Every finding on record at Maplewood Center

Based on interviews and record review, the facility did not ensure that all alleged violations, including injuries of unknown source, were reported to the State Survey Agency within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 of 1 (R3) residents reviewed.R3 reported she fell in a facility transportation van. The following day, she was sent to the hospital and was diagnosed with bilateral femur fractures. The facility did not report the injury to the State Survey Agency within two hours after R3 reported the injury to facility staff. Findings include:The facility's policy and procedure titled Abuse, Neglect, Exploitation, Misappropriation and Injuries of Unknown Origin, revised 4/26, documents: It is the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Serious Bodily Injury means an injury involving extreme physical pain; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.7. Reporting/Responsea). The facility will:i. Report all alleged violations to the state agency within specified timeframes:Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.b. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.On 8/19/26, at 9:42 a.m., R3 informed Surveyor that as R3 was coming back from the hospital in the facility's transport van, she fell in the van and broke both her hips. R3 stated, It happened so fast I don't even know how it happened. I tried to put my hands up to block myself, next thing I was on the floor. All I know is two people lifted me under my armpits and put me back in my wheelchair and took me to my room. Surveyor asked if the van driver put R3 back in the chair. R3 reported R3 did not think it was the van driver. R3 told Surveyor that R3 could not remember how R3 got in bed when R3 returned to the facility but was in terrific pain in her back, hips and legs and couldn't move her legs.Facility progress notes document:6/2/26 at 6:28 PM: Resident came back from appointment in the facility van and the driver stated that she made a hard stop and the residents w/c (wheelchair) jerked. When she was transported to her room by staff, she told them that she fell forward in the van when the driver stopped too fast and she fell to her hands and knees and that they had to get someone to help them get her up. She said that a white lady helped them get her back into her w/c. She is c/o (complaining of) pain to her bilateral LE (lower extremities). At this time requested a pain pill for pain to her legs that Tramadol did not cover. I spoke with the administrator and the RN (Registered Nurse) supervisor and left a message for the DON (Director of Nursing). Will continue to monitor.6/2/26 at 8:45 PM: Writer and floor nurse went to the patient after she returned from her appointment with her doctor; patient stated that she fell in the van while returning back to the nursing home; she is in severe pain; level was 7-8 but did not want to go to the hospital; when she went down for the night, writer and the floor nurse assessed her; She is alert and oriented 2-3 at that time. There was no internal/external rotation of extremities; there were two large bruises on the left side of her body; one bruise on the left upper thigh was 6 cm (centimeters) by 4 cm and the other was on left the outer lower leg was 4 cm by 3 cm; hand grasps were equal; pupil was round and non-reactive to light; will continue to monitor for pain and changes. Cran (cranial) checks were started during the shift. Moreover, the resident is okay just in severe pain; given medication to manage the pain/will try to convince/encourage the patient to go the hospital for pain or if the condition worsens.6/2/26 at 8:49 PM: DON, Administrator and the drivers' supervisor are aware that the client said she fell and two people picked her up off the floor in the van. She said that this was white women who help her off the floor. At this time, she said she was in pain and did not want to go to the hospital. Staff will continue to monitor.Surveyor noted that progress notes on 6/2/26 documented that R3 reported to staff that she fell to the floor in the transport van. She complained of severe pain and two large bruises were noted on her left lower extremity. There was no evidence the physician was notified and no evidence the facility reported the incident/allegation to the State Agency.The facility 24-hour board on 6/2/26 documents: resident (R3) c/o (complains of) severe pain, refused going to hospital. Surveyor noted that there were no other progress notes documented until the next morning.6/3/26 at 7:05 AM: Resident in her room, pale, with v/s (vital signs) as follows: BP (blood pressure) 85/54, RR (respiratory rate) 18, HR (heart rate) 72, T (temperature) 98.2, SPO2 (oxygen saturation) 85-88% RA (room air). O2 administered at 2 L (liters) pnc (per nasal cannula). O2 rechecked 95%, c/o 4/10 pain left upper thigh, bruise noted. Resident stated she had a fall yesterday in the van from her doctor's appointment, awake, alert. Supervisor aware. Notified PA (Physician Assistant), resident to be sent to hospital for further eval and MGT (management).6/3/26 at 10:42 AM: Received a call from (hospital) resident has bilateral hip fracture, notified supervisor, PA was updated.Surveyor reviewed R3's hospital record which documented: Diagnosis: Closed fracture of both hips. Chronic lymphocytic leukemia, extensive orthopedic history including prior left femur fracture with intramedullary nail 2025 and Osteonecrosis/avascular necrosis (AVN) (when blood supply to the top of the femoral head stops, the bone tissue dies leading to tiny cracks, the collapse of the bone sphere and severe hip arthritis). Imaging confirmed moderately displaced intertrochanteric fracture of left femur and comminuted moderately displaced intertrochanteric fracture of right femur. Chronic deformity of left femur and advanced degenerative changes of left hip and knee.On 8/24/26, at 9:35 a.m., Surveyor verified the facility has its own transport van.Surveyor noted the facility completed a thorough investigation including review of the timeline of events; data from van surveillance, resident statement, transportation staff statements, nursing documentation and assessments, the event report, notifications and follow-up documentation, and transportation securement procedures. A simulation/re-enactment was also conducted. Transportation staff statements (driver) documented: To avoid collision needed to apply brakes suddenly. Resident screaming, other transport staff went to back, stated resident leaning forward and shaken up. Waited for her to give her the OK to drive. Other transport staff (passenger) statement: After sudden stop with brakes, resident yelled. I went to back, and the resident was leaned forward in chair. I adjusted her in the chair and made sure seat belt was safely together. I gave the OK to keep driving to the facility. Upon return, resident was taken out of the van to room and told the nurse what happened before leaving the building.On 8/24/26, at 11:03 a.m., Surveyor spoke with Administrative Assistant (AA)-F. AA-F informed Surveyor that AA-F sits at the front desk, answers the phone and makes appointments. AA-F told Surveyor R3 had an appointment that day (6/2/26) and left at 12:30 PM to the hospital cancer clinic for a follow-up visit and returned maybe between 3:30-4:30 PM. AA-F stated, I was still here, I don't leave until after 5:00. I was on the phone and saw the van pull up and the driver took (R3) out of the van in her wheelchair past me to her room. A little while later the aid came down to tell me (R3) was crying and said she fell in the van. I went up to talk to her, and she said they made an abrupt stop and she fell on the floor. I immediately came back down and called the driver to see what happened. They said they had to slam on the brakes, and she was jerked in the wheelchair and needed to be repositioned, but she didn't fall out of the chair.Surveyor asked if she saw anyone from the facility go outside to the van to assist R3 into her wheelchair. AA-F said, No, no one from here went out to the van. Whatever happened didn't happen here, it happened before she came back.On 8/24/26, at 11:49 a.m., Surveyor reviewed the investigation documentation regarding van surveillance and asked what that meant. Nursing Home Administrator (NHA)-A told Surveyor they looked at the van surveillance that recorded the speed and they weren't speeding. Surveyor asked if it records how long the van was stopped when the incident happened. NHA-A informed Surveyor she did not know, the Chief Operating Officer (COO) was involved because the van is a corporate campus-wide van that is owned and used by the facility.On 8/24/26, at 12:05 p.m., Surveyor asked NHA-A if anyone from management (i.e.: NHA, DON or ADON) was in the building when R3 made the allegation she fell in the van. NHA-A stated, No, I had just left, I was in my car when I got the call a little after 5:00. The nurse told me what the resident said, she was on the phone with me while she was asking (R3) questions. I told her to ask her if she was belted in and she said she was. She actually said that multiple times when she was asked. I wasn't really part of the investigation per se, because it's the corporate van and technically not my employees, but I was involved in the reenactment.Surveyor asked NHA-A if the injury of unknown origin was reported to the State Agency. NHA-A stated, No, because we talked about it and it was determined we knew how it happened. Surveyor informed NHA-A that the injury determination was made only after the investigation was completed. When R3 told staff she fell in the van, R3 was complaining of severe pain and 2 large bruises were found, Surveyor stated the facility was unaware of the exact cost of the injuries. Surveyor informed NHA-A that the injury of unknown origin should have been reported to the State Survey Agency at the time and then the investigation started. NHA told Surveyor she would have the COO-E and director of building and grounds speak with Surveyor.On 8/24/26, at 12:21 p.m., NHA-A, Director of Building and Grounds-Y, Chief Executive Officer (CEO)-D and COO-E met with Surveyor to discuss the incident. Surveyor asked if the transport van has a camera. CEO-D stated, Yes, we looked at the camera it shows the front and back, however the handicap sticker was on it, so we couldn't see the whole back of the van except for the driver and slightly to the right of the driver. The camera to front showed speed limit was 32. COO-E added, When we reviewed the footage, it showed the driver never left the front seat. When the driver hit the brakes, we could partially see the 2nd passenger get up and go to the back of the van and a short time later they began driving again. (R3's) story of falling on the floor didn't make sense because she said she fell on the floor and was lifted by 2 people. There were only 2 people in the van, and the camera showed the driver never left her seat and (R3) is a Hoyer lift. Also, the van only stopped for a very short time. CEO-D stated, We also did a simulation to try to recreate the situation, and there is an alarm that sounds if a resident isn't strapped in securely.Surveyor informed NHA-A, Director of Building and Grounds-Y, CEO-D and COO-E that R3 reported an allegation she fell in the transport van, was complaining of severe pain, had 2 large bruises that were found on her lower extremities and she was subsequently admitted to the hospital with diagnoses of bilateral hip fractures. Surveyor stated that the injuries were not reported to the State Agency. COO-E stated, We didn't report because we had an idea of how it happened. Surveyor informed NHA-A, Director of Building and Grounds-Y, CEO-D and COO-E that the determination of the origin of R3's bruising and fracture was only made after the investigation was initiated. Surveyor informed NHA-A, Director of Building and Grounds-Y, CEO-D and COO-E that the injuries should have been reported initially to the State Survey Agency, within the required timeframe and then investigated.On 8/28/26, the facility provided Surveyor with additional information via email. The documentation provided stated that the facility did not believe the event met the definition of an injury of unknown source because the facility was aware of the transportation event, the resident reported falling during the sudden stop, and the resident was reportedly secured in the wheelchair. The facility further stated that the resident initially denied pain and had no visible injuries and that there was no allegation or suspicion of abuse, neglect, mistreatment, or intentional injury.Surveyor reviewed the information provided by the facility and noted that the facility was aware of the transportation event but did not establish the source of R3's injuries at the time R3 reported falling, reported severe pain, and had two large bruises documented. Based on the facility's own investigation, the facility's determination that the source of the injuries was known was made after the investigation was completed and did not eliminate the requirement to report the injury within the required timeframe.

Based on observations, record review, and interviews, the facility failed to ensure two of seven sampled residents (Resident (R) 3 and R11) reviewed for falls were left in a safe position while staff stepped away from the resident's bedside, resulting in R3 and R11 falling from the bed and sustaining injuries. In addition, the facility failed to ensure that staff were aware of R1's change in mode of transfer to ensure safe transfers. Findings include: 1. Review of R3's Resident Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed an admission date of 09/27/24 with diagnoses of Parkinson's disease without dyskinesia and dementia. Review of R3's Care Plan, located in the EMR under the Resident Assessment Instrument (RAI) tab, revealed a category of Falls which stated, [R3] has potential for falls related to Parkinson's, freq [frequent] falls, anemia, weakness. An approach, dated 05/13/25, stated, Frequent checks for safety and toileting needs; low bed with floor mat next to it while the resident remains in bed. Review of R3's quarterly Minimum Data Set (MDS), located in the EMR under the RAI tab with an Assessment Reference Date (ARD) of 10/13/25, revealed R3 had a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating R3 was severely cognitively impaired. R3 was dependent on staff for chair/bed-to-chair transfers. Review of R3's John Hopkins Fall Risk assessment, completed on 10/23/25, located in the EMR under the Resident tab under Observations, revealed a score of 8, which indicated she was a moderate fall risk. On 12/21/25, the facility submitted a report titled ALLEGED NURSING HOME RESIDENT MISTREATMENT, NEGLECT, AND ABUSE REPORT to the state agency at 2:11 PM under allegation type: Other: Reportable incident that is not misconduct related. R3's name was listed as the person affected, and Certified Nursing Assistant (CNA) 5 was listed as the accused person. The report indicated the incident occurred on 12/21/25 at approximately 8:20 AM. The Brief Summary of Incident revealed, The aide was in residents room cleaning up the resident and got the resident dressed. Aide reported she left the room to get assist to transfer resident out of bed. Resident was heard by the unit nurse calling out. The nurse went to the room and found the resident on the floor. Resident was sent out to ER [Emergency Room]. The aide was sent home pending investigation of the fall. RN [Registered Nurse] Supervisor attempted to get results from ER several times, however due to ER volume wasn't able to get results until 1:17 PM. Resident was found to have a Nondisplaced Right Femur fracture. Upon initial investigation the bed position may have been a contributing factor of the injury, hence staff education initiated on leaving beds in appropriate height when leaving a room. A house wide audit was also done to ensure all beds in appropriate height. During an interview on 05/19/26 at 1:26 PM, CNA5 stated she cared for R3 every time she was at the facility. CNA5 stated that R3 was total care for all aspects of care and utilized a Hoyer (mechanical) lift with two people assisting for transfers. CNA5 reported at the time of R3's fall, she took care of R3 so much, she just knew the care that she needed and knew there was a care plan somewhere. CNA5 stated she believed R3 was a fall risk. CNA5 reported that on the day of the fall, she dressed R3 and asked another CNA to help with the Hoyer lift. CNA5 said while she was waiting for the other CNA, she heard another resident across the hallway yelling for help. She said she knew that resident was also a fall risk so she left the room to check on the other resident, and when she was returning, she heard R3 yelling from across the hall. CNA5 said she forgot to lower the bed down to the floor, and R3 had fallen out of bed. CNA5 said she was sent home after the incident and when she returned, she received training on where to locate the care plan. During an interview on 05/20/26 at 11:30 AM, Licensed Practical Nurse (LPN) 2 stated she was the nurse that was working when R3 fell from her bed. LPN2 stated she was at the medication cart doing the medication pass and heard someone yelling out for help. LPN2 stated she went down to see what was going on and noticed R3's bed was high, with the top of the mattress approximately three feet from the floor, and R3 was not in it. LPN2 stated she saw R3 on the floor, laying on her left arm. LPN2 said there was a fall mat in place and R3 was laying on it. The CNA was in the room adjacent (across the hall). LPN2 said they did not move the resident, immediately notified the DON (Director of Nursing), and called 911. LPN2 stated that there was staff training on bed heights following the fall. During an interview on 05/20/26 at 4:00 PM, the DON explained the steps taken to investigate the incident and the actions taken after the incident occurred to include staff training regarding falls and bed heights, the location of the care cards for instruction on care needs, and a house-wide review of bed heights for safety. 2. Review of R11's Resident Face Sheet, located in the EMR under the Resident tab, revealed an admission date of 06/18/24 with diagnoses of chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic kidney disease, stage 3 unspecified, and Alzheimer's disease, unspecified. Review of R11's annual MDS assessment with an ARD of 03/02/26, located in the EMR under the RAI tab, indicated R1 had a BIMS score of zero out of 15, indicating R11 was severely cognitively impaired. The assessment indicated R11 was dependent on staff for chair/bed-to-chair transfers, rolling left and right in bed, toilet hygiene, personal hygiene, and dressing. Review of R11's Care Plan located in the EMR under the RAI tab revealed, [R11] has potential for falls related to impaired mobility, weakness and impulsiveness. Approaches, dated 11/26/24, were to Recline Broda [specialized wheelchair] back when not eating for comfort and safety and Resident cares completed at the start of shift. Pool noodle when in bed to help define edge of bed. The care plan did not include approaches for the resident's bed to be in the low position with a mat beside the bed. Review of R11's John Hopkins Fall Risk assessment, completed on 12/17/25, located in the EMR under the Resident tab under Observations, revealed a score of 13, which indicated R11 was a high fall risk. During an observation on 05/18/26 at 3:20 PM, R11 was seated in the common area of the unit on which she resided in a Broda chair. R11 was observed to have stitches across her forehead with yellowish bruising on her forehead and down below her eyes. When asked what happened to R11, CNA11 stated she was off for a few days and when she came back, R11 had fallen. During an interview on 05/19/26 at 8:40 AM, LPN3 stated R11 fell about a week ago from her bed. When asked if the bed was in a high or low position at the time of the fall, LPN3 demonstrated that the bed was at about her hip's height. During an interview on 05/19/26 at 8:43 AM, CNA10 stated that she was assigned to R11 the day of the fall, on 05/12/26. While providing care for R11, CNA10 stepped away to go to the bathroom to wet a face towel, and when she was going back to the resident's bedside, R11 was rolling onto the floor. When asked what the position of the bed was at the time of the resident's fall, CNA10 demonstrated it was at the height of her hip. CNA10 said she met with the DON and RN supervisor and went over what took place. During an interview with the DON on 05/20/26 at 2:30 PM, the DON was asked about the investigation that was conducted for R11's fall. The DON said that the CNA was providing cares in bed. The DON said that the CNA went to the bathroom to wet a towel to clean R11's face, and R11 was too close to the edge of the bed. The DON stated that it was an unfortunate mishap. On 05/21/26 at 10:15 AM, CNA10 was asked to go to R11's room and demonstrate the height of the bed at the time of the fall. CNA10 lifted the bed to the height she recalled it was at when she left the resident to go to the bathroom and stated the height was at a normal working height for providing cares. The height of the bed was described as being over two feet from the floor to the top of the mattress. CNA10 stated that the RN supervisor came in and took pictures to see how high the bed was. CNA10 explained that R11 was not in the middle of the bed but further to the left side of the bed, demonstrating where the resident's left shoulder was by pointing to the mattress, approximately six inches from the edge of the mattress. CNA10 said the floor mat was not in position by the bed because she was still providing cares when she left the resident to go to the resident's bathroom. During an interview on 05/20/26 at 10:22 AM, RN1, the first-floor supervisor on the AM (morning) shift, confirmed she took pictures of the height of the bed on her supervisor phone when R11 fell. RN1 shared two pictures taken on 05/21/26 at 7:36 AM (per date and time on the iPhone). RN1 described one of the pictures as the CNA standing beside the bed to show the height of the bed when R11 fell. The other picture was described by RN1 as a picture of the bed height and the body of the resident, without a picture of R11's face, still lying on the floor after the fall. A mat was not on the floor beside the bed. The bed was observed to be in a high position, greater than two feet off the floor in the pictures. An observation was made on 05/21/26 at 12:30 PM with CNA10, the Administrator, the DON, RN1, and the Director of Buildings and Grounds (DOBG) present in the room of R11. CNA10 was asked to place the bed in the position at the height when the resident fell from the bed. CNA10 raised the bed using the remote. The DOBG measured from the floor to the top of the mattress with the measurement being 30 inches. CNA10 was asked to show the distance of R11's left shoulder to the edge of the bed when she left R11 to wet the towel. The distance where CNA10 showed the resident's left shoulder to be to the edge of the bed measured 8 inches per measurement by the DOBG. When the pictures taken by RN1 were mentioned at the end of the observation, RN1 stated she deleted the pictures. During an observation of the care card located inside R11's closet door on 05/21/26 at 2:00 PM it was revealed that the care card did not include any information about the resident's risk for falls or that the bed was to be at a low position. The latest date for any interventions for R11's care to be provided was 03/29/26, which was prior to the R11's fall. 3. Review of R1's Resident Face Sheet located in the EMR under the Resident tab, revealed an admission date of 09/18/25 with a diagnosis of Parkinsonism. Review of R1's significant change MDS with an ARD of 02/26/26 revealed R1 had a BIMS score of eight out of 15, which indicated moderate cognitive impairment. The assessment indicated R1 required partial/moderate assistance for chair/bed-to-chair transfers, toilet transfers, and transitioning from sitting to standing. Review of R1's Care Plan, provided by the Administrator, revealed a problem area, I have impaired mobility related to weakness, falls, Parkinsons. An approach, dated 03/22/26, was for the resident to be transferred utilizing the Hoyer lift and the assistance of two staff. R1's care card, located in her closet during her stay, was unavailable since the resident was no longer in the facility. Review of the facility's investigation into R1's injury of unknown origin on 03/28/26, provided by the facility, revealed that CNA2 deviated from the care plan by transferring R1 by herself. The resident's care plan reflected a change in R1's transfer status; effective 03/22/26, staff were to utilize a Hoyer lift. The facility was unable to determine that the improper transfer caused any injury to R1. During an interview on 05/20/26 at 11:31 AM, CNA2 stated R1 was a one person assist to the toilet but could not be left unattended on the toilet. CNA2 stated R1 was a fall risk but after she had COVID, R1 declined. She had been able to stand and pivot but was not able to walk independently. When asked about her transfer of R1 on 03/28/26, CNA2 stated she transferred R1 from the chair to the bed by herself. CNA stated that once she got R1 from the chair to the bed using a one person assist, the resident didn't say anything. When CNA2 started to undress R1, she noticed an open area on the resident's left leg. CNA2 stated she went straight to the nurse to report it. CNA2 said R1 was still a one person assist in the computer but not on paper at that time. CNA2 clarified the paper was the care card. CNA2 said they were taught to look in the computer because the paper card wasn't always updated. CNA2 said the computer was not updated until after the incident. CNA2 said that she assumed R1 was a one person assist until it was changed in the computer but that the facility said she (CNA2) had not properly transferred R1. During an interview with the Administrator on 05/21/26 at 3:30 PM, the Administrator verified that CNA2 improperly transferred R1 on 03/28/26. The care plan reflected it was updated on 03/22/26 to add in the Hoyer lift for R1's transfers.

