revising the care plan after the pressure injury declined to unstageable on 09/07/21, and not clarifying encourage frequent repositioning when R18 required extensive assistance with bed mobility and the progression of the coccyx pressure injury to a Stage 4 on 11/29/21, created a finding of Immediate Jeopardy (IJ) which began on 11/29/21. Surveyor notified Nursing Home Administrator (NHA) A & ADON (Assistant Director of Nursing) D of the immediate jeopardy on 09/21/22 at 2:05 p.m. The immediate jeopardy was removed on 09/22/22. The deficient practice continues at a scope and severity of D (potential for harm/isolated) related to the example involving R13 and as the facility continues to implement its action plan. *R13's heels were not off-loaded according to the plan of care. Findings include: The Pressure and Non-pressure Injuries policy & procedure with an original effective date of 08/2/21 documents under Policy: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. Under procedure documents: Complete the Braden scale to assess risk of developing a PI (pressure injury). It consists of six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A Braden Scale assessment tool will be completed: i. Upon admission/re-admission ii. Weekly for 3 more weeks in addition to initial assessment. iii. Upon a significant Change in Condition iv. Quarterly with the MDS (minimum data set) schedule v. As needed. Under the Care Plan section documents: A Comprehensive Skin Integrity Care Plan is based on resident history, review of Skin Assessment, Braden Scale Scoring, Nutritional Assessments, resident and family interviews, and staff observations. Consider the area of risk, as well as overall risk assessment score of the Braden Scale. Communicate identified risk factors and interventions to direct care staff. 2. Develop interventions based on individual Risk Factors including, but not limited to, weight, presence of edema, overall health status/comorbidities, use of medical devices, presence of acute infection, end-of life/hospice, resident choice/preferences, or medications that may impact healing. a. In the context of the resident's choices, clinical condition, and physician input, the resident's care plan should establish relevant goals and approaches to stabilize or improve co-morbidities, such as attempts to minimize clinically significant blood sugar fluctuations, and other interventions aimed at limiting the effects of risk factors associated with pressure injuries. Alternatively, center staff and practitioner should document clinically valid reasons why such interventions were not appropriate or feasible. For a resident to exercise his or her right appropriately to make informed choices about care and treatment or to decline treatment, the center and the resident (or if applicable, the resident representative) must discuss the resident's condition, treatment options, expected outcomes, and consequences of declining treatment or interventions. Centers should document this discussion in the Risk vs Benefit UDA in the electronic medical record. The care plan should be updated to reflect the resident's choice and what interventions will be in place to minimize risk to the resident. R18 was admitted to the facility on [DATE]. Diagnoses include diabetes mellitus (DM), Parkinson's Disease, and hypertension. R18 was admitted to hospice on 06/17/21. The at risk for unavoidable skin integrity condition or pressure sores r/t lymphedema, edema, DM care plan initiated 09/02/20 & revised 06/27/22 has the following interventions: * Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. Initiated 09/20/20 and revised & canceled on 07/28/22. * Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately. Initiated 09/02/20 & revised 07/28/22. * Conduct pressure injury skin assessments (i.e. Braden scale) as indicated. Initiated 09/02/20. * Encourage frequent repositioning in bed and chair. Initiated 09/02/20 & revised 09/30/20. * Encourage to float heels off the surface of the bed. Initiated 09/30/20. * Head to toe assessment by licensed nurse performed weekly at minimum. Initiated 09/02/20. * Keep resident clean and dry. Use barrier cream after good peri-care. Apply proper incontinent products as indicated. Initiated 09/02/20 & revised 07/19/21. * Place washcloth (palm guards) between hands check placement every shift. Initiated 12/10/21 & revised 07/28/22. * Unavoidable statement signed by MD (medical doctor). Initiated 05/27/22. * Apply alternating pressure air mattress to bed if indicated. Assure proper inflation check frequently. Initiated & revised 07/28/22. * Avoid friction/shearing while repositioning: if Resident is unable to assist use at least 2 staff members, use lift sheet, bed should be as flat as possible with lifting. Initiated 07/28/22. * Prevalon boots on while in bed and as tolerated by resident. Initiated 08/03/22. The significant change MDS (minimum data set) with an assessment reference date of 06/24/21 documents R18 has short term & long term memory problems and is severely impaired in cognitive skills for daily decision making. R18 requires extensive assistance with one person physical assist for bed mobility, transfer, eating, & toilet and does not ambulate. R18 is coded as always being incontinent of urine and frequently incontinent of bowel. R18 is at risk for pressure injuries and is coded as not having any pressure injuries. The pressure injury CAA (care area assessment) dated 06/24/21, under analysis of findings documents: Significant change in status assessment. Resident signed onto hospice services. Diagnoses include; Parkinson's, DM2 (diabetes mellitus) with Neuropathy, HLD (hyperlipidemia), HTN (hypertension), Lymphedema, UTI (urinary tract infection). Always incontinent of bladder and frequently incontinent of bowel during the look back period. Staff provides incontinence cares. Incontinent briefs in place. Takes diuretic which can contribute to urgency and frequency. Staff to provide incontinence care in timely manner to maintain clean dry skin. Staff to assess skin integrity. Staff to assist with repositioning while in bed and/or chair. The wound evaluation tracker dated 07/13/22 for the question, When was the wound identified? documents 07/13/2021. Under current wound status/additional comments documents, New acquire stage III (3) pressure injury to coccyx. 0.4 x (times) 0.4 x 0.1 in dimensions. 100% granular tissue. No drainage, no s/s (signs/symptoms) of infection, surrounding tissues are warm, dry and intact. No pain with cleansing. New wound care orders received. Applying air mattress through hospice care. Hospice nurse in to eval. (evaluate). POA (power of attorney) [name] updated. [Name] NP (Nurse Practitioner) updated. A treatment to wash, dry, apply foam dressing with directions to change every 72 hours and as needed was implemented on 07/14/21 and continued until the treatment was discontinued on 09/08/21. A pressure ulcer actual or at risk care plan was initiated on 07/15/21. The Braden Scale assessment dated [DATE] has a score of 15 which indicates at risk. Surveyor noted the next Braden was completed 07/02/22. The pressure ulcer actual or at risk care plan initiated 07/15/21 & revised 08/03/22 documents interventions of: * Air mattress - monitor for proper setting/function q (every) shift and prn (as needed) (keep at 150 pounds). Initiated 7/15/21 & revised 7/28/22. * Complete Braden scale per Living Center Policy. Initiated 7/15/21. * Conduct weekly skin inspection. Initiated 7/15/21. * Do not massage over bony prominence. Initiated 7/15/21. * Nutritional and hydration support. Initiated 7/15/21. * Prevalon boots on while in bed and as tolerated by resident. Initiated 7/19/21 & revised 8/3/22. * Provide pressure reducing wheelchair cushion. Initiated 7/15/21. * Provide pressure reducing/relieving mattress. Initiated 7/15/21. * Provide thorough skin care after incontinent episodes and apply barrier cream. Initiated 7/15/21. * Skin assessment to be completed per Living Center Policy. Initiated 7/15/21. * Treatments as ordered. Initiated 7/15/21. * Weekly wound assessment. Initiated 7/15/21. * Turn and reposition Q (every) 1-2 hours. Initiated 06/16/22. The social service note dated 07/16/21 documents: Writer met with husband this date. Aware of change in transfer status; Res currently requires hoyer lift with staff due to decreased strength/difficulty standing. Support provided to husband. No concerns noted at this time. SS (social service) will cont (continue) to follow. The wound evaluation tracker dated 07/20/21 under current wound status/additional comments documents: Wound is now closed. Continue to monitor weekly for re-opening with wound rounds. Surrounding tissues are warm, dry, and intact. The nurses note dated 08/18/21 documents: CNA called writer to room to report open area, pressure injury to top crease of buttocks. Writer cleansed area with saline and covered with Mepilex. Resident skin warm and dry. No active bleeding noted, no s/s (signs/symptoms) of infection noted. Call out to MD (medical doctor) to update. Call out to POA (power of attorney) to update. All aware. Will monitor. The weekly skin review dated 08/18/21 documents: Sacrum Stage 2 pressure injury in top crease of buttocks. Surveyor noted there are no measurements or description of wound bed for this weekly skin review. The pressure injury weekly tracker dated 08/19/21 documents: Coccyx, Pressure, with measurements of 4.6 x 2.5 x 0.1. Stage III (3), 100% granulation. The nurses note dated 08/19/21 documents: Follow up O/A (open area) to crease in buttocks. O/A (open area) measured today by unit manager. Treatment changed and C/D/I (clean dry intact). Skin warm and dry. Resident in bed resting at this time. Will monitor. The nurses note dated 08/20/21 documents: IDT (interdisciplinary team) reviewed new pressure injury to coccyx. Resident with stage 3 4.6 x 2.5 x 0.1 cm pressure injury to coccyx. Resident often sitting in Broda chair with limited mobility to reposition off of one spot d/t (due to) disease process. Resident with air mattress in place and protective foam dressing. Reposition side to side q 2 hours and as patient tolerates while in bed. POA, ADON, and MD aware and dressing order received. Will follow with weekly wound rounds. The Facility did not clarify R18's at risk for unavoidable skin integrity condition or pressure sores intervention of encourage frequent repositioning in bed and chair when R18 required extensive assistance with one person physical assist for bed mobility. The Facility did not revise R18's pressure ulcer actual or at risk care plan after R18 developed the stage 3 coccyx pressure injury. This care plan did not include repositioning until 06/16/22. The pressure injury weekly tracker dated 08/24/21 for the coccyx pressure injury documents measurements as 4.0 x 3.0 x 0.1, Stage III (3) and the wound bed described as 100% granulation. The pressure injury weekly tracker dated 08/31/21 for the coccyx pressure injury documents measurements as 4.0 x 3.0 x 0.1, Stage III (3) and the wound bed described as 100% granulation. The pressure injury weekly tracker dated 09/07/21 for the coccyx pressure injury documents measurements as 4.0 x 3.0 x 0.1. The stage is unstageable and the wound bed is 75% slough and 25% granulation. Under comments, documents slough scattered throughout wound bed, new order received for santyl. Surveyor noted there was no revision to either at risk for unavoidable skin integrity condition or pressure sores or pressure ulcer actual or at risk care plan until 05/27/22. R18's treatment was changed on 09/09/21 with directions to wash with 1/2 strength Dakins, dry, apply santyl to wound bed, apply foam dressing and change every day and as needed. This treatment was discontinued on 11/23/21. The nutrition note dated 09/09/21 documents: Last weight was 152.9# (8/9), has order for d/c (discontinue) weights per hospice. Has S-DTI (suspected deep tissue injury) to L (left) heel (unchanged per 9/7 wound tracker) and PI unstageable to coccyx (worsening per 9/7 wound tracker). Estimated needs are 1738-2085 kcal (kilocalorie's) (25-30 kcal/kg(kilogram)) and 70-83 g (grams) PRO (protein)(1-1.2 g/kg). Intake is 73% avg (average) plus snacks of a regular diet. Meal intake provides approximately 1791 kcal and 70 g PRO. Has order for 2 cal supplement 4 oz BID (twice daily) (480 kcal and 20 g PRO), per MAR (medication administration record) res (resident) drinks 50-100% of supplement. Meeting estimated needs. No new nutrition interventions recommended at this time. Goal is comfort cares. Will continue to monitor/follow-up PRN. The pressure injury weekly trackers dated 09/14/21 & 09/21/21 for coccyx pressure injury documents measurements as 4.0 x 3.0 x 0.1. Stage is unstageable and wound bed is 100% slough. The quarterly MDS with an assessment reference date of 09/24/21 documents R18 has short & long term memory problems and is severely impaired in cognitive skills for daily decision making. R18 is dependent with two plus person physical assist for bed mobility & transfer, does not ambulate, requires extensive assistance with one person for eating, and is dependent with one person physical assist for toilet use. R18 is always incontinent of urine and bowel. R18 is at risk for developing pressure injuries and is coded as having 1 Unstageable pressure injury. The pressure injury weekly tracker dated 09/28/21 for coccyx pressure injury documents measurements as 2.7 x 2.0 x 0.1. Stage is unstageable and wound bed is 25% granulation and 75% slough. The pressure injury weekly tracker dated 10/05/21 for coccyx pressure injury documents measurements as 2.0 x 1.5 x 0.1. Stage is unstageable and wound bed is 50% granulation and 50% slough. The pressure injury weekly tracker dated 10/12/21 for coccyx pressure injury documents measurements as 2.0 x 1.1 x 0.1. Stage is unstageable and wound bed is 90% granulation and 10% slough. The pressure injury weekly tracker dated 10/19/21 for coccyx pressure injury documents measurements as 2.0 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 100% granulation. The pressure injury weekly tracker dated 10/26/21 for coccyx pressure injury documents measurements as 1.8 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 100% granulation. The NP (nurse practitioner) note dated 10/28/21 documents no new open areas on skin noted. Under plan, includes pressure offloading. The pressure injury weekly tracker dated 11/02/21 for coccyx pressure injury documents measurements as 1.5 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 100% granulation. The pressure injury weekly tracker dated 11/08/21 for coccyx pressure injury documents measurements as 1.0 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 100% granulation. The pressure injury weekly tracker dated 11/15/21 for coccyx pressure injury documents measurements as 1.0 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 95% granulation and 5% necrotic. Under comments documents same as previous week. Small amount of necrotic tissue noted towards wound margin. Scant serous drainage noted. No pain. Surveyor noted there was no MD notification on this pressure injury weekly tracker. Surveyor noted there was no revision to either at risk for unavoidable skin integrity condition or pressure sores or pressure ulcer actual or at risk care plan until 05/27/22 and the treatment was not changed until 11/24/21. The pressure injury weekly tracker dated 11/22/21 for coccyx pressure injury documents measurements as 1.3 x 1.2 x 0.2. Stage is unstageable and wound bed is 25% granulation and 75% slough. Surveyor noted there was no revision to either at risk for unavoidable skin integrity condition or pressure sores or pressure ulcer actual or at risk care plan until 05/27/22. R18's treatment was changed with a start date of 11/24/21 with direction to wash coccyx pressure injury with 1/2 strength Dakins, dry, apply medihoney to wound bed, apply foam dressing change every day and as needed. This treatment was discontinued on 12/01/21. The nutrition note dated 11/23/21 documents Using 11/3 weight res (resident) triggers for 6.3% weight loss over 1 month and 10.7% weight loss over 3 months. Weight loss likely r/t (related to) varied intake at times and overall decline in condition, on hospice. Weight is PRN per hospice. Per wound trackers on 11/15 res has shearing to R (right) butt and PI stage 3 to coccyx (unchanged). Intake is 71% avg plus snacks of a regular diet x 7 days. Meal intake provides approximately 1754 kcal and 68 g PRO. Has order for 2 cal supplement 4 oz BID (twice daily) (480 kcal, 20 g PRO, Per MAR drinking avg 68% of supplement). Estimated needs are 1586-1904 kcal (25-30 kcal/kg) and 76-95 g PRO (1.2-1.5 g/kg). Meeting estimated needs. BMI is 26.4 (overweight but optimal for geriatric population). Potential for weight fluctuations r/t fluid shifts d/t (due to) diuretic tx. Potential for weight loss r/t decline in condition. Goal is comfort cares. Will monitor/follow-up PRN. The MD note dated 11/23/21 includes pressure offloading and wound cares as ordered. The pressure injury weekly tracker dated 11/29/21 for coccyx pressure injury documents measurements of 2.0 x 2.0 x 0.4. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. On 11/29/21, WD (wound doctor) R assessed R18's coccyx pressure injury. The initial wound evaluation & management summary dated 11/29/21 for site (1) documents: Stage 4 pressure wound sacrum full thickness with measurements of 2 x 2 x 0.4 cm (centimeters). Under surgical excision debridement procedure for indication for procedure documents. Remove necrotic tissue and establish the margins of viable tissue. Under dressing treatment plan for primary dressing(s) documents: Sodium hypochlorite solution (Dakins) apply twice daily for 30 days: soaked gauze. Secondary dressing(s) documents: Gauze island w/bdr (with border) apply twice daily for 30 days. For plan of care reviewed and addressed under recommendations documents: Limit sitting to 60 minutes; off-load wound; reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able. Surveyor noted R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. The treatment to R18's coccyx pressure injury to wash with soap and water, dry, apply Dakins soaked gauze to wound bed, apply bordered gauze, change twice daily and as needed was not started until 12/02/21, three days later. This treatment was discontinued on 12/07/21. Surveyor noted WD R assessed R18's coccyx pressure injury weekly with the exception of the week of 05/01/22 to 05/07/22 and 07/03/22 to 07/09/22. The pressure injury weekly tracker dated 12/06/21 for coccyx pressure injury documents measurements of 1.5 x 2.2 x 0.5. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. WD R's wound evaluation & management summary dated 12/06/21 under dressing treatment plan for primary dressing(s) documents: Leptospermum honey apply once daily for 30 days and secondary dressing(s) documents: Gauze island w/bdr apply once daily for 23 days. The Facility started a treatment to wash with soap and water, dry, apply medihoney to wound bed, apply bordered gauze, change daily and as needed on 12/08/22, two days later. This treatment was discontinued on 12/17/21. WD R continues to recommend limit sitting to 60 minute; off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able. Surveyor noted R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. Surveyor noted there is no indication the facility clarified WD R's recommendation if there were questions regarding WD R's recommendations on repositioning for R18. The pressure injury weekly tracker dated 12/13/21 for coccyx pressure injury documents measurements of 2.0 x 2.5 x 0.5. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. On 12/17/21 the treatment was changed from the day shift to the evening shift. The pressure injury weekly tracker dated 12/20/21 changes the pressure injury site to sacrum. Measurements are 1.8 x 2 x 0.7. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. Under additional intervention/plan documents: slowly improved no s/s of infection. The pressure injury weekly tracker dated 12/27/21 for the coccyx pressure injury documents measurements are 1.8 x 2.8 x 1.2. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. WD R's wound evaluation & management summary dated 12/27/21 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents: Deteriorated. Under dressing treatment plan for primary dressing(s) documents: Collagen gel/paste apply once daily for 30 days; Alginate calcium apply once daily for 30 days and secondary dressing(s) documents Gauze island w/bdr apply once daily for 30 days. The Facility started the treatment to wash with soap and water, dry, apply silvakollagen to wound bed, cover with calcium alginate followed by bordered gauze change daily and as needed on 12/29/21, two days later. This treatment was discontinued on 01/19/22. WD R continues to recommend limit sitting to 60 minutes; off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able. Surveyor noted R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. The pressure injury weekly tracker dated 01/03/22 for the coccyx pressure injury documents measurements of 2.0 x 3.0 x 1.5. Stage is Stage 4 and wound bed is 30% granulation, 40% slough, & 30% necrotic. Under comments documents continue treatment x 1 more week if continues to deteriorate then change larger in size moderate drainage no s/s of infection wound doctor debrided necrotic/slough tissue as able 30% necrotic. The pressure injury weekly tracker dated 01/10/22 for the coccyx pressure injury documents measurements of 2.5 x 2.4 x 1.5. Stage is Stage 4 and wound bed is 40% granulation, 40% slough, & 20% necrotic. The physician progress note dated 01/13/22 under plan includes every two hours turning and skin & back care. The pressure injury weekly tracker dated 01/17/22 for the coccyx pressure injury documents measurements of 2.5 x 2.4 x 1.5. Stage is Stage 4 and wound bed is 40% granulation, 40% slough, & 20% necrotic. WD R's wound evaluation & management summary dated 01/17/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents no change. Under dressing treatment plan for primary dressing(s) documents Alginate calcium apply once daily for 9 days; Leptospermum honey apply once daily for 30 days and secondary dressing(s) documents Gauze island w/bdr apply once daily for 9 days. The Facility started the treatment to wash with soap and water, dry, apply medihoney to wound bed, cover with calcium alginate followed by bordered gauze change daily and as needed on 01/19/22, two days later. This treatment was discontinued on 02/01/22. The pressure injury weekly tracker dated 01/24/22 for the coccyx pressure injury documents measurements of 2.5 x 2.4 x 2.0. Stage is Stage 4 and wound bed is 50% granulation, 30% slough, & 20% necrotic. The pressure injury weekly tracker dated 01/31/22 for the coccyx pressure injury documents measurements of 2.5 x 2.0 x 2.0. Stage is Stage 4 and wound bed is 50% granulation, 30% slough, & 20% necrotic. WD R's wound evaluation & management summary dated 01/31/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents improved. Under dressing treatment plan for primary dressing(s) documents Sodium hypochlorite solution (Dakins) apply twice daily for 30 days: pack the wound with a wet gauze, wet to dry dressing and secondary dressing(s) documents Gauze island w/bdr apply twice daily for 23 days. The Facility started the treatment to wash with soap and water, dry, lightly pack with Dakins soaked gauze, cover with bordered gauze twice daily and as needed on 02/01/22. This treatment was discontinued on 02/15/22. The pressure injury weekly tracker dated 02/07/22 for the coccyx pressure injury documents measurements of 3.0 x 3.0 x 2.5. Stage is Stage 4 and wound bed is 30% granulation, 30% slough, & 40% necrotic. Under comments documents worsening. No s/s of infection. New wound treatment started last week. Improvement to wound bed noticed. Larger in size. WD R's wound evaluation & management summary dated 02/07/22 continues to recommend limit sitting to 60 minute; off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able. Surveyor noted R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. The pressure injury weekly tracker dated 02/14/22 for the coccyx pressure injury documents measurements of 3.0 x 3.0 x 2.5. Stage is Stage 4 and wound bed is 50% granulation, 30% slough, & 20% necrotic. Under comments documents Size remains same. Tissue to wound bed improving significantly since prior week. More granular tissue present with less amount of slough/necrotic tissue. Surrounding tissue is warm, dry and intact. No s/s of infection. Debrided with wound doctor. New treatment ordered. WD R's wound evaluation & management summary dated 02/14/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents improved. Under dressing treatment plan for primary dressing(s) documents Leptospermum honey apply once daily for 30 days; Alginate calcium apply once daily for 30 days and secondary dressing(s) documents Gauze island w/bdr apply twice daily for 9 days. The Facility started the treatment to cleanse, dry, apply medihoney to wound bed, cover with calcium alginate then bordered gauze daily and as needed with a start date of 02/16/22, two days later. This treatment was discontinued on 02/21/22. The pressure injury weekly tracker dated 02/21/22 for the coccyx pressure injury documents measurements of 4.5 x 3.5 x 3. Stage is Stage 4 and wound bed is 10% granulation, 30% slough, & 60% necrotic. Under comments documents Wound is larger in size with worsening tissue noted to wound bed. New treatment ordered. Wound debrided by wound doctor. Surrounding tissue is warm, dry and intact. No pain noted to area. WD R's wound evaluation & management summary dated 02/21/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents deteriorated. Under dressing treatment plan for primary dressing(s) documents Metronidazole gel apply once daily for 30 days; Sodium hypochlorite solution (Dakins) apply twice daily for 30 days and secondary dressing(s) documents Gauze island w/bdr apply twice daily for 30 days. The Facility started the treatment to cleanse, dry, apply Metronidazole cream to wound bed for AM shift followed by Dakins soaked gauze. Change twice daily and as needed with a start date of 02/22/22. This treatment was discontinued on 03/16/22. The pressure injury weekly tracker dated 02/28/22 for the coccyx pressure injury documents measurements of 4.5 x 3.5 x 3.2. Stage is Stage 4 and wound bed is 30% granulation, 30% slough, & 40% necrotic. The pressure injury weekly tracker dated 03/07/22 for the coccyx pressure injury documents measurements of 5.0 x 4.5 x 3.5. Stage is Stage 4 and wound bed is 40% granulation, 30% slough, & 30% necrotic. Under comments documents Larger in size but tissue type is improving with more granulation tissue present than prior week. WD R's wound evaluation & management summary dated 03/07/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents deteriorated. The pressure injury weekly tracker dated 03/14/22 for the coccyx pressure injury documents measurements of 4.5 x 4.5 x 3.5. Stage is Stage 4 and wound bed is 50% granulation, 30% slough, & 20% necrotic. WD R's wound evaluation & management summary dated 02/21/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents improved. Under dressing treatment plan for primary dressing(s) documents Metronidazole gel apply once daily for 9 days; Sodium hypochlorite solution (Dakins) apply twice daily for 9 days; Leptospermum honey apply once daily for 30 days; alginate calcium apply once daily for 30 days and secondary dressing(s) documents Gauze island w/bdr apply twice daily for 30 days. The Facility started the treatment to cleanse, dry, apply medihoney to wound bed f [TRUNCATED]