Based on record review, interview, and review of the facility's policy, the facility failed to ensure that injuries of unknown origin were reported to the state agency for one of one sampled resident (Resident (R) 1) out of a total sample of 18 residents. This failure had the potential to result in unidentified abuse, incomplete investigations, and the continuation of unidentified injuries. Findings include: Review of R1's Resident Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed an admission date of 09/18/25 with a diagnosis of Parkinsonism. Review of R1's Care Plan, located in the EMR's Resident Assessment Instrument (RAI) tab, revealed a Problem Start Date: 08/18/25 with the Category: ADLs [Activities of Daily Living] Functional Status Potential ADLs: I have impaired mobility related to weakness, falls, Parkinsons. An Approach Start Date: 02/10/26 stated, Gait/Ambulation: limited assist x2 [assist of two staff] with 2ww [wheeled walker], gait belt, and wc [wheelchair] follow. Another approach with a start date of 02/10/26 indicated, Transfer status: limited assist of 1 with gait belt and 2WW. Review of R1's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/26, located in the EMR under the RAI tab, revealed R1 had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated moderate cognitive impairment. The assessment indicated R1 required partial/moderate assistance for chair/bed-to-chair transfers, toilet transfers, and transitioning from sitting to standing. Review of a Resident Progress Note dated 03/27/26 at 11:30 AM, located in the EMR under the Resident tab, stated, Writer was called to [room number of R1] by the unit nurse to discuss a new skin issue that was first found by the [name of hospice agency] nurse. Per the unit nurse there was a laceration to the resident's R [right] lower leg. Writer arrived to [room number of R1] and found the resident in her broda [specialized wheelchair] chair. She was calm and appeared not to be in any distress. Writer instructed the unit nurse to notify the provider . Upon inspection of the wound/laceration to the resident's R calf, the writer noticed that there was no active bleeding. The laceration measured 4 cm [centimeters] x [by] 3 cm. The laceration was in a J shape. The surrounding skin was bruised and noticed to be thin and fragile. The resident at the time didn't complain of pain. The unit CNA [certified nursing assistant] and hospice nurse placed a hoyer [mechanical lift] sling underneath the resident to transfer her to bed. Per the hospice nurse, she got the okay to send the resident out to the hospital for an evaluation . Review of an Event Report dated 03/27/26, located in the resident's EMR under the Resident tab, completed by Licensed Practical Nurse (LPN) 1 at 4:37 PM, revealed the section titled DESCRIPTION documented a Right posterior calf wound. In the section titled PHYSICAL OBSERVATION the following was documented: Type of Injury: Laceration. Location and Size of Skin Tear/Laceration: Right Posterior calf wound. Depth of Skin Tear/Laceration: Deep. Blood Loss-Note Amount and Control: Controlled Bleeding. Wound Edges: Irregular. Activity During Skin Tear/Laceration Occurrence: Unknown. In the INTERVENTIONS – Immediate measures taken section of the report, Other – Sent to the Hospital was checked. Review of a Resident Progress Note dated 03/28/26 at 10:59 PM, located in the EMR under the Resident tab, revealed, Pt [patient] Sustained Skin Tear To L [left] Lat [lateral] Leg during assisted transfer. Area measured 1.8 x 3.9 cm, exposed adipose [fat] tissue w/ [with] md [moderate] bleeding. Pt. AO [Alert and Oriented] @ [at] baseline, no distress S/sx [signs or symptoms] . Review of an Event Report dated 03/28/26, located in the resident's EMR under the Resident tab, completed by LPN4 at 9:02 PM, revealed the section titled DESCRIPTION documented a S/T [skin tear] to the later [lateral] L shin. In the section titled PHYSICAL OBSERVATION the Type of Injury selected was a Skin Tear. The Location and Size of Skin Tear/Laceration was 2.1 x 1.5 L lateral shin. For the Depth of Skin Tear/Laceration, Deep was selected. Wound Edges was marked as Irregular. The facility's Incident Investigation Summary for R1, provided by the facility, revealed the following Investigative Findings: Both incidents involved different staff members; Re-enactments of both transfers were completed with involved staff to assess technique and potential contributing factors; A thorough environmental review of the resident's room and equipment was conducted, including the bed, frame, and surrounding areas; While the bed frame was considered as a potential contributing factor, this was deemed unlikely due to the presence of an air mattress overlay; As a precaution, maintenance conducted a facility-wide audit of bed frames and removed exposed bolts used for positioning rails; At the time of both incidents, the resident was wearing long pants, and there was minimal blood noted on clothing or bedding, making it difficult to determine the exact mechanism of injury. There was also no cuts or holes in the pants found at either time; Despite comprehensive review, the specific cause of the lacerations could not be determined. The investigation concluded, Based on the investigation findings, the injuries are considered inconclusive in origin, with the resident's significant skin fragility/skin failure and overall clinical decline being major contributing factors. There is no evidence to support that the injuries were intentional, and no abuse or neglect is suspected. An interview was conducted with the Administrator on 05/21/26 at 5:30 PM. The Administrator was asked if the instances where R1 received injuries of unknown origin were reported to the state agency. The Administrator stated that the injuries were not reported because they could not determine what caused the injuries. Review of the facility's policy titled, Administration Policy and Procedure with Subject: Abuse, Neglect, Exploitation, Misappropriate and Injuries of Unknown Origin, revised April 2026, revealed an Alleged Violation is defined as . a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be an indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The policy section titled Reporting/Response stated, The facility will: i. Report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: 1. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or 2. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. b) The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on observations, interviews, record review, and policy review, the facility failed to ensure one of two residents (Resident (R) 2), during one of three opportunities for the provision of incontinence care, received incontinence care in a manner that prevented cross-contamination from a dirty area to a clean area. This failure had to the potential to result in urinary tract infections. Findings include: Review of the Resident Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed R2 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic (congestive) heart failure, chronic kidney failure, stage 3b, fibromyalgia, overactive bladder, and a history of urinary tract infections. R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/26, located in the EMR under the Resident Assessment Instrument (RAI) tab, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R2 was cognitively intact. This assessment also indicated that R2 was dependent on staff for toileting hygiene, was frequently incontinent of urine, and utilized an external catheter. During an observation on 05/19/26 at 10:10 AM, Certified Nursing Assistant (CNA) 6 provided incontinence and perineal care (peri-care) for R2. After providing incontinence care by cleaning the right and left labia in a downward motion, changing the position of the washcloth for each side and cleaning down the middle of the labia, the CNA was observed to use a dry washcloth to dry in between the resident's labia in an up and down motion from the front to the back and then from the back to the front. The resident turned on her right side for the CNA to clean and dry her buttocks. The resident turned onto her back and the CNA again provided perineal care for R2, again using a washcloth to clean the labia in a front to back manner. However, to dry the resident's labia, a dry cloth was used, with the aide drying between the labia in an up and down motion. During an interview on 05/19/26 at 10:35 AM, CNA6 was notified of the surveyor's observations. CNA6 denied she had used the up and down motion during the drying of the resident on both observations of peri-care. The facility's policy titled, Perineal Care of the Female Resident, reviewed May 2020, revealed the following under the section Implementation: Separate the resident's labia with one hand and wash the other using gentle downward strokes from the front to the back of the perineum to prevent intestinal organism from contaminating the urethra or vagina. Avoid the area around the anus, and use a clean washcloth for each stroke by folding each used section inward. This method prevents the spread of contaminated secretions or discharge. Pat the area dry with a bath towel because moisture can cause skin irritation and discomfort.

Based on document review and interview, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 99 current residents. This failure had the potential to inaccurately inform any resident, family member, or visitor of the available nursing staff caring for residents.Findings include:Review of the daily nurse staff posting document, dated 07/07/25 for the night shift, indicated that two Registered Nurses (RNs), three Licensed Practical Nurses (LPNs) and seven Certified Nurse Aides (CNAs) were on the shift. Review of the nurse schedule, dated 07/07/25 and provided by the night supervisor, revealed the night shift had three RNs, two LPNs and five CNAs on the schedule.During an interview with the night supervisor on 07/07/25 at 11:35 PM, she stated that she completed the daily nurse staffing document this morning before she left her shift and had not revised the document this evening to reflect the staff on duty for the night shiftDuring an interview on 07/08/25 at 3:12 PM, the Director of Nursing (DON) verified that the daily nurse staffing document dated 07/07/25 indicated seven CNAs and there was only five CNAs; and the form indicated two RNs, but it should have been three RNs. During this interview, the facility's Staff/Scheduler stated that she revises the day and evening shifts, and the night supervisor is responsible for revising the night shift information on the document. The Staff/Scheduler stated that the normal staffing pattern for the night shift was for six nurses and eight CNAs.Review of a sample of daily nurse staffing document and the nursing schedule revealed for the night shift on the following dates indicated:On 07/03/25- five nurses (one RN and four LPNs) and seven CNAS were on the nursing schedule; however, the daily nurse posting indicated three RNs, four LPNs and eight CNAs.On 07/02/25- six nurses (six LPNs) and seven CNAs were on the nursing schedule; however, the daily nurse posting indicated one RN, six LPNs and seven CNAs.On 07/01/25- five LPNs and eight CNAs were on the nursing schedule; however, the daily nurse posting indicated one RN, six LPNs and eight CNAs.During an interview on 07/09/25 at 9:32AM, Administrator 2 stated the facility does not have a policy for daily nurse staff posting.

Based on observation, interview, and record review, the facility did not ensure Residents received adequate supervision and assistive devices to prevent accidents for 11 (R49, R72, R83, R12, R315, R79, R100, R51, R38, R94, and R6) of 14 Residents reviewed for accidents. This has the potential to affect 64 residents who use a mechanical hoyer lift, a mechanical sit to stand, or a Sara Steady lift. Staff did not always use the correct lift or use it correctly. The facility does not have a process in place for staff to ensure residents that are transferred using a mechanical lift or sit to stand have the appropriate sling to use during the transfer. *On 3/23/25, R72 fell from a Sara Steady and suffered a displaced spiral fracture of the left femur. At the time, R72 was to be transferred with the use of a mechanical sit to stand. *R83, R12 and R315 were observed during a transfer with a mechanical hoyer lift to not have the correct size sling used. On 3/28/25, R49 slid off a mechanical lift sling left under R49 while in the wheelchair to the floor. The facility had not assessed the safety risks associated with leaving a sling under R49 including whether the presence of the sling could lead to an unsafe seating situation for R49 in their wheelchair. R49 suffered a right humerus fracture. The facility policy is to remove all slings once the Resident has been transferred. *R79 was observed to be sitting in a wheelchair with a sling left underneath. The facility policy is to remove all slings once the Resident has been transferred. *R100 was up in the air over R100's Broda chair when the mechanical lift battery stopped working. *R51 was observed being pushed a long distance in the Sara Steady to the bathroom., however, the Sara Steady is only designed for a simple very short distance transfer. *R38 was observed during a transfer with a mechanical lift to not have the correct size sling. *Upon interview, staff did not know what size sling to safely transfer R42. *Upon interview, staff did not know what size sling to safely transfer R6. *R94's care plan documented R94 was to transfer with the assistance of a 2 wheeled walker which was not available during the survey process. Facility failure to have a process in place for staff to ensure the safe transfer of residents created a finding of immediate jeopardy that began on 3/23/2025. Surveyor notified Nursing Home Administrator (NHA)-C, Director of Nursing (DON)-B, Chief Executive Officer (CEO)-A, and Director of Clinical Operations (DOC)-D of the immediate jeopardy on 4/21/2025 at 2:07 PM. The Immediate Jeopardy was removed on 5/1/25, however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its removal plan. Findings include: The facility's Safe Resident Handling (Safe Lift/No Lift Transfers) Effective 10/09, Revised 3/19, Reviewed 3/24 documents: Guidelines: Therapy/Nursing will complete the following: 1. Therapy will determine the safest transfer technique for each Resident being assessed or followed by therapy. Therapy will communicate to nursing the best method of transfer in electronic health record (EHR). 2. If Resident is not on therapy caseload, nursing will consult with therapy as needed to update Resident transfer status. a. Admission Screening -Therapy will determine Residents transfer status upon admission within 48 hours. 1. Therapy/Nursing will document transfer technique on the Resident care plan and Resident care guide in EHR. 2. Therapy/Nursing will provide training and education as needed to nursing staff regarding safest transfer technique for Resident being assessed. 3. Therapy/Nursing staff will monitor safety of current transfer technique and implement changes as appropriate. 4. Nursing staff will receive annual education and training on the safe transfer techniques by therapy/nursing. Criteria for determining transfer status of Resident: 3. Mechanical Stand (Sit to Stand) 1-2 people a. Resident is partially dependent and has some weight bearing ability and has sufficient upper body strength and usage. b. Residents that have difficulty following directions, panics during transfers or grabbing for a perceived safe surface. c. Compromised balance. d. Resident stands for less than 5 seconds or is unpredictable. 4. Full Mechanical lift-2 people a. Resident is non-weight bearing. b. Resident is weight bearing but won't bear weight. 5. Non-mechanical/One Person (Sara Steady): a. Suitable for who can partially weight-bear, but need an extra hand tasks like dressing or stabilizing during transfer b. Have some upper body strength and can follow basic transfer instructions c. May have compromised balance or difficulty following directions but can still participate in the transfer. 10. A minimum of two people must be present for mechanical lift transfers. 11. Caregivers may NEVER utilize less assistance with a transfer than the care plan states. If more assistance is required, the CNA must report change in status to the nurse. The nurse will determine safest transfer at time and inform therapy of change and document change in transfer in EHR. 12. Slings must be correctly matched to Residents (Small, Medium, Large, X-Large). 13. Slings must be matched to appropriate mechanical lift by manufacturer name. QIC 1. Regular observation of the staff CNA's transferring of Residents will take place on hire and/or annually with evaluation. Unit nurses, managers, supervisors, nurse educator and therapy should perform these evaluations in room observations. 2. Transfer incidents/injuries will be reported and thoroughly investigated per policy by interdisciplinary, as needed. Education and Training of Staff 1. All current nursing staff will be in serviced to the Safe Resident Handling Policy. 2. Nursing staff to complete demonstration for each device at training evaluation and annual evaluation. 3. All new staff to complete education and training within first orientation period. 4. Therapy and/or Nursing to re-evaluate Resident's current abilities to continue with current plan of care if a noted change in condition is identified (decline or improvement). 5. All Residents requiring physical assist and/or devices will be screened quarterly. Equipment Inspection and Maintenance 1. Daily visual by nursing staff prior to all transfers. 2. Preventative Maintenance Program by Buildings and Grounds. 3. Monthly form inspections with documentation for each type of lift device done by Buildings and Grounds . On 4/21/25, at 7:22 AM, Surveyor reviewed the manuals for the mechanical hoyer lifts and sit to stands that the facility provided. Medline MDS400SA and MDS600-Revised 4/16/13 .Warning! -Page 5 Together with the Resident's doctor, nurse, or medical attendant, select a Medline sling that is both practical and comfortable. The sling selected should be one that serves the needs of the Resident, while providing the Resident with optimal safety. .Warning! -Page 5 Medline slings are specially designed for use on Medline Lift equipment. For optimum performance use only, Medline stand assist slings. USE OF NON-MEDLINE SLINGS IS UNSAFE AND MAY RESULT IN INJURY TO THE RESIDENT OR CAREGIVER. Warning! Do not put anything between the Resident and the sling. This may cause the Resident to slide out of the sling and cause injury. .Page 12 Maintenance Schedule Slings-Check entire sling inventory for fraying, tearing, excessive wear of any kind and replace any worn or damaged slings with Medline slings. .Page 13 Do Not Operate Lift Unless All Maintenance Points Pass Inspection Warning: -Always carry out the daily checklist before using the lift -Do not use a sling unless it is recommended for use with the lift -Always check if the sling is suitable for the particular patient and is of the correct size and capacity -Never use a sling which is frayed or damaged -Always fit the sling according to the instructions provided -Always check the safe working load of the lift to be sure it is suitable for the weight of the patient -DO NOT use electric lifts in the shower -DO NOT charge an electric lift in a bathroom or shower room -CAUTION: Keep the batteries fully charged. Arjo Huntleigh [NAME] 300-11/2014 .Page 9 Preparation before transfer Before approaching the Resident, the caregiver shall always tell the Resident what they are going to do and have the correct size sling ready. .Using Standing Sling, and their different parts referred to in this manual Warning! An assessment must be made for each individual Resident being raised by the [NAME] 3000-by a medically qualified person-as to whether the Resident requires the lower leg straps when using the standing sling. The top of the sling can be recognized by the washing label which is placed on the outside top rim of the sling. .Pg 19 Caution:! It is recommended that equipment, accessories and slings supplied by ARJO Huntleigh are regularly cleaned and/or disinfected between each Resident use if necessary, or daily as a minimum. .Page 21 Care and Preventative Maintenance. The Arjo Huntleigh [NAME] 300 takes 2 different slings, a transfer and standing sling. .Providing the right sling for the individual patient type and need, is vital, to promote optimal safety and comfort. MAXI 500 4/2016 2 different models in the facility, 1 takes a straight bar, 1 does not. .Page 11 Sling Selection The spreader bar that is attached to the lift determines what slings can be used to transfer a patient Slings are color coded for size by having a different color edge binding or attachment strap coloring. Invacare Roze Stand Assist Patient Lift 2017 .Pg 15 Warning! Risk of Injury of Death Improperly attached, improperly adjusted or damaged slings can cause the Resident to fall -Use Invacare approved sling that is recommended by a health care professional for the comfort and safety of the individual being lifted -Invacare slings and Resident lift accessories are specifically designed to be used in conjunction with Invacare patient lifts -After each laundering (in accordance with instructions on the sling) inspect sling(s) for wear, tears, and loose stitching. Invacare Roze Stand Assist Patient Lift 2017 .Pg 15 Warning! Risk of Injury of Death Improperly attached, improperly adjusted or damaged slings can cause the Resident to fall -Use Invacare approved sling that is recommended by a health care professional for the comfort and safety of the individual being lifted -Invacare slings and Resident lift accessories are specifically designed to be used in conjunction with Invacare patient lifts -After each laundering (in accordance with instructions on the sling) inspect sling(s) for wear, tears, and loose stitching. Invacare Get-U-Up 2018 .Page 7 Invacare Stand Assist and Transfer slings are specifically designed to be used in conjunction with Invacare patient lifts. Slings and accessories are designed by other manufacturers are not to be utilized as a component of Invacare's patient lift system. Use the sling that is recommended by the individual's doctor, nurse or medical assistant for the comfort and safety of the individual that is being lifted. Surveyor notes all the models specify must use their sling for safety. On 4/16/25, at 10:38 AM, Surveyor was approached by the Occupational Therapist (OT)-E who has worked at the facility for about one year. OT-E shared that OT-E felt that there were significant safety concerns in regard to the Residents who required mechanical lifts, mechanical sit to stands, or a Sara Steady. OT-E explained to Surveyor that any Resident that is a minimal assist requires a Sara Steady. A Sara Steady is for only very short transfers, for instance from bed to wheelchair. It is not meant to be pushed to the bathroom with the Resident on it. OT-E informed Surveyor that physical therapy determines the safe transfer status of a Resident. OT-E stated that an outside therapy consultant (TC)-F came in and trained the therapy department about two weeks ago. OT-E stated that the therapy department was told by TC-F that something had happened to a Resident. A Resident had been left unattended on a Sara Steady. OT-E had no further details. OT-E explained to Surveyor that each Resident has to have the right sling for the right lift. OT-E informed Surveyor the facility has a [NAME] podge of slings. Certified Nursing Assistants (CNAs) take whatever sling is available, use the same sling from Resident to Resident, wiping the sling down between Residents. OT-E spends a lot of time searching for the right sling to match the machine. No one has been trained on what sling to use. CNAs don't know what sling to use or what loop to put it on. There is no care plan of what sling to use for each Resident. OT- E has sometimes seen a single CNA transfer a resident using a mechanical lift when it should have been two-person transfer. There is a major issue of the batteries not working. Looks green like it is charged, but then can't handle the load of the Resident so it stops working with the Resident up in the air. Because of short staff, the therapy department uses the Sara Steady by themselves, but it should be two to assist. On 4/16/25, starting at 11:17 AM, Surveyor took a tour with OT-E of all six units in the facility. Surveyor observed all mechanical lifts, and all areas that stored the slings. Some mechanical lifts in the hallways with slings draped over the lifts. Storage of mechanical lifts and sit to stands, and slings was very haphazard on each unit. ParkView 1 Multiple slings. Different colors, different brands, unable to determine what sizes on most. 1 hoyer and 1 mechanical sit to stand. TerraceView 1 2 mechanical sit to stands. 1 pump up sit to stand. Multiple different brands of slings-1 sling marked XL 650 pounds on the sit to stand. SunnyView 1 L sling marked 650 pounds on a sit to stand. On a mechanical lift a sling marked L 650 pounds was marked. ParkView 2 The end room has a wheelchair with a pile of multiple slings, multiple brands, multiple colors. OT-E stated, That's why they don't know what slings to use, that's why they use the same sling on all the Residents. TerraceView 2 3 different sit to stands in the closet, hoyer is a different brand other than maxi move from the other units. Certified Nursing Assistant (CNA)-I came into the room at this time. Surveyor interviewed CNA-I. CNA-I explained to Surveyor that CNA-I was checking on the midline sit to stand because it wasn't working in the morning. Surveyor asked if the Resident was still in bed. Surveyor notes it was about 11:10 AM. CNA-I stated, I just used another sit to stand. Per CNA-I, slings are piled up or hanging over the mechanical lift and CNA-I never knows what size to use. CNA-I informed Surveyor the mechanical lift is a Midline and the battery has not been charged and doesn't know what sling to use for that one. SunnyView 2 The shower room has 3 different mechanical lifts, 5 different slings, different brands, and colors. The netting is shredded on one sling. OT-E stated OT-E doesn't know what the colors mean. OT-E explained that 1 sling hanging is a sling from the hospital which is meant for a lift that is anchored to the ceiling. OT-E stated that if it was used on a facility lift it would act as like an accordion and fold in on the Resident. On 4/16/25, at 2:01 PM, Surveyor interviewed CNA-J about all the different slings. CNA-J stated, that you just look at the sling and decide if it fits the size of the Resident. There is no actual size to the sling, and they are not marked. On 4/16/25, at 2:20 PM, Surveyor made observations in the shower room. There were multiple different slings on hooks, multiple brands, no sizes on the slings. CNA Care Coordinator (CCC)-P came into the shower room and informed Surveyor that CCC-P was doing an audit of slings and mechanical lifts. CCC-P stated, She was doing an audit because state is here. The slings here are a waste of money. There are no actual sizes available in the shower room. Can't use any of these. Right now, there are 58 Hoyer's (sic) and 37 slings that I have counted. We have been telling the facility there is a problem for a couple of years. On 4/16/25 at the daily exit meeting with the facility, Surveyor requested a count of how many Residents require the assistance of mechanical lifts, mechanical sit to stands, and Sara Steady's. On 4/17/25, Surveyor notes that currently the facility states the facility has the following: 50 Residents require a mechanical hoyer lift 5 Residents require a mechanical sit to stand 9 Residents require a Sara Steady On 4/17/25, starting at 7:30 AM, Surveyor observed 3 mechanical lift transfers. On the mechanical lift, the color code read: XS burgundy Small red Medium yellow Large green LL light blue XL dark blue 1.) R83 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease Affecting Left Dominant Side (complete paralysis on one side of body and partial/incomplete weakness on one side following stroke). R83 currently has an activated Health Care Power of Attorney (HCPOA). R83's Quarterly Minimum Data Set (MDS) completed 3/11/25 documents R83's Brief Interview for Mental Status (BIMS) score to be 11, indicating R83 demonstrates moderately impaired skills for daily decision making, requiring cues and supervision. R83 has range of motion (ROM) impairment on one side. R83 is dependent assistance for dressing, mobility, and transfers. R83 requires partial/moderate assistance for eating. R83's Assistance of Daily Living (ADL) care plan initiated 12/9/24 documents R83 has impaired mobility and requires a full body mechanical lift with assist of 2. On 4/9/25, R83 weighed 149 pounds. On 4/17/25, at 7:30 AM, Surveyor asked CNA-L where CNA-L obtained the sling that CNA-L was using for R83. CNA-L stated CNA-L found it in the shower room. Surveyor asked CNA-L what size it was. CNA-L stated, I do believe it's a large, no its a medium. Surveyor notes CNA-L was not wearing glasses when CNA-L shared the size. Surveyor observed the sling was light blue with blue edging. CNA-L informed Surveyor the size was on the white tag. Surveyor asked CNA-L where the size was. CNA-L and Surveyor both went to look. CNA-L informed Surveyor that CNA-L can't see a thing and Surveyor observed CNA-L put CNA-L's glasses on. The tag on the sling read XL. CNA-L informed Surveyor that CNA-L likes to get a little larger sling than what the Resident is. CNA-L informed Surveyor we can use whatever sling we can find. We take what we can get. It really just matters what end we use for the sling we get. Either the loop or the clip one. It doesn't matter what size. 2.) R12 was admitted to the facility on [DATE] with diagnoses that include Chronic Congestive Heart Failure (long term condition where the heart muscle is too weak or still to pump blood efficiently), Paroxysmal Atrial Fibrillation (Irregular, rapid heart rate that causes poor blood flow), Legal Blindness (visual impairment), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R12 currently has an activated HCPOA. R12 is currently on hospice. R12's Significant Change MDS completed 2/6/25 documents R12 has short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R12 has no range of motion impairment and is dependent for eating, dressing, mobility, and transfers. R12's care plan initiated 12/5/24 documents R12 is a full body lift and extensive assist of two. On 4/9/25, R12 weighed 192 pounds. On 4/17/25, at 8:12 AM, Surveyor observed R12's transfer utilizing the same mechanical lift as R83. Surveyor observed a different sling, different brand being used on the same mechanical lift as R83. Surveyor observed the sling had green edging. The sling matched as a large per color code on the mechanical lift. Surveyor interviewed CNA-N where CNA-N obtained the sling. CNA-N informed Surveyor the sling was in R12's Broda chair already. CNA-N stated, we have a hard time finding slings. R12 is on hospice and hospice brought two slings in with R12's name on it. They must be down in laundry and waiting for them to come back up, so I used this one. 3.) R315 was admitted to the facility on [DATE] with diagnoses that include Vascular Dementia (brain damage caused by