Based on observation, interview and record review, the facility did not ensure manufacturer instructions for cleaning and disinfecting glucometers were being followed potentially spreading infection for 4 (R9, R39, R24, and R8) of 4 residents that were sharing a glucometer. On 6/9/2021, Licensed Practical Nurse (LPN)-F was observed to obtain R24's blood sugar. LPN-F went to another medication cart and retrieved antiseptic wipes that were individually packaged and were intended to be used to clean a cut or a wound. LPN-F wiped off the glucometer and wrapped the glucometer in the antiseptic wipe. Surveyor noted germicidal and bleach wipes were available in the bottom drawer of the medication cart. Surveyor asked LPN-F if bleach wipes were used to clean the glucometers. LPN-F stated she only uses the individually packaged antiseptic wipes to clean the glucometers. Review of the residents residing on the unit indicated 4 residents utilize the same glucometer for blood sugar checks. One of the residents that has their blood sugar checked had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . By not properly disinfecting the glucometer between each resident use, LPN-F exposed 3 additional residents to possibly contract [CONDITION(S)]. The Facility's failure to properly sanitize and disinfect a shared glucometer created a situation of immediate jeopardy that started on 6/9/2021. Nursing Home Administrator (NHA)-A was notified of the determination of immediate jeopardy on 6/9/2021 at 1:13 PM. The immediate jeopardy was removed on 6/9/2021 when the facility implemented an action plan to address sanitizing glucometers. The deficient practice continues at a scope and severity of an F (potential for more than minimal harm that is not immediate jeopardy/widespread) for the following identified deficient practice: The facility did not review the Infection Prevention and Control Policies and Procedures annually. Findings include: 1.) The glucometer's manufacturer's instructions on the website for Cleaning & Disinfecting the Gluco Navii Blood Glucose Meter states: it is the manufacturer's policy to advise healthcare professionals to clean and disinfect blood glucose meters between each resident test in order to avoid cross-contamination issues. Whether your facility uses an alcohol based solution or a bleach based solution should depend upon your individual resident requirements and your facility's disinfection protocol . Cleaning Guidelines: Use a lint free cloth dampened with soapy water or [MEDICATION(S)] (70%-80%) to clean the outside of the blood glucose meter . Disinfecting Guidelines: To disinfect the meter, dilute 1 mL of household bleach (5%-6% sodium hypochlorite solution) in 9 mL of water to achieve a 1:10 dilution (final concentration of 0.5%-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the damped towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 quaternary/alcohol wipes and bleach wipes from a variety of manufactures (sic) . With all recommended glucose meter cleaning methods, it is crucial that the Gluco Navii meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. On 6/9/2021 at 7:55 AM, LPN-F was passing medications on the 300 Unit and was observed obtaining R24's blood sugar. LPN-F came out of R24's room, placed the glucometer on the medication cart next to a second glucometer and opened the top drawer of the medication cart without taking anything out of the drawer and then opened the bottom drawer of the medication cart. Surveyor observed bleach wipes in a canister in the bottom drawer of the medication cart. LPN-F did not remove anything from the bottom drawer of the medication cart. LPN-F went to a medication cart down the hallway across from the nurses' station and retrieved individually packaged antiseptic wipes. LPN-F opened a wipe and cleaned one glucometer, wrapped the glucometer in the wipe, and placed it in a plastic cup. LPN-F repeated the process with the second glucometer. Surveyor asked LPN-F if she ever used bleach wipes. LPN-F stated the bleach wipes were used to clean down the cart and equipment. Surveyor asked if the bleach wipes were used to clean the glucometers. LPN-F stated she only uses the sanitizing wipes for cleaning the glucometers. Surveyor asked LPN-F if each resident had their own glucometer or if they shared glucometers. LPN-F stated the residents share the glucometers. Surveyor asked LPN-F how many residents on this unit had their blood sugars checked. LPN-F stated three residents had blood sugar checks and that she had completed doing them that morning. In an interview on 6/9/2021 at 9:07 AM, Director of Nursing (DON)-B and Registered Nurse Unit Manager (RN UM)-D stated some residents have their own glucometers and some do not and have to share a glucometer. DON-B stated the glucometers are cleaned with an antiseptic wipe. Surveyor asked to see the wipe DON-B was referring to. DON-B retrieved an antiseptic wipe from the top drawer of a medication cart and provided it to Surveyor. The antiseptic wipe packaging stated: 1 single use, premoistened extra large wipe. Uses: First aid to help prevent infection in minor cuts, scrapes, and [CONDITION(S)]. The active ingredient was [MEDICATION(S)] chloride 0.133% w/v (weight per volume). This active ingredient was not effective in killing blood borne pathogens. In an interview on 6/9/2021 at 9:17 AM, Surveyor shared with DON-B the concern the glucometers were not being disinfected with an appropriate product that would kill blood borne pathogens and requested information on residents that were potentially affected. In an interview on 6/9/2021 at 10:20 AM, DON-B provided resident information for the residents that had their blood sugars checked that morning by LPN-F. LPN-F had been contacted by the facility to verify which residents had blood sugars checked that morning and LPN-F informed them the following residents had their blood sugars checked in this order: R39, R9, R24, and R8. (LPN-F had initially stated three residents had blood sugars checked that morning.) LPN-F is a full-time employee working on mainly one unit, but has been known to float to other units as the need arises. R9 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 was not actively being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R9's hospital discharge summary dated 3/5/2021 stated the RNA (Ribonucleic Acid) level was more than 3 million and should be evaluated as an outpatient. (An RNA level greater than 800,000 IU/ml is a high [CONDITION(S)] load and R9 was almost 4 times that level.) [CONDITION(S)] is a liver infection, with symptoms that can include abdominal pain, fatigue, fever, jaundice, joint pain, poor appetite, nausea and vomiting. WebMD (https://www.webmd.com/[CONDITION(S)]/digestive-diseases-[CONDITION(S)]-c) states: About 75% to 85% of people who have it get a long-term infection called chronic [CONDITION(S)]. If the condition goes untreated, it can lead to: [CONDITION(S)], or scarring of the liver; liver cancer; liver failure. According to the Centers for Disease Control and Prevention (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html), An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV, [CONDITION(S)] virus, and HIV) through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of [CONDITION(S)] B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. In the last [AGE] years, alone, there have been at least 15 outbreaks of HBV infection associated with providers failing to follow basic principles of infection control when assisting with blood glucose monitoring. Due to under-reporting and under recognition of acute infection, the number of outbreaks due to unsafe diabetes care practices identified to date are likely an underestimate. Although the majority of these outbreaks have been reported in long-term care settings, the risk of infection is present in any setting where blood glucose monitoring equipment is shared or those assisting with blood glucose monitoring and/or insulin administration fail to follow basic principles of infection control. In an interview on 6/9/2021 at 11:30 AM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concerns of R9 having [CONDITION(S)] [CONDITION(S)] with a high [CONDITION(S)] load and sharing glucometers with other residents that were not disinfected properly. DON-B agreed LPN-F should not have used the anti-septic wipe on the glucometer and the facility was already re-educating the staff on the proper disinfecting technique. The facility's failure to ensure glucometers were properly sanitized and disinfected led to a situation of immediate jeopardy. The facility removed the immediate jeopardy on 6/9/2021 when they implemented the following action plan: -All Residents involved in identified glucometer event have been assessed, notifications to family and MD completed along with recommended updates and changes in care planning. -Education was initiated for all licensed staff as follows: - Glucometer disinfection utilizing the appropriate wipes. The designated wipe is one that will kill blood borne pathogens - Appropriate product for disinfecting per manufacturers guidelines have been reviewed - Antiseptic wipes are not to be used to disinfect a glucometer -The facility has reviewed the Diabetic Management policy and procedure and manufacturers guidelines and ensured it addresses the proper cleaning and sterilization of the glucometers to prevent the risk of spread for blood borne pathogens. -The facility has initiated education to ensure staff collecting blood sugar levels are competent in carrying out the task and in sanitizing and disinfecting equipment and devices that are shared between residents. -The facility has reviewed the assessment process for individuals with blood borne pathogens and whether they should be using a shared device involving blood borne pathogens and is implementing additional processes to decrease the risk of future similar occurrences. - All medication carts were inspected to validate the appropriate wipes were on the cart. - All medication rooms, treatments rooms, and central supply rooms were inspected to validate the appropriate wipes are available and in stock - The procedure for disinfecting glucometers was reviewed by the IDT and Medical Director ?? -DON and/or designee will complete audits 5x/week for 8 weeks, then 5 times monthly -Results of the audits will be reviewed by the QAPI committee for further recommendations The deficient practice continues at a scope and severity of an F (potential for harm/widespread) based upon the additional example. 2.) On 6/10/21, Surveyor reviewed the facility's Infection Control Policies and noted the policies were not updated annually. Policy #1 reviewed was the Infection Prevention and Control Program from the 2001 Med-Pass Program and revised October 2018, included Coordination, Oversight, Surveillance, Antibiotic Stewardship, Data Analysis, Outbreak Management, Prevention, Immunization, Monitoring Employee Health & Safety. Policy #2 reviewed was Antibiotic Stewardship which was dated 6/1/17. Policy #3 reviewed was Influenza and Pneumococcal Immunizations for Residents which was dated 6/1/17. On 6/10/21, at 12:59 PM, Surveyor interviewed DON-B (Director of Nursing) regarding infection control. Surveyor noted that the policies are not updated annually. DON-B stated she was aware the policies were not updated annually.

Based on observation, record review, and interview, the facility did not thoroughly assess, document, and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 7 (R43, R35, R211, R212, R161, R45, and R58) of 8 residents reviewed for pressure injuries. *R43 had pressure injuries to the coccyx and left heel that developed and healed multiple times. When the wounds were present, comprehensive assessments were not completed timely. R43's coccyx pressure injury initially assessed on 3/30/2021 was determined to be moisture associated skin damage and was changed to a Stage 3 pressure injury on 4/6/2021. R43's left heel had a Deep Tissue Injury that was brought to the facility's attention on 6/10/2021. *R35 was admitted on [DATE] with pressure injuries to the coccyx, the left heel, and the right heel. The left heel and the right heel were not assessed comprehensively on admission and the right heel progressed from a Stage 3 pressure injury with 100% granulation on 5/25/2021 to Unstageable with 100% necrotic tissue on 6/1/2021. *R211 had an abscess to the sacrum that was identified on 12/27/2020 that progressed into a Stage 4 to the coccyx after debridement in the hospital. R211 was readmitted on [DATE] and the wound was not comprehensively assessed until 1/19/2021. Comprehensive assessments were not completed timely. *R212 was readmitted to the facility on [DATE] with a Stage 2 pressure injury to the right buttock and a Stage 2 pressure injury to the left buttock that were not comprehensively assessed until 6/1/2021. *R161 was readmitted to the facility on [DATE] and the left heel was not comprehensively assessed until 6/1/2021. *R45 was admitted on [DATE] at risk for pressure injury. Interventions were not put in place and R45 developed an unstageable pressure injury to the left heel on 5/31/2021. *R58 was admitted on [DATE] with a Stage 2 pressure injury to the sacrum that developed into an Unstageable pressure injury. Treatment was not provided as ordered. Examples involving Residents R43, R35, R211, R161, and R45 are all being cited at the scope and severity of an H (actual harm/pattern). Findings include: The facility policy and procedure entitled Skin Management Policy - CAWs, undated, states: The facility will provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless pressure ulcers are unavoidable due to the predictable patterns of the resident's clinical condition or the resident or his/her representative's refusal of care and treatment to prevent pressure ulcers. Care Assessment Worksheets (CAW's) are used to assess causal factors of decline or potential for improvement of pressure ulcers. Aggressive and appropriate preventive measures and care are provided to address a resident's unique risk factors. Based on each resident's comprehensive assessment, appropriate treatment and services are provided to prevent the formation of pressure ulcers. Residents having pressure ulcers receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Residents who have issued advance directives to refuse or withhold treatment may be at risk for skin breakdown, and the development of pressure ulcers may be unavoidable. Appropriate measures to promote healing and prevent infection will be provided in accordance with the resident's plan of care. The facility policy and procedure entitled Skin Assessment, undated, states: On admission, the initial skin check needs to be completed within 2 hours of admission. Ask the resident to put on a gown, grab an additional clinical staff member, and complete the skin assessment. Please refer to the attached anatomical chart - it's critical for documentation purposes to know the correct terminology of where the skin issue is located. The more specific you can be - the better. Completing a comprehensive skin assessment is an important component of providing the highest quality care to our residents. All areas of the body need to be checked for skin issues (cuts, abrasions, skin tears, pressure injuries, dryness, bleeding, excessive moisture, bruising, etc.), pay special attention to areas that are considered pressure points. Once a skin check has been initiated, ensure that you are making clear notes about what you're finding on the skin to transcribe into (the computer charting system). If you have identified a pressure injury/issue on the resident, it is critical to describe the issue in-depth in your documentation. How to Describe? Needs to be Objective and Descriptive! Other clinical staff should be able to visualize the skin injury/issue based upon your written word. Description of Characteristics: -Drainage -Color (See below) -Odor -Location (Be specific - use bony landmarks, proximal/distal, medial/lateral, right/left) -Shape -Condition of surrounding tissue, ulcer edges and wound bed -Does it appear there is an active infection? -Presence of pain -Measure: this is how we will know if the current/future treatment is effective or not. 1.) R43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R43 needed total assistance with bed mobility, toileting, and bathing, and extensive assistance for other activities of daily living. R43 was cognitively intact and resident-responsible. R43 had a suprapubic urinary catheter due to neuromuscular dysfunction of the bladder. R43's Actual Skin Integrity Break and/or Pressure Sore Care Plan was initiated on 3/1/2019. Interventions include: -Air mattress -Apply chair cushion to wheelchair, ensure proper placement and clean daily -Assess and measure all skin integrity areas per policy -Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications -Follow up with wound physician as needed -Initiate skin monitoring forms per facility policy -Initiate treatment per physician order -Monitor and report any new open areas, drainage, increased drainage or pain to nurse immediately -Monitor for complaints of pain; medicate as needed and offer pain medication prior to treatment; update physician regarding effectiveness and increased need for pain medications -Prevalon boots while in bed -Provide treatment to wound(s) per current treatment order; assess wound(s) for signs or symptoms of infection with each dressing change/treatment; report findings of redness, warmth, swelling, increased drainage or increased pain to physician immediately -Report wound progress or decline to physician with any changes or lack of response to treatment per facility guidelines R43's at Risk for Skin Integrity Condition Care Plan was initiated on 3/6/2020 related to the history of pressure sores, impaired mobility, incontinence, and obesity. Interventions include: -Apply alternating pressure air mattress to bed if indicated; assure proper inflation, check frequently -Assess skin for redness or pressure related changes with each care encounter; report any changes immediately -Avoid friction/shearing while repositioning; if [R43] is unable to assist, use at least 2 staff members, use lift sheet, bed should be as flat as possible with lifting -Conduct pressure injury skin assessments (i.e. Braden scale) as indicated -Encourage frequent repositioning in bed and chair -Head to toe assessment by licensed nurse performed weekly at minimum -Keep [R43] clean and dry; use barrier cream after good peri-care; apply proper incontinent products as indicated Surveyor noted the care plan was not reviewed or revised as R43 developed new or recurring pressure injuries. COCCYX/SACRUM On 6/30/2020, trauma was noted to the coccyx. A comprehensive assessment was not completed on that date. A comprehensive assessment was completed on 7/1/2020 on the Wound Evaluation Tracker form with a wound measuring 1.0 cm x 0.5 cm x 0.2 cm with 100% granulation tissue. No etiology of the trauma to the wound was documented. The wound was comprehensively assessed weekly from 7/1/2020 through 7/21/2020. On 7/21/2020 on the Wound Evaluation Tracker form, the wound measured 0.73 cm x 0.25 cm x 0.1 cm with 24% granulation, 20% slough, and 34% necrotic tissue. (The percentages equal 78%.) The comment section of the form stated the wound tissue was identified with 4% pink tissue, 18% other, and as listed above, with fully granulated tissue. It does not describe what the 18% other tissue is. On 7/29/2020, the Wound Evaluation Tracker form is signed but there is no documentation of the wound. The form is blank. The wound was comprehensively assessed weekly from 8/4/2020 until the wound healed on 8/25/2020. On 9/29/2020 on the Wound Evaluation Tracker form, nursing documented the coccyx had a wound that was caused by trauma that measured 3.03 cm x 0.85 cm x 0.3 cm with 100% granulation tissue. No etiology of the trauma to the wound was documented. On 11/3/2020 on the Wound Evaluation Tracker form, the wound etiology was changed from trauma to moisture associated skin damage. The wound was comprehensively assessed weekly from 9/29/2020 until the wound healed on 12/15/2020. On 12/22/2020, a treatment order for [MEDICATION(S)] cream to be applied to the coccyx every shift for incontinence associated [CONDITION(S)] was initiated. On 3/30/2021 on the Wound Evaluation Tracker form, nursing documented the sacrum had a wound that was caused by moisture measured 0.6 cm x 0.5 cm x 0.5 cm with 100% granulation tissue. On 3/31/2021, a treatment order for the coccyx wound to be cleaned with normal saline, skin prep to the peri-wound followed by iodosorb followed by a bordered gauze daily was initiated. The treatment was not signed out on the Treatment Administration Record (TAR) as being completed on 3/31/2021 and 4/2/2021. On 4/6/2021 on the Wound Evaluation Tracker form, nursing documented the sacral wound was assessed by the wound physician and measured 3.02 cm x 2.09 cm x 0.8 cm with 40% granulation tissue and 60% skin. The wound physician determined the wound was a Stage 3 pressure injury. On 4/7/2021, a treatment order for the coccyx wound to be cleaned with half-strength Dakin's, skin prep to the peri-wound followed by collagen powder to the wound bed followed by calcium alginate with silver followed by a bordered gauze daily was initiated. The treatment was not signed out on the TAR as being completed on 4/7/2021, 4/15/2021, 4/22/2021, 4/23/2021, 4/29/2021, 5/2/2021, 5/6/2021, 5/8/2021, 5/10/2021, and 5/11/2021, 10 out of 34 days. On 4/13/2021 on the Wound Evaluation Tracker form, Assistant Director of Nursing (ADON)-C documented the Stage 3 pressure injury measured 1.7 cm x 0.9 cm x 0.7 cm with 100% granulation tissue. The form was signed by ADON-C on 4/22/2021. No comprehensive assessment was documented between 4/13/2021 and 4/27/2021, for 14 days. On 4/27/2021 on the Wound Evaluation Tracker form, nursing documented the Stage 3 pressure injury measured 1.38 cm x 0.6 cm x 0.6 cm with 100% granulation tissue. On 5/12/2021, the treatment order for the coccyx wound was changed to be cleaned with half-strength Dakin's, skin prep to the peri-wound followed by iodosorb followed by bordered gauze daily was initiated. The treatment was not signed out on the TAR as being completed on 5/27/2021, 5/30/2021, 6/3/2021, and 6/5/2021, 4 out of 32 days. The wound was comprehensively assessed weekly from 4/27/2021 to 6/1/2021. On 6/1/2021 on the Wound Evaluation Tracker form, nursing documented the Stage 3 pressure injury measured 1.0 cm x 0.4 cm x 0.3 cm with 100% granulation tissue. On 6/10/2021 at 1:03 PM, Surveyor observed Licensed Practical Nurse (LPN)-E and Certified Nursing Assistant (CNA)-J perform wound care to R43. R43 had an open area to the coccyx that appeared to be approximately 2.0 cm x 2.0 cm with an undetermined depth. LPN-E stated the treatment is done to the coccyx wound daily. In an interview on 6/14/2021 at 7:42 AM, ADON-C stated the wound physician assessed R43's sacral wound on 4/6/2021 and determined the wound was caused by pressure as opposed to moisture as originally thought. Surveyor reviewed with ADON-C the assessment dated [DATE] with ADON-C's signature of 4/22/2021 and the lack of assessment for 4/22/2021. ADON-C was unable to explain the confusion with dates, but would see what further documentation was in R43's medical record. In an interview