multiple strokes), and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side (complete paralysis on one side of body and partial/incomplete weakness on one side following stroke). R315 currently has an activated HCPOA. R315's care plan initiated on 4/9/25 documents R315 is a full body lift with extensive assist of two. On 4/16/25, R315 weighed 116 pounds. On 4/17/25 at 8:30 AM, Surveyor observed CNA-O pull a sling out of R315's drawer. Surveyor observed a blue sling with yellow trim. Surveyor interviewed CNA-O on how CNA-O knows what sling to use. CNA-O explained to Surveyor it's a small. According to yellow on the mechanical hoyer lift, the sling would be a medium. CNA-O stated, I thought it was a small. Some slings are medium but look and fit like a small because they shrunk. I hide it in R315's drawer because I know it fits R315. Surveyor observed CNA-O use the loop of the sling and not the clip. Surveyor asked how CNA-O knew what loop to use. I use the one closer because it's just easier. R315 was transferred to a reclining Broda chair. Surveyor notes that R83, R12, and R315's sling size are not documented on their comprehensive care plans or on the CNA assignment sheet. The unit SunnyView 1 where R83, R12, and R315 reside have CNA care cards. Surveyor notes that R12 is listed on there as being a sit to stand lift. Surveyors on other units indicated there were different CNA care cards being utilized than those on the SunnyView 1.unit. On 4/17/25, at 10:54 AM, Surveyor interviewed physical therapy (PT)-H. PT-H stated that slings are not supposed to be left under the Resident. Physical Therapy establishes the transfer status of a Resident and determines what is the safest transfer for that Resident. PT-H would then update the care plan, 24 hour board, and find a staff member to tell them what the transfer status is. Surveyor asked PT-H how many brands of mechanical lifts the facility has. PT-H stated, Great question, not sure how many. Surveyor asked PT-H how many brands of mechanical sit to stands. PT-H is not sure of that as well. PT-H explained that slings for Residents should be based on weight. You have to know the weight of the Resident and grab the appropriate sling. Therapy does not care plan the size for the Resident. Once the size is found, it should stay in the Resident's room. Therapy is not responsible for putting the size in a Resident's care plan. CNA-H stated that there is a question about safety of all the different types of slings in the facility. PT-H agreed that there are multiple different mechanical lifts and sit to stands and multiple different brands of slings. That's a lot of different slings, variety, opens up the door for a lot of confusion. PT-H also explained that the loop should be closer if transferring to a sitting position, farther away if transferring to a reclining Broda chair. PT-H also stated that the batteries are not holding a charge, and therapy is not responsible for completing audits of slings in disrepair. Surveyor notes that based on PT-H's explanation of what loop to use on the sling when transferring a Resident with the mechanical lift, CNA-O should have used the loop farthest away as R315 was being transferred to the reclining Broda chair. 4.) R79 was admitted to the facility on [DATE] with diagnoses that include Lumbar Spina Bifida (birth defect where the spine doesn't close completely), Unspecified Osteoarthritis (breakdown of cartilage), and Tachycardia (rapid heartbeat). R79 is currently her own person. R79's Quarterly MDS completed 3/10/25 documents R79 BIMS score to be 12, indicating R79 demonstrates moderately impaired skills for daily decision making. R79 has ROM impairment on one side of upper and lower extremity. R79 is set up for eating, and dependent for dressing, mobility, and transfers. R79's care plan initiated 12/6/24 documents R79 is a full body mechanical lift with assist of 2. R79's sling size is not documented on R79's care plan. On 4/15/25, R79 weighed 127 pounds. R79's most recent fall risk assessment completed 3/4/25 documents a score of 6 indicating R79 is moderate risk for falls. On 4/17/25, at 8:42 AM, OT-E pointed out to Surveyor that R79 was sitting in R79's wheelchair in the dining room and was sitting on a sling with green edging. R79 informed Surveyor that the facility always leaves the sling underneath R79. Surveyor notes that PT-H informed Surveyor that all staff had recently received a re-education to not leave any Resident sitting on a sling while up in the chair. Surveyor notes that R83 was observed in an XL sling but as of 4/18/25 has now a care plan in place for medium, R315 was observed in a medium sling, but now has a care plan in place for a small, and R79 was observed sitting on a large sling while in wheelchair, but now has a care plan in place for a medium sling. Surveyors requested a list of Residents with major injury. The facility informed Surveyors there were two Residents in the last 90 days with an incident involving a major injury. R49 and R72. 5.) R49 was admitted to the facility on [DATE] with diagnoses that include Chronic Respiratory Failure with Hypoxia (long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide).R49 currently has an activated HCPOA. R49's Fall Risk completed 2/18/25 documents R49 is at high risk for falls. R49's Quarterly MDS completed 3/4/25 documents R49 has a BIMS score of 5, indicating R49 demonstrates severely impaired skills for daily decision making. R49's MDS documents R49 requires supervision for eating, has no ROM impairment and substantial/maximum assistance for mobility. R49 is dependent for dressing and transfers. R4's care plan documents: Initiated 11/22/24 -Potential for falls -Full body mechanical lift with assist of 2 On 3/28/25, R49's sling was left under R49, contrary to facility policy, and R49 slid off the sling from the wheelchair. The facility had not assessed the safety risks associated with leaving a sling under R49 including whether the presence of the sling could lead to an unsafe seating situation for R49 in their wheelchair. R49 was sent to the emergency room due to pain and right tenderness to R49's right shoulder. Surveyor reviewed R49's hospital paperwork dated 3/28/25. R49 suffered a fractured right humerus and a hematoma of the right upper forehead. R49 then required an immobilizer. Surveyor reviewed R49's facility incident report. On 3/29/25, Nursing Home Administrator (NHA)-C documented that R49 was assessed and deemed to have the appropriate sling size at time of fall. There was no assessment of what factors contributed to the fall. A review of all other Residents' slings was conducted to ensure they had the correct sling size, and it was confirmed that all Residents were equipped with appropriate slings. Educations was started on 3/28/25 regarding proper techniques for safely removing lift slings from Residents while in the seated position. Ongoing training will continue until all staff members demonstrate competency in safely removing slings without requiring the Resident to lie down. On 4/3/25, R49 had a significant change MDS completed due to the right humerus fracture. R49 now has range of motion impairment on 1 side of upper extremity, now requires partial/moderate assistance with eating and is dependent for mobility. On 4/17/25, at 3:23 PM, Surveyors met with NHA-C, Director of Nursing (DON-B), CEO-A, and Director of Clinical Operations (DCO)-D. Surveyor asked NHA-C how many different mechanical lifts are used in the building. NHA-C is unsure and will have to get back to Surveyor. Surveyor asked how may mechanical sit to stands are used in the building. NHA-C is unsure and will have to get back to Surveyor. Surveyor asked how you determine what sling to use for what machine and how do you determine which sling is appropriate for each Resident. NHA-C informed Surveyor it is based on the Residents' weight. NHA-C repeated this 3 times to Surveyor that it is based on weight throughout the interview. Surveyor asked who determines the correct size and what is the process of finding the right size sling? NHA-C stated nursing would look at it and therapy completes an evaluation and then nursing, and therapy work together. Surveyor asked where the size of the sling for each Resident is documented. NHA-C was quiet and did not answer the question. I can't answer that, I'm not sure where it is located. Surveyor explained that therapy had shared that therapy did not complete an audit of sling sizes for each Resident requiring a mechanical machine for transfers. NHA-C stated that ideally each Resident should have their own size sling in a drawer in their room. Slings should be the same manufacturer for the same manufacturer lifts. 47094 6.) R72 was admitted to the facility on [DATE] and has diagnoses that include Congestive heart failure, muscle weakness, osteoporosis, adult failure to thrive, depression, and radiculopathy of the lumbar region. R72's quarterly minimum data set (MDS) dated [DATE] indicated R72 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 and the facility assessed R75 needing moderate assistance with 1 staff member for transferring with a gait belt and 2 wheeled walker and 1 staff member repositioning. R75 used a wheelchair for long distances and R72 did not have impairments to the upper or lower extremities. R72's activity of daily living (ADLs) care plan was initiated on 11/19/2024. (R72) has impaired mobility related to recent falls and new atrial fibrillation (A-fib) as evidenced by decrease mobility. On 2/17/2025 R72's ADL care plan was revised with the following intervention: -Transfer: Limited assist with 1 staff member (X1) with 2 wheeled walker and gait belt, if fatigued may use sit to stand mechanical lift with assist X2. Surveyor reviewed a physical therapy (PT) discharge summary for date of service 2/17/2025 - 3/20/2025. R72's baseline was documented as . - Sara Steady transfers= unable to complete due to complaints of pain in left hip. - Unit transfers= limited assist X1 staff member with 2 wheeled walker and gait belt, if fatigued may use sit to stand mechanical lift with assist X2. On 3/21/2025, at 8:38 PM, in the progress notes nursing documented (R72) had witnessed fall. The certified nursing assistant (CNA) was trying to get (R72) up from the wheelchair for transfer. (R72) became weak when standing and the CNA lowered R72 to the floor. (R72) was lifted off the floor with a Hoyer lift. On 3/23/2025, at 8:49 PM, in the progress notes registered nurse (RN) supervisor-QQ documented (R72) had witnessed fall, noted (R72) sitting up on R72's bedroom floor with back resting against the bed. (R72) left leg slightly inverted and unable to move it without pain. sent out to hospital for further evaluation. On 3/23/2025, at 9:30 PM, in the progress notes licensed practical nurse (LPN)-OO documented (R72) was lowered to the floor during a transfer with the Sara Steady. CNA-PP with nurse-OO lowered (R72) to the floor after (R72's) left leg buckled [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R78, R100, and R11) of 4 residents reviewed for pressure injuries. * R78 was originally admitted to the facility on [DATE] with multiple pressure injuries. On 2/23/25, R78 was discharged to the hospital and was readmitted on [DATE]. Upon readmission, the facility did not comprehensively assess R78's pressure injuries until 3/13/25 during wound rounds,7 days later. Multiple observations were made of R78's feet/heels resting directly on the air mattress and not being offloaded. On 4/17/25, during wound rounds with Wound Nurse Registered Nurse (RN)-EE, Certified Nursing Assistant/Care Coordinator (CNA/CC)-P and Wound Physician-JJJJ Surveyor observed a pressure injury on R78's right lateral foot. The facility was unaware of this area until it was brought to their attention by Surveyor and two DTIs (deep tissue injuries) were observed on R78's right lateral foot. R78's weight is 200 pounds. R78's air mattress was set at 330, 700, 260, and 460 pounds. R78 is being cited at a scope/severity level of G actual harm isolated. * R100's heels were not being offloaded and R100's at risk for skin breakdown care plan does not include an approach to offload R100's heels. * R11 was hospitalized from 12/8/24 to 12/10/24. There was not a comprehensive assessment of R11's Stage 4 sacral pressure injury until two days after readmission on 12/12/24. R11 was hospitalized on [DATE] to 3/25/25. There was not a comprehensive assessment of R11's Stage 4 sacral pressure injury until two days after readmission on 3/27/25. Findings include: The facility's policy titled, Pressure Sore Prevention and Treatment, reviewed 4/25 documents under policy: Each resident will be assessed routinely during cares to prevent breakdown. If wound is present, monitor and assess wound with each dressing change and measure and document progress weekly. Documented under Procedure is: 3a. At a minimum, all residents at risk for pressure sore development or that receive active treatment for pressure sores will have an an appropriate pressure relief/reduction support surface while in and out of bed. Each resident will be assessed on an individual basis according to need, b. residents at risk must be repositioned and turned per individual schedule. c. Use positioning devices to relieve pressure and to prevent direct skin to skin contact as assessed on an individual need. Positioning devices include but are not limited to: *Boots, *Pillows, *Splints, *Wedges,*PTIOT (physical therapy/occupational therapy) Recommendations. K. The resident's refusal of treatment or non-compliance with preventive measures must be documented in the resident's medical record. The resident and legal representative will be notified and educated to the risks associated with not complying with preventative measures. The Care Plan will also be updated to reflect non-compliance and alternative interventions will be considered for residents with positioning needs caused by contractures that promote pressure areas. 1.) R78 was originally admitted to the facility on [DATE] with multiple pressure injuries. R78's diagnoses includes Chronic respiratory failure, Quadriplegia (paralysis of all four limbs), Dependence on respirator (ventilator), Atrial fibrillation (irregular & rapid heart beat), Congestive heart failure (heart doesn't pump enough blood to meet the body's needs), Anxiety disorder, and Diabetes mellitus. R78's pressure ulcer/injury CAA (care area assessment) dated 8/13/24 documents under description of problem: CAA triggered due to resident noted to have multiple pressure areas present upon admit, see wound care notes. Documented under causes and contributing factors: [R78's first name] readmitted to the facility following a hospitalization for [NAME] (ventilator associated pneumonia), MDRO (multidrug resistant organism). Other diagnoses include but are not limited to acute and chronic respiratory failure, resident is vent and trach dependent. [R78's first name] is NPO (nothing by mouth) and receives enteral feedings and has a colostomy and indwelling Foley in place. [R78's first name] was noted to have a hx (history) of MVA (motor vehicle accident) in 2021 and is quadriplegic and was admitted with multiple pressure areas that are being monitored by the wound care team for healing. Goal is for [R78's first name] to remain LTC (long term care) at this time. R78's current Impaired Skin Integrity care plan with a start date of 1/2/25 documents the following approaches: Address pain, as needed, to promote resident comfort, and to encourage adherence to interventions to maintain skin integrity. Start date 1/2/25 & edited 4/13/25. Air mattress to bed. Check placement, function and set to proper firmness every shift. Start date 1/2/25 & edited 4/13/25. Apply lotion to arms and legs every AM (morning), HS (hour sleep) and PRN ( as needed). Start date 1/2/25 & edited 4/13/25. Assess for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. Start date 1/2/25 & edited 4/13/25. Encourage physical activity, mobility and range of motion to maximum potential. Start date 1/2/25 & edited 4/13/25. Moisture management - insure abdominal, groin, & chest folds are cleaned & thoroughly dried, twice daily, with AM/PM (morning/evening) cares. Start date 1/2/25 & edited 4/13/25. Monitor skin daily with cares, during baths, and weekly. MD (medical doctor) update if indicated. Start date 1/2/25 & edited 4/13/25. Monitor wounds for S&S (signs and symptoms) of infection. Start date 1/2/25 & edited 4/13/25. Nurse will assess skin - upon admission, weekly on scheduled bath days, prn (as needed). Abnormalities will be documented in chart, and reported to primary physician & wound team for f/u (follow up). Start date 1/2/25 & edited 4/13/25. Turn resident q (every) 1-2 hours. Start date 1/2/25 & edited 4/13/25. Use fluidizer positioner or pillows on legs as appropriate. Keep feet and heels elevated at all times. Monitor calves and call MD/NP (medical doctor/nurse practitioner) if unable to avoid new pressure areas to calves/while attempting to position feet/heels off bed. Start date 1/2/25 & edited 4/17/25. Utilize draw sheet, when available, to minimize risk of friction/shear. Encourage side to side positioning when in bed. Start date 1/2/25 & edited 4/13/25. Wound assessment/measurement performed weekly by wound team. If resident unavailable, assessment to be completed at earliest availability. Start date 1/2/25 & edited 4/13/25. Wound treatments to be performed by nursing, as ordered by MD/NP. Nursing to monitor integrity of drsgs (dressings), with each encounter, and replace drsgs if soiled, loose, or missing. Start date 1/2/25 & edited 4/13/25. R78's Braden assessment dated [DATE] has a score of 10 which indicates high risk for pressure injury development. R78's quarterly MDS (minimum data set) with an assessment reference date of 3/10/25 assesses R78 for speech clarity as no speech. R78 has short and long term memory problems and is severely impaired for cognitive skills for daily decision making. R78 is assessed as not having any behavior including refusal of cares. R78 is assessed as being dependent for toileting hygiene, roll left and right and chair/bed to transfers. R78 has an indwelling urinary catheter and colostomy. R78 is at risk for pressure injuries and is assessed as having two Stage 4 pressure injuries which were present on admission, 2 unstageable pressure injuries which were present on admission and a diabetic ulcer. R78 receives oxygen, suctioning, trach care, and ventilator services. On 2/23/25, R78 was discharged to the hospital for a change of condition. R78 was readmitted on [DATE]. R78's Braden assessment dated [DATE] has a score of 10 which indicates high risk for pressure injury development. R78's nurses note dated 3/6/25 at 5:46 p.m. written by Registered Nurse (RN)-IIII documents: Resident arrived to facility via: Ambulance At this time: 04:20 PM. From (hospital name or other description): hosp (hospital). Their arrival condition was: Stable. Their admitting diagnoses are: osteomyelitis (bone infection). Other relevant diagnoses include: on vent. Mental Status: alert. Behavior (wandering, agitation, resists care): no. Skin assessment: has woulds sic (wounds) midback, sacral, right lower leg Devices/equipment (dentures, catheters, IVs (intravenous), CPAP (continuous positive airway pressure), etc): Foley, TF(tube feeding), IV pic (peripherally inserted central catheter) right upper arm, vent. Bowel/Bladder continence: Incontinent of bowel. Admission Transfer Status: admitted . Other assessment details. R78's nurses note dated 3/7/25 at 3:06 a.m. written by RN-OOO documents: PAD (post admission) #1 Osteomyelitis/IV ABT (antibiotic) x 2 (times two) for sepsis/wounds. Alert. No SOB (shortness of breath) or cough noted. On vent without difficulties. S/s (signs/symptoms) of pain relieved by APAP (acetaminophen). No adverse reactions. No temp. (temperature). No s/s of infection or infiltration. GJ tube running without difficulties. Foley flowing with yellow urine. Dressings C/D/I (clean/dry/intact). Will monitor. R78's nursing note dated 3/13/25 at 4:26 p.m. documents: STAGE 4 PRESSURE WOUND SACRUM FULL THICKNESS Etiology (quality) Pressure MDS 3.0 Stage 4 Duration > (greater) 1059 days Objective Healing/Maintain Healing Wound Size (L x W x D) (length times width times depth): 3 x 1.5 x 2 cm (centimeter) Surface Area: 4.50 cm ^2 Exudate: Moderate Serous Slough: 10 % Granulation tissue: 90 % Wound progress: Improved evidenced by decreased surface area DRESSING TREATMENT PLAN Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily for 30 days: 1/2 strength cleanse; Alginate calcium apply once daily for 30 days; Blastx apply once daily for 30 days Secondary Dressing(s) Gauze island w/ bdr (with border) apply once daily for 30 day STAGE 4 PRESSURE WOUND OF THE RIGHT ISCHIUM FULL THICKNESS Etiology (quality) Pressure MDS 3.0 Stage 4 Duration > 456 days Objective Healing/Maintain Healing Wound Size (L x W x D): 2.5 x 2.5 x 3 cm Surface Area: 6.25 cm Exudate: Moderate Serous Granulation tissue: 100 % Epibole present within the wound margins. Wound progress: Improved evidenced by decreased surface area EXPANDED EVALUATION PERFORMED The progress of this wound and the context surrounding the progress were considered in greater detail today. Impaired nutritional status discussed with patient, family, nursing staff, and/or dietitian. Reviewed off-loading surfaces and discussed surfaces care plan. DRESSING TREATMENT PLAN Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily for 30 days: 1/2 strength cleanse; Alginate calcium apply once daily for 30 days; Blastx apply once daily for 30 days Secondary Dressing(s) Gauze island w/ bdr apply once daily for 30 days UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT ISCHIUM FULL THICKNESS Etiology (quality) Pressure MDS 3.0 Stage Unstageable Necrosis Duration > 50 days Objective Healing/Maintain Healing Wound Size (L x W x D): 5 x 2.5 x 0.2 cm Surface Area: 12.50 cm Exudate: Moderate Serous Thick adherent devitalized necrotic tissue: 80 % Granulation tissue: 20 % Wound progress: Improved evidenced by decreased depth, decreased surface area DRESSING TREATMENT PLAN Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily for 30 days: 1/2 strength cleanse; Alginate calcium apply once daily for 30 days; Blastx apply once daily for 30 days Secondary Dressing(s) Gauze island w/ bdr apply once daily for 30 days UNSTAGEABLE (DUE TO NECROSIS) OF THE RIGHT, POSTERIOR SHOULDER FULL THICKNESS Etiology (quality) Pressure MDS 3.0 Stage Unstageable Necrosis Duration > 36 days Objective Healing/Maintain Healing Wound Size (L x W x D): 1.5 x 4 x 0.1 cm Surface Area: 6.00 cm Cluster Wound open ulceration area of 4.80 cm Exudate: Moderate Serous Thick adherent devitalized necrotic tissue: 30 % Granulation tissue: 50 % Skin: Intact normal color 20 % Wound progress: Improved evidenced by decreased surface area DRESSING TREATMENT PLAN Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily for 30 days: 1/2 strength cleanse; Alginate calcium apply once daily for 30 days; Blastx apply once daily for 30 days Secondary Dressing(s) Gauze island w/ bdr apply once daily for 30 days DIABETIC WOUND OF THE LEFT, PLANTAR, FIRST TOE FULL THICKNESS Etiology (quality) Diabetic Duration > 1 days Objective Healing/Maintain Healing Wound Size (L x W x D): 1 x 1 x 0.1 cm Surface Area: 1.00 cm ^2 Exudate: Light Serous Granulation tissue: 100 % DRESSING TREATMENT PLAN Primary Dressing(s) Xeroform gauze apply once daily for 30 days Secondary Dressing(s) Gauze island w/ bdr apply once daily for 30 days Surveyor was unable to locate a comprehensive assessment of R78's pressure injuries until 3/13/25. On 4/22/25, at 3:32 p.m., Surveyor asked Wound RN-EE who is responsible for comprehensively assessing resident's skin when they are readmitted from the hospital. Wound RN-EE informed Surveyor the nurse taking that resident and if not an RN the supervisor is responsible for doing the assessment when the resident comes back. Usually they like to do skin checks with two people unless it's an RN. They will verify orders with the NP or MD. On 4/22/25, at 3:40 p.m., Surveyor informed Wound Care RN-EE R78 was hospitalized on [DATE] and readmitted on [DATE]. Surveyor informed Wound Care RN-EE Surveyor noted a comprehensive wound assessment on 3/13/25, one week after R78's readmission and asked if there is an assessment prior to 3/13/25. Wound RN-EE informed Surveyor she will look into this and get back to Surveyor. On 4/23/25, at 10:05 a.m., Surveyor asked Wound Care RN-EE if she was able to locate a comprehensive pressure injury assessment prior to 3/13/25. Wound Care RN-EE informed Surveyor she wasn't able to find it and asked [first name] of Director of Nursing (DON)-B to look into for Surveyor. Wound Care RN-EE informed Surveyor he probably came in on the evening shift so we probably didn't see him until the following week unfortunately. On 4/23/25, at 12:35 p.m. DON-B provided Surveyor with a copy of R78's nurses notes dated 3/6/25 at 5:46 p.m. and 3/7/25 at 3:06 a.m. Surveyor informed DON-B these notes are not a comprehensive assessment of R78's pressure injuries. Surveyor informed DON-B there wasn't a comprehensive assessment of R78's pressure injuries until R78 was seen on wound rounds on 3/13/25. Surveyor asked DON-B if there should be a comprehensive assessment after R78 was admitted . DON-B responded correct. The facility did not comprehensively assess R78's pressure injuries until 7 days after R78 was readmitted . R78's Braden assessment dated [DATE] has a score of 12 which indicates high risk for pressure injury development. R78's weight on 4/4/25 was 201 pounds and on 4/18/25 was 200 pounds. On 4/15/25, at 10:28 a.m., Surveyor observed R78 in bed on the right side with the head of the bed elevated and a wedge under R78's left upper side. R78's tube feeding of Isosource 1.5 is running at 65 ml (milliliter) per hour and R78 is on a ventilator. Surveyor observed R78 has bare feet and R78's heels are resting directly on the mattress. R78's feet and heels are not being offloaded. Surveyor observed the Medline air mattress is set at 330 pounds. On 4/15/25, at 11:32 a.m. Surveyor observed R78 continues to be on the right side with the head of the bed elevated. R78's heels are resting directly on the mattress and R78's heels/feet are not being offloaded. Surveyor observed R78 air mattress continue to be set at 330 pounds. On 4/15/25, at 1:37 p.m. Surveyor observed R78 in bed on his back with the head of the bed elevated. There is a folded blanket under R78's left arm and R78's heels are resting directly on the air mattress. R78's feet/heels are not being offloaded. On 4/15/25, at 3:14 p.m., Surveyor observed R78 in bed on his back with the head of the bed elevated. Surveyor observed R78's continues to have bare feet with R78's heels resting directly on the mattress. R78's feet/heels are not being offloaded. On 4/16/25, at 7:05 a.m., Surveyor observed R78 in bed on his back with the head of the bed elevated. Surveyor observed R78's heels are resting directly on the mattress and R78's heels/feet are not being offloaded. On 4/16/25, at 9:42 a.m., Surveyor observed R78 in bed towards the left side with the head of the bed elevated. R78's tube feeding of Isosource 1.5 is running at 65 ml/hr (hour). There is a pillow under R78's upper right side and a folded blanket under R78's left arm. Surveyor observed R78's legs are not covered with bedding and observed R78's heels are resting directly on the mattress. Surveyor observed R78's feet/heels are not being offloaded. On 4/17/25, at 7:11 a.m., Surveyor observed R78 awake in bed on his back with the head of the bed elevated. Surveyor observed there is a pillow under R78's lower legs. Surveyor observed R78's left heel is resting directly on the mattress and the right heel is being offloaded. On 4/17/25, from 8:38 a.m. to 8:56 a.m., Surveyor observed wound rounds with Wound RN-EE, Wound Physician-JJJJ, and CNA/CC-P for R78's right ischium Stage 4, left ischium Unstageable, sacrum stage 4, and right posterior thigh unstageable DTI (deep tissue injury). Wound RN-EE informed Surveyor all of R78's pressure injuries are community acquired and he has been in and out of the facility multiple times. Surveyor observed at the start of this observation R78's air mattress was set at 700 pounds. During this observation at 8:49 a.m. Surveyor observed a pressure injury on the lateral side of R78's right foot near the pinky toe. Surveyor observed during this observation neither Wound RN-EE or Wound Physician-JJJJ assessed R78's feet. After R78's treatments were completed at 8:56 a.m. Wound RN-EE & CNA/CC-P positioned R78 up in bed and rolled R78 on the left side placing a pillow under R78's right side. Surveyor observed R78's heels were not offloaded and the lateral side of R78's right foot is resting directly on the mattress. At 8:59 a.m. Wound RN-EE informed Surveyor she knows [first name] of DON-B ordered fluidizer for R78 and R78 was covered with a sheet. At 9:02 a.m. Surveyor observed CNA/CC-P placed a pillow under R78's lower legs. Surveyor observed R78's left heel is now being offloaded but the lateral side of R78's right foot is resting directly on the air mattress. CNA/CC-P then adjusted the weight for the air mattress to 260 pounds. Surveyor noted R78's weight is 200 pounds. On 4/17/25, at 1:09 p.m., Surveyor observed R78 in bed on the right side with the head of the bed elevated. There is a pillow under R78's upper left side. Surveyor observed R78's heels/feet are not being offloaded. Surveyor reviewed R78's medical record and was unable to locate any documentation regarding any pressure injuries on R78's right foot. On 4/17/25, at 4:14 p.m., Surveyor asked Wound RN-EE if she could come with Surveyor to look at R78's feet. Wound RN-EE informed Surveyor she usually checks feet during wound rounds but didn't this morning. Wound RN-EE placed PPE (personal protective equipment) on and Surveyor and Wound RN-EE entered R78's room. Surveyor observed R78's heels/feet are not being offloaded. Surveyor asked Wound RN-EE to look at R78's right foot. Wound RN-EE raised R78 right foot off the mattress and Surveyor showed her the pressure injury on the lateral side of R78's right foot near the pinky toe. Wound RN-EE stated, oh yes that's a DTI (deep tissue injury). Surveyor and Wound RN-EE then observed a second DTI on the lateral side. Wound RN-EE stated he's prone, doesn't take much. Wound RN-EE informed Surveyor she will call name of Wound Physician-JJJJ, measure and get a treatment tonight. Wound RN-EE again informed Surveyor she usually looks at residents feet but didn't today and thanked Surveyor. The nurses note dated 4/17/25, at 7:20 p.m., written by Wound RN-EE documents Wound care nurse visit - Post wound care visit with [Wound Physician-JJJJ's name], New pressure areas noted to outer aspect of right foot. Distal DTI on foot near right 5th toe is purple non-blanchable Unstageable DTI, measures 2.2 cm (centimeters) x (times) 1 cm. Resident denies pain with palpation. Proximal DTI lateral aspect of mid foot measures 0.8 x 1.2 cm, depth is unmeasurable (sic), Purple nonblanchable area. resident denies pain with palpation. Contacted [Wound Physician-JJJJ's name] and [APNP-RRR's name] re orders. Skin prep to area daily. Updated floor staff related to off-loading with pillows. Orders updated. On 4/21/25, at 7:17 a.m., Surveyor observed R78 in bed on his back with the head of the bed elevated. R78's heels are not being offloaded and the lateral side of R78's right foot is resting directly on the mattress. On 4/21/25, at 10:38 a.m., Surveyor asked CNA/CC-P what they are doing to prevent pressure injuries from developing on R78's feet/heels. CNA/CC-P informed Surveyor they used to have fluidizer pillow under but when R78 would go to the hospital he would not return with them so they are using a pillow. Surveyor informed CNA/CC-P Surveyor didn't observe anything for offloading R78's heels/feet. CNA/CC-P stated to be honest I didn't have a pillow under there today. On 4/22/25, at 8:39 a.m., Surveyor asked RN Supervisor-AA what is the facility to prevent pressure injuries from developing on R78's feet/heels. RN Supervisor-AA informed Surveyor they should elevate R78's heels. RN Supervisor-AA explained R78 used to have offloading boots but they were causing him to breakdown on his calves. RN Supervisor-AA informed Surveyor they should be using pillows or fluidizer on. Surveyor asked RN Supervisor-AA when staff are doing cares on R78 should they be looking at his feet. RN Supervisor-AA replied yes. On 4/22/25, at 9:08 a.m., Surveyor asked RN Supervisor-AA how should a resident's air mattress be set at. RN Supervisor-AA informed Surveyor it is based on the resident's weight and they can ask the resident if they want it soft or firmer. Surveyor informed RN Supervisor-AA of the observations of R78's feet/heels not being offloaded and the air mattress not set at R78's weight of 200 pounds. On 4/22/25, at 9:12 a.m., Surveyor observed R78's mattress is set at 460 pounds. Surveyor observed R78 on the right side with a wedge and pillow under R78's left side and a blanket under R78's left arm. There is a pillow under R78's lower legs and both of R78's heels are being offloaded. On 4/23/25, at 12:35 p.m., Surveyor informed DON-B of the observations of R78's air mattress not being set according to R78's weight, the multiple observations of R78's feet/heels not being offloaded and Surveyor observed pressure injury on R78's right lateral foot which the facility was not aware of until it was brought to their attention by the Surveyor. 2.) R100's diagnoses includes chronic respiratory failure, dependence on respirator (ventilator), Encephalopathy (general brain dysfunction characterized by alteration in brain function or structure), Quadriplegia (paralysis of all four limbs), and Guillain-Barre syndrome (rare neurological disorder where the body's immune system attacks the peripheral nervous system). R100's admission MDS (minimum data set) with an assessment reference date of 2/12/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Speech clarity is assessed as no speech. For functional limitation in range for motion R100 is assessed as having upper extremity and lower extremity impairments on both sides. Toileting hygiene & roll left and right are assessed as being dependent and chair/bed to chair transfer was not attempted due to medical conditions or safety concerns. R100 has an indwelling catheter and is occasionally incontinent of bowel. R100 is at risk for pressure injury development and is assessed as not having any pressure injuries. R100 is checked as receiving oxygen, suctioning, trach care and ventilator. R100's pressure injury CAA (care area assessment) dated 2/19/25 under analysis of findings documents This CAA triggers as resident is at risk for pressure injuries. Resident had botulism and ended up on a trach/vent and now is quadriplegic. Resident cannot feel pressure due to paralysis. Resident is also incontinent of stool. Stoma to trach site, g (gastrostomy)-tube site also must be monitored for s/s of infection. Barrier cream used to protect skin, trach care per RT, nursing cleans G tube site. Pressure reducing mattress on the bed. Resident is on a turning program and does ask to be repositioned. R100's care plan I am at risk for skin breakdown r/t (related to) immobility with a start date of 2/12/25 & edited 4/13/25 documents approaches of Avoid shearing my skin during positioning, transferring, and turning with a start date of 2/12/25 & edited 4/13/25. Handle me with care during direct care with a start date of 2/12/25 and edited 4/13/25. I was offered air mattress but chooses regular mattress after risk/benefit discussion with me and my husband/POA (power of attorney) with a start date of 2/12/25 & edited 4/13/25. Manage pain using pharmacological and nonpharmacological techniques with a start date of 2/12/25 and edited 4/13/25. Measure and record description of area (e.g. location, size (length, width, and depth), color, surrounding skin, presence/absence of drainage, presence/absence of pain, presence/absence of signs of healing) with a start date of 2/12/25 and edited 4/13/25. Monitor and report signs of localized infection (localized swelling, redness, pain or tenderness, heat at the infected area, purulent drainage, loss of function) with a start date of 2/12/25 and edited 4/13/25. Treat area following physician orders with a start date of 2/12/25 and edited 4/13/25. Use mechanical devices with care (e.g., lifts, wheelchairs, bedside tables, restraints, etc) with a start date of 2/12/25 and edited 4/13/25. Utilize the following preventative skin interventions based on Braden score of 13 or more: with a start date of 2/12/25 and edited 4/13/25. Surveyor noted no approaches regarding offloading heels and how often R100 should be repositioned. R100's Certified Nursing Assistant care plan under problem category for skin has a start date of 2/12/25 and under approach description documents I was offered air mattress but chooses regular mattress after risk/benefit discussion with me and my husband/POA. R100's Braden assessment dated [DATE] has a score of 12. A score of 10-12 equals high risk. On 4/15/25, at 11:37 a.m. Surveyor observed Certified Nursing Assistant (CNA)/Care Coordinator (CC)-P and CNA-CC in R100's room. CNA/CC-P asked R100 if she was ready and R100's bedding was removed. Surveyor observed there are pillows under R100's lower legs but R100's heels are resting directly on the mattress and are not being offloaded. On 4/16/25, at 7:10 a.m., Surveyor observed R100 in bed on her back with eyes closed and appears to be sleeping. There is a pillow along R100's left and right upper side and pillows under R100's lower legs. R100's right heel is resting directly on the mattress and the left heel is resting on the pillow. R100's heels are not being offloaded. On 4/16/25, at 9:55 a.m., Surveyor observed R100 in bed with the head of the bed elevated and a visitor by the bedside. There is a pillow under R100's upper left and right side and a pillow under each lower leg. Surveyor observed R100's heels are not being offloaded. On 4/17/25, at 7:19 a.m., Surveyor observed R100 awake in bed on her back with the head of the bed elevated. Surveyor observed there is a pillow under each lower leg. R100's heels are resting directly on the mattress and are not being offloaded. On 4/17/25, at 9:16 a.m. Surveyor observed R100 continues to be in bed on her back with the head of the bed elevated. R100's heels continue to be on the mattress and are not being offloaded. On 4/21/25, at 7:21 a.m., Surveyor observed R100 in bed with her eyes closed and the head of the bed elevated. There is a pillow under R100's right shoulder and under R100's left upper side. There is a pillow under each of R100's lower legs. Surveyor observed R100's heels are resting directly on the pillow and are not being offloaded. On 4/21/25, at 10:32 a.m., Surveyor observed R100 continues to be in the same position as the previous observation with R100's heels resting directly on the pillows. R100's husband informed Surveyor he repositioned his wife last night before he left and this is the way I left her which tells me they didn't change or reposition her. On 4/21/25, at 10:37 a.m. Surveyor asked CNA/CC-P what is being done so R100 doesn't develop pressure injuries on her heels. CNA/CC-P informed Surveyor R100 doesn't like boots and she wants her pillows a certain way. On 4/21/25, at 11:52 a.m., Surveyor observed R100 sitting in a Broda chair in R100's room. Surveyor asked R100 if staff offloads her heels. R100 started to mouth her words but Surveyor was unable to understand what R100 was mouthing and asked R100 to write on the white board. R100 wrote no when my feet hurt I have them or my family change the position. Surveyor asked R100 if she would let staff position her heels so they were hanging off the pillows. R100 mouthed yes. On 4/21/25, at 12:00 p.m., Surveyor asked Licensed Practical Nurse (LPN)-MMM how they are preventing pressure injuries from developing on R100's heels. LPN-MMM informed Surveyor normally try to put pillows under to try to float her legs. On 4/22/25, at 8:34 a.m., Surveyor asked Registered Nurse (RN) Supervisor-AA what the facility is doing to prevent pressure injuries from developing on R100's heels. RN Supervisor-AA informed Surveyor they should be floating her feet so her heals aren't touching either the pillows or blankets. RN Supervisor-AA informed Surveyor he can't specifically say if R100 has refused boots. Surveyor informed RN Supervisor-AA of the observations of R100's heels not being offloaded and R100's care plan doesn't address offloading heels nor is there any documentation that R100 refuses to have her heels offloaded. On 4/22/25, at 9:01 a.m., Surveyor observed R100 in bed on her right side. Surveyor observed there are pillows under R100's legs and R100's heels are being offloaded. Surveyor noted this is the first observation where R100's heels are being offloaded. On 4/22/25, at 11:22 a.m., Surveyor informed Director of Nursing (DON)-B of R100 at high risk of developing pressure injuries, the observations of R100's heels not being offloaded, and care plan does not have any approaches regarding R100's heels. 47094 3.) R11 was initially admitted to the facility on [DATE] and has diagnoses that include chronic stage 4 pressure injury at the sacral area, dementia, chronic kidney disease stage 3, type 2 diabetes mellitus, major depressive disorder, weakness, history of myocardial infarctions and transient cerebral ischemic attacks. R11's quarterly minimum data set (MDS) dated [DATE] indicated R11 had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 and the facility assessed R11 needing extensive assist with repositioning with 2 staff members and total assist with 2 staff members for toileting hygiene and transferred using a Hoyer lift with 2 staff members. R11 is incontinent of bowel