on 6/14/2021 at 9:40 AM, ADON-C provided the wound log dated 4/20/2021 with the sacral wound assessment and the wound physician documentation dated 4/20/2021. ADON-C agreed the wound log was not part of R43's medical record. The coccyx wound started as moisture associated skin damage and progressed to a Stage 3 pressure injury. The wound was not comprehensively assessed weekly and treatments were not documented as being provided as ordered. R43's care plan was nor reviewed or revised as R43 developed new or recurring pressure injuries. LEFT HEEL On 9/22/2020 in the progress notes, nursing charted R43 had a rash to bilateral feet. The areas were not comprehensively assessed. On 9/29/2020 on the Wound Evaluation Tracker form, LPN-I documented R43 had a vascular wound to the left heel that measured 0.61 cm x 1.0 cm x 0.1 cm with 100% granulation tissue. LPN-I documented the wound Nurse Practitioner had assessed R43's wound and ordered a treatment. The wound was not comprehensively assessed from 9/29/2020 to 10/13/2020, 14 days. On 10/13/2020, the wound had healed. On 12/1/2020 on the Wound Evaluation Tracker form, nursing documented a Stage 3 pressure injury to the left heel measuring 2.14 cm x 3.93 cm x 0.1 cm with 50% epithelial and 50% granulation tissue. Nursing documented in the comment section of the form R43 does not always wear heel boots was educated on the use of heel boots. There is no indication the care plan was reviewed or revised at this point in time. On 12/8/2020 on the Wound Evaluation Tracker form, nursing documented the Stage 3 pressure injury measured 2.0 cm x 3.5 cm x 0.1 cm with 50% granulation and 50% necrotic tissue. Nursing documented in the comment section of the form the wound was starting to scab over. (Scabs are not considered necrotic tissue.) The wound was comprehensively assessed from 12/8/2020 until the wound healed on 2/16/2021. R43 had two pressure injuries to the left heel that healed. There was no plan to prevent this heel wound from recurring. On 3/16/2021 on the Wound Evaluation Tracker form, nursing documented a Stage 3 pressure injury to the left heel measuring 0.6 cm x 0.4 cm x 0.1 cm with 100% granulation tissue. Nursing documented in the comment section of the form R43's left heel re-opened, healed and the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/2021, a treatment was ordered for the left heel wound: cleanse with normal saline, pat dry and apply bordered foam twice daily. On 3/23/2021 on the Wound Evaluation Tracker form, nursing documented the left heel pressure injury had healed. No documentation was found in R43's medical record of a wound to the left heel after 3/23/2021. There was no plan to prevent the pressure injury from redeveloping a fourth time. On 6/10/2021 at 1:03 PM, Surveyor observed LPN-E and CNA-J perform wound care to R43. R43 had a dressing to the left heel in place. LPN-E removed the dressing and a darkened red area that measured approximately 3 cm x 5 cm had an open area in the center that measured approximately 1.5 cm x 2.5 cm with red tissue in the wound bed. The area was cleansed with Dakin's by LPN-E and a bordered gauze was placed over the area. In an interview on 6/10/2021 at 3:06 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the observation of R43's left heel treatment and the concern no documentation was in R43's medical record that R43 had a current wound to the left heel. DON-B stated they would look for that documentation and provide it to Surveyor. In an interview on 6/14/2021 at 1:06 PM, Surveyor reviewed the documentation and observation of R43's left heel with DON-B, ADON-C, and Registered Nurse Unit Manager (RN UM)-D. No documentation had been provided to Surveyor of an active wound to the left heel. RN UM-D stated the left heel was assessed on 6/10/2021 by RN UM-D late in the afternoon, after Surveyor had brought the left heel wound to the facility's attention. RN UM-D stated when the left heel was assessed, no open area was observed at that time and determined the area was a Deep Tissue Injury. Surveyor asked for the documentation of the left heel pressure injury completed by RN UM-D on 6/10/2021. The Wound Evaluation Tracker form was provided. It was dated 6/11/2021 and documented the left heel had a Suspected Deep Tissue Injury that was identified as a new area on 6/11/2021 that measured 3.5 cm x 4.0 cm with no depth. In the comments section of the form, ADON-D documented R43 had a new Deep Tissue Injury to the left heel, R43 had an air mattress and Prevalon heel boots on at all times. The wound physician was notified, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The left heel had a vascular wound that healed, a Stage 3 pressure injury that healed, and currently has a Deep Tissue Injury. The wound was not comprehensively assessed weekly from 9/29/2020 to 10/13/2020. The left heel had an active wound that was identified by Surveyor on 6/10/2021; the facility was unaware of the pressure area until it was presented to them by Surveyor. 2.) R35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R43 needed extensive assistance with bed mobility and total assistance with other activities of daily living. R35 had an indwelling urinary catheter and was always incontinent of bowel. R43 had a Brief Interview for Mental Status (BIMS) score of 06 indicating severe cognitive impairment; R43 was resident-responsible. R35's Pressure Ulcer Care Plan for an Unstageable pressure injury to the coccyx, a Stage 3 pressure injury to the left heel, and a Stage 3 pressure injury to the right heel was initiated on 4/29/2021 with the following interventions: -Complete Braden Scale per policy -Conduct weekly skin inspection -Do not massage over bony prominence -Float heels -Heel boots -Nutritional and hydration support -Preventative foot care: shoes, inserts, pads -Provide pressure reducing wheelchair cushion -Provide pressure reduction/relieving mattress -Provide thorough skin care after incontinent episodes and apply barrier cream -Skin assessment to be completed per policy -Treatments as ordered -Turning and repositioning schedule per assessment -Weekly Wound assessment R35's At Risk for Skin Integrity Care Plan was initiated on 5/11/2021 with the following interventions: -Apply alternating pressure air mattress to bed if indicated; assure proper inflation, check frequently -Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed; ensure cushion is properly placed, clean and dry -Assess skin for redness or pressure related changes with each care encounter; report any changes immediately -Avoid friction/shearing while repositioning: if [R35] is unable to assist, use at least two staff members, use lift sheet, bed should be as flat as possible with lifting -Conduct pressure injury skin assessments (i.e. Braden scale) as indicated -Frequent repositioning in bed and chair -Head to toe assessment by licensed nurse performed weekly at minimum -Keep [R35] clean and dry; use barrier cream after good peri-care; apply proper incontinent products as indicated LEFT HEEL On 4/28/2021 on the Admission/Readmission Evaluation form in the skin section, the Braden Scale indicated R35 was at moderate risk for skin breakdown. No open areas or areas of concern were documented. The Skin Assessment paper form dated 4/28/2021 in the hard chart had documentation that was hand-written by Licensed Practical Nurse (LPN)-G. The left heel had a circle around it with a P indicating Pressure. No measurements or wound description was documented. On 4/29/2021 on the Wound Evaluation Tracker form, nursing documented the left heel Stage 3 pressure injury was identified on 4/29/2021 and measured 2.0 cm x 4.0 cm x 0.1 cm with 75% epithelial and 25% granulation tissue. On 4/30/2021, a treatment order for bilateral heels to be washed with normal saline, pat dry, apply [MEDICATION(S)] gauze followed by ABD and kerlix wrap daily was initiated. The treatment was not signed out on the Treatment Administration Record (TAR) indicating the treatment was completed on 4/30/2021. On 5/5/2021, the treatment order was changed to wash the left heel with normal saline, pat dry, apply xeroform gauze followed by ABD and kerlix wrap daily. The treatment was not signed out on the TAR indicating the treatment was completed on 5/7/2021. The wound was comprehensively assessed from 4/29/2021 until the wound healed on 5/11/2021. The left heel pressure injury was not comprehensively assessed by a Registered Nurse on admission 4/28/2021; was assessed on 4/29/2021. There was a delay in obtaining a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RIGHT HEEL On 4/28/2021 on the Admission/Readmission Evaluation form in the skin section, the Braden Scale indicated R35 was at moderate risk for skin breakdown. No open areas or areas of concern were documented. The Skin Assessment paper form dated 4/28/2021 in the hard chart had documentation that was hand-written by Licensed Practical Nurse (LPN)-G. The right heel had a circle around it with a P indicating Pressure. No measurements or wound description was documented. On 4/29/2021 on the Wound Evaluation Tracker form, nursing documented the right heel Stage 3 pressure injury was identified on 4/29/2021, yet the data was collected on 4/28/2021, and measured 2.0 cm x 3.5 cm x 0.1 cm with 100% granulation tissue. The comments section of the form has the following documentation: New admission with multiple wound sites. Right heel stage III that is 1.5 x 1.5 in dimensions, no drainage. no s/s (signs or symptoms) of infection. wound treatments in place. (Wound physician) to follow with wound rounds. The form was signed on 5/12/2021 by Registered Nurse Unit Manager (RN UM)-D. (The wound dimensions are contradictory.) On 4/30/2021, a treatment order for bilateral heels to be washed with normal saline, pat dry, apply [MEDICATION(S)] gauze followed by ABD and kerlix wrap daily was initiated. The treatment was not signed out on the TAR indicating the treatment was completed on 4/30/2021. On 5/5/2021, the treatment was changed to: wash and apply skin prep to right heel, allow to dry, and cover with border gauze daily. The treatment was not signed out on the TAR indicating the treatment was not completed on 5/7/2021. On 5/13/2021, the treatment was changed from daily to three times a week on Tuesday, Thursday, and Saturday. The treatment was not signed out on the TAR indicating the treatment was not completed on 5/20/2021. The right heel Stage 3 pressure injury was comprehensively assessed weekly from 4/30/2021 to 6/1/2021. On 6/1/2021 on the Wound Evaluation Tracker form, nursing documented the right medial heel (previously was the right heel) pressure injury was Unstageable measuring 0.96 cm x 0.8 cm x 0 cm with 100% necrotic tissue. Surveyor noted there is no indication the care plan was reviewed or revised with the worsening pressure injury. On 6/8/2021 on the Wound Evaluation Tracker form, nursing documented the right medial heel Unstageable pressure injury measured 0.68 cm x 0.49 cm x 0.1 cm with 100% necrotic tissue. On 6/9/2021, the treatment was changed to: cleanse with normal saline, apply skin prep to peri-wound, apply xeroform gauze cut to size to wound bed, and cover with bordered gauze daily. The treatment was not signed out on the TAR indicating the treatment was not completed on 6/11/2021. The right medial heel Unstageable pressure injury was comprehensively assessed weekly with the wound physician starting on 5/4/2021 and continued to be followed by the wound physician weekly. On 6/10/2021 at 3:43 PM, Surveyor observed R35's wound care by LPN-G and Certified Nursing Assistant (CNA)-H. R35 had a pillow between the knees and a heel boot on the left foot. The right foot had a kerlix wrap around the heel. LPN-G removed the kerlix wrap and dressing to the right heel. The right heel had three open areas: the lateral measuring approximately 0.5 cm x 1.0 cm with red tissue, the central measuring approximately 0.5 cm x 0.5 cm with black tissue, and the medial measuring approximately 1.0 cm x 1.0 cm with black tissue. The heel was dark in color surrounding the three open areas measuring approximately 1.5 cm x 4.0 cm. Xeroform gauze was cut into two pieces, one piece covered the lateral open area and one piece covered the two medial and central open areas. Surveyor confirmed with LPN-G R35's heel had three separate areas. In an interview on 6/14/2021 at 7:53 AM, Surveyor shared with ADON-C the observation of R35's right heel with three open areas and the documentation of the right heel only described one area. ADON-C stated she would follow up with the wound physician to see if the wound physician documented on the three separate areas. In an interview on 6/14/2021 at 11:20 AM, ADON-C provided wound documentation by the wound physician of R35's right heel dated 6/8/2021. Attached to the documentation is a photograph of the right heel. ADON-C agreed R35's heel had multiple areas that were visible in the photograph. ADON-C stated the wound physician uses a program that photographs the wound or wounds, but only captures one wound if there are multiple open areas in the same general location and measures and assigns tissue type to that single area. In an interview on 6/14/2021 at 1:06 PM, ADON-C stated R35's heel wound was starting to scab over and the wound was documented as necrotic; ADON-C stated it should not have been charted as necrotic. The right heel pressure injury was not comprehensively assessed by a Registered Nurse on admission 4/28/2021; it was assessed on 4/29/2021. The treatment was not signed out as being completed as ordered. Conflicting measurements were documented on 4/29/2021. The Stage 3 pressure injury developed into necrotic tissue and Unstageable per the wound physician. Surveyor observed three open areas on the right heel and documentation only included one area. On 6/16/2021 at 11:17 AM, ADON-C provided additional information: the wound physician made an addendum to the 6/8/2021 wound documentation on 6/16/2021: wound bed description, other clarification: dried exudate/blood clot, not necrotic area; wound seen to be healing at 6/8/21, as evidenced by documentation on 6/15/21. The 6/8/2021 wound physician documentation listed color of tissue, but did not assign a tissue type; R35 had 19% red tissue, 54% black tissue, and 27 % pink tissue. This does not correlate to the wound documentation by the facility on 6/8/2021 where the wound was documented as being 100% necrotic. COCCYX On 4/28/2021 on the Admission/Readmission Evaluation form in the skin section, the Braden Scale indicated R35 was at moderate risk for skin breakdown. No open areas or areas of concern were documented. The Skin Assessment paper form dated 4/28/2021 in the hard chart had documentation that was hand-written by Licensed Practical Nurse (LPN)-G. The coccyx had a circle around it with a P unstg indicating an unstageable Pressure injury. No measurements or wound description was documented. On 4/28/2021 on the Wound Evaluation Tracker form, nursing documented R35 had an Unstageable pressure injury to the coccyx measuring 8.5 cm x 12 cm x 0.1 cm with 15% granulation and 85% necrotic tissue. No treatment order for the coccyx wound was on the Treatment Administration Record (TAR) on admission 4/28/2021. On 4/30/2021, a treatment order for the coccyx to be washed with half-strength Dakin's, pat dry, apply Santyl to the wound base followed by ABD and tape to secure daily was initiated. The treatment was not signed on the TAR out indicating the treatment was completed on 4/30/2021. On 5/4/2021 on the Wound Evaluation Tracker form, nursing documented the Unstageable pressure injury measured 8.27 cm x 12.3 cm x 5.0 cm with 85% slough and 15% necrotic tissue. Nursing documented in the comments section the wound had been debrided by the wound physician and a large amount of necrotic/slough tissue was removed. On 5/5/2021, the treatment order was changed to: wash with half-strength Dakin's, pat dry, apply Santyl to the wound bed, pack with normal saline damp gauze followed by ABD with tape to secure twice daily. The treatment was not signed out on the TAR as completed on 5/6/2021 for both treatment times on that date and 5/7/2021, 5/8/2021, 5/10/2021 and 5/12/2021 for one of the two treatment times on those dates. On 5/11/2021 on the Wound Evaluation Tracker form, nursing documented the Unstageable pressure injury measured 8.9 cm x 11.5 cm x 5.0 cm with 25% slough and 75% necrotic tissue. Nursing documented in the comments section the wound was worsening with a foul odor. The wound physician was aware and ordered intravenous antibiotics for a wound infection. On 5/12/2021, the treatment order was changed to: wash with half-strength Dakin's, pat dry, pack with half-strength Dakin's damp gauze followed by ABD with tape to secure twice daily. The treatment was not signed out on the TAR as completed on 5/18/2021 for one of the two treatment times on that date. R35 received IV antibiotics from 5/12/2021 to 5/24/2021 for the coccyx wound infection. During this time there is no indication the care plan was reviewed, revised or individualized for R35. On 5/18/2021 on the Wound Evaluation Tracker form, nursing documented the Unstageable pressure injury measured 8.06 cm x 10.9 cm x 4.5 cm with undermining of 4.7 cm from 10-5 o'clock with 35% granulation tissue, 30% slough, and 35% necrotic tissue. Nursing documented in the comments section the wound had less necrotic/slough tissue and more granulation, but had new undermining. The wound had a foul smell with the dressing change and multiple organisms were present in the wound bed from the culture on 5/14/2021. R35 remained on IV antibiotics and were increased to a total of 14 days. On 5/19/2021, the treatment order was changed to: wash with half-strength Dakin's, pat dry, apply Santyl to the wound bed on the AM shift dressing change only, pack with half-strength Dakin's damp gauze followed by ABD with tape to secure twice daily. The treatment was not signed out on the TAR as completed on 5/20/2021 and 5/26/2021 for one of the two treatment times on those dates. On 5/25/2021 on the Wound Evaluation Tracker form, nursing documented the Unstageable pressure injury measured 8.42 cm x 11.2 cm x 4.8 cm with no undermining. The wound bed was 40% granulation, 40% slough, and 20% necrotic tissue. Nursing documented in the comments section the wound was stable, [TRUNCATED]

Based on observation, interview and record review, the facility did not ensure that 1 (R58) of 2 residents reviewed received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. * On 6/3/21 R58 had a urine sample collected to determine if R58 has a UTI (urinary tract infection). The facility did document the specimen was collected on 6/3/21 however, no results were noted in R58's medical record. It was only after the Surveyor asked did the facility review the process related to the delay in obtaining UA (urinalysis) and results for R58. The laboratory had notified the facility the sample was contaminated and a new sample would be needed. The repeat sample was not obtained by the facility until 6/7/21 by which time R58 had worsening symptoms and was requesting transfer to the hospital where R58 was admitted for a UTI with a fever in an adult. The delay in obtaining a clean urine sample for analysis created a delay in possibly implementing treatment in the facility and resulted in R58 being transferred to the hospital. Findings include: R58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R58's Admission MDS (Minimum Data Set) dated 5/21/21 documents a BIMS (Brief Interview for Mental Status) score of 14, indicating that R58 was cognitively intact. Section H (Bladder & Bowel) documents that R58 has an indwelling catheter present. R58's Urinary CAA (Care Area Assessment) dated 5/21/21 documents under the Analysis of Findings section, Resident is .admitted from acute care hospital where he was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Other dx (diagnosis) include: neuromuscular dysfunction of bladder . he has alteration in elimination of bowel and bladder r/t (related to) indwelling urinary catheter, [CONDITION(S)] bladder and bowel. R58's nursing note dated 6/3/21 documents, Health Status Note Text: Urine spec (specimen) obtained via foley for possible UTI (Urinary Tract Infection). Lab notified of pick up @ 2300 (11:00 PM). Surveyor was unable to locate any laboratory results for R58's urine sample documented as picked up on 6/3/21. Surveyor was unable to locate any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor was unable to locate any nursing notes or and documentation that documented R58's urinalysis was analyzed by the laboratory and or that the facility had received R58's UA results. R58's nursing note dated 6/7/21 documents, Health Status Note Text: Resident C/O (complains of) pain to his shoulder, back of neck, and lt (left) leg,and being cold and shivering. Upon assessment resident VS (vital signs): 73 (pulse) 73, 78/50 (blood pressure). NP(nurse practitioner) made aware; per NP (nurse practitioner) administer IV (intravenous) fluids NS (normal saline), give p.o. (oral) Tylenol 650 mg Resident continues to request transfer to hospital. Report given to ER charge nurse .Resident transferred to ER (emergency room ). On 6/15/21, Surveyor received R58's hospital emergency room admission documentation dated 6/7/21. The hospital admission documentation documents, Medical Decision Making: .male with chronic indwelling Foley presents with fever and concerns for UTI (Urinary Tract Infection). He was febrile prior to arrival and received Tylenol for a temp (temperature) of 100.9 F (degrees Fahrenheit). Concern for UTI based on appearance of urine. While patient does have a large decubitus ulcer this does not appear acutely infected, there is some necrotic tissue however no drainage or surrounding [CONDITION(S)]. Will pursue septic workout, suspect patient will require admission. R58's hospital emergency room admission documentation dated 6/7/21 also documents, Clinical Impressions: Acute UTI, Fever in Adult. R58's Urinalysis Final Report dated as colleted on 6/7/21 at 9:30 a.m. and reported to the facility on [DATE] at 11:54 p.m. documents, Specimen positive for leukocyte esterase and/or nitrites. Urine culture has been ordered; Appearance: Turbid, Nitrite: 2+, Leukocyte Urine 500 A, WBC (White Blood Cells): 51-100, WBC Clumps: Present. Surveyor noted that R58's urinalysis report documents that R58's UA sample was not collected until 6/7/21 and not on 6/3/21. Surveyor also noted that R58's UA results were not reported to the facility until 6/7/21 at 11:54 PM, after R58 had been transferred to the hospital after experiencing a change in condition. On 6/10/21 at 3:40 p.m., Surveyor asked DON-B if the facility had received the results of R58's UA documented as picked up on 6/3/21 and or if R58 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DON-B informed Surveyor that she believed R58's initial UA was contaminated and that the facility obtained another urine sample on R58 for a UA on 6/7/21. DON-B informed Surveyor that she would call the laboratory and request the results for R58's UA. Surveyor noted there is no indication the facility reviewed how R58's specimen was collected to determine how it was contaminated causing a delay in processing the results. On 6/11/21 at 3:01 p.m., Surveyor received an email from DON-B documenting, 1. MD (medical doctor) ordered the UA on 6/3 and urine was collected, lab picked it up. I spoke with lab (laboratory) and they confirmed that there was a sample from 6/3 (6/3/21) that ended up not being good, informed facility that they needed another sample which was obtained. On 6/18/21 at 1:22 p.m., Surveyor asked ADON-C how long it usually takes the facility to receive urinalysis reports after the sample has been collected from the facility. ADON-C informed Surveyor that the facility usually gets notified of the preliminary urinalysis reports within 24 hours of the sample being collected from the facility. Surveyor asked ADON-C what facility staff are expected to do if they are not notified or the urinalysis reports after 24 hours of the sample being collected from the facility. ADON-C informed Surveyor that nursing staff is expected to call the laboratory if the facility is not notified of the preliminary urinalysis reports after 24 hours. Because staff did not follow up with the lab results on 6/4/21, staff did not know that the culture was contaminated and that another specimen needed to be obtained. This did not occur until two days later, during which time R58's symptoms worsened. On 6/18/21 at 1:33 p.m., Surveyor informed DON-B of the above findings. Surveyor asked DON-B why nursing staff had not called the laboratory on 6/4/21 to obtain R58's preliminary urinalysis report. DON-B informed Surveyor that the laboratory had called the facility sometime between 6/5/21 and 6/6/21 and informed nursing staff that R58's original urine sample collected on 6/3/21 had been contaminated and that the laboratory required another sample. Surveyor asked DON-B why the sample was not collected until 6/7/21 and not on 6/6/21. DON-B informed Surveyor that due to it being the weekend on 6/6/21, there were delays in getting the UA sample collected by the laboratory. On 6/18/21 at 2:26 p.m., Surveyor asked DON-B why the facility had not obtained another urine sample, prior to 6/7/21, for R58's urinalysis as originally ordered on 6/3/21. DON-B informed Surveyor that she could not provide any additional information. No additional information was provided as to why R58 did received appropriate services to prevent urinary tract infections.

Based on interview and record review the Facility did not ensure 2 (R3 & R7) of 5 Residents did not develop avoidable pressure injuries. * On [DATE] R3 was identified with a dime sized, superficial open area to right buttocks. A RN (Registered Nurse) did not assess this area and a care plan was not developed. This area was not documented until [DATE], 18 days later, on a wound worksheet. This is not an assessment of R3's pressure injury as there are no measurements, description of the wound bed & periwound and is not stao staging of the wound. The wound round worksheet is dated [DATE] and is not a complete assessment of the wound. The next wound round worksheet is dated [DATE], 14 days later, when the pressure injury is now documented as a scar. There is no explanation written as to how this pressure injury became a scar nor is there any measurement or description. The next weekly skin review is dated [DATE]. This weekly skin review documents a 5.5 x 8.0 open area on the right buttocks with 100% red granulated tissue. The facility did not develop a care plan after R3 developed this open area. On [DATE] R3 was transferred to the hospital and returned to the facility on [DATE]. Upon readmission to the Facility R3 was identified as having an unstageable coccyx pressure injury, right & left heel and left lateral foot suspected deep tissue injury pressure injuries. R3's pressure injuries were assessed on [DATE] when she returned but the next assessment wasn't until [DATE], 11 days later. The coccyx wound evaluation dated [DATE] is staged incorrectly and there are no further revisions in R3's skin care plan. The skin assessment sheet dated [DATE] identified two stage 2 pressure injuries to the right and left of the coccyx. There are no measurements, description of the wound bed or further documentation of these areas. The [DATE], [DATE], & [DATE] assessments of R3's right medial heel are not staged correctly and there are no revisions to the care plan. On [DATE] R3 was identified as having a stage 2 pressure injury on the front left lower leg with no revision to the care plan. * R7 developed a suspected deep tissue injury on [DATE]. The at risk for skin integrity care plan initiated [DATE] did not include any interventions to prevent pressure injuries from developing on R7's heels. After R7 developed the right heel pressure injury the Facility did not develop an actual skin impairment care plan until [DATE]. On [DATE] R7's right heel pressure injury was assessed but this assessment did not include the stage. R7's pressure injury was not assessed again until [DATE], 14 days later. The next assessment is dated [DATE], 15 days later. R7's care plan was not revised when the pressure injury was noted to be 100% necrotic or when the pressure injury increased in size. Findings include: The Skin Management System policy and procedure dated ,[DATE] documents 1. A head to toe body evaluation will be completed on every resident upon admission or readmission and weekly thereafter. These evaluations will be documented on the Weekly Skin Integrity Review form or EMR (electronic medical record). If skin is intact, no further action is required. If skin is compromised, proceed to the appropriate form below. A. Pressure Ulcers, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on the Ulcer, Surgical Site Treatment and Progress Record form or EMR. Use one form per wound. Wound progress is to be documented each week with measurements and wound descriptions. Daily treatments are also documented on the same form. I. treatment for [REDACTED]. a. Assess all residents for pain and act accordingly during treatments. b. All dressings are to be dated and initialed upon completion. c. Keep open lines of communication with physicians, families, and residents regarding status of wounds. d. Responsible Party will be notified on the onset of an identified area as well as with all treatment changes, decline in the status of the area, and when the area is healed. Documentation of the notification is to be in the Nurses Notes in the clinical record or EMR. II. Progress of the identified area, will be documented on the back of the Ulcer, Surgical Site Treatment and Progress Record form at least every 7 days, or less if the wound shows a decline or is healed. The physician is to be contacted after 14 days if the area has not shown improvement or immediately if it shows a decline. Documentation of the Physician notification is to be in the Nurse Notes in the chart or EMR. 1. R3's [DIAGNOSES REDACTED]. R3 expired on [DATE] and was reviewed as a closed record. The at risk for skin integrity care plan initiated [DATE] has interventions all initiated [DATE] of: * Apply alternating pressure air mattress to bed if indicated. Assure proper inflation - check frequently. * Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. * Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately. * Avoid friction/shearing while repositioning: if Resident is unable to assist, use at least two staff members, use lift sheet, bed should be as flat as possible with lifting. * Conduct pressure injury skin assessments (i.e. Braden scale) as indicated. * Frequent repositioning in chair and bed. * Head to toe assessment by Licensed Nurse performed weekly at minimum. * Keep Resident clean and dry. Use barrier cream after good peri-care. Apply proper incontinent products as indicated. The actual skin integrity care plan initiated [DATE] and resolved [DATE] has interventions all initiated [DATE] and resolved on [DATE] of : * Treatment per MD (medical doctor) order. * Use extra large briefs. * Monitor left buttock skin tear for healing. * Apply alternating pressure air mattress to bed if indicated. Assure and maintain proper inflation controls. * Apply chair cushion to wheelchair, geri chair or broda chair. Ensure proper placement and clean daily. * Assess and measure all skin integrity areas per policy. * Initiate skin monitoring forms per facility policy. * Initiate treatment per Physician order. * Monitor and report any open areas, drainage, increased drainage or pain to nurse immediately. * Monitor for c/o pain. Medicate PRN (as needed) and offer pain medication prior to treatment. Update physician regarding effectiveness and increased need for pain medication. * Provide treatment to wound(s) per current treatment with each dressing order. Assess wound(s) for s/s of infection with each dressing change/treatment. Report findings of redness, warmth, swelling, increased drainage or increased pain to physician immediately. * Report wound progress or decline to MD with any changes or lack of response to treatment per facility guidelines. The quarterly MDS (minimum data set) with an assessment reference date of [DATE] documents a BIMS (brief interview mental status) score of 8 which indicates moderately impaired. R3 is dependent with two plus person physical assist for bed mobility & toilet use, requires extensive assistance with two plus person physical assist for transfers and doesn't ambulate. R3 is always incontinent of urine & bowel, is at risk for pressure injury development and is coded as not having a pressure injury. The Braden assessment dated [DATE] has a score of 12. A score of ,[DATE] is high risk. The weekly skin review dated [DATE] & [DATE] is checked for skin intact. The SBAR (situation,background, appearance, review & notify) dated [DATE] under appearance documents Resident has a dime sized, superficial open area to right buttocks. No bleeding or pain to site. Resident has previous pressure injury areas near site that are pink. Pressure Ulcer is checked under skin evaluation. This SBAR was completed by a LPN (licensed practical nurse) and there is no RN (Registered Nurse) assessment. The Facility did not develop a plan of care after R3 developed this pressure injury on her right buttocks. The nurses note dated [DATE] documents Resident sleeping in intervals. Dressing dry and intact to o/a (open area) to buttock. Resident afebrile. No issues noted. Will continue to monitor. Surveyor was unable to locate an documentation of R3's right buttocks pressure injury until a wound rounds worksheet dated [DATE], 18 days later. This wound round worksheet documents under site buttocks, measurements, wound description, odor and periwound are blank. Under treatment/comments documents Barrier. Surveyor noted this is not an assessment of R3's pressure injury as there are no measurements, description of the wound bed & periwound and no staging of the wound. The nurses note dated [DATE] documents Alert. O/A to butt. Has bandage to site. No bleeding or itching. The nurses note dated [DATE] documents OA to buttocks remains although healing. Dressing intact, changed PRN (as needed) No c/o (complaint of) pain or discomfort at this time. The wound rounds worksheet dated [DATE] under site documents buttocks; measurements, wound description, odor, periwound and treatment are blank. Surveyor noted this is not an assessment of R3's pressure injury as there are no measurements, description of the wound bed & periwound and no staging of the wound. The nurses note dated [DATE] documents No s/s (signs/symptoms) of discomfort to o/a to buttocks. The nurses note dated [DATE] documents Open area is resolved. Pink tissue present. Surveyor noted this is the only nurses note that documents the open area is resolved. The nurses note dated [DATE] documents Continues with buttocks o/a. Is clean and dry. The nurses note dated [DATE] documents No c/o pain or discomfort to O/A on Right buttocks. The nurses note dated [DATE] documents Resident sleeping well. No c/o pain to OA on right buttock. Resident positioned off open area. The nurses note dated [DATE] documents No c/o pain or discomfort to O/A to R (right) buttocks, no cough/congestion noted this shift. The next wound round worksheet is dated [DATE], 14 days later. Under site documents buttock. The word excoriated is crossed off and scar is written. Under treatment documents barrier cream. There is no explanation written as to how this pressure injury became a scar nor are there any measurements or description. Surveyor noted during R3 electronic and paper record review the next nurses note documenting an open area is dated [DATE]. There is also no weekly skin review assessments until [DATE]. The weekly skin review dated [DATE] is checked for open area and new. Under site documents 31) Right buttocks. Under description documents 5.5 x (times) 8.0 100% red granulated tissue. Peri wound pink and blanches. Surveyor noted there is no stage documented and this weekly skin review was completed by Former Administrator-E. The Facility did not develop a plan of care after R3 developed this pressure injury on her right buttocks. The orders administration note dated [DATE] documents Barrier cream to open area and buttocks every shift. R3 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The nurses note date [DATE] documents Arrived via ambulance at 1600 (4:00 p.m.) via two attendants. Put to bed and acclimated to room ___, phone, call light, and remotes. VSS (vital signs stable) Skin w/d (warm dry) and very pale Dry hair and skin. Thick, elongated toenails. Dry heels and elbows. Has open area to coccyx site, stage two. No bruises. No I.V.S. (intravenous site). No Foley. Inc. (incontinent) of b/b (bowel/bladder). Large BM (bowel movement). Transfers x (times) 2. Is a feeder. Is very weak. Coughing. Congested. Nasily. C/o (complained of) leg pain. No redness. No warmth. Husband aware at 1730 (5:30 p.m.). MD (medical doctor) verified orders and aware at 1900 (7:00 p.m.). NOR (new order received); Obtain CBC (complete blood count) and BMP (basic metabolic panel) on Monday. The admission/readmission evaluation dated [DATE] under the skin integrity/braden scale section for site documents 23) coccyx type pressure, length 6.0, width 7.0, and stage Unstageable. For site documents 49) Right heel, type pressure, length 5.0, width 6.0 and stage Suspected Deep Tissue Injury. Under site 50) Left heel, type pressure, length 1.0, width 4.0 and stage Suspected Deep Tissue Injury. Under site Other (specify) left lat (lateral) foot, type pressure, length 2.0, width 3.5 and stage Suspected Deep Tissue Injury. Surveyor noted there are no description of the wound bed & periwound for R3's pressure injuries. This section was signed on [DATE] and completed by Previous DON (Director of Nursing)-M. The Braden assessment dated [DATE] has a score of 11. A score of ,[DATE] is high risk. The baseline care plan dated [DATE] under the skin care needs section is checked for pressure ulcer/injury present. Under location documents coccyx and under interventions documents reposition Q,[DATE] (small circle) (every two to three hours) Santyl F/b (followed by) foam drsng (dressing). Turn and reposition every ,[DATE] hours and Skin treatments see TAR (treatment administration record) are checked. The nurses note dated [DATE] documents Resident in bed, sleeping. No complaints. F/U (follow up) Readmit; Alert. Forgetful and confused. Has closed rt. (right) heel blister. Has open area to coccyx site. VSS (vital signs stable). The pressure ulcer care plan initiated [DATE] documents interventions all dated [DATE] of: * Complete Braden scale per living center policy * Conduct weekly skin inspection * Do not massage over bony prominence * Float heels * Heel boots * Nutritional and Hydration support * Provide pressure reducing wheelchair cushion * Provide pressure reduction/relieving mattress * Provide thorough skin care after incontinent episodes and apply barrier cream * Skin assessments to be completed per Living Center Policy * Treatments as ordered * Turning and repositioning schedule per assessment * Weekly wound assessment The nurses note dated [DATE] documents Wound care done to lower extremity and sacral area. Dressing clean and dry with no S/S of pain, discomfort or distress. The weekly skin review dated [DATE] is checked for blisters, bruise and open area. Site and description are blank. This weekly skin review was completed by a LPN. The weekly skin review dated [DATE] is checked for open area. Site and description are blank. COCCYX The wound evaluation tracker is dated [DATE], 11 days after readmission. The site is documented as 23) Coccyx, type Pressure, Length 5.0, Width 1.0, Depth is blank and Stage Unstageable. For the question when was the wound identified documents [DATE]. Surveyor noted R3 was readmitted with this pressure injury on [DATE]. The wound bed is 50% granulation, 20% slough and 30% necrotic. The nurses note dated [DATE] documents Resident alert, tired. Open area to coccyx change in condition. Referred to wound care team for evaluation. The wound evaluation week 2 for the coccyx dated [DATE] documents length 14.4, Width 0.2 Depth is blank, tunneling is checked and describe the position via clock method documents 12--0.3 3--0. 3 6--.2. The stage is documented as Suspected Deep Tissue Injury. The wound bed is 30% slough and 70% necrotic. Surveyor noted the pressure injury should have been staged as unstageable. Surveyor noted there is no revision in R3's care plan. R3 was transferred to the hospital on [DATE], returned to the facility on [DATE] and was placed on hospice. The skin assessment sheet dated [DATE] on the body diagram has the coccyx area circled with measurements of 7.4 x 13.6 x 2.0 and Stage III (3). To the right of the coccyx circle is a small circle with Stage II (2) documented. There is no further documentation of the area to the right of the coccyx. The nurses note dated [DATE] documents Dressing changed to coccyx completed. Gauze soaked in dakins packed into wound with ABD (abdomen) placed over and taped. Wound has large eschar area in the middle with tunneling 9 to 10 oclock. surrounding wound bed has red, granulated tissue, large area of the edges are macerated. The wound evaluation week 3 for the coccyx dated [DATE] documents length 7.2, Width 13.5, and depth 1.4. The stage is Unstageable. Under the section exudate color/type is documented as [MEDICAL CONDITION], consistency thick, tenacious, amount moderate and odor foul. The wound bed is described as 10% granulation, 10% slough, and 80% necrotic. Under additional notes documents Resident is now on hospice services for overall declining condition. Surveyor noted there is no revision in R3's care plan. The skin/wound note dated [DATE] documents Has an unstageable wound to coccyx which tunnels 80% necrotic, 10% slough, and 10% granulation. Is on hospice services. Has DTI (deep tissue injury) to right heel present upon readmission, [MEDICATION NAME] applied. On left lower leg had a fluid filled blister upon readmission, skin is intact to this area, blister is resolved. LEFT BUTTOCKS The wound evaluation week 1 dated [DATE] documents for site 32 Left buttock, type Pressure, length 1.2, width 1.0, depth 0.1 and Stage II (2). For the question when was the wound identified documents [DATE]. Wound bed is 100% granulation. Surveyor noted there is no revision in R3's care plan. The wound evaluation week 2 dated [DATE] for left buttocks documents length 0, width 0, depth 0 and wound bed is 100% skin. Yes is answered for the question has this wound healed. R3 was transferred to the hospital on [DATE], returned to the facility on [DATE] and was placed on hospice. The skin assessment sheet dated [DATE] on the body diagram has the coccyx area circled. To the left of the coccyx circle is a small circles with Stage II (2) documented. There is no further documentation of the area to the left of the coccyx. RIGHT MEDIAL HEEL The wound evaluation tracker is dated [DATE], 11 days after readmission. The site is documented as Right medial heel, length 3.3, Width 4.0, and stage SDTI (suspected deep tissue injury). For the question when was the wound identified documents [DATE]. Surveyor noted R3 was readmitted with this pressure injury on [DATE]. The wound color is documented as black. A suspected deep tissue injury is purple or maroon localized area of discolored intake skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Surveyor noted there is no revision in R3's care plan. The wound evaluation week 2 for the right medial heel dated [DATE] documents length 4.0, width 3.0 and stage suspected deep tissue injury. Wound bed is 100% granulation. A suspected deep tissue injury does not have a wound bed that is 100% granulation. R3 was transferred to the hospital on [DATE], returned to the facility on [DATE] and was placed on hospice. The skin assessment sheet dated [DATE] on the body diagram has the back of the right heel circled and documentation of closed intact hard blister 4.0 x 4 L (length). The wound evaluation week 3 for the right medial heel dated [DATE] documents length 4.0, width 4.5, depth 0 and stage Suspected Deep Tissue Injury. The wound bed is 100% necrotic. A suspected deep tissue injury would not have necrotic tissue and should be staged as unstageable. Surveyor noted there is no revision in R3's care plan. There is wound evaluation week 1 dated [DATE]. The site is 49) Right heel, Type Pressure, length 4.0, Width 4.1, Depth 0.0 and stage Unstageable. For the question when was the wound identified documents [DATE] The wound bed is 100% necrotic. This wound evaluation was signed by Former Administrator-E. LEFT HEEL The wound evaluation tracker is dated [DATE], 11 days after readmission. The site is documented as 50) left heel, type pressure, length 0.5, width 0.8, depth 0.1 and stage II (2). For the question when was the wound identified documents [DATE]. The wound bed is 100% granulation. Surveyor noted there is no revision in R3's care plan. The wound evaluation week 2 for the left heel dated [DATE] documents length 0, width 0, depth 0 and wound bed 100% [MEDICATION NAME]. For date wound healed documents [DATE]. LEFT LOWER LEG (FRONT) The wound evaluation tracker for the left lower leg is dated [DATE]. The site is documented as 42) Left lower leg (front), type Other (specify) fluid filled blister, Length 7.0, Width 2.0, Depth 0 and Stage II (2). For the question when was the wound identified documents [DATE]. Wound type documents pressure ulcer. Wound bed is documented as 100% skin Surveyor noted there is no revision in R3's care plan. The wound evaluation week 2 for the left lower leg is dated [DATE]. The length is 7.2, width 2.7, depth 0 and the wound bed is 100% skin. R3 was transferred to the hospital on [DATE], returned to the facility on [DATE] and was placed on hospice. The skin assessment sheet dated [DATE] on the front body diagram documents for the left lower leg fluid/dried blister 3 x 1.0. The wound evaluation week 3 for the lower leg front dated [DATE] does not document any measurements. Under current wound status/additional comments documents Prior week was noted to be a fluid filled blister, today there is just dark skin where the blister had been, area healed. For date of wound healed documents [DATE]. This assessment was signed by Previous Interim DON-Q. There is another wound evaluation week 3 dated [DATE] for site documents 42) left lower leg (front), type pressure, length 3.0, width 1.0, stage II (2) and for when was the wound identified documents [DATE]. Under additional descriptions documents Fluid filled blister on admission Blister no longer filled, skin intact, skin bruised. The wound bed is 100% skin. No is documented for the question has this wound healed. This assessment is signed by Former Administrator-E. Surveyor noted there is no further documentation regarding the left lateral foot which on [DATE] had measurements of length 2.0, width 3.5 and stage Suspected Deep Tissue Injury. On [DATE] at 7:30 a.m. Surveyor spoke to LPN (Licensed Practical Nurse)-R on the telephone regarding R3. LPN-R informed Surveyor she remembered R3 and took care of her when she was doing her clinical's at the Facility before she was hired. Surveyor asked LPN-R if she ever did any of the treatments for R3's pressure injuries. LPN-R informed Surveyor she remembers that the pressure injury smelled but doesn't remember when this was. LPN-R informed Surveyor after R3 came back from the hospital the second time she declined. On [DATE] at 8:04 a.m. Surveyor spoke to LPN-N on the telephone regarding R3. Surveyor read LPN-N her [DATE] note which stated Continues with buttocks o/a. Is clean and dry. and asked if R3's skin was not intact. LPN-N informed Surveyor it is hard to explain that the area was pinkish red ifs he is remembering it correctly. LPN-N informed Surveyor she remembers the area on R3's breast more than her buttocks. Surveyor asked who was assessing pressure injuries. LPN-N informed Surveyor Previous DON (Director of Nursing)-M and Former Administrator-E, who