Based on interview and record review, the facility did not develop, implement and maintain an effective training program for all new and existing staff based on their facility assessment potentially affecting 108 of 108 residents in the facility. The facility did not have a training policy and procedure for new staff or continued training for existing staff. Findings include: The Facility assessment dated [DATE] documents: Staff are trained to care for residents on all units to meet the needs of the facility. Staff Education, Training, and Competencies Education and competencies for all staff include dementia training upon hire and annually. Ventilator education is available to our clinical staff who are working in those areas and opportunities for education both onboarding and annually exist for the clinical staff focusing on rehabilitation. Modifications were made to our general orientation process that moved most training to an online module format. Clinical onboarding includes in-person competency skills checkoffs with our Staff Educator. We require all of our direct care vendors to provide competency training and abuse/neglect, infection control/BBP/PPE, customer service and HIPPA annually. Additional competencies are determined according to the amount of resident interaction required by the job role, job-specific knowledge, skills and abilities, and those needed to care for the resident population. Training Topics for general orientation and ongoing education: -(Facility) Mission, Vision and Values -IT-Security policy/HIPPA Compliance- -Emergency Preparedness Plan -Codes/Disaster/Emergency/Fire Safety- -Resident Rights/Abuse and Neglect -Blood Borne Pathogens -Hepatitis -Transmission -Exposure Control Plans -Engineering Controls -Workplace Controls (handwashing, sharps safety, personal hygiene) -PPE -Good Housekeeping (general housekeeping, biohazard warning labels, eye wash) -TB/Introduction to N95 mask- -Open wounds/Infection Control -Change in condition (nursing) -STOP AND WATCH FOR ALL DEPARTMENTS -Gait belt use (nursing) -Oxygen Emergency- -Dementia Training -EMR and policies -Falls prevention- -Understanding Communication in Persons with Dementia -Blood Borne Pathogens -Customer Service- -Hazardous Chemicals- -HIPPA Overview -Workplace Emergencies and Natural Disasters: An Overview -Fire Safety -Hand Hygiene -Infection Prevention -Protecting Resident Rights -Corporate Compliance -Matrix care EMR Documentation On 5/1/2025 at 10:23 AM, Surveyor requested from Director of Nursing (DON)-B a copy of the facility policy and procedure for training new employees and for annual training of all staff. Surveyor requested from DON-B the documentation of training for Licensed Practical Nurse (LPN)-AAAA, Registered Nurse (RN)-MMMM, Certified Nursing Assistant (CNA)-NNNN, CNA-OOOO, and CNA-BB. DON-B stated the facility uses Relias, a online computer-based training program, for staff education. Surveyor reviewed the provided training transcripts for LPN-AAAA, RN-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. Each employee had required training topics (effective communication, resident rights, abuse/neglect/exploitation, QAPI, Infection Control, compliance and ethics, and behavioral health) that had not been addressed on their transcripts. On 5/1/2025 at 2:29 PM, Surveyor shared with Nursing Home Administrator NHA-A, DON-B and Director of Clinical Operations (DCO)-D the concern the five selected employees did not have training on the required topics either when hired or annually. DON-B requested a list of what training was required. Surveyor provided DON-B a list of the five employees selected for the review and the required training categories. DON-B stated DON-B would review the employee files to find the documentation of their training. Surveyor requested a copy of their policy and procedure for new employee training, such as their on-boarding training packet, as well as a policy and procedure for continuing, or annual, employee training. On 5/1/2025 at 4:21 PM, DON-B provided an agenda and sign-in sheet for a staff meeting dated November 13 and 14 (no year documented) and an agenda and sign-in sheet for a staff meeting dated March 19 and 20, 2025. The agendas did not contain any of the required training topics. CNA-OOOO and CNA-BB signatures were on the sign-in sheets for both staff meetings; LPN-AAAA, RN-MMMM, and CNA-NNNN did not have signatures on the sign-in sheets. On 5/5/2025 at 4:39 PM, Surveyor received an email from NHA-A documenting: While a formal education policy does not exist we do have our procedure on how Relias is registered and what modules are completed day one of orientation and those that are calendared annually. I am rechecking to support additional education and will send ASAP tomorrow. NHA-A included the attachment of the undated document: Annual Relias Trainings Procedure -All (facility) employees are registered in Relias upon hire. -They are activated and their hire date is added -The hire date prompts the start of their module's annual cycle -Upon Relias registration, employees are assigned a Hierarchy, which notes their work division (Nursing, Activities, Administration, etc.) -All employee accounts, regardless of hierarchy, are automatically added into the annual Mandatory Training Training Plan -Modules in the annual Mandatory Training training plan: -Hand Hygiene Basics -Dementia Care: Exploring Alzheimer's Disease -Workplace Emergencies and Natural Disasters: An Overview -Essentials of HIPPA -Understanding Bloodborne Pathogens -Basics of Corporate Compliance -Hazardous chemicals: SDS and Labels -Dementia Care: Understanding Communication -Basics of Personal Protective Equipment -Providing Customer Service -Safeguarding Resident Rights in Nursing Facilities -Infection Control: Essential Principles -Preventing, Recognizing, and Reporting Abuse -Fire Safety -Active Shooter Response -One to two training modules are released to employees each month. Surveyor noted not all the required training was listed on the training plan for new and existing hires. On 5/6/2025 at 12:55 PM, Surveyor received an email from NHA-A stating Relias reports for each of the employees were attached that indicated compliance. NHA-A documented: This exercise clearly demonstrates a need for deeper back-up as to how to run reports and have access to the administrative side of these platforms. I have reached out to them for that training. Surveyor reviewed the attached employee trainings and were the same as previously provided by DON-B; not all required trainings were completed by the employees. The facility did not have a policy and procedure for new staff or continued training for existing staff.

Based on interview and record review, the facility did not ensure 3 of 5 direct care staff chosen at random received effective communication training potentially affecting all 108 residents in the facility. Certified Nursing Assistant (CNA)-NNNN, CNA-OOOO, and CNA-BB did not receive effective communication training. Findings include: On 5/1/2025 at 10:23 AM, Surveyor requested from Director of Nursing (DON)-B a copy of the facility policy and procedure for training new employees and for annual training of all staff. Surveyor requested from DON-B the documentation of training for Licensed Practical Nurse (LPN)-AAAA, Registered Nurse (RN)-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. DON-B stated the facility uses Relias, an online computer-based training program, for staff education. Surveyor reviewed the provided training transcripts for LPN-AAAA, RN-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. Surveyor noted CNA-NNNN was hired on 1/202025 and did not have any documentation of receiving effective communication training. CNA-OOOO was hired on 6/24/2024 and did not have any documentation of receiving effective communication training. CNA-BB had documentation of completing a course titled Understanding Communication in Persons with Dementia on 10/14/2020; no annual communication training was completed. On 5/1/2025 at 2:29 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, DON-B and Director of Clinical Operations (DCO)-D the concern three of the randomly selected employees did not have the required communication training. DON-B stated DON-B would review the employee files to find the documentation of their training. Surveyor requested a copy of their policy and procedure for new employee training, such as their on-boarding training packet, as well as a policy and procedure for continuing, or annual, employee training. On 5/5/2025 at 4:39 PM, Surveyor received an email from NHA-A documenting: While a formal education policy does not exist we do have our procedure on how Relias is registered and what modules are completed day one of orientation and those that are calendared annually. I am rechecking to support additional education and will send ASAP tomorrow. NHA-A included the attachment of the undated document: Annual Relias Trainings Procedure -All (facility) employees are registered in Relias upon hire. -They are activated and their hire date is added -The hire date prompts the start of their module's annual cycle -Upon Relias registration, employees are assigned a Hierarchy, which notes their work division (Nursing, Activities, Administration, etc.) -All employee accounts, regardless of hierarchy, are automatically added into the annual Mandatory Training Training Plan -Modules in the annual Mandatory Training training plan: -Hand Hygiene Basics -Dementia Care: Exploring Alzheimer's Disease -Workplace Emergencies and Natural Disasters: An Overview -Essentials of HIPPA -Understanding Bloodborne Pathogens -Basics of Corporate Compliance -Hazardous chemicals: SDS and Labels -Dementia Care: Understanding Communication -Basics of Personal Protective Equipment -Providing Customer Service -Safeguarding Resident Rights in Nursing Facilities -Infection Control: Essential Principles -Preventing, Recognizing, and Reporting Abuse -Fire Safety -Active Shooter Response -One to two training modules are released to employees each month. On 5/6/2025 at 12:55 PM, Surveyor received an email from NHA-A stating Relias reports for each of the employees were attached that indicated compliance. NHA-A documented: This exercise clearly demonstrates a need for deeper back-up as to how to run reports and have access to the administrative side of these platforms. I have reached out to them for that training. Surveyor reviewed the attached employee trainings and were the same as previously provided by DON-B; CNA-NNNN, CNA-OOOO, and CNA-BB did not have any documentation of communication training.

Based on interview and record review, the facility did not ensure 1 of 5 direct care staff chosen at random received resident rights training potentially affecting all 108 residents in the facility. Certified Nursing Assistant (CNA)-BB did not receive resident rights training annually. Findings include: On 5/1/2025 at 10:23 AM, Surveyor requested from Director of Nursing (DON)-B a copy of the facility policy and procedure for training new employees and for annual training of all staff. Surveyor requested from DON-B the documentation of training for Licensed Practical Nurse (LPN)-AAAA, Registered Nurse (RN)-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. DON-B stated the facility uses Relias, an online computer-based training program, for staff education. Surveyor reviewed the provided training transcripts for LPN-AAAA, RN-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. Surveyor noted CNA-BB did not have any documentation of receiving resident rights training since 4/14/2020. On 5/1/2025 at 2:29 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, DON-B and Director of Clinical Operations (DCO)-D the concern one of the randomly selected employees did not have annual resident rights training. DON-B stated DON-B would review the employee file to find the documentation of the training. Surveyor requested a copy of their policy and procedure for new employee training, such as their on-boarding training packet, as well as a policy and procedure for continuing, or annual, employee training. On 5/5/2025 at 4:39 PM, Surveyor received an email from NHA-A documenting: While a formal education policy does not exist we do have our procedure on how Relias is registered and what modules are completed day one of orientation and those that are calendared annually. I am rechecking to support additional education and will send ASAP tomorrow. NHA-A included the attachment of the undated document: Annual Relias Trainings Procedure -All (facility) employees are registered in Relias upon hire. -They are activated and their hire date is added -The hire date prompts the start of their module's annual cycle -Upon Relias registration, employees are assigned a Hierarchy, which notes their work division (Nursing, Activities, Administration, etc.) -All employee accounts, regardless of hierarchy, are automatically added into the annual Mandatory Training Training Plan -Modules in the annual Mandatory Training training plan: -Hand Hygiene Basics -Dementia Care: Exploring Alzheimer's Disease -Workplace Emergencies and Natural Disasters: An Overview -Essentials of HIPPA -Understanding Bloodborne Pathogens -Basics of Corporate Compliance -Hazardous chemicals: SDS and Labels -Dementia Care: Understanding Communication -Basics of Personal Protective Equipment -Providing Customer Service -Safeguarding Resident Rights in Nursing Facilities -Infection Control: Essential Principles -Preventing, Recognizing, and Reporting Abuse -Fire Safety -Active Shooter Response -One to two training modules are released to employees each month. On 5/6/2025 at 12:55 PM, Surveyor received an email from NHA-A stating Relias reports for each of the employees were attached that indicated compliance. NHA-A documented: This exercise clearly demonstrates a need for deeper back-up as to how to run reports and have access to the administrative side of these platforms. I have reached out to them for that training. Surveyor reviewed the attached employee trainings and were the same as previously provided by DON-B; CNA-BB did not have any documentation annually of resident rights training.

Based on interview and record review, the facility did not ensure 5 of 5 direct care staff chosen at random received QAPI (Quality Assurance and Performance Improvement) training with the potential to affect all 108 residents in the facility. Licensed Practical Nurse (LPN)-AAAA, Registered Nurse (RN)-MMMM, Certified Nursing Assistant (CNA)-NNNN, CNA-OOOO, and CNA-BB did not receive QAPI training as a new hire or annually. Findings include: On 5/1/2025 at 10:23 AM, Surveyor requested from Director of Nursing (DON)-B a copy of the facility policy and procedure for training new employees and for annual training of all staff. Surveyor requested from DON-B the documentation of training for Licensed Practical Nurse (LPN)-AAAA, Registered Nurse (RN)-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. DON-B stated the facility uses Relias, an online computer-based training program, for staff education. Surveyor reviewed the provided training transcripts for LPN-AAAA, RN-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. LPN-AAAA, RN-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB did not have any documentation of receiving QAPI training. On 5/1/2025 at 2:29 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, DON-B and Director of Clinical Operations (DCO)-D the concern the five randomly selected employees did not have QAPI training. DON-B stated DON-B would review the employee file to find the documentation of the training. Surveyor requested a copy of their policy and procedure for new employee training, such as their on-boarding training packet, as well as a policy and procedure for continuing, or annual, employee training. On 5/5/2025 at 4:39 PM, Surveyor received an email from NHA-A documenting: While a formal education policy does not exist we do have our procedure on how Relias is registered and what modules are completed day one of orientation and those that are calendared annually. I am rechecking to support additional education and will send ASAP tomorrow. NHA-A included the attachment of the undated document: Annual Relias Trainings Procedure -All (facility) employees are registered in Relias upon hire. -They are activated and their hire date is added -The hire date prompts the start of their module's annual cycle -Upon Relias registration, employees are assigned a Hierarchy, which notes their work division (Nursing, Activities, Administration, etc.) -All employee accounts, regardless of hierarchy, are automatically added into the annual Mandatory Training Training Plan -Modules in the annual Mandatory Training training plan: -Hand Hygiene Basics -Dementia Care: Exploring Alzheimer's Disease -Workplace Emergencies and Natural Disasters: An Overview -Essentials of HIPPA -Understanding Bloodborne Pathogens -Basics of Corporate Compliance -Hazardous chemicals: SDS and Labels -Dementia Care: Understanding Communication -Basics of Personal Protective Equipment -Providing Customer Service -Safeguarding Resident Rights in Nursing Facilities -Infection Control: Essential Principles -Preventing, Recognizing, and Reporting Abuse -Fire Safety -Active Shooter Response -One to two training modules are released to employees each month. Surveyor noted QAPI training was not included in the topics on the training plan. On 5/6/2025 at 12:55 PM, Surveyor received an email from NHA-A stating Relias reports for each of the employees were attached that indicated compliance. NHA-A documented: This exercise clearly demonstrates a need for deeper back-up as to how to run reports and have access to the administrative side of these platforms. I have reached out to them for that training. Surveyor reviewed the attached employee trainings and were the same as previously provided by DON-B; LPN-AAAA, RN-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB did not have any documentation of receiving QAPI training.