was an RN (Registered Nurse) would. On [DATE] at 8:17 a.m. Surveyor spoke with LPN-S on the telephone regarding R3. LPN-S informed Surveyor she remembered R3 and took care of her. Surveyor asked about R3's pressure injuries. LPN-S informed Surveyor she doesn't remember about her pressure injuries just that when she came back from the hospital after contracting COVID she didn't go back to her usual self and then went on hospice. On [DATE] at 8:59 a.m. Surveyor asked MDS/LPN (minimum data set Coordinator/ Licensed Practical Nurse)-O when she became responsible for wound rounds. MDS Coordinator/LPN-O informed Surveyor in June. Surveyor asked MDS Coordinator/LPN-O if she was wound certified. MDS Coordinator/LPN-O replied no and explained Former Administrator-E was. Surveyor asked MDS Coordinator/LPN-O if Wound MD (medical doctor)-P saw R3. MDS Coordinator/LPN-O replied noand explained she was never on his case load. MDS Coordinator/LPN-O informed Surveyor they were going to have Wound MD-P see R3 but then she went on hospice and Wound MR-P does not see hospice residents. Surveyor inquired how wound rounds are conducted. MDS Coordinator/LPN-O explained they have a wound paper that they write on when they go into everyone's room and then this information is entered into PCC (pointclickcare). Surveyor inquired who would stage pressure injuries. MDS Coordinator/LPN-O informed Surveyor for a new pressure injury she would never stage the ulcer that Former Administrator-E would. Surveyor asked MDS Coordinator/LPN-O why the coccyx wound evaluation dated [DATE] with slough and necrotic tissue why pressure injury still a suspected deep tissue injury. MDS Coordinator/LPN-O explained subsequent wound evaluations don't ask for a stage and carry forward the staging from week 1. MDS Coordinator/LPN-O informed Surveyor if the staging changed a note probably wasn't written. On [DATE] at 10:26 a.m. Surveyor informed Administrator-A, DON-B and Corporate Consultant-G of the above. On [DATE] at 11:26 a.m. Surveyor spoke with Previous Interim DON-Q. Previous Interim DON-Q informed Surveyor she started on [DATE] and today is her last day at the Facility. Surveyor asked what her involvement with pressure injuries was. Previous Interim DON-Q informed Surveyor she was doing wound rounds with MDS Coordinator-Q typically on Tuesday & Wednesday. Previous Interim DON-Q explained they would work together and input the reports. Surveyor asked about R3's wound evaluation week 3 for the right medial heel dated [DATE] which documents the wound bed as 100% necrotic but was staged as suspected deep tissue injury. Previous Interim DON-Q informed Surveyor she probably hit the wrong button. Surveyor asked after the pressure injury information is inputted into PCC does anyone review this information to ensure the information is accurate. Previous Interim DON-Q informed Surveyor not that she is aware of. 2.) R7's [DIAGNOSES REDACTED]. R7 was discharged to the community on [DATE] and was reviewed as a closed record. The at risk for skin integrity care plan initiated [DATE] documents interventions all dated [DATE] of * Apply alternating pressure air mattress to bed if indicated. Assure proper inflation - check frequently. * Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. * Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately. * Avoid friction/shearing while repositioning: if Resident is unable to assist, use at least two staff members, use lift sheet, bed should be as flat as possible with lifting. * Conduct pressure injury skin assessments (i.e. Braden scale) as indicated. * Frequent repositioning in bed and chair. * Head to toe assessment by Licensed Nurse performed weekly at minimum. * Keep Resident clean and dry. Use barrier cream after good peri-care. Apply proper incontinent products as indicated. Surveyor noted the at risk for skin integrity care plan does not include interventions to prevent pressure to R7's heels such as floating heels. The quarterly MDS (minimum data set) with an assessment reference date of [DATE] documents a BIMS (brief interview mental status) score of 3 which indicates severe impairment. R7 requires extensive assistance with one person physical assist for bed mobility, limited assistance with one person physical assist for transfers, and is coded as having ambulated once or twice with one person physical assist. R7 is at risk for developing pressure injuries and is coded as not having any pressure injuries. Pressure reducing device for chair and pressure reducing device are checked under skin and ulcer/injury treatment. The interact change in condition evaluation dated [DATE] under the skin status evaluation section for site documents 49) Right heel and under description documents Large intact blood filled blister 5.7 x (times) 5.6 cm (centimeters). There is no documented staging of R7's right heel pressure injury. The SBAR (situation, background, assessment, recommendation) note dated [DATE] documents The change in condition/s reported on this CIC (change in condition) Evaluation are/were: Skin wound or ulcer. and Primary Care Provider responded with the following feedback: Recommendations: Apply skin prep to bilat (bilateral) heels bid (twice daily), float heels off bed, apply air mattress. The nurses note dated [DATE] documents Has lt. (left) heel blood blister. Is clean and dry. No active bleeding. Surveyor noted should be right heel. The weekly skin review dated [DATE] is checked for skin intact and open area. Under site documents 49) Right heel and under description documents 5.6 x 4.6 100% black eschar. There is no documented staging of R7's right heel pressure injury. The weekly skin review dated [DATE] is checked for open area. The site & description section are blank. There is no assessment of R7's right heel pressure injury during the week of [DATE] to [DATE]. The weekly skin review dated [DATE] is checked for open area. The site & description section are blank. The nurses note dated [DATE] documents RT (right) heel blister is clean and dry and wrapped. The actual skin integrity care plan initiated [DATE] documents interventions of: * No shoes, gripper socks only initiated [DATE]. * Encourage to float heels in bed initiated [DATE]. * Encourage to wear prevlon boot right foot in bed initiated [DATE] & revised on [DATE]. * Monitor right heel for healing initiated [DATE]. * Apply alternating pressure air mattress to bed if indicated. Assure and maintain proper inflation controls. Refusing initiated [DATE]. * Apply chair cushion to wheelchair, Geri chair or Broda Chair. Ensure proper placement and clean daily initiated [DATE]. * Assess and measure all skin integrity areas per policy initiated [DATE]. * Float heels while in bed initiated [DATE]. * Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications initiated [DATE]. * Initiate skin monitoring forms per facility policy initiated [DATE]. * Initiate treatment per Physician order [REDACTED]. * Monitor and report any new open areas, drainage, increased drainage or pain to nurse immediately initiated [DATE]. * Monitor for c/o (complaint of) pain. Medicate PRN (as needed) and offer pain medication prior to treatment. Update Physician regarding effectiveness and increased need for pain medications initiated [DATE]. * Provide treatment to wound(s) per current treatment order. Assess wound(s) for s/s (signs/symptoms) of infection<b (TRUNCATED)

Based on interview, observation and closed record review, the facility did not ensure 1 (R2) of 6 residents sampled received quality of care with all treatments provided to facility residents. The facility did not ensure that resident received treatment and care in accordance with professional standards of practice. * R2 developed abdominal wounds while at the facility. R2's care plan was not updated and reassessments were not completed. The Wound MD did not assess R2's wounds and the MD/NP (Nurse Practitioner) were not notified of worsening wounds. R2 was transferred to the hospital after her wounds were found to be infected. Findings included: On 3/19/2020 a complaint was called into the State Agency alleging (R2) developed sores to the abdominal folds . (R2) was hospitalized due to abdominal sores becoming infected. Abdomen required debridement with surgery and time in ICU. Surveyor reviewed facility's Skin Management System policy with a date of 12/17. Documented was, 1. A head to toe body evaluation will be completed on every resident upon admission or readmission and weekly thereafter. These evaluations will be documented on the Weekly Skin Integrity Review form or (Electronic Medical Record (EMR)). If skin is intact, no further action is required. If skin is compromised, proceed to the appropriate form below . B. Non-ulcer/surgical skin issues such as skin tears, bruises, rashes, abrasions,[MEDICAL CONDITION]. will be documented on the Altered Skin Integrity Treatment & Progress Record. Use separate record for each area. I. treatment for [REDACTED]. a. Assess all residents for pain and act accordingly during treatments. b. All dressings are to be dated and initiated upon completion. c. Keep open lines of communication with physicians, families, and residents regarding status of wounds. d. Responsible Party will be notified at the onset of an identified area as well as with all treatment changes, decline in status of the area, and when the area is healed. Documentation of the notification is to be in the Nurses Notes in the clinical record or EMR. III. Progress of the identified area will be documented on the back of the Altered Skin Integrity Treatment & Progress Record form or EMR at least every 7 days, or less if the wound shows a decline or is healed. The physician is to be contacted after 14 days if the area has not shown improvement or immediately if it shows a decline. Documentation of the Physician notification is to be in the Nurses Notes in the chart or EMR. 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. R2 was admitted to the facility on [DATE]. R2's [DIAGNOSES REDACTED]. R2 was discharged [DATE] to the hospital and did not return to the facility. Surveyor reviewed R2's Hospital Paperwork with a discharge date of [DATE]. R2 was admitted to hospital from 10/13/19 to 10/19/19. Documented under Wound Abdomen Skin fold was Date first assessed: 10/14/19; Wound type: Moisture Associated Skin Damage (MASD). Documented under Assessments was 10/19/19 1215: Wound exudate: none; Wound bed/tissue type: red, pink; Periwound condition: moist; Topical agent: antifungal powder. Documented under Discharge Summary Patient Instructions was Wound care: none needed. Surveyor reviewed R2's 10/19/19 Admission/Readmission Evaluation. Documented under Section D. Skin Integrity/Braden Scale was Braden Scale Total Score: 15 which indicated R2 was at risk for skin breakdown. Documented under Skin Observation was Skin color: normal; Temperature: warm; dry; Turgor: normal. Documented under Integrity: If skin condition present, initiate Plan of Care and Weekly Skin Report was Site: 23) coccyx; Type: Pressure. There is no documentation of breakdown to abdominal region. Surveyor reviewed R2's 10/19/19 Admission Skin Assessment. Documented on a picture of the front of the body was an O on the abdominal region, left side which stated (O-other) open red sore. No other abdominal wound documentation, measurements or assessments were documented. Surveyor reviewed R2's Baseline Care Plan with a start date of 10/19/19. Documented was Skin Care Needs: At risk for skin breakdown; Interventions: Buttocks/coccyx. Pressure ulcer/injury present; Location: Buttocks/coccyx. Turn and reposition every 2 hours. Skin treatments - see (Treatment Administration Record (TAR)): (blank). No other abdominal wound documentation or interventions were documented. Surveyor reviewed R2's TAR for October 2019. Documented with a start date of 10/19/19 was (Left) wound abdomen (abd) (treatment): (Normal Saline wash (NSW)) (followed by (FB)) [MEDICATION NAME] FB dry dressing (once daily (QD))/(as needed (PRN)). Surveyor reviewed R2's Daily Skilled Observation for 10/20/19, 10/21/19, 10/22/19 and 10/23/19. There was no documentation of abd wound or open area to abd. Surveyor reviewed R2's admission MDS (Minimum Data Set) with an assessment reference date of 10/23/19. Documented under Cognition was a BIMS (brief interview mental status) score of 11 which indicated moderate impairment. Documented under Functional Status for Bed Mobility and Transfer Status was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Skin Conditions was Other Ulcers, Wounds and Skin Problems: z. None of the above. Surveyor reviewed R2's Care Area Assessment (CAA) for 16. Pressure Ulcer/Injury with an assessment reference date of 10/24/19. Documented under Analysis of Findings was .She is at risk for skin integrity condition or pressure sores (related to) DM2, [MEDICAL CONDITION], impaired mobility, obesity, recent illness. Surveyor reviewed R2's Comprehensive Care Plan with an initiation date of 10/24/19. Documented was Resident is at risk for skin integrity condition, or pressure sores (related to (r/t)): Diabetes, ([MEDICAL CONDITIONS]), end-stage renal, Impaired mobility, Obesity, Recent illness/surgery. Interventions included Assess skin for redness or pressure or pressure related changes with each care encounter. Report any changes immediately. Head to toe assessment by Licensed Nurse performed weekly at minimum. There is no care plan in place for abd MASD, wound or prevention of breakdown. No revisions or updates were made to care plan to reflect abd wound during R2's time at facility. Surveyor reviewed R2's Daily Skilled Observation for 10/24/19 and 10/25/19. There was no documentation of abd wound or open area to abd. Surveyor reviewed Nurse Practitioner (NP) visit note from 10/25/19. Documented under Physical Assessment was Skin: General: Skin is warm and dry. No documentation of abd wound or skin breakdown noted. Surveyor reviewed R2's Daily Skilled Observation for 10/27/19 and 10/28/19. There was no documentation of abd wound or open area to abd. Surveyor reviewed facility's Wound Round Worksheet with a date of 10/28/19. Documented for R2 was Site: (Left) abd wound. Treatments/comments: NSW foam. Measurements, Wound Description, Odor and Periwound areas were left blank and not documented on. Surveyor reviewed NP visit note from 10/28/19. Documented under Physical Assessment was Skin: General: Skin is warm and dry. 1. Four opened areas to coccyx. Three open on the right side of the buttocks. One to left buttocks partially open. No documentation of abd wound or skin breakdown noted. Surveyor reviewed R2's Daily Skilled Observation for 10/29/19 and 10/30/19. There was no documentation of abd wound or open area to abd. Surveyor reviewed NP visit note from 10/30/19. Documented under Physical Assessment was Skin: General: Skin is warm and dry. 1. Open area to coccyx, off white drainage. 2. (right heel) Blister intact. 3. (left heel) Blister intact. No documentation of abd wound or skin breakdown noted. Surveyor reviewed R2's TAR for November 2019. Documented 11/1/19 through 11/30/19 was (Left) Abdominal wound - cleanse (with) (Normal Saline (NS)) apply [MEDICATION NAME] FB dry dressing daily and PRN. Surveyor reviewed R2's Daily Skilled Observation for 11/1/19, 11/2/19, 11/3/19, and 11/4/19. There was no documentation of abd wound or open area to abd. Surveyor reviewed Wound MD-P documents from in facility visit 11/4/19. MD-P did not assess R2's abd wound during this visit. Surveyor reviewed NP visit note from 11/5/19. Documented under Physical Assessment was Skin: General: Skin is warm and dry. 1. Open area to coccyx with mixed yellow/off white slough and pink wound bed. 2. Blister to right heel opened - serosanguinous drainage. Skin mostly intact. 3. Blister to left heel intact. No documentation of abd wound or skin breakdown noted. Surveyor reviewed R2's Daily Skilled Observation for 11/5/19 and 11/6/19. There was no documentation of abd wound or open area to abd. Surveyor reviewed facility's Wound Round Worksheet with a date of 11/10/19. Documented for R2 was Site: (Left) abd. Measurements: 3.5 X 1.5 (no unit of measurement). Wound Description: 100% eschar. Treatments/comments: Santyl FB (Dry Sterile Dressing (DSD) change once daily (QD)). Odor and Periwound areas were left blank and not documented on. Documented also was Site: Abd distal. Treatments/comments: Santyl FB DSD (change) QD. Measurements, Wound Description, Odor and Periwound areas were left blank and not documented on. Surveyor reviewed facility's Wound Round Worksheet with a date of 11/12/19. Documented for R2 was Site: (Left) Abd. Treatments/comments: NSW, [MEDICATION NAME], dry daily. Measurements, Wound Description, Odor and Periwound areas were left blank and not documented on. Handwritten on sheet in Measurements column was Dr. J noting Wound MD-P would have measurements. Surveyor reviewed Wound MD-P documents from in facility visit 11/14/19. MD-P did not assess R2's abd wound during this visit. Surveyor reviewed updates to R2's TAR for November 2019. Documented 11/18/19 through 11/30/19 was (Left upper) abd and (medial lower) abd: cleanse (with) NS FB Santyl cover (with dry sterile dressing, change once daily) and PRN. Surveyor reviewed MD-C visit note from 11/20/19. Documented was Assessment/Plan: .10. Pressure injury of buttock, stage 2, unspecified laterally (CMS/HCC). 11. Blisters of multiple sites: Being followed by wound care MD . No documentation of abd wound or skin breakdown noted. Surveyor reviewed facility's Wound Round Worksheet with a date of 11/25/19. Documented for R2 was Site: (Left upper) Abd. Measurements: 1.5 X 3.0 (no unit of measurement). Wound Description: 100% scabbed. Treatments/comments: NS, Santyl FB DSD. Odor and Periwound areas were left blank and not documented on. Documented also was Site: (Left Lower) Abd. Measurements: 1.0 X 6.0 cm, 1.0 X 2.0 cm. Wound Description: 100% slough. Treatments/comments: NS, Santyl FB DSD. Odor and Periwound areas were left blank and not documented on. Surveyor reviewed NP visit note from 11/26/19. Documented under Physical Assessment was Skin: General: Skin is warm and dry. 1. Three open wounds across lower midline abdominal wall/pannus region. Wounds with surrounding [DIAGNOSES REDACTED] and white slough in wound bed . Documented under Assessment and Plan was .9. Open wound of abdominal wall, initial encounter. STAT (Complete Blood Count (CBC)) and procalcitonin ordered. Wound dressing ordered until can be evaluated by Wound MD tomorrow. Monitor. Surveyor reviewed lab results that were unremarkable and no new orders were made by NP. Surveyor reviewed R2's Progress Notes. Documented on 11/30/19 at 10:49 PM was Tx to underside of abdominal flap done, drainage noted from (open area), boarders are red and warm and (R2) complains of pain upon touch. Patient is now resting in bed at this moment with call light in reach. No documentation of change in wound status update to NP or MD was found in EMR. Surveyor reviewed R2's TAR for December 2019. Documented 12/1/19 through 12/2/19 was Santyl Ointment. Apply topically to Abd wounds after cleansing FB dry dressing once daily and PRN as needed. Cleanse (with) NS. This treatment was discontinued on 12/2/19. Surveyor reviewed MD visit note from 12/2/19 performed by Wound MD-P in facility. Documented for abd wound was .Length: 2.82 cm. Width 7.01 cm. Perimeter: 19.94 cm.Maximum Depth: 0.1 cm. Red Tissue: 19%. Black Tissue: 27%. Yellow Tissue: 17%. Other Tissue: 17%. Pink Tissue: 20%. Etiology: Other. Margin Details: Attached edges. Woundbed Assessment: Early/Partial granulation. Drain amount: Small. Drain Description: Serous. Odor: Normal Odor. Periwound: Indurated. Surveyor reviewed updates to R2's TAR for December 2019. Documented 12/2/19 through 12/11/19 was Cleanse with Dakin's Solution FB Santyl and (Abd bandage) to abdominal wounds (twice daily). Surveyor reviewed R2's Daily General Follow-Up Observation with a date of 12/8/20. Documented under Current Status was Wound care provided . Abdominal wounds 10% granular 90% slough, no (signs or symptoms of infection . No documentation of change in wound status update to NP or MD was found in EMR. Surveyor reviewed R2's Change in Condition Evaluation with a date of 12/11/19 documented by Licensed Practical Nurse (LPN)-H. Documented under Summarize your observations and evaluations was went in to complete (abd) tx writer found abdomen was necrotic. (MD-C) was called and wanted to send resident to hospital. On 7/28/20 at 10:26 AM Surveyor interviewed LPN-H. Surveyor asked about R2's abdominal wounds. LPN-H stated the wounds continually got worse while she was at the facility. LPN-H stated she updated Former Director of Nursing (DON)-M and other Supervisors of wound status on multiple occasions. LPN-H stated none of the Supervisors or DON-M worked at the facility anymore. LPN-H stated on 12/11/19 she went to do her treatment and noted the wound was black. LPN-H stated she had the previous 2 to 3 days off but the last shift she had worked she had done the treatment and the wound was slough. LPN-H stated because of the dramatic change she updated DON-M and updated MD-C and was instructed to send R2 to the hospital. LPN-H stated she called 911 and R2 was transferred to the hospital via ambulance. No other employees who performed wound care or assessed R2's wounds were able to be interviewed due to no longer working at the facility. Surveyor reviewed R2's Hospital Discharge Summary with a date of 1/6/20. Documented under Hospital Course was (R2) who was admitted to Aurora St. Luke's Medical Center with a complaint of abdominal wound and drainage. She was at a nursing facility. (Computerized Tomography (CT)) of the abdomen showed extensive soft tissue infection with extensive subcutaneous gas [MEDICAL CONDITION] changes. She was started on broad-spectrum antibiotics. Subsequently underwent excisional debridement of necrotizing infection on 12/12/2019. She was transferred to the (Intensive Care Unit (ICU)) postoperatively. She did have transient [MEDICAL CONDITION] (postoperatively) requiring pressors briefly. She was subsequently transferred back to the floor on 12/19/19. She underwent an additional debridement on 12/21/2019. Wound VAC is placed. She has completed 16-17 treatments of (Hyperbaric Oxygen (HBO) Therapy.) Antibiotic courses also completed. Pathology suggests [DIAGNOSES REDACTED]. She is continued with [MEDICAL TREATMENT]. She is also being treated with sodium [MEDICATION NAME]. Patient also has additional wounds in bilateral heel as well as sacral area. No clear infection in this areas.

Based on a complaint received at the Southeastern Regional office, interview and record review the Facility did not ensure 1 (R8) of 1 Residents was provided with pain management consistent with professional standards of practice. On 7/19/20 when LPN (Licensed Practical Nurse)-R started her day she could hear R8 screaming at the top of her lungs. LPN-R inquired about R8. LPN-N, the night nurse, informed her she had given R8 all of her pain medication. Interviews revealed R8 was crying and screaming during the night. R8 described the pain that night as excruciating. LPN-N did not complete any pain assessments during the night shift prior to R8 being transferred to the hospital nor did she contact the Director of Nursing, Administrator, Assistant Director of Nursing, or the physician regarding R8's pain. LPN-R sent R8 911 to the hospital where they noted the Foley balloon was at the urethral meatus and diagnosed R8 with a UTI (urinary tract infection). Findings include: The Pain Management Policy revised 3/2016 under policy statement documents Effective pain recognition and management requires an ongoing facility-wide commitment to the resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that resident, families, and staff may have about managing pain. Nursing home residents are at high risk for having pain that may affect function, impaired mobility, impaired mood, or disturb sleep, and diminish quality of life. The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated. Under Policy Interpretation and Implementation includes A pain Assessment will be completed upon admission, readmission, significant change and any new episode of pain or exacerbation of pain. and If the Patient/Resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED]. R8 [DIAGNOSES REDACTED]. R8's care plan indicates the Resident has pain or the potential for pain r/t (related to) or evidenced by: malnutrition, [MEDICAL CONDITIONS], hx (history of) stage 3 breast ca (cancer). Care plan initiated 8/12/19 documents interventions all dated 8/12/19 of: * Administer [MEDICATION NAME] per MD (medical doctor) orders. Give prior to treatments, therapy or cares. * Anticipate Resident's need for pain relief and respond as soon as possible to any complaint of pain. * Ask Resident about which positions are comfortable, encourage frequent repositioning. * Discuss Resident's pain with IDT (interdisciplinary) members i.e. Therapy, Social Service, Activities for adjunct methods and ideas to deal with pain. * Document pain on 1-10 scale or use pain faces. Monitor response to [MEDICATION NAME] and pain alleviation measures. * Educate Resident and Family about Pain. Encourage Resident to stay on top of pain needs so that pain does not spike up making pain relief harder to control and taking longer to take effect. * Explore non pharmacological pain alleviating interventions such as heat, ice, massage, elevation, relaxation, repositioning and food. * Monitor/document for side effects of pain medication - i.e. constipation, drowsiness. * Observe Resident during cares for signs of pain i.e. facial grimacing, hesitancy with movement, furrowed brows, saying Ouch, refusing to move or transfer. Always ask Resident about their pain with each encounter. * Update Physician on effectiveness of [MEDICATION NAME] and pain treatments as necessary. The quarterly MDS (minimum data set) with an assessment reference date of 5/18/20 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R8 is not coded for any behavior symptoms including verbal behavior. R8 is dependent with two plus person physical assist for bed mobility, transfer, & toilet use, does not ambulate and is checked for an indwelling catheter. Under the pain management section R8 received scheduled pain medication and PRN (as needed) pain medication. R8 answered yes for the question have you had pain or hurting at any time in the last 5 days. For the question how much of the time have you experienced pain or hurting over the last 5 days occasionally is answered. For the question over the past 5 days has pain made it hard for you to sleep at night yes is answered. For the question over the past 5 days, have you limited your day to day activities because of pain no is answered. R8 rated on a 0-10 scale pain as 4. The nurses note dated 7/18/20 at 0321 (3:21 a.m.) documents Foley patent. Urine is golden yellow. The nurses note dated 7/18/20 at 1314 (1:14 p.m.) documents Resident is alert, verbal. Foley is patent draining clear, yellow urine. Fluid taken at 100%, fluid flushes given. The nurses note dated 7/18/20 at 1943 (7:43 p.m.) documents Foley patent. Urine is golden, clear yellow. Surveyor noted there is no documentation during the night shift on 7/18 into the 7/19/20 shift. The nurses note dated 7/19/20 at 0700 (7:00 a.m.) documents At start of shift resident was screaming and crying uncontrollably of pain to vaginal area and body. Report from previous shift was that pain meds (medication) were given an hour and two hours prior with no relief. Resident requested to go to the emergency room . Writer sent out via 911 and was transported via Curtis ambulance to Froedtert hospital. Primary physician, daughter, and hospital were notified. The nurses note dated 7/19/20 at 1304 (1:04 p.m.) documents Resident returned from Froedtert emergency department at 1300 (1:00 p.m.) via Curtis ambulance. Resident has a UTI (urinary tract infection) and ER (emergency room ) replaced Foley. Resident was sent with a prescription for antibiotics. Foley is now patent and draining cloudy urine. Resident denies any pain at the moment. Prescription faxed over to pharmacy. Surveyor reviewed Facility's 24 hour report/change of condition report dated 7/18/20 for the night shift. The night shift works 10:00 p.m. on 7/18/20 to 6:00 a.m. on 7/19/20. Surveyor noted under the night section documents Foley patent. The hospital ED (emergency department) triage notes dated 7/19/20 documents Pt (patient) arrived from maple ridge via Curtis Ambulance with cc (complaint) vaginal pain rated 10/10. Pt had Foley placed within the last few days with no output in the Foley bag. Facility states patient has been incontinent of urine. VSS (vital signs stable) enroute to hospital. Patient RR (respiratory rate) 20. The hospital HPI (history of present illness) dated 7/19/20 documents R8 is a 62 Y (year old) female with a PMH (past medical history) of [MEDICAL CONDITION] s/p (status [REDACTED]. The pain began last evening after receiving a Foley exchange w/in (within) the past 2 days. The pain was sharp, stabbing, and constant. It did not radiate. She was not getting any urine output from her Foley but was leaking urine around her Foley. This pain is similar to when she has had prior UTIs (urinary tract infection). After arrival the Foley was exchanged and it was noticed the original Foley balloon was at the urethral meatus. There was 366cc (cubic centimeters) in the bladder prior to the exchange and 68cc after the exchange. After the exchange the pain decreased to 5/10 as a dull ache. Under Review of Systems for [MEDICAL CONDITION] documents Positive for dysuria (discomfort, pain or burning when urinating). Negative for frequency and urgency. Foley problem. On 7/20/20 a grievance was filed. Under describe grievance/complaint using factual terms documents Daughter states she does not feel night shift nurse adequately addressed Res. (resident) pain on 7/18/20. SW (Social Worker)-K statement dated 7/28/20 documents Writer interviewed R8 regarding concerns with nurse, LPN (licensed practical nurse)-N. Resident stated that the night (sic) she was yelling out in pain, LPN-N came in and gave her pain medication (incident on 7/18). Writer asked resident if nurse closed her door and resident reported that she closed it slightly and stated other residents were trying to sleep. Res. states she does not feel her pain was addressed until the nurse came in the following morning. R8's physician orders includes pain medications of: * [MEDICATION NAME] 325 mg (milligrams). Give 2 tablet by mouth every 4 hours as needed for pain/fever not to exceed 3 gm (grams) APAP ([MEDICATION NAME]) in 24 hours from all sources. * Diclofencac Sodium Gel 1% Apply 2 gram [MEDICATION NAME] every 6 hours as needed for pain. * [MEDICATION NAME] Capsule 100 mg Give 2 capsule by mouth three times a day for pain. * [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 mg Give 1 tablet by mouth every 8 hours as needed for pain. * [MEDICATION NAME] Cream 2.5% Apply to affected areas topically every 6 hours as needed for pain. * Icy Hot Extra Strength Cream 10-30% (Methol-[MEDICATION NAME]) Apply to affected areas topically every 8 hours as needed for pain. * [MEDICATION NAME] HCI Tablet 10 mg Give 10 mg by two times a day related to unspecified abdominal pain. * Proctosol HC Cream 2.5% ( [MEDICATION NAME]) Insert 1 application rectally every 6 hours as needed for pain. * Tylenol Extra Strength Tablet 500 mg ([MEDICATION NAME]) Give 500 mg by mouth three times a day related to unspecified abdominal pain. Surveyor reviewed R8's July 2020 MAR (medication administration record) and noted R8 did not receive any of the PRN pain medications during the night shift starting at 10:00 p.m. on 7/18/20 until 6:00 a.m. on 7/19/20 including [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. Review of the narcotic sheet dated 7/14/20 for [MEDICATION NAME] 10 mg under directions indicates every 12 hours PRN. Surveyor noted according to physician orders [MEDICATION NAME] is scheduled and not PRN. The narcotic sheet for [MEDICATION NAME] 10 mg on 7/19/20 line 9 under time is written 2400 (midnight) and then 20 is written over 24 for a time of 8:00 p.m. One tablet was dispensed. The narcotic sheet for [MEDICATION NAME] 10 mg on 7/19/20 line 10 under time is 0400 (4:00 a.m.). One tablet is dispensed. According to the July 2020 MAR indicated [REDACTED] Surveyor noted R8 received Oxycodon on 7/18/20 at 9:00am (as ordered) and the 9:00 pm is blank on the MAR. Surveyor noted R8 received the [MEDICATION NAME] on 7/19/20 at 4 am (no physician's order for a PRN). R8 also received [MEDICATION NAME] on 7/19/20 after she returned from the hospital at 12:50 p.m. and 8:00 p.m. On 8/10/20 at 10:12 a.m. Surveyor reviewed R8's pain medication orders with DON (Director of Nursing)-B and showed DON-B R8's [MEDICATION NAME] 10 mg narcotic sheet dated 7/14/20 and asked about the directions indicating every 12 hours PRN. DON-B informed Surveyor he would look into this and get back to Surveyor. On 8/10/20 at 11:10 a.m. DON-B informed Surveyor he didn't see an order which would indicate PRN and has a call into the pharmacy. On 8/10/20 at 12:17 p.m. Surveyor asked DON-B for clarification on R8's [MEDICATION NAME] 10 mg narcotic sheet regarding line 9 with the time written over. DON-B informed Surveyor they will look into this. No additional information was provided to Surveyor. On 8/6/20 at 9:02 a.m. Surveyor spoke with LPN (Licensed Practical Nurse)-R on the telephone. Surveyor read LPN-R her nurses note dated 7/19/20 at 7:00 a.m. and asked LPN-R to explain to Surveyor what occurred that morning. LPN-R explained to Surveyor she came on the floor and could hear R8 screaming at the top of her lungs, it was a painful scream, could hear R8 down the hall & around the corner. LPN-R stated this was not (like) R8. LPN-R explained she asked LPN-N who was the night nurse why R8 was screaming. LPN-N told LPN-R she gave R8 all the pain medication she can give her. LPN-R told Surveyor she told LPN-N she can't give pain medication without knowing what the underlying issue is. LPN-R informed Surveyor CNA (Certified Nursing Assistant)-AA came to get her and said something is wrong with R8. LPN-R informed Surveyor she went to R8's room with CNA-AA but LPN-N did not come to the room and when she (LPN-R) left R8's room, LPN-N had left the Facility. LPN-R explained when she got to the room she asked R8 where she was hurting and R8 informed LPN-R her stomach, back and down in her vaginal area. LPN-R informed Surveyor they tried to examine R8's vaginal area but R8 was screaming so bad and wanted to go to the emergency room . LPN-R informed Surveyor the Foley bag was bone dry but LPN-N had told her the Foley was draining and she flushed it during the night. LPN-R informed Surveyor she asked R8 what happened and R8 told her she was screaming all night and LPN-N told her she couldn't give her any more pain medication but didn't look at her. LPN-R informed Surveyor R8 said LPN-N told her she needs to be quiet, will wake other residents up and closed her door. LPN-R informed Surveyor R8 doesn't like her door closed and doesn't scream either. LPN-R said to Surveyor maybe Surveyor could speak to R8 she's alert and knows what's going on. LPN-R informed Surveyor R8 is a very easy resident, everything is scheduled for her so R8 is hardly ever in pain. LPN-R informed Surveyor she called 911 for R8. Surveyor asked if LPN-R knew what the hospital did for R8. LPN-R informed Surveyor they placed a new Foley, said it was in the wrong place something about the balloon being in the meatus. On 8/6/20 at 9:26 a.m. Surveyor spoke with LPN-N, who worked the night shift prior to R8 being transferred to the hospital, on the telephone. Surveyor asked LPN-N to explain what happened during her night shift with R8. LPN-N explained to Surveyor she did her rounds, R8 had no fever, not throwing up, tolerating tube feeding and thinks she was on an antibiotic for UTI (urinary tract infection). Surveyor asked if R8 slept during the night. LPN-N replied on and off. Surveyor asked if R8 was yelling. LPN-N informed Surveyor near the end of her shift and R8 gets scheduled Tylenol and [MEDICATION NAME] which she had. Surveyor asked LPN-N if she did anything for R8 during the night. LPN-N informed Surveyor she checked R8's vital signs, did repositioning with pillows, applied lotion and medication. Surveyor asked when R8 started yelling what did she do. LPN-N explained she tried to talk to her to see what was wrong and R8 told her she has legs & hip pain and then said it was generalized pain all over. Surveyor asked LPN-N if she checked R8's Foley bag. LPN-N replied yes, there was urine, golden yellow. Surveyor informed LPN-N Surveyor had been informed by the day nurse the Foley bag was bone dry. LPN-N informed Surveyor there was urine in the bag. Surveyor asked LPN-N if R8 usually yelled out at night. LPN-N replied yes. Surveyor asked how often does R8 yell out. LPN-N replied every night. LPN-N informed Surveyor sometimes people will say ow when you knock on their door before going in and R8's doctor said she has an unusual low tolerance for pain. Surveyor asked LPN-N if R8 likes her door open or closed. LPN-N informed Surveyor the door should be open. Surveyor asked LPN-N if she closed R8's door because she was yelling out. LPN-N replied no, never. Surveyor asked LPN-N if she told R8 she needs to be quiet as she going to wake up the other residents. LPN-N replied no. Surveyor asked if there was a RN (registered nurse) in the building. LPN-N replied no and explained she could call the DON, Administrator, or ADON (assistant director of nursing). Surveyor asked LPN-N if she called any of these staff that night. LPN-N replied no and explained because when she had her [MEDICATION NAME], she fell asleep and there was no need to call anyone. Surveyor asked LPN-N when R8 started screaming and crying. LPN-N informed Surveyor she didn't hear R8 uncontrollably screaming and that could have been after she left at 6:00 a.m. On 8/6/20 at 10:10 a.m. Surveyor spoke with SW (Social Worker)-K on the telephone to inquire if there were any concerns brought to her attention regarding R8. SW-K informed Surveyor there was one which the daughter didn't feel the nurse addressed R8's pain and didn't follow up with the doctor. Surveyor asked what the issue was with R8's pain. SW-K informed Surveyor the daughter felt like the night shift nurse didn't adequately address her mom's pain. R8 was still in pain after receiving pain medications, felt the nurse should have called the doctor, and followed up more. Surveyor asked SW-K if R8 was alert and orientated. SW-K replied yes and no and explained the daughter is the activated power of attorney but R8 is verbal. Surveyor asked SW-K if R8 usually yells out. SW-K replied not typically, no. On 8/6/20 at 10:35 a.m. Surveyor spoke with CNA-AA on the telephone. Surveyor asked CNA-AA to explain what happened when R8 went to the hospital on [DATE]. CNA-AA explained to Surveyor he gets to work early probably around 3:30 to 4:00 in the morning and does a walk through of his unit and then goes to the break room. CNA-AA explained R8 saw him, told him she was in so much pain and asked him to speak to LPN-N. CNA-AA explained he told LPN-N R8 was in a lot of pain and LPN-N told him she gave R8 everything for pain. CNA-AA indicated he asked LPN-N why R8 was like this and asked LPN-N if R8 had a pain pill. LPN-N told CNA-AA she took care of it. CNA-AA asked Surveyor what am I suppose to do as a CNA. CNA-AA informed Surveyor what concerned him is when he came up from the break room R8 was really screaming. CNA-AA informed Surveyor he went and told LPN-R we need to go to R8. CNA-AA informed Surveyor they pulled down R8's diaper, it was completely saturated and the bag was bone dry. CNA-AA informed Surveyor he spoke with the night CNA who said R8 was yelling most of the night. Surveyor asked CNA-AA if R8 usually yells out. CNA-AA informed Surveyor it is very unusual for R8 to yell out, she's very mild, and only if she was in pain would she scream out. Surveyor asked CNA-AA if R8 was alert and could tell them what's wrong. CNA-AA replied absolutely. Surveyor asked CNA-AA if R8 said anything about her door. CNA-AA informed Surveyor LPN-N came in told R8 she was disturbing other residents, needs to be quiet, and shut the door. CNA-AA told Surveyor R8 doesn't like her door closed. CNA-AA informed Surveyor he knows his residents and when R8 came back from the hospital she was much better. On 8/6/20 at 3:05 p.m. Surveyor spoke with CNA-BB on the telephone regarding R8 and the night shift she worked prior to R8 being transferred to the hospital. CNA-BB informed Surveyor she (CNA-BB) and the nurse went in and R8 was complaining of pain. R8 told the nurse she was in pain. CNA-BB informed Surveyor when they were repositioning R8 she was crying hysterically. CNA-BB informed Surveyor the nurse gave R8 what ever for pain. Surveyor asked CNA-BB if R8 screams and cries at night. CNA-BB informed Surveyor sometimes she does and explained she hasn't worked a lot with R8 as she's only been at the facility a month. Surveyor asked CNA-BB if the nurse talked to R8 about her pain. CNA-BB informed Surveyor R8 was screaming and crying but she left as there was nothing else she could do. Surveyor asked CNA-BB if she gave report to the oncoming shift. CNA-BB informed Surveyor she gave CNA-AA report, said everyone was checked & changed, R8 had a rough night and was crying. On 8/6/20 at 3:20 p.m. Surveyor spoke with CNA-CC on the telephone and inquired if she took care of R8 during the night shift 7/18/20 into 7/19/20. CNA-CC replied no and explained she was on another unit. CNA-CC informed Surveyor for the most part R8 is quiet, sometimes at night she is in pain and you'll hear her yelling nurse to get someone's attention. CNA-CC informed Surveyor she hasn't heard her scream just yells out nurse. Surveyor was unable to locate any pain assessment in July for R8. On 8/10/20 at approximately 10:05 a.m. Surveyor asked Administrator-A for any pain assessments completed in July 2020 for R8. On 8/10/20 at 10:36 a.m. Surveyor spoke to R8 who was in bed on her back, with the head of the bed elevated and the call pad on her chest near her chin. Surveyor estimated R8's room is more than 50 feet from the nurses station. Surveyor asked R8 if she remembered going to the hospital on July 19th. R8 informed Surveyor she did. Surveyor asked R8 if she could explain to Surveyor what happened during the night shift prior to her going to the hospital. R8 informed Surveyor she didn't sleep well as she was in a lot of pain and had pain in her abdomen. Surveyor asked if LPN-N came in her room. R8 informed Surveyor LPN-N came in and gave her pain medication but it didn't take care of the problem. R8 informed Surveyor LPN-N was going to shut my door because I was crying out in pain and LPN-N said I would wake up the other residents. R8 informed Surveyor she asked LPN-N not to close her door. Surveyor asked R8 if LPN-N closed her door. R8 said yes. Surveyor asked R8 if LPN-N closed her door partially or all the way. R8 informed Surveyor partially and that she doesn't like her door closed. Surveyor asked R8 if R8 could describe her pain to Surveyor. R8 stated It was excruciating. I couldn't sleep. I couldn't think straight. It was a very bad pain. The medication she gave me didn't eliminate the pain. Surveyor asked R8 if she told LPN-N the medication didn't help. R8 replied, Yes I told her I was in pain that's why I was crying out. Surveyor asked what LPN-N did. R8 replied She didn't do anything, she just walked away. Surveyor asked if LPN-N felt her abdomen or looked at her private area where the catheter is. R8 replied no. Surveyor asked if she was in pain all night. R8 replied yes. R8 informed Surveyor the first shift nurse could hear her screaming out and said she was going to call the doctor & see if she could go to the ER. R8 said I said please, please do that. Surveyor asked R8 if the pain she felt that night was usual for her. R8 replied no, I'm usually pretty satisfied when they give me my pain medication. Surveyor asked R8 if she remembered what time she started to have the pain. R8 informed Surveyor she didn't remember. Surveyor asked if she had the pain during the evening shift. R8 replied no. On 8/10/20 at 11:51 a.m. Administrator-A informed Surveyor there aren't any pain assessment completed in July and could only find one completed in August. On 8/10/20 at 12:17 p.m. Administrator-A and DON-B were informed of the above.

Based on observation, interview and record review the facility did not ensure a resident with a [DIAGNOSES REDACTED]. -R3 has a [DIAGNOSES REDACTED]. R3 is documented as having sustained episodes of calling out throughout entire shifts, The facility did not ensure R3's plan of care was updated with individualized approaches when his behaviors continued and escalated to the point the police were called, and did not provide accurate information to behavioral health services about R3's behavioral status. R3 continued to experience a tapering of medications as episodes of uncontrolled behaviors occurred leading to transfers to the hospital and police involvement due to a lack of coordination of care to R3. Findings include: The state agency received a complaint that the facility does not know how to take care of residents with dementia. R3 has [DIAGNOSES REDACTED]. R3's Cognitive Loss/ Dementia Care Area Analysis, dated 12/23/2019, states Resident to remain alert and oriented to self, family, and general surroundings through review period as well as remain involved and interested in plan of care and facility during stay. R3's Psychosocial Well-Being Care Area Analysis, dated 12/23/2019, states Will be addressed in behavior care planning. See behavior caa (care area analysis) and poc (plan of care). R3's Behavioral Symptoms Care Area Analysis, dated 12/23/2019, states Resident can be physically aggressive an (sic) verbally assertive with direct care staff during ADL (activities of daily living) performance on occasion. Resident's behavior to be targeted, monitored, care planned, with interventions in place to address. resident (sic) to accept redirection, resident to be praised for cooperation, resident to be encouraged to engage in activities of choice, SS (social services) to visit resident regularly, assist support, and to update, as needed on resident's case. R3's care plan includes a focus area for Cognitive loss as evidenced by low score on the BI[CONDITION] Cognitive Assessment/Interview r/t (related to) dx (diagnosis) of dementia. Resident scored 5 out of possible 15, with deficits noted in long term memory, short term memory, and short term memory recall ability. Interventions initiated on 1[DATE] are: Allow adequate time to respond. Do not rush or supply words; Approach/speak in a calm positive/reassuring manner; Explain each activity/care procedure prior to beginning it; Identify self when speaking to patient; Provide cueing and prompting for such things as activities, personal cares, or room location; Repeat communication using more than one method (words, gestures, facial expressions); Use brief/simple words, cues, and or statements when speaking with patient; Use patients name when addressing. R3's care plan includes a focus area for At risk for behavior symptoms r/t (related to) dementia. Resident can be physically aggressive and verbally assertive with direct care staff during ADL (activity of daily living) performance, on occasion. Interventions initiated on [DATE] are: Behavior: Resident can be physically aggressive and verbally assertive with direct care staff during ADL performance on occasion Intervention #1: Approach resident and redirect. Reapproach if necessary. (The surveyor noted the care plan did not include resident specific information on how to redirect the resident) Intervention #2: Praise cooperation for desired behavior. Intervention #3: Encourage and promote resident to attend activities of choice to involve and engage; Psych referral as needed; Use consistent approaches when giving care (the surveyor noted R3's plan of care did not include information on what consistent approaches to use when giving care). On 1/8/2020 an intervention was added for: Behavior: Yelling/Screaming out Intervention #1: Meet with resident -ensure resident's safety; Intervention #2: Address resident's needs- offer food/drink (the surveyor noted the care plan did not include specific food or drink that may interest R3) Intervention #3 Redirect resident- offer to have resident sit and enjoy the company of staff, attend activities, encourage out of room activities. R3's plan of care includes a focus area for At risk for adverse effects r/t (related to): use of antipsychotic medications for agitation. Interventions initiated on [DATE] include: Non-Pharm Interventions for behaviors: 1. Address in a calm manner 2. Attempt to orientate to place and time 3. Allow patient to express feelings or frustrations and provide reassurance as needed 4. Provide assistance as needed 5. Family visits- from wife/daughter 6. Offer activities of choice 7. Provide emotional support to resident as needed 8. Offer to close door and curtains to facilitate sleep; Notify MD of decline in ADL ability or mood/behavior related to a dosage change; Psychiatrist consult and follow up as needed; Reduce environmental noise/distractions to facilitate sleep; TARGET BEHAVIORS: Anxious Behavior (fidgety, climb out of bed, calling out-help) Intervention #1: Meet with resident 1:1 - talk with resident, validate feelings, concerns Intervention #2: Meet resident's needs- toileting, food, drink, reposition Intervention #3: Invite wife/daughter to call/visit. An intervention initiated on 12/20/2019 includes: TARGET BEHAVIOR: Paranoia-of staff (resident not trusting) Intervention #1: Meet with resident 1:1, gain rapport, gain familiarity with resident Intervention #2: Talk with resident -eye contact, talk slowly and calmly Intervention #3: Involve resident in cares- talk through them and help resident understand what is occurring. Progress notes on [DATE] at 11:54 AM document Res (resident) reviewed at behavior meeting this date. IDT (interdisciplinary team) present.Has had falls since admission. Has a [DIAGNOSES REDACTED]. Res is calling out for help frequently, paranoid stating he doesn't trust staff here, tearful regarding current medical status/placement. Accepts 1:1 For staff, visits from family. Res admitted with [MEDICATION NAME] and [MEDICATION NAME]. Recommend referral to behavioral solutions and d/c (discontinue) [MEDICATION NAME] and prn [MEDICATION NAME]. Will cont (continue) to monitor. A behavioral services request and consent form, signed by R3's responsible party on [DATE], documents the purpose of the evaluation for a problem of anxiety with symptoms documented as paranoid and agitation. From 1/8/2020-2/3/2020 the behavior of Yelling/Screaming out even after needs have been met is documented as being present 21 days. Interventions documented as attempted include Meet with resident- ensure resident's safety, Address resident's needs - offer food/drink and Redirect resident - offer to have resident sit and enjoy the company of staff, attend activities, encourage out of room activities. On 10 days from 1/8/20-2/3/20 