Based on interview and record review, the facility did not ensure 4 of 5 direct care staff chosen at random received behavioral health training potentially affecting all 108 residents in the facility. Registered Nurse (RN)-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB did not receive behavioral health training. Findings include: The Facility assessment dated ,d+[DATE] documents the facility cares for residents with psychiatric/mood disorders such as psychosis (hallucinations, delusion, etc.), impaired cognition, mental disorder, depression, post-traumatic stress disorder, anxiety disorder, and behavior that needs interventions. The number/average or range of residents per day with behavioral symptoms and cognitive performance is 1-2 with 8 hours per week to address behavioral health needs. The facility provides care and services based on the needs of the residents to include behavioral health issues and psychosocial support. On 5/1/2025, at 10:23 AM, Surveyor requested from Director of Nursing (DON)-B a copy of the facility policy and procedure for training new employees and for annual training of all staff. Surveyor requested from DON-B the documentation of training for Licensed Practical Nurse (LPN)-AAAA, Registered Nurse (RN)-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. DON-B stated the facility uses Relias, an online computer-based training program, for staff education. Surveyor reviewed the provided training transcripts for LPN-AAAA, RN-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB and noted: LPN-AAAA completed the courses Caring for the Person with Dementia: Behaviors and Communication on 3/13/2024 and Dementia Care: Challenging Behaviors on 3/7/2024. RN-MMMM completed the courses Managing Elopement on 9/23/2024 and Dementia Care: Understanding Alzheimer's Disease on 7/31/2023 and 9/23/2024. CNA-NNNN and CNA-OOOO had no documentation of behavioral health training. CNA-BB completed the courses Managing Elopement on 7/17/2024 and Trauma-Informed Care on 1/17/2020. Surveyor noted no specific training behavioral health training was was identified as required and completed when newly hired or on an annual basis. On 5/1/2025, at 2:29 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, DON-B and Director of Clinical Operations (DCO)-D the concern the randomly selected employees did not have annual behavioral health training. DON-B stated DON-B would review the employee file to find the documentation of the training as outlined in the facility assessment. Surveyor requested a copy of the facility policy and procedure for new employee training, such as their on-boarding training packet, as well as a policy and procedure for continuing, or annual, employee training. On 5/5/2025, at 4:39 PM, Surveyor received an email from NHA-A documenting: While a formal education policy does not exist we do have our procedure on how Relias is registered and what modules are completed day one of orientation and those that are calendared annually. I am rechecking to support additional education and will send ASAP (as soon as possible) tomorrow. NHA-A included the attachment of the undated document: Annual Relias Trainings Procedure -All (facility) employees are registered in Relias upon hire. -They are activated and their hire date is added -The hire date prompts the start of their module's annual cycle -Upon Relias registration, employees are assigned a Hierarchy, which notes their work division (Nursing, Activities, Administration, etc.) -All employee accounts, regardless of hierarchy, are automatically added into the annual Mandatory Training Training Plan -Modules in the annual Mandatory Training training plan: -Hand Hygiene Basics -Dementia Care: Exploring Alzheimer's Disease -Workplace Emergencies and Natural Disasters: An Overview -Essentials of HIPPA -Understanding Bloodborne Pathogens -Basics of Corporate Compliance -Hazardous chemicals: SDS and Labels -Dementia Care: Understanding Communication -Basics of Personal Protective Equipment -Providing Customer Service -Safeguarding Resident Rights in Nursing Facilities -Infection Control: Essential Principles -Preventing, Recognizing, and Reporting Abuse -Fire Safety -Active Shooter Response -One to two training modules are released to employees each month. Surveyor noted behavioral health training was not included in the topics on the training plan. On 5/6/2025, at 12:55 PM, Surveyor received an email from NHA-A stating Relias reports for each of the employees were attached that indicated compliance. NHA-A documented: This exercise clearly demonstrates a need for deeper back-up as to how to run reports and have access to the administrative side of these platforms. I have reached out to them for that training. Surveyor reviewed the attached employee trainings and were the same as previously provided by DON-B.

Based on interview and record review, the facility did not ensure that 3 of 5 CNAs (Certified Nursing Assistants)(CNA) reviewed completed the required annual 12 hours of educational training. CNA-V, CNA-W, and CNA-Y did not receive the annual 12 hours of educational training. This had the potential to affect all 108 Residents who reside in the facility. Findings include: The facility assessment dated [DATE] documents: Staff Education, Training, and Competencies . Education and competencies for all staff include dementia training upon hire and annually. Modifications were made to our general orientation process that moved most training to an online module format. We require all of our direct care vendors to provide competency training in abuse/neglect, infection control/BBP (Bloodborne Pathogens)/PPE (Personal Protective Equipment), customer service and HIPPA (Health Insurance Portability and Accountability Act) annually. On 4/25/25, at 8:25 AM, Surveyor randomly selected 5 CNAs for review of their annual training hours. Surveyor reviewed the employee records of CNA-V, CNA-W, and CNA-Y. The facility was unable to provide documentation CNA-V, CNA-W and CNA-Y received the required 12 hours of educational training within a year based on their hire date. CNA-V date of hire was 10/30/23. CNA-V completed 1.25 hours of the required 12 hours of training. Surveyor noted Abuse and Dementia training was not completed as part of the required 12 hours of training. CNA-W date of hire was 12/11/23. CNA-W completed 10.50 hours of the required 12 hours of training. CNA-Y date of hire was 4/18/05. CNA-Y completed the required 12 hours of training, however, Abuse and Dementia training was not completed as part of the required 12 hours of training. On 4/21/25, at 3:21 PM, Surveyor shared the above concerns with previous Nursing Home Administrator (NHA)-C, Director of Nursing (DON)-B, Chief Executive Officer (CEO)-A, and Director of Clinical Operations (DOC)-D. Additional information was requested, if available. At this time, no further information has been provided as to why CNA-V, CNA-W, and CNA-Y did not receive the required 12 hours of educational training. On 4/22/25, at 9:02 AM, Surveyor interviewed Staff Development Specialist (SDS)-Q. SDS-Q informed Surveyor SDS-Q has only been in the position for a week, but is aware CNAs must complete the required 12 hours of training per year based on hire date. SDS-Q is aware 3 of 5 CNA employee records reviewed document CNA-V, CNA-W, and CNA-Y do not have the 12 hours of annual required training. Further, SDC-Q confirmed SDC-Q is aware part of the 12 hours of required training must include Abuse and Dementia training. SDC-Q plans to have more consistent trainings and do monthly check-ins with the CNAs in order to make sure the CNAs have completed their required trainings.

Based on interview and record review, the facility did not ensure 1 of 5 direct care staff chosen at random received infection control training with the potential to affect all 108 residents in the facility. Certified Nursing Assistant (CNA)-BB did not receive infection control training annually. Findings include: On 5/1/2025 at 10:23 AM, Surveyor requested from Director of Nursing (DON)-B a copy of the facility policy and procedure for training new employees and for annual training of all staff. Surveyor requested from DON-B the documentation of training for Licensed Practical Nurse (LPN)-AAAA, Registered Nurse (RN)-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. DON-B stated the facility uses Relias, an online computer-based training program, for staff education. Surveyor reviewed the provided training transcripts for LPN-AAAA, RN-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB. Surveyor noted CNA-BB had documentation of receiving Basics of Hand Hygiene and Prevention of Urinary Tract Infections on 7/17/2024 but had not had Infection Control: Essential Principles since 1/31/2021. On 5/1/2025, at 2:29 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, DON-B and Director of Clinical Operations (DCO)-D the concern one of the randomly selected employees did not have annual infection control training. DON-B stated DON-B would review the employee file to find the documentation of the training. Surveyor requested a copy of their policy and procedure for new employee training, such as their on-boarding training packet, as well as a policy and procedure for continuing, or annual, employee training. On 5/5/2025 at 4:39 PM, Surveyor received an email from NHA-A documenting: While a formal education policy does not exist we do have our procedure on how Relias is registered and what modules are completed day one of orientation and those that are calendared annually. I am rechecking to support additional education and will send ASAP tomorrow. NHA-A included the attachment of the undated document: Annual Relias Trainings Procedure -All (facility) employees are registered in Relias upon hire. -They are activated and their hire date is added -The hire date prompts the start of their module's annual cycle -Upon Relias registration, employees are assigned a Hierarchy, which notes their work division (Nursing, Activities, Administration, etc.) -All employee accounts, regardless of hierarchy, are automatically added into the annual Mandatory Training Training Plan -Modules in the annual Mandatory Training training plan: -Hand Hygiene Basics -Dementia Care: Exploring Alzheimer's Disease -Workplace Emergencies and Natural Disasters: An Overview -Essentials of HIPPA -Understanding Bloodborne Pathogens -Basics of Corporate Compliance -Hazardous chemicals: SDS and Labels -Dementia Care: Understanding Communication -Basics of Personal Protective Equipment -Providing Customer Service -Safeguarding Resident Rights in Nursing Facilities -Infection Control: Essential Principles -Preventing, Recognizing, and Reporting Abuse -Fire Safety -Active Shooter Response -One to two training modules are released to employees each month. On 5/6/2025 at 12:55 PM, Surveyor received an email from NHA-A stating Relias reports for each of the employees were attached that indicated compliance. NHA-A documented: This exercise clearly demonstrates a need for deeper back-up as to how to run reports and have access to the administrative side of these platforms. I have reached out to them for that training. Surveyor reviewed the attached employee trainings and theywere the same as previously provided by DON-B. Surveyor noted CNA-BB did not have any documentation of receiving annual infection control training.

Based on interview and record review the facility did not ensure nursing staff had the competencies and skill sets necessary to care for resident's needs for 1 (R414) of 1 resident with a chest tube (a plastic catheter inserted between the ribs to drain air, fluid, or blood from the pleural space around the lungs, heart, or esophagus) and PICC (a long flexible tube inserted into an arm vein and threaded into a large vein near the heart) line, 20 of 20 residents that utilize ventilators and tracheostomies, and all 108 of 108 residents for general nursing competencies. *Review of 16 staff indicate they did not have competencies for providing care of a chest tube and PICC line for R33. *20 residents in facility that are on ventilators and have tracheostomies, 12 of 47 staff members reviewed had incomplete competencies for ventilator and tracheostomy care. *On the 03/11/2025 PM shift and 04/12/2025 night shift, there was no competent Registered Nurse (RN) to oversee the vent unit. *The Facility does not have an effective process to ensure all new staff and Agency staff have the necessary competencies to care for residents residing in the facility. Findings include: *General Staffing process On 04/21/2025, at 03:28 PM, Surveyor interviewed Staff Coordinator-RR regarding staff orientation and competencies. Staff Coordinator-RR indicated that the Facility uses agency nursing staff for Licensed Practical Nurses (LPN)s and RNs. Staff Coordinator-RR indicated that Agency staff will get a folder out of the education office and will sign acknowledging receipt of the contents in the folder. On 04/22/2025, at 12:13 PM, Surveyor interviewed Agency LPN-QQQ. Agency LPN-QQQ informed Surveyor that they began picking up shifts at the Facility about 3 years ago and received no orientation. Agency LPN-QQQ indicated that the staffing agency said to get to the Facility an hour early, Agency LPN-QQQ received a log in for computer, a tour, and after that Agency LPN-QQQ stated it was an ask and learn as you go process. On 04/22/2025, at 12:15 PM, Surveyor interviewed LPN-HH. LPN-HH indicated they started at the Facility last month around March 17th. LPN-HH informed Surveyor that LPN-HH is a new nurse and obtained their LPN license in January 2025. LPN-HH informed Surveyor that orientation sucked, especially for a brand-new nurse. LPN-HH indicated LPN-HH was put on floor with nurses who just got off orientation, no check off list and no training on ventilators. On 04/22/2025, at 12:31 PM, Surveyor interviewed Staff Development Specialist-Q. Staff Development Specialist-Q informed Surveyor that Staff Development Specialist-Q is brand new to the position and started 1 week ago. Staff Development Specialist-Q indicated that she is still working on developing and implementing a more solid process with new hires. Staff Development Specialist-Q indicated speaking with Wound Care RN-EE, who was doing the position prior, regarding Agency orientation. Staff Development Specialist-Q indicated on the first day of staff orientation, they will come in on a Tuesday, will do TB (tuberculosis) skin test, fitted for N-95 mask, verify flu shot, vaccines, and go over hand washing competency. The new staff member will then come back Thursday to have their TB test read and have Human Resources (HR) training in the morning. Thursday afternoon- will go through Electronic Health Record (HER) and sign in, with the goal to be able to sign in and get familiar prior to going on the floor. New staff will also get a tour of the whole building. Staff Development Specialist-Q indicated at the very end, they will bring the new staff to their manager and set up schedule for orientation shifts. Staff Development Specialist-Q indicated Nurses/ CNAs have orientation check lists that they get while on the floor, it is the preceptors' responsibility to ensure going over those, although Staff Development Specialist-Q has not been able to get that far in the process yet. Staff Development Specialist-Q indicated Staff Development Specialist-Q would like to set up time where new staff will do one week check ins regarding competencies. On 04/22/2025, at 12:40 PM, Surveyor interviewed Wound Care RN-EE. Wound Care RN-EE indicated that there is an orientation check list for new hires. New hires will go through the check list with whomever they are paired with and before their first shift on their own they are supposed to go through with their supervisor. It is the responsibility of new employees to bring check list with them, but the check list disappears, and this has been an issue. Wound Care RN-EE indicated the Facility has talked about how they can make it better and have now made a full-time staff development position, where responsibilities can be divided and to ensure things are going well with new staff. For Agency staff, Wound Care RN-EE indicated a packet is given to the agency staff but they do not give a check list. Agency will have a sign off sheet of basic topics included in folder and contact information for supervisors and departments. They are supposed to contact a supervisor with any questions. Wound Care RN-EE indicated Staff Development Specialist-Q will be taking on the Agency orientation process as well. Wound Care RN-EE indicated a staff member who is no longer at the Facility was doing the new staff/agency orientation, as of January 1st, 2025, a gentleman took over who did not work out and quit without notice. Staff Coordinator-RR oversees making sure competencies for Agency staff and will email confirming with Agencies on those competencies. On 04/23/2025, at 01:19 PM, Surveyor interviewed Staff Coordinator-RR who indicated Staff Coordinator-RR will reach out to the agency and the agency will send the paperwork to Staff Coordinator-RR if needed. On 04/23/2025, at 03:51 PM, Surveyor informed the Facility of the concerns regarding new staff/Agency staff orientation and ensuring competency process. *03/11/2025 PM shift and 04/12/2025 night shift, no competent Registered Nurse (RN) to oversee the vent unit. Surveyor reviewed direct care staff schedules from March to current. Surveyor noted on the 03/11/2025 PM shift, there was no RN supervisor scheduled and no RN with competencies to oversee the ventilator unit. On 04/12/2025, night shift, Surveyor noted there was no RN supervisor scheduled and no competent RN to over see the ventilator unit from 0315 AM to 6 AM the next morning. On 04/23/2025, at 03:51 PM, Surveyor informed the Facility of the concerns regarding new staff orientation process and no competent RN for the ventilator unit on 03/11/2025 and 04/12/2025. On 04/24/2025, at 07:44 AM Director of Clinical Operations-D informed Surveyor that all competencies were given to Previous NHA-C and that Respiratory Therapist-JJJ was working with the staff to ensure competencies. On 04/24/2025, at 12:55 PM, Surveyor interviewed DON-B. DON-B indicated that if there was a code or an emergency that other nurses (LPNs) with competencies, as well as expert Respiratory Therapists would have been available to respond to the vent unit. Surveyor asked DON-B about the Facility's plan from a previous survey (cross reference event ID HUY911) regarding staffing for the vent unit which documents the following, A competent registered nurse (RN) will be available to always respond to all emergency situations for ventilator and tracheostomy residents. The RN will be available on a STAT basis to ensure a timely and comprehensive response to any resident demonstrating a potential change in condition when a competent Respiratory Therapist (RT) is assigned to the ventilator unit. In the absence of an assigned RT, a competent RN will be assigned to the ventilator unit ensuring there is no gap in competent staff on the unit. DON-B did not provide any further information. 