0 is documented as Which interventions where successful? From 1/5/20- 2/3/20 the behavior of Resident can be physically aggressive with direct care staff during ADL performance, on occasion is documented as being present 20 days. Interventions documented as attempted include Approach resident and redirect. Assure safety and reapproach if necessary, Praise cooperation for desired behavior, and Encourage and promote resident to attend activities of choice to involve and engage. Res enjoys watching TV, talking about past work as a truck driver, visiting with family, talking about the packers. On 7 days from 1/5/20-2/3/20 0 is documented as Which interventions where successful. Progress notes on [DATE] at 11:54 AM document Res (resident) reviewed at behavior meeting this date. IDT (interdisciplinary team) present .Has had falls since admission. Has a [DIAGNOSES REDACTED]. Res is calling out for help frequently, paranoid stating he doesn't trust staff here, tearful regarding current medical status/placement. Accepts 1:1 For staff, visits from family. Res admitted with [MEDICATION NAME] and [MEDICATION NAME]. Recommend referral to behavioral solutions and d/c (discontinue) [MEDICATION NAME] and prn [MEDICATION NAME]. Will cont (continue) to monitor. Progress notes on [DATE] document .Resident continues to be anxious, crawling out of bed- dtr (daughter) states this is due to him wanted (sic) to be independent and wanting to walk and return him .Referral to be made to Behavioral Solutions for psychiatry/medications evaluation . Progress notes on 12/24/19 document .declines cares, spit out 2400 BP (blood pressure) medication into writers face with force. Re-advised client that medication is for his blood pressure and was told 'get the hell out!' Progress notes on 12/29/19 at 4:01 AM document Resident yelling out most of shift. When writer asks Resident if he needs something, he responds that he does not need anything . Progress notes on 12/31/19 document .He was noted to be yelling all throughout shift and also using profanity and inappropriate language at times. Redirection helpful at times . Progress notes on 1/1/2020 at 2:09 AM document .found @0200 (2:00 AM) with legs out of bed, CNA & I replaced client into center of bed, client yelled at us You can't life (sic) me that way!!. Gave PRN TYL for discomfort, provided cares with linen change, client in bed sleeping frequently this NOC shift, calling out nearly constantly . Progress notes on 1/2/20 document .Is verbally aggressive with staff. Needs cues and redirection. Allowed to vent. Approached in calm manner. Progress notes on [DATE] at 12:25 AM document Resident continuously yelling out this shift .Resident given PRN Quetiapine (an anti-psychotic medication) @2315 (11:15 pm) for agitation. When asked Resident why he is yelling Resident states, 'I didn't know I was yelling.' When writer asked Resident if he needed anything Resident would state No I am fine. Progress notes on 1/7/2020 at 11:55 PM document .The current status is Resident found lying on the floor on top of floor mats next to bed .Resident very aggressive. Resident yelling at staff, swearing. Resident continuously trying to crawl out of bed and on to floor. Resident refusing to allow staff to assist him .Resident would not calm down even after speaking with daughters. Family requested to have resident sent out, updated (nurse practitioner). Resident sent to [ENTITY] south shore for evaluation. Progress notes on 1/9/20 document This morning (primary MD) was here. MD changed [MEDICATION NAME] 2.5mg to 5mg QD (every day). Psych NP (Psych NP-J) was here as well. She ordered [MEDICATION NAME] acid 125mg Q (each) AM. NP decreased [MEDICATION NAME] to 25mg QAM and Qnoon from 50mg. But she is keeping [MEDICATION NAME] 50mg for bed time. (Primary MD) is aware of those meds changes at 1440 (2:40 pm). MD agreed with psych NP . Psychiatric Consult Notes on 1/9/20 document Assessment, Recommendations & Rationale: [AGE] year old male who is seen today for initial consult. He is currently being treated with [MEDICATION NAME], and [MEDICATION NAME]. Past medical history is significant for:[MEDICAL CONDITION], DM II (diabetes mellitus type 2), [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) w (with) [MEDICAL TREATMENT], Closed Femur FX (fracture). Dysphagia, Multiple Wounds, [MEDICAL CONDITIONS], HDL (high cholesterol) [MEDICAL CONDITION] ([MEDICAL CONDITION] Nursing has documented: At times able to make simple needs known. Denies pain when asked but staff gave PRN (as needed) TYL ([MED]) and he fell asleep on 9 NOC shift. Found on floor NOC shift 0. Seen in ED (emergency department) with closed head injury. Was yelling out continuously noc shift. When asked why he was yelling would state he didn't realize he was. Received PRN [MEDICATION NAME] @ 2315 (at 11:15 PM). Denied needed anythingXXX 0 verbally aggressive with staff. Allowed to vent. Accepts cues and redirection. 20 more confused on NOC shift and difficult to appease. 9 PM shift yelling out much of shift using profanity and other inappropriate language. Social worker notes: 9 does make comments that he does not trust staff here and can be tearful. Family would like him to be able to go home but may be here for LTC (long term care) .Nurse states that he was up most of the night which is why he was too tired. Due to continued behaviors will start [MEDICATION NAME] 125mg QAM (every morning) for mood stabilization. Would recommend starting to taper off the [MEDICATION NAME]. Decrease AM and afternoon dose to 25mg keep 50mg QHS (each hour of sleep) Staff encouraged to continue to monitor mood and behaviors and to notify BSI (Behavioral Solutions) with any concerns. Progress notes on [DATE] at 12:59 AM document Resident very verbally and physically aggressive towards staff this shift. Resident yelling out. Resident attempting to self-transfer out of bed Progress notes on 1/12/20 document He was noted to be very loud and boisterous and yelling help for various reasons even after his needs were addressed. He was also trying to get out of bed this shift. He was name calling and using profanity also Progress notes on 1/13/20 document Resident was continuously yelling out for help and using unappropriated language when staff not in room. Redirection not effective unless staff present in room with patient MD progress notes on 1/16/20 document Mostly bedridden has underlying dementia [MEDICAL CONDITION] currently on [MEDICATION NAME] and [MEDICATION NAME] Under assessment and plan includes a section for advanced dementia with the assessment documented as with [MEDICAL CONDITION] and the plan documented as Continue with [MEDICATION NAME] and [MEDICATION NAME] Progress notes on 1/17/20 at 6:05 AM document Resident found lying on the floor next to bed on top of floor mat. Resident attempting to get out of bed. Resident very aggressive towards staff. Resident being combative. Resident yelling out. Resident refused vitals. Progress notes on 1/17/20 at 6:54 AM document Resident found lying on the floor for a second time @0640 (6:40 am). Resident continues to be combative and physically and verbally aggressive towards staff. Bell ambulance here to pickup Resident. MD progress notes on 1/20/20 documents under Assessment and Plan includes a [DIAGNOSES REDACTED]. The plan is documented as Currently on [MEDICATION NAME] and [MEDICATION NAME] along with [MEDICATION NAME] GDR (gradual dose reduction) per behavioral health recommendation. Under Advanced dementia the assessment is documented as with [MEDICAL CONDITION] with a plan to Monitor for any organic cause of symptoms. Progress notes on 1/21/20 document Behavioral Solutions recommended to DC (discontinue) PRN [MEDICATION NAME] and decrease HS to 25mg. MD to be updated and to okay dosing. No changes made until then. Progress notes on 1/21/20 at 11:44 PM document The current status is Resident very physically and verbally aggressive towards staff this shift. Resident hitting, scratching, kicking, swearing, throwing things at staff. Resident threw himself out of bed and onto floor mat and stated, I wanted to fall. Resident won't let staff assist Resident back into bed. Resident attempted to kick pregnant staff member in stomach stating, I know you're pregnant. DON (Director of Nursing) here and aware of situation. Unable to collect vitals or neuro check due to resident refusing and being aggressive. (Primary MD)'s NP aware, new orders to send Resident out to ER for treatment and evaluation. Bell ambulance called Progress notes on 1/22/20 at 1:34 AM document Bell ambulance and police just convinced Resident to agree to go to hospital. Progress notes on 1/22/20 at 12:21 PM document SS (social services) spoke with resident's daughter. (Resident's daughter) was very upset that police were called regarding her father's behaviors. (Resident's daughter) feels that her father needs to be in a different facility- placement that deals with dementia and Alzheimer's to address his behaviors. (Resident's daughter) has noticed also that her father has more behaviors in the evening and talked about past sundowning behavior. The surveyor reviewed R3's plan of care and noted no new interventions to attempt to assist R3 with his behaviors after the police had been called to assist with R3. MD notes on [DATE] document patient was see in follow-up for multiple falls behavioral symptoms has underlying dementia very pleasant when family is visiting otherwise gets agitated restless and falls. The note documents under Assessment and Plan includes a [DIAGNOSES REDACTED]. The plan is documented as Currently on [MEDICATION NAME] and [MEDICATION NAME] along with [MEDICATION NAME] GDR (gradual dose reduction) per behavioral health recommendation. Under Advanced dementia the assessment is documented as with [MEDICAL CONDITION] with a plan to Monitor for any organic cause of symptoms. Progress notes on [DATE] at 11:18 PM document Resident found lying on the floor on top of floor mats, next to bed. Resident pulled off heat register cover. Resident physically and verbally aggressive towards staff. Resident hitting, kicking, threatening staff. Assisted Resident back into bed. Resident won't allow staff to assess him, or take vitals. Progress notes on 1/24/20 at 12:05 AM document Spoke with on call for (Primary MD) NP. Orders received to send resident to ER for treatment and evaluation. Resident continues to be physically and verbally aggressive towards staff. Resident continuously trying to hit and threaten staff. Resident pulling cords out of the wall. Resident still will not let staff assess Resident for injuries. The surveyor reviewed R3's plan of care and noted no new interventions to assist R3 with his behaviors upon his return from the ER. Progress notes on 1/26/20 at 8:24 PM document He was quiet before supper. He however started trying to go in out of resident's rooms and hitting staff and grabbing. He was also using profanity (Resident's daughter) was called in to calm him down. She was able to get him to take his medicine which he was refusing at first and let the staff put him into bed . (Other daughter) called and stated that she wants him to go to a psych unit. Progress notes on [DATE] at 12:45 AM document While attempting to give client his 2400 RX (12 AM medication), client punched me in the face really hard, scratched at my arms and threatened my life with I'll get my gun and show your honkey ass. With CNA present we were able to return his bed back to usable condition as client had removed all the bedding, pulled out the power cords and pulled the plug on his air mattress. Client is in bed with clean fresh linen, call light pad within reach all other cords out of client's reach. Noted that client pulled call light system so hard the wall unit is dislodged. Daughter would like a mental Health evaluation. Client continues to pull out call light cords. Progress notes on 1/30/20 document Resident continuously yelling out. Resident using inappropriate language. Resident in bed. Needs met. The surveyor reviewed incident reports provided by the facility that the facility declined to provide copies of and noted from 12/16/18-2/4/20 R3 had 9 falls on [DATE], [DATE], 1/3/20, 1/8/20, twice on 1/17/20, 1/21/20, [DATE], and 1/28/20. On 2/4/20 at 8:23 AM the surveyor interviewed RN-H. RN-H informed the surveyor at night R3 has many behaviors. RN-H stated R3 yells out, that sometimes it is 8 hours of yelling, that R3 is physically and verbally aggressive, yelling racial slurs, hitting, yelling, and kicking. RN-H stated she is pregnant and R3 tried kicking her in the stomach. RN-H stated she no longer goes into R3's room to physically care for him after the incident. The surveyor asked RN-H when R3 is having agitation what does she do. RN-H stated he had an order for [REDACTED]. The surveyor asked about a care planned intervention to take R3 to the nurses station. RN-H stated when he is that aggressive you are unable to even touch him, there is no way staff could transfer him, RN-H stated nothing seems to work. The surveyor asked RN-H about when the police were called on [DATE]. RN-H stated the ambulance company called the police for their safety. RN-H stated the police were able to convince R3 to go to the hospital. The surveyor asked if RN-H could think of anything that could help R3's behaviors. RN-H stated they have tried all options, that she can't think of anything else. RN-H stated it is super bad at night and she was not sure if the doctor doesn't see that. On 2/3/20 at 2:25 PM the surveyor interviewed RN-F. The surveyor asked RN-F about R3's behaviors. RN-F stated she has concerns with his aggressive behaviors such as spitting. RN-F stated R3 does not always have behaviors, but daily has problems. RN-F stated R3 has been falling because he wants to get out. On 2/3/20 at 3:13 PM the surveyor spoke with [MEDICAL TREATMENT] Nurse-I. [MEDICAL TREATMENT] Nurse-I stated R3 has had very aggressive behaviors during his [MEDICAL TREATMENT] treatment. On 2/4/20 at 3:35 PM the surveyor interviewed RN-G. RN-G informed the surveyor she has noticed R3's behaviors are increasing; that lately she feels he has behaviors on a daily basis. RN-G stated the facility has tried a lot of different approaches. The surveyor asked about what types of behaviors R3 has. RN-G stated slapping, grabbing, spitting, scratching, and calling you names. On 2/4/20 at 12:51 PM the surveyor interviewed Psych NP-J. The surveyor asked if Psych NP-J has had a follow up visit to see R3 since her visit on 1/9/20. Psych NP-J stated she called the facility about 7-10 days later and was told R3 was improving so she told the facility to continue the taper of his psych meds as she had been told he had been improving. The surveyor asked Psych NP-J if she had been made aware of R3 having physically aggressive behavior towards staff including kicking and hitting, and that the police had been called to the facility related to R3. Psych NP-J stated no, that she had been told R3 was improving, that is why she continued the taper. The surveyor asked if the facility is able to call her in between her visits to the facility. Psych NP-J stated they are able to call the office who will get in touch with her. Psych NP-J stated she relies on the staff for information as they are there 24/7. Psych NP-J stated it was unfortunate they did not let her know as she could have made changes to his medication. On 2/3/20 at 4:38 PM the surveyor interviewed ADON (Assistant Director of Nursing)-C. ADON-C stated it was her second week at the facility. ADON-C stated she feels R3 needs a dementia unit. ADON-C stated R3 yells out and is physically and verbally aggressive. On 2/4/20 at 1:20 PM the surveyor interviewed DON-B. The surveyor asked DON-B what the facility has done to help R3 with his behaviors. DON-B stated redirecting, providing one to one when needed, followed by behavioral solutions, and try to have family come on. The surveyor asked if R3's behaviors have been improving. DON-B stated they have gotten worse since he was admitted . The surveyor informed DON-B of the above conversation with Psych NP-J being informed his behaviors were improving. During the interview the surveyor and DON-B discussed R3's falls. DON-B stated she feels R3's falls are behavioral even though they are a change in plane. DON-B informed the surveyor pain meds are offered and turning side to side and offered [MED] has been tried to assist with his behaviors. The surveyor noted R3's progress notes and medication record do not always document R3 is offered pain medication when he is having behaviors. DON-B stated she is not sure if the pain meds even helped his behaviors. DON-B stated R3 will be having behaviors and then when the family comes he seems calm. On 2/4/20 at 2:22 PM the surveyor interviewed SW (social worker)-D. The surveyor asked SW-D to tell her about R3's behaviors. SW-D stated it is hard for all the staff from night shift to day shift. SW-D stated they have talked with the family and have tried getting food and drink to calm him down, get food and drink, bring to the nurses' station, try tv, and have been looking to see if a different placement could better meet his needs. The surveyor asked SW-D if R3's behaviors have improved. SW-D stated R3 falls have been on a regular basis, that R3 seems angry, but that his paranoia has improved. SW-D stated she did not know why behavioral solutions would have said R3's behaviors improved, that Psych NP-J did not talk to her during the initial evaluation or for any follow up. The surveyor asked SW-D who updated care plans. SW-D stated all staff does. The surveyor informed SW-D she was unable to find updates to R3's care plan as behaviors are documented more frequently and when the police were called related to R3. SW-D stated she thinks part of it is we are all still learning, aides go in and he can be fine, each interaction is different. DON-B stated it depends on the time of day, even if the approach is the same it is not always working. On 2/4/20 at 4:38 PM the surveyor interviewed NHA (Nursing Home Administrator)-A. Nursing Home Administrator-A informed the surveyor on [DATE] Physician-R chose not to follow behavioral health solutions recommendations to further decrease the [MEDICATION NAME]. NHA-A stated the facility should have contacted behavioral health solutions with Physician-R's recommendations and when the police were contacted regarding R3. On 2/4/20 at 5:28 PM the surveyor interviewed Physician-R. Physician-R stated R3 has fallen several times, has not always been taking his medication, and is refusing cares. Physician-R stated R3 has dementia with behaviors. Physician-R stated they have been adjusting medication for his care. The surveyor asked Physician-R if Behavioral Solutions is involved what is his involvement with psych medication management. Physician-R stated if it is something acute he gets involved and makes sure we do the right things. On 2/6/20 NHA-A provided the surveyor with additional information. NHA-A provided the surveyor with a CNA Care sheet date 2/4/20. The CNA care card states Likes the TV on-likes the Packers, Jazz Music. The surveyor did not observe Jazz music being played during observations of R3 during the survey. The care card continues to state Targeted Behavior: physically aggressive- verbally aggressive-swearing, yelling, derogatory comments. Interventions: Offer to call wife/daughter, offer food/drink of his choice, attend activities, play music-likes jazz, likes talking about the packers, was a trucker drive, take for a walk around the facility, likes thickened coffee, re-approach if needed, allow to express feelings. This information was not provided to the surveyor during the survey.

Based on observation, interview and record review the facility did not ensure that 1 Resident (R1) of 11 residents reviewed received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. R1 was admitted to the facility on [DATE]. On [DATE], twelve days prior to admission, R1 completed a Power of Attorney for Health Care Document designating her daughter as her primary health care agent and her son-in-law as her secondary health care agent. On this document, R1 initialed I want Cardiopulmonary Resuscitation (CPR) attempted unless my physician determines one of the following: I have an incurable illness or injury and am dying; or I have no reasonable chance of survival if my heart stops; or I have little chance of long term survival if my heart stops and the process of resuscitation would cause significant suffering. Handwritten by R1 under the section additional guidance is #6: CPR o.k. only if chance of recovery is possible. R1's determination regarding the power of attorney and choices were designated on this form however, it was not formally activated and R1 remained acting as her own person. On [DATE] R1 signed a CPR consent form with both resuscitation and no resuscitation checked and with the box for resuscitation having both a check mark and an X on the box. There is no indication the facility clarified with R1 or had R1 initial which selection was an error to clearly designate R1's code status on this document. On [DATE] R1 signed another CPR document indicating she wanted to receive cardiopulmonary resuscitation. On [DATE] the physician signed the July-August orders which indicate R1's code status to be CPR. On [DATE] R1 stopped breathing and CPR was not performed as R1 requested. These failures created a situation of immediate jeopardy beginning on [DATE]. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on [DATE] at 11:00 a.m. This immediate jeopardy was removed on [DATE]. The deficient practice continues as a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's CPR policy dated [DATE] indicates the applicable CPR consent form will be reviewed and signed by the resident or legal representative on admission. Be presented to the resident/or legal representative if they change their original CPR choice. Allow the resident/legal representative to make an informed consent regarding their decision to have or not have CPR initiated. Describe the process of what occurs relative to CPR in a language understandable to the non-medical person. The facility's CPR policy dated [DATE] also indicates, unless a decision not to initiate CPR has previously been made by resident and State guidelines are in place, CPR will be initiated on any resident that experiences a witnessed or unwitnessed cardiopulmonary arrest while in the center. According to Wisconsin Statute 154.19(1) No person except an attending physician may issue a do-not-resuscitate order. An attending physician may issue a do-not-resuscitate order to a patient only if all of the following apply (b) Except as provided in s. 154.225 (2), the patient requests the order . (c) The order is in writing. (d) Except as provided in s. 154.225 (2), the patient signs the order. According to s. 154.225(2) a guardian or health care agent can request a do-not-resuscitate order on behalf of an incapacitated qualified patient if he or she receives written information about the resuscitation procedures that the patient has chosen to forego and the methods by which the do-not-resuscitate order may be revoked, consents to the order, and signs it. Wisconsin's Power of Attorney for Health Care document, as printed in chapter 155 Wisconsin Statutes indicates, If I am no longer able to make health care decisions for myself, due to my incapacity, I hereby designate (print name, address and telephone number) to be my health care agent for the purpose of making health care decisions on my behalf. If he or she is ever unable or unwilling to do so, I hereby designate (print name, address and telephone number) to be my alternate health care agent for the purpose of making health care decisions on my behalf. On [DATE] Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], twelve days prior to admission R1 completed a Power of Attorney for Health Care (POAHC) document designating her daughter as her primary health care agent and her son-in-law as her secondary health care agent. On this document, R1 initialed I want Cardiopulmonary Resuscitation (CPR) attempted unless my physician determines one of the following: I have an incurable illness or injury and am dying; or I have no reasonable chance of survival if my heart stops; or I have little chance of long term survival if my heart stops and the process of resuscitation would cause significant suffering. Handwritten by R1 under the section additional guidance is: #6: CPR o.k. only if chance of recovery is possible. On [DATE] R1 created her power of attorney documents, however the power of attorney for healthcare was not activated at this time and R1 remained her own decision maker. On [DATE], upon admission to the facility, R1 signed a CPR consent form with both resuscitation and no resuscitation checked and with the box for resuscitation having both a check mark and an X on the box. There is no indication the facility clarified with R1 or had R1 initial which selection was an error to clearly designate R1's code status on this document. R1's admission physician orders [REDACTED]. Printed orders for [DATE] have for code status dated [DATE] DNR. The admission MDS (minimum data set) dated [DATE] indicates R1's BIMS (brief interview for mental status) score was 13, which indicates little to no cognitive impairment. R1 also needed limited assistance of two staff for transfers, dressing and hygiene. On [DATE] R1 signed a CPR document in the facility indicating R1 wanted to receive CPR consistent with the POAHC forms developed by R1 on [DATE]. On [DATE] R1 was still her own decision maker as her POAHC had not been activated. On [DATE] R1 was sent to the hospital following a change of condition with altered mental status, hallucinations, decreased appetite and fluid intake. R1 returned to the facility on [DATE]. Review of R1's hospital documents includes an activation document attached to R1's POAHC Documents indicating R1's POAHC was activated on [DATE] while R1 was hospitalized . Review of R1's physician orders [REDACTED]. A significant change MDS dated [DATE] indicates R1's BIMS score as a 12, which indicates moderate cognitive impairment. A CPR Consent form dated [DATE] was noted in R1's medical record with No Resuscitation checked and a handwritten note by a Licensed Practical Nurse stating, Spoke to (name of R1's granddaughter) and received verbal order for DNR status. Will sign when she comes in. Surveyor noted there is no signature on this CPR consent form or any other CPR consent form in R1's medical record. Surveyor also noted the person referenced in the note as giving consent to changing R1's code status is R1's granddaughter, who is neither the designated primary nor secondary health care agent. Review of R1's physician orders [REDACTED]. This designation has a typed date of [DATE] reflecting the date of the original order and no hand written date or notation of when the handwritten change to the code status was made. Surveyor noted on [DATE] R1's code status was full code indicating CPR was to be administered. Surveyor also notes the physician orders [REDACTED]. On [DATE] at 11:43 a.m. Surveyor spoke with LPN-I who had written the note on the CPR consent form dated [DATE] referencing verbal consent from R1's granddaughter. Surveyor asked LPN-I what prompted getting the change in consent for code status. LPN-I indicated, she believed it was the director of nursing or RN Manager (G) that told her to call her granddaughter because her CPR form wasn't signed. LPN-I indicated she called the POA who she believed was R1's granddaughter. LPN-I indicated she got the information and number for the granddaughter from R1's medical record face sheet. Surveyor reviewed the face sheet and noted the face sheet lists R1's granddaughter first as emergency contact rather than the activated POAHC who is R1's daughter. Surveyor also noted the face sheet has R1's son-in-law listed last as the emergency contact and POA is handwritten next to his name and highlighted yellow. R1's daughter is not clearly identified as the activated POAHC on the facility face sheet. Review of R1's Nurse's notes dated [DATE] indicates, ,,, 1936 (7:36 p.m.) staff was with resident when she stopped . breathing. 1940 (7:40 p.m.) staff found no vital signs at all. 1943 (7:43 p.m.) MD was paged (name of physician covering for attending physician). 1950 (7:50 p.m.) family was notified. Family called back at 2020 (8:20 p.m.) too (sic) notify staff the (name of funeral home) would be coming for the body. They took her purse and cell phone with them and stated all other remaining things the facility could have. (Name of) funeral home here at 2150 (9:50 p.m.) and removed the body. Surveyor noted there is no indication facility staff provided CPR to R1 despite the determination that she stopped breathing. On [DATE] at 11:01 a.m. Surveyor spoke with Social Services Director (SSD)-M for clarification on who was R1's activated Power of Attorney for Health Care. SSD-M indicated the activated POA was R1's son-in-law. SSD-M indicated it was originally R1's daughter but R1's daughter has health problems. SSD-M indicated the granddaughter was just a very involved family member. Surveyor again noted the most recent CPR form in R1's chart was not signed but dated [DATE] and indicates a verbal order for DNR received by the grand-daughter who is not the POA. Surveyor also noted there is no documentation indicating R1's daughter was unable or unwilling to make choices for R1 officially relinquishing her role as the POAHC and activating R1's son in-law as the POAHC, therefore R1's daughter should have been the decision maker up to R1's death. On [DATE] at 2:15 p.m. Surveyor spoke with LPN-J, who worked on R1's unit on [DATE], along with Surveyor , Surveyor and Director or Nurses (DON)-B present. Surveyor asked LPN-J if anyone performed CPR on R1. LPN-J stated No, she was a DNR. Surveyor asked LPN-J if she was CPR certified. LPN-J indicated, Yes. Surveyor asked LPN- J how she determined R1's code status. LPN-J indicated it was in the chart under advanced directives. Surveyor then showed LPN-J the CPR form dated [DATE] that has the hand written statement at the bottom referencing R1's granddaughter giving verbal consent to change the code status despite not being the POAHC. Surveyor asked LPN-J if this was the form used to determine that R1 had a DNR code status. LPN-J indicated, yes, and that was R1's wish. LPN-J indicated they have to go with what is on the paper. LPN-J indicated she looked for a signature on the form but there was verbal consent. Surveyor asked LPN-J if LPN-J looked to see who the activated POA was when determining R1's code status. LPN-J indicated she did not check. Surveyor asked LPN-J if she had known that the verbal order was provided by someone who was not R1's activated POA what she would have done. LPN-J indicated if she had known that the verbal consent wasn't from the POA LPN-J would have started CPR. On [DATE] at 2:25 p.m. Surveyor spoke with DON-B regarding R1's CPR status with Surveyor , Surveyor and LPN-J present. Surveyor showed DON-B both of R1's most recent CPR consent forms; one form is signed and dated by the resident on [DATE] indicating R1 would like CPR to be done in the event of [MEDICAL CONDITION]. When this form was completed R1 was her own person as her POA was not activated until [DATE] when she appointed her daughter as her POAHC. Surveyor then showed DON-B the second CPR consent form not signed but dated [DATE] with the hand written statement indicating R1's granddaughter gave verbal consent to change R1's code status. In discussing the forms, DON-B indicated that now knowing that the form is not valid because R1's granddaughter was not the POA she would have started CPR. DON-B stated: No decision is a decision for CPR. On [DATE] at 3:35 p.m. Surveyor spoke with RN-K. RN-K indicated she thought LPN-J checked the status and she (R1) was a DNR and on the report sheet we had she was a DNR. RN-K indicated she went back in the room with CNA-L and R1 was actively dying. RN-K indicated she stayed in the room until R1 had no pulse. RN-K indicated she then went to the nurse's station and told LPN (J) and LPN-J then came in to double check. RN-K indicated LPN-J then called the family and doctor and took care of the rest. On [DATE] at 1:44 p.m., Surveyor again spoke with RN-K. RN-K indicated that (on [DATE]) around 7:00 p.m. (CNA-L) said resident (R1) was complaining of shortness of breath and the resident didn't look good. I went in the room and assessed the resident. RN-K indicated she was in there a good ,[DATE] minutes. RN-K indicated she stepped out to go over it with (LPN-J). RN-K reported (R1's) vitals were clear, chest clear, heart rate irregular, pulse-, checked out OK. Resident complained of shortness of breath but vitals and lungs were clear. RN-K indicated that she didn't actually think RI was short of breath as R1 was wearing oxygen at the time . Surveyor asked RN-K did she get the impression that (CNA-L) thought that R1 was having a change of condition. RN-K indicated, Yes, she said she (R1) was complaining of shortness of breath. RN-K indicated she felt like when she went back to the room, (R1) was actively dying I wasn't positive she was actively dying but didn't know for sure. (Cross-reference F514) On [DATE] at 7:28 a.m. SSD-M spoke with Surveyor regarding R1's CPR status. SSD-M now indicated they had spoken with her R1's son-in-law and that it was after the verbal consent from R1's granddaughter. SSD-M indicated she called and spoke to R1's son-in-law and he indicated he wanted (R1) to be a DNR and he was supposed to come in and sign the forms. Surveyor asked SSD-M if there was documentation related to this. SSD-M stated No because I thought he would come in and sign. We had a care conference after that and discussed the plan for treatment and the DNR status, we talked about CPR status and he was supposed to sign the form. SSD-M then reviewed the social services notes dated [DATE]. After the review, SSD-M then indicated: they had a care conference on ,[DATE] and they must have called the family and got the verbal signature on ,[DATE]. SSD-M stated I realized they called (name of the granddaughter) and not (the name of the Son-in-law), so I called (the son-in-law's name) he was supposed to sign but didn't. I didn't document or get a signature. Surveyor noted the following review of the care conference documentation dated [DATE] the documentation does not mention there was a discussion about R1's CPR status. Social Services notes dated [DATE] state .Care conference held this date. SS (social services), therapy, BOM (business office manager), POA, granddaughter present. BOM answered financial questions. Res (resident) at times has been refusing to participate in therapy, get out of bed etc. Has refused to get out of bed since readmission. Res agreeable to cont (continue) working with therapy and attempt to sit up in w/c (wheelchair) for meals. Goal is to transfer to CBRF (Community Based Residential Facility) when able. Awaiting appointment for oncologist on Tuesday to determine further treatment plans. Continues [MEDICAL TREATMENT] MWF (Monday, Wednesday, Friday), will cont to follow. Surveyor noted there is no mention of CPR status and R1's activated POA (her daughter) was not present at the meeting nor involved in changing the consent for CPR. On [DATE] at 9:07 a.m. NHA-A and DON-B came to speak to Surveyor and Surveyor . NHA-A indicated that they knew the facility does not have a signature on the document but clearly they had consent for DNR on (R1). NHA-A indicated it was clear to their team R1 did not want CPR. NHA-A indicated the Social Services Director (M), Business Office Manager, son-in-law who they believe was the POA, and her granddaughter were all present. NHA-A indicated that while the granddaughter was not the POA she was the primary contact and heavily involved in decision making. NHA-A indicated it was clear he (the son-in-law) did not want CPR and that they had asked the son-in-law to sign documents. NHA-A indicated they knew he didn't sign them and that they made several attempts to get him to sign because they knew he didn't want CPR. Surveyor noted on [DATE], twelve days prior to admission, R1 completed a Power of Attorney for Health Care document designating her daughter as her primary health care agent and her son-in-law as her secondary health care agent. There is no documentation R1's first choice for the Health Care Agent had been deemed unable or unwilling to make choices for R1. The facility's failure to ensure R1 received CPR consistent with her signed consent and choices designated in her power of attorney for health care document created a situation of immediate jeopardy. The facility removed the immediate jeopardy when it implemented the following action plan: On [DATE] the Director of Clinical Services conducted education with the ED (Executive Director), DON (Director of Nursing), DSS (Director of Social Services), DONIT (Director of Nursing in training), and UM (Unit Managers) regarding review of the legal documents (Power of Attorney for Health Care Document) and identifying the legal responsible party. Education also included the CPR policy including proper completion of CPR forms. Further education discussing clinical meetings and review of admission and readmission charts. Licensed staff will be educated regarding the Legal documents of Power of Attorney for Health Care, proper way of completion of CPR forms and CPR policy. Education began on [DATE]. Staff will not begin their next shift without receiving this education. Audit of charts to ensure CPR forms are signed by responsible part or POA also verifying that there were no verbal consents without a signature. Notification to the Medical Director regarding the issue of concern regarding CPR and proper documentation. QAPI meeting was held discussing concern of the CPR and policy. Audit of licensed nurses to verify CPR certification. CPR certified licensed nurses will be identified on the schedule. New admissions/readmissions record will be reviewed by the ED, DON, DSS, or designee for necessary legal POA and CPR documentation daily times 14 day; 3 X week 4 weeks and weekly thereafter. Results of audits will be forwarded to center QAPI committee.

Based on interview and record review, the facility did not always ensure that 1 out of 8 residents sampled, Resident #2, received adequate supervision and assistance to prevent accidents. Resident #2 had severe osteoporosis and was very brittle and the facility had identified her needing slow and gentle care with the use of 2 persons. Resident #2 fell to the floor while being weighed during a mechanical lift on 12/9/09. A facility staff member conducting the mechanical lift did not ensure that the sling device used to support Resident #2 was properly attached to the mechanical lift while lifting Resident #2 up off her bed in order to be weighed. The facility staff member conducted this mechanical lift without the support of another staff member, which violated the safety policy of the facility and mechanical lift manufacturer's recommendations of using 2 staff members to conduct lifts with this mechanical device. Resident #2 sustained significant injury and impairment as exhibited by a cervical neck fracture that needed surgical repair, bilateral subdural hematomas (blood collection on the brain), fractured finger, 14 cm forehead laceration requiring suturing and a complicated hospital course consisting of aspiration pneumonia, bilateral deep vein thrombosis (blood clots in legs), ileus of the intestines, sepsis and septic shock, ventilator placement and permanent tracheostomy placement. Resident remains dependent on a tracheostomy at this time. The failure to apply the mechanical lift sling appropriately and the failure to have 2 staff members use a mechanical lift, as specified in the facility policy and recommended in the mechanical lift instruction manual, led to a fall with serious injury, resulting in a finding of immediate jeopardy for Resident #2, which began on 12/9/09. The facility was notified of the immediate jeopardy on 10/18/10. The immediate jeopardy had been removed on 12/9/09 and the deficient practice corrected on 1/4/10. Findings include: 1. Resident #2 is a [AGE] year old resident with [DIAGNOSES REDACTED]. Resident #2 was admitted to the facility on [DATE] following hospitalization for urinary tract infection with MRSA. A Resident Assessment Protocol (RAP) documented on 2/18/09 that Resident #2 was in a weakened state and needed extensive staff assist of 2 for bed mobility, repositioning, dressing, incontinence care and bathing. Resident #2 was described being transferred with a Hoyer lift and staff propelling wheelchair. Resident #2 is described as having contractures to bilateral lower extremities (legs) and followed by Physical and Occupational (PT/OT) therapy in an effort to regain strength and whatever function possible. Nursing progress notes documentation of 4/15/09 describe the use of a Hoyer lift with 2 persons being used. On 4/15/09 at 12:00 noon, Resident #2 had a fall out of her bed and was found on the floor on the mat next to the bed with the pillow and sheets and on her right side. Nursing progress notes identify that on 4/19/09 at 7:25 PM, resident was in her bed and the left leg and knee were found to be swollen, hard with no bruising. The physician was notified and an x-ray was to be obtained on 4/20/09. On 4/20/09, a left femur fracture was diagnosed and Resident #2 was transferred to the hospital. On 4/20/09, the hospital record indicated that the resident had a left femur fracture, displaced, without pain. The physician documented that this fracture is most likely due to pathological fracture because of a history of [DIAGNOSES REDACTED] and she also has rib fractures of the right 3rd rib of undetermined age. The physician noted that resident had a fall a week prior to coming to the hospital, but the opposite side of the fracture. The summary of this hospitalization documented that the resident did not have any pain, which is unusual for this type of fracture and questionable if this fracture was secondary to a fall. The plan was to treat the resident conservatively and resident was discharged back to the nursing home. On 4/24/09, a plan of care was instituted for Fall/injury prevention and management. This plan of care had a goal of "will be free of a serious injury if a fall would occur." The interventions mentioned on this plan of care indicated resident to be transferred with 2 assist with a Hoyer device. Supervision needed on this plan of care was increased supervision. On 4/24/09, a plan of care documented that resident's goal is transfer with 2 assist with Hoyer device and will mobilize in bed with 2 assist. Interventions listed to provide assistive device as needed for mobility with assist of 2 and provide assistive device as needed for transfer with 2 and Hoyer. On 5/20/09, a special inservice training was provided to 29 staff members in regards to care for Resident #2. This inservice objective was: 1. Must have 2 people assist with cares/transfers due to soft, brittle bones; 2. may fracture bones if not handled gently; 3. slow, steady gentle with cares at all times to decrease fractured bones. Forteo, para[DIAGNOSES REDACTED] medication, was started for Resident #2 for Osteoporosis (brittle bone disease), 5/21/09. On 12/7/09, a nursing summary described resident as total care assist of 2, Hoyer lift, feed per staff and resident may assist with feeding self at times and all needs met by staff. On 12/9/09 at 7:35 AM, documentation of an accident was noted in the clinical record at the nursing facility. The accident report indicated that resident slid out of Hoyer sling landing face down on floor next to bed. A laceration was noted to the right eye and resident was not moved until paramedics arrived. Resident was complaining of headache. The Resident Transfer summary described resident's weight as 218 pounds and resident sent to hospital via 9-1-1. Hospital emergency room records from 12/9/09 were reviewed. A deep 14 cm, bleeding laceration to the right eyebrow was noted. An x-ray was taken of the left hand, which indicated a fractured left hand finger. CT scans of the orbits (eye sockets) were taken that indicated evidence of a right frontal scalp laceration with soft tissue defect and air within the subcutaneous soft tissues and accompanying swelling of the periorbital soft tissues. The diagnostic impression was a right frontal scalp laceration, an acute inflammatory sinus disease with chronic inflammatory sinus disease present, partial visualization of extra-axial left frontal mass with accompanying post surgical changes. A CT scan of the head without contrast indicated findings consistent with the patient's known [DIAGNOSES REDACTED] and has not changed considerably when allowing for differences in technique and absence of intravenous contrast. A CT scan of the cervical (neck) spine without contrast conducted on 12/9/09 at 11:39 AM indicated no fracture or subluxation of the vertebral bodies were noted and cervical alignment is within normal limits. Mild degenerative facet arthropathy is present on the right at C2-C3 and C3-C4. Moderate to marked loss of intervertebral disk space height at C5-C6 and mild loss of intervertebral disk space height at C6-C7. At C5-C6, posterior disc and osteophyte ridge results in narrowing of the thecal sac and probable impression upon the anterior aspect of the spinal cord. A posterior disc bulge is identified at C4-C5 which narrows the thecal sac and may abut the spinal cord as well. The final impression was moderate degenerative spondylosis of the lower cervical spine. Consider MRI of the cervical spine or CT myelogram for exact determination of spinal canal compromise. The head laceration was sutured closed, left hand finger fracture was splinted, antibiotic was started and Resident #2 was discharged back to the nursing facility. Nursing facility documentation of 12/9/09 at 4:20 PM indicated resident returned to the nursing facility by ambulance. Resident has a gauze bandage across forehead, an injured area to right forehead, right eye swollen and unable to open. Resident is in bed and stable with a splint on left hand. On 12/10/09 at 2:00 PM, documentation of resident's condition described the left hand up on pillow and as needed Tylenol every 4 hours given for pain. Resident had no intake for breakfast, or lunch and gave extra fluids vis G tube, 620 cc of water. The MD was called and updated to the CBC (lab work)(elevated white blood cells of 20) results and new orders were received for work up, cranial checks were done every 4 hours. Resident was lethargic. Resident transferred to hospital on [DATE] at 2:30 PM. On 12/10/09, Resident #2 was readmitted to the hospital. MD-F documented that resident was admitted due to mental status changes and leukocytosis. Dictation reviewed indicated Resident #2 was sent to the hospital due to mental status changes, lethargy, poor eating and leukocytosis, with elevated white blood cell count. The MD indicated that yesterday (12/9/09) Resident was on a Hoyer lift, fell off and landed on her head. The head CT did not show any intracranial bleeding or skull fracture. The CT spine showed DJD (degenerative joint disease). Today (12/10/09) in the emergency room , the CT shows subdural hematoma (blood collection on the brain). The MD noted that the resident is confused more than her baseline, disoriented and does not recognize her husband. Resident was admitted to intensive care. On 12/11/09, a neurosurgical consultation was conducted while Resident #2 was hospitalized . The consultation indicated that resident was neurologically at her baseline with interhemispheric subdural. On 12/13/09, Resident #2 had a MRI scan of the spine. A minimally displaced fracture at the base of the odontoid process was noted. On 12/13/09, Resident #2 had another CT of the cervical spine without contrast. At this time, this CT was compared to the CT of the spine taken on 12/9/09. On 12/13/09, a Type II fracture at the base of the odontoid with 2 mm posterior displacement of the odontoid tip was detected. This finding is similar to findings seen on the MRI of the same date. Resident #2 had cervical neck surgery on 12/14/09 and a screw was placed to repair the odontoid process fracture. Resident was placed into a cervical neck collar following surgery. Post operatively, Resident #2 suffered bilateral acute on chronic deep venous thrombosis (blood clots) in her legs. Resident post-operatively also struggled with her secretions, developed aspiration pneumonia and worsening respiratory status with eventual respiratory failure necessitating ventilator placement. Resident then required tracheostomy placement, which remains in place as of July of 2010. Resident has been unsuccessful in being weaned from a permanent tracheostomy. Post-operative complications also included development of an ileus (bowel stops working) and in January of 2010 resident was receiving care in a vent hospital and developed sepsis and septic shock necessitating hospital re-admission with lengthy hospital stays continuing into most of 2010. Surveyor interviewed MD-F on 10/18/10 at 9:30 AM. MD-F continues to follow Resident #2 at a different nursing facility. MD-F described Resident #2's ongoing struggles to this day with repeated complications, respiratory infections and hospital admissions. MD-F said they expect continued decline to occur. MD-F told the surveyor that the fall on 12/9/09 did speed Resident #2's overall decline. The facility investigation revealed that on 12/9/09, Certified Nursing Assistant (CNA)- D was using a Hoyer lift on Resident #2 attempting to obtain her weight. While in the Hoyer sling, one of the sling loops came detached from the Hoyer. Resident #2 slipped out of the sling to the floor. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B interviewed CNA-D, CNA-E and other staff regarding the incident. Staff interviews are consistent and show fall occurred while Hoyer lift was in use. Activities of Daily Living (ADL) care sheets were reviewed and note Resident #2's transfer status reflects use of a Hoyer. Maintenance Director-C inspected mechanical lift. Lift was in good working order. Hoyer lift operators manual was reviewed. Education provided to direct care staff regarding Hoyer lift procedures, transfer status. A statement dated 12/9/09, written by NHA-A, indicates that the NHA and the DON interviewed CNA-D. CNA-D states she was getting Resident #2's weight. CNA-D said she assisted Resident #2 with the Hoyer lift by herself. Stated Resident #2's feet were dangling out of the sling and touching the bed. CNA-D moved the Hoyer slightly away from the bed so that Resident #2's feet were no longer touching the bed and she could get an accurate weight. CNA-D stated Resident #2 slid out of the sling and it happened very quickly. CNA-D stated one of the Hoyer loops was off. A statement dated 12/9/09, written by NHA-A, indicates that the NHA and DON interviewed CNA-E regarding the incident with Resident #2. CNA-E stated he was the first responder to the fall. CNA-E stated the top loop on the sling on the resident's right side was off. Surveyor interviewed CNA-E on 10/18/10 at 11:00 AM regarding the events of 12/9/09 with Resident #2. CNA-E said he was 3 doors down when he heard a need for help to Resident #2's room. CNA-E told the surveyor that he was the first person in the room after Resident #2 fell from the lift device. CNA-E said that Resident #2's body was face down on the floor next to the bed, the straps of the sling were still criss-crossed between her legs with her ankles still in the sling hanging approximately 2-3 feet off of the floor. CNA-E remembered seeing the bed pushed up against the window and thought the brakes may have been off of the bed. CNA-E remembered Resident #2 having a bariatric sized specialty air bed. Resident #2 as always having a lean of her body to the right side, affected side. CNA-E said Resident #2 was able to reach out with her left hand and would normally lean in bed facing the window. CNA-E told the surveyor that in order to properly weigh Resident #2, her body has to be pulled away from the bed so her bottom would not touch the bed. CNA-E described the specialty air bed as pumping up firm when body weight was removed from it. CNA-E said he had weighed the resident before with a lift, but always with another staff member present. CNA-E said that sometimes it is not obvious that the loops are not attached because there are multiple loops on the sling so it would be easy to miss, that is why 2 people are required to be there to double check the loops and help with the transfer of residents. CNA-E recalled that the upper right loop was not connected to the hook on the lift device when he entered the room, but the left loop was connected. CNA-E said that her body weight and the lean of her body is what pulled her down and over on her face. CNA-E said CNA-D said she hadn't slept all night and didn't know what she was thinking, CNA-E described CNA-D as "freaking out." CNA-E described knowledge of the facility policy of always having 2 people present with lifts and that this was taught in orientation to the facility and constant ongoing education. Manufacturer's instructions on the use of the Invacare Portable Patient Lift device was reviewed by Surveyor # during the course of this survey. On page 13 of the instruction manual, under the title of "Operating the Lift", the manufacturer indicates that "although Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation the health care professional for each individual case." On page 14 of the manual, the title of "Lifting the Patient" indicates instructions that state "when the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place, lower the patient back onto the stationary surface and correct this problem-otherwise, injury or damage may occur." On page 14 of the manual, the title of "Using the Sling" indicates instructions that "...be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode)." On page 27 of the manual, the title "Lifting/Moving the Patient" indicates "...the patient should be elevated high enough to clear the bed with their weight fully supported by the lift." On page 28 of the manual, a section, titled "WARNING" indicates that when the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place, lower the patient back onto the stationery surface and correct this problem - otherwise injury or damage may occur. On page 45 of the manual, a section, titled "weighing the patient" refers back to instructions on page 20 of the manual on how to place the sling under the patient, page 27 on how to attach the sling straps to the swivel bar and also refers back to page 26 of the manual on how to lift the patient. The OSHA (Occupational, Safety and Health) safety manual, used by the facility for staff training and guidance, indicates a policy, revised April and May of 2009 titled, "Safety Rules and Regulations." In the procedure, a section addressing "all personnel" indicates in step #5 to "use assistance or appropriate safety equipment when lifting or transfer." Training records for CNA-D revealed inservice training attended 4/10/08 with objectives of "if resident requires 2 assist, per ADL sheet, 2 people will be used. ADL sheets to be followed and carried." CNA-D was 1 of 29 staff who also attended the special inservice for Resident #2 on 5/20/09 requiring 2 staff to assist with cares due to Resident #2's brittle bones. On 10/18/10 at 10:15 AM, Surveyor # interviewed Registered Nurse (RN)-G regarding staff training. RN-G told the surveyor that following the incident with Resident #2 on 12/9/09, inservicing with staff began which included sit down classroom training and return demonstration with staff members for 4 weeks, spot checking staff conducting care with the mechanical lifts. The return demonstrations ended on 1/4/10. The main point of this inservicing was to always have 2 people present with mechanical lift use and to make sure the straps are connected to the lift properly. The inservicing was done in verbal and written communication. On 10/14/10, Surveyor observed 2 CNA staff members conduct a mechanical lift transfer using an Invacare Reliant 450 battery operated lift device for Resident #7. Surveyor observed staff correctly place the sling loops over the hooks on the swivel bar past the safety clasp. Two staff members were also present during this observation, one to operate the lift and the other to guide the resident from the wheelchair to the bed. No negative outcomes occurred to Resident #7 during this observation. Staff interviewed expressed knowledge that 2 persons were required as a facility policy for the use of this lift device. Failing to ensure that the mechanical lift was connected correctly and used with 2 persons, which was determined to be necessary in the care of Resident #2, created a situation of immediate jeopardy for Resident #2 on 12/9/09. The facility removed the immediate jeopardy on 12/9/09, by which time it had: 1.1 Inserviced staff beginning on 12/9/09 on the importance of making sure 2 persons were always present when using mechanical lift devices, making sure the loops are connected properly; 1.2 Return demonstrations by direct care staff in the use of mechanical lifts was conducted until 1/4/10; 1.3 The mechanical lift device used for Resident #2 on 12/9/09 was thoroughly inspected on 12/9/09. All other mechanical lift equipment was inspected by the maintenance department.