20483 * Staff competencies to care for a resident with a chest tube and PICC line The facility assessment dated [DATE] under the section Staff Education, Training, and Competencies documents Education and competencies for all staff include dementia training upon hire and annually. Ventilator education is available to our clinical staff who are working in those areas and opportunities for education both on boarding and annually exist for the clinical staff focusing on rehabilitation. Modifications were made to our general orientation process that moved most training to an online module format. Clinical on boarding includes in-person competency skills check offs with our Staff Educator. We require all of our direct care vendors to provide competency training in abuse/neglect, infection control/BBP (blood borne pathogens)/PPE (personal protective equipment), customer service and HIPPA (Health Insurance Portability and Accountability Act) annually. Additional competencies are determined according to the amount of resident interaction required by the job role, job-specific knowledge, skills and abilities, and those needed to care for the resident population. * R414 was admitted to the facility on [DATE] at 2:27 p.m. and left AMA (against medical advice) on 3/22/25. Diagnoses includes pleural effusion (fluid accumulate between lungs & chest wall), acute respiratory distress, malignant neoplasm (cancer) of unspecified ovary, anxiety disorder, and depression. The hospital assessment/plan not dated under recommendations documents (1) Pleurx placed -Drain daily -Up to 1L (liter) drainage -Bedside nurse to complete self education for patient and patient's son -Interventional Pulm (pulmonary) f/u (follow up) as outpatient. (2) Neoadjuvant therapy for metastatic ovarian cancer per Gyn/Onc (Gynecology/Oncology). R414's pre admit note dated 3/20/25, at 1:28 p.m., written by Director of Admissions/ Licensed Practical Nurse (LPN)-FF for admission diagnosis document R (right) pleural effusion. For PICC (peripherally inserted central line catheter) documents R brachial double lumen. Under notes documents R side chest tube-hospital sending back up Pleurx kit, NO chemo planned while in rehab. R414's admission note dated 3/20/25, at 4:00 p.m., written by Licensed Practical Nurse (LPN)-PPP documents Skin assessment:: Per Supervisor, BUE (bilateral upper extremity) bruising, Dressing R side. Devices/equipment (dentures, catheters, IVs (intravenous), CPAP (continuous positive airway pressure) etc):: Double lumen PICC RUE (right upper extremity), Bilateral HA (hearing aids). Bowel/Bladder continence:: Continent of bowel, Continent of bladder. Admission Transfer Status:: 1 assist. Other assessment details:: General diet, Bilateral Ovarian CA (cancer), Dressing R side s/p (status post) Pleurx. R414's nurses note dated 3/21/25, at 12:51 p.m., written by LPN-JJ documents writer called into residents room by CNA (Certified Nursing Assistant) and therapy dept. (department) to meet w/ (with) resident and son. Son demonstrated cares for chest tube drainage and site care. Writer observed site; no inflammation or drainage present. There are approx. (approximately) 4 stitches present on pt's (patients) right side (mid intercostal) bra line holding chest tune in place. Pt uses padding underneath tubing and gauze w/ tegaderm on top for protective measures. Dressing must be removed prior to draining tube into PLEUR -X drainage vacuum bottle. Writer and son remove 1L (liter) of fluids. Drainage can be held if pt experiences pain. R414's nurses note dated 3/22/25, at 2:46 p.m., written by LPN-SSS documents Res (Resident) left the building with the her son -AMA (against medical advice). Writer received report that this res was upset in regards to a drain/treatment. Day shift nurse stated to writer that she did not see any order in regards to a drain/treatment. Stated that she looked in the orders and didn't see any orders listed or charting. Writer did review orders and was reviewing DC (discharge) summary when staff nurse approached writer to state that this resident left the grounds. Res did not voice any concerns/complaints with writer before leaving. On duty RN made aware. Surveyor reviewed the facility's daily nursing schedule and noted the following: On 3/20/25 the following staff worked on R414's unit: Agency LPN-VVV, Agency LPN-QQQ, & LPN-DD worked the day shift. LPN-WWW, LPN-PPP, & LPN-DD worked the evening shift. LPN-XXX & Agency LPN-YYY worked the night shift. On 3/21/25 the following staff worked on R414's unit: Agency LPN-VVV, Agency LPN-ZZZ, LPN-JJ & LPN-HH worked the day shift. LPN-PPP & LPN-DD worked the evening shift. LPN-AAAA & LPN-XXX worked the night shift. On 3/22/25 the following staff worked on R414's unit: Agency LPN-BBBB, Agency LPN-CCCC, and LPN-DDDD worked the day shift. LPN-WWW, LPN-SSS and LPN-PPP worked the evening shift. Surveyor noted the following staff were nursing supervisors while R414 resided at the Facility: Registered Nurse (RN)-X, RN Supervisor-QQ, and RN Supervisor-AA. On 4/23/25, at 12:42 p.m., Surveyor asked Director of Nursing (DON)-B for licensed staff chest tube competencies. On 4/23/25, at 3:49 p.m., during the end of the day meeting Surveyor informed DON-B and Director of Clinical Operations-D Surveyor has not received any chest tube competencies. On 4/24/25, at 8:16 a.m. Director of Clinical Operations-D informed a Surveyor this is all she could find. Surveyor was provided with the facility's policy Chest Tube, Caring for a Resident with a & inservice sign in sheet dated 4/2/25. Surveyor was not provided with any chest tube competencies and noted this inservice was provided after R414 was discharged . On 4/24/25, at approximately 9:00 a.m., Surveyor asked Director Clinical Operations-D for any PICC line competencies for licensed staff. On 4/24/25, at 10:10 a.m. Surveyor asked Director Clinical Operations-D if she has any PICC line competencies. Director of Clinical Operations-D informed Surveyor she could not find any and provided Surveyor with education provided on PICC lines on 4/2/25. Surveyor noted this education was after R414 was discharged . On 4/24/25, at 9:42 a.m. Surveyor asked Staffing Coordinator-RR if she had any chest tube or PICC line competencies for agency staff. Staffing Coordinator-RR informed Surveyor she will have to look into this. Surveyor provided Staffing Coordinator-RR with the names of agency staff who worked R414's unit from 3/20/25 to 3/22/25. On 4/24/25, at 10:52 a.m., Staffing Coordinator-RR informed Surveyor she does not have any chest tube or PICC line competency for agency staff but can call the agency and ask. On 4/24/25, at 11:27 a.m., Staffing Coordinator-RR informed Surveyor so far two of the agencies have gotten back to her and they do not do training on chest tubes or PICC lines. On 4/24/25, at 11:57 a.m. during a meeting with Chief Executive Officer (CEO)-A, DON-B, & Director Clinical Operations-D Surveyor informed staff Surveyor was not provided chest tube or PICC line competencies for licensed staff. No information was provided to Surveyor as to why these competencies were not completed. 38253 * Staff competencies to care for residents with tracheostomies and ventilator care The facility had 10 residents that had tracheostomies and 10 residents that had tracheostomies and were ventilator dependent. The facility assessment dated [DATE] under the section Staff Education, Training, and Competencies documents Education and competencies for all staff include dementia training upon hire and annually. Ventilator education is available to our clinical staff who are working in those areas and opportunities for education both onboarding and annually exist for the clinical staff focusing on rehabilitation. Modifications were made to our general orientation process that moved most training to an online module format. Clinical onboarding includes in-person competency skills check offs with our Staff Educator. We require all of our direct care vendors to provide competency training in abuse/neglect, infection control/BBP/PPE, customer service and HIPPA annually. Additional competencies are determined according to the amount of resident interaction required by the job role, job-specific knowledge, skills and abilities, and those needed to care for the resident population. Surveyor observed a sign posted on the window at the nurses' station on the ventilator unit: ATTENTION!!! Nurses and RTs, if you were unable to attend the mandatory competency training on 2/7 (2025) and have not received the training, you are not permitted to work on the unit until you receive the training. Please see the nurse supervisor to complete your competency. The RN Supervisor's cell phone number was posted after the statement. In an interview on 4/22/2025 at 12:13 PM, Surveyor asked Registered Nurse (RN)-AA what kind of training RN-AA went through to be competent on taking care of ventilator residents. RN-AA stated a class was offered by Respiratory Therapist (RT)-JJJ at the end of February or the beginning of March 2025; RN-AA was not sure of the date. RN-AA stated the class was a couple of hours long and included papers that RN-AA has in RN-AA's office that RN-AA still refers to when needed. Surveyor asked RN-AA if administration knew who attended the training sessions. RN-AA stated administration should have a list and there were at least six or seven sessions offered. Surveyor asked RN-AA if agency staff were included in the training. RN-AA stated yes. In an interview on 4/22/2025 at 12:24 PM, Surveyor asked RT-JJJ when and how many classes were offered to staff at the facility to provide care to residents on a ventilator. RT-JJJ stated RT-JJJ had eight classes in February, March, and April 2025 and when anyone new comes in, RT-JJJ goes over the training with the employee and the employee takes the test. Surveyor asked RT-JJJ who keeps the completed tests. RT-JJJ stated previous Nursing Home Administrator (NHA)-C was given all the materials after completion by the employee. RT-JJJ stated RT-JJJ does not keep any copies for RT-JJJ's record. RT-JJJ stated RT-JJJ had worked at the facility previously and left in 2023 but returned January 2025 per diem and then full time 4/7/2025. On 4/22/2025 at 1:21 PM, Surveyor asked previous Nursing Home Administrator (NHA)-C what staff members had been trained to work on the ventilator unit. NHA-C stated all RTs, RNs, and LPNs that work on the ventilator unit have been trained and competencies have been completed. Surveyor requested from NHA-C a list of those trained and competent staff as well as the training and competencies that had been completed for review. NHA-C provided a list of 41 facility and agency staff. The list was not in any discernable order, did not include the position the individual held, the date of the training and competencies completed. Surveyor noted there was no master list of employees and agency staff that were required to have the specialized training in ventilator residents to cross reference. NHA-C provided a stack of packets for the employees that had been trained and deemed competent to work on the ventilator unit. Surveyor received 44 packets. Surveyor reviewed the packets provided comparing them with the list of employees provided. A complete packet consisted of a Training Acknowledgement cover sheet with the employee's name, signature, and date, a Nursing Tracheostomy Exam with 23 multiple choice questions, a Ventilator Care for Nurses Post Test B with 50 multiple choice questions, and a Skills Module Checklist for tracheostomy suctioning. None of the exams or skills checklists had the employee's name or date written on them. The competent staff list had 41 facility and agency staff names. A total of 47 staff were reviewed. -1 staff member on the list did not have a packet. -4 staff members had packets that were not named on the list. -2 staff members had the Training Acknowledgement cover sheet but no other documents. -9 staff members did not have a Nursing Tracheostomy Exam. -2 staff members did not have a Nursing Tracheostomy Exam or a Skills Module Checklist. -7 staff members had Nursing Tracheostomy Exam and Ventilator Care for Nurses Post Test B photocopies. One test had been photocopied 7 times and placed in staff packets. Surveyor noted the photocopied exams to have consistent errors: Nursing Tracheostomy Exam question #2 was left unanswered, Ventilator Care for Nurses Post Test B question #4 had A and D circled, and question #5 was left unanswered. The circled answers on the multiple exams were consistent in shape and size and were easily determined to be photocopied. No names were on any of the exams or skills checklist within the packets. On 4/22/2025 at 3:10 PM at the daily exit with the facility, Surveyor asked who was responsible for ensuring staff on the ventilator unit are trained and who keeps the packets. NHA-C stated RT-JJJ creates the training packets and NHA-C keeps track of all the training packets. In an interview on 4/22/2025 at 3:39 PM, Surveyor shared with NHA-C concerns with the ventilator training packets. Surveyor shared with NHA-C the observation of not all packets included the Nursing Tracheostomy Exam. NHA-C stated after review by NHA-C and RT-JJJ, it was discovered the questions in the Nursing Tracheostomy Exam were covered in the Ventilator Care for Nurses Post Test B and it was duplicating the content, so they no longer had staff complete the Nursing Tracheostomy Exam. Surveyor reviewed and compared the content of the two exams and agreed the Ventilator Care for Nurses Post Test B was comprehensive of all the content. NHA-C stated because of that decision, the packets only need to contain the Ventilator Care for Nurses Post Test B and the skills checklist. NHA-C stated RT-JJJ gives NHA-C the completed packets and NHA-C puts them in a binder. Surveyor shared with NHA-C the concerns of incomplete packets, missing skills checklist to show competencies, missing pages of exams, not all staff were listed on the staff list provided by NHA-C as well as not all staff listed had packets, and the Nursing Tracheostomy Exam and the Ventilator Care for Nurses Post Test B for 7 staff members had been photocopied. Surveyor showed NHA-C the 7 photocopied exams and NHA-C agreed one exam had been photocopied and placed in employee packets. NHA-C stated NHA-C gets the packets but did not verify the information in the packets. NHA-C was no longer available for interview after this encounter. In an interview on 4/22/2025 at 4:13 PM, Surveyor asked RT-JJJ for a copy of the training packet that is provided to staff on the ventilator unit. RT-JJJ stated a new RT was starting the next shift and had a packet all ready that Surveyor could have. Surveyor noted the packet consisted of the Ventilator Care for Nurses Post Test B. The packet did not contain a Training Acknowledgement form or a skills checklist. Surveyor asked RT-JJJ who completes the skills checklist with the staff. RT-JJJ did not know what checklist Surveyor was referring to. RT-JJJ stated RT-JJJ has a Ventilator Check Off for Respiratory Therapists, which RT-JJJ provided, but does not have a checklist for nurses. In an interview on 4/23/2025 at 9:49 AM, Surveyor confirmed with RT-JJJ the Tracheostomy Exam was no longer given to staff as NHA-C had stated. RT-JJJ stated the trach exam was for Certified Nursing Assistants (CNAs) and the vent test covered both the trach and the vent. Surveyor had not heard of CNAs being trained to suction residents. Surveyor asked RT-JJJ what the process was for training ventilator staff. RT-JJJ stated if the class size was small, RT-JJJ would grade the test papers but if it was a larger class, then RT-JJJ would go over the answers at the end of the class. RT-JJJ stated RT-JJJ would not necessarily write anything on the papers, but that would also depend on class size. RT-JJJ stated then the completed packet would be given to NHA-C. RT-JJJ stated RT-JJJ used to keep a soft file of all the training and attendees, but RT-JJJ does not do that anymore. Surveyor showed RT-JJJ the competency checklist. On the checklist at the top of the form, it included DON-B and RT-JJJ's names as being the educators. RT-JJJ stated RT-JJJ had nothing to do with that paper. RT-JJJ stated DON-B used the checklist before RT-JJJ came back full time. RT-JJJ stated they are not using the checklist anymore, but RT-JJJ had nothing to do with the checklist. Surveyor showed RT-JJJ the seven copied tests. RT-JJJ agreed one test had been photocopied multiple times. RT-JJJ denied making any copies stating RT-JJJ would never do that. RT-JJJ stated RT-JJJ did not know what happened with those packets. In an interview on 4/23/2025 at 12:49 PM, Surveyor asked DON-B who did education and competencies with staff on the ventilator unit. DON-B stated DON-B did some education with nurses and observations for ventilators and tracheostomies along with RT-JJJ, but DON-B stated DON-B could not give the names of the staff that DON-B personally trained. Surveyor asked DON-B if DON-B was familiar with the skills checklist form. DON-B stated DON-B had seen the checklist for return demonstration and thought RT-JJJ had completed those checklists with staff. Surveyor shared with DON-B that RT-JJJ had never seen the checklist until Surveyor showed it to RT-JJJ earlier that day. DON-B did not know if anyone else had watched staff do a return demonstration and speculated an RT on the second shift may have completed some but was not sure. DON-B stated once the training was done, NHA-C took over all the documentation and DON-B had nothing further to do with it. DON-B stated NHA-C was very possessive of the training packets. In an interview on 4/23/2025 at 2:12 PM, Surveyor shared with Director of Clinical Operations (DCO)-D the same concerns that were shared with NHA-C the previous day. Surveyor shared with DCO-D the conversation with NHA-C the questions in the Nursing Tracheostomy Exam were covered in the Ventilator Care for Nurses Post Test B and it was duplicating the content, so they no longer had staff complete the Nursing Tracheostomy Exam. Surveyor shared with DCO-D the packets only need to contain the Ventilator Care for Nurses Post Test B and the skills checklist. Surveyor shared with DCO-D the concerns of incomplete packets, missing skills checklist to show competencies, missing pages of exams, not all staff were listed on the staff list provided by NHA-C as well as not all staff listed had packets, and the Nursing Tracheostomy Exam and the Ventilator Care for Nurses Post Test B for 7 staff members had been photocopied. Surveyor showed DCO-D the 7 photocopied exams and DCO-D agreed one exam had been photocopied and placed in employee packets. DCO-D stated every staff member had a competency for the revisit survey by the State Survey Agency on 3/10/2025. DCO-D stated everybody's full packet was there. DCO-D stated DCO-D made sure everything was complete at that time. DCO-D stated DCO-D was not sure what happened to the packets since that time. DCO-D stated the records were not kept in good order with no names or dates on the paperwork. DCO-D stated DCO-D was finding random pages from packets but with no name on them, DCO-D could not know who they belonged to. DCO-D stated DCO-D would check each employee's personnel file to see if the originals were kept there. DCO-D agreed with Surveyor that papers were just copied and stapled in no particular order to make up the packets. Surveyor shared the concern that with the packets as they were presented, it was not possible to determine which staff had been trained on the care of residents with tracheostomies and ventilators. DCO-D agreed and would be working with RT-JJJ to come up with a system to ensure there is documentation of all staff that need to be competent to work on the ventilator unit.

Based on interview and record review, the facility did not ensure sufficient nursing staff was provided to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect 2 of 6 units at the facility. *On 04/15/2025, staff member informed Surveyor that 4 residents, who required an assistance of 2 staff with a mechanical lift, remained in bed due to not having a second staff assistance available. *On 04/17/2025, Surveyor observed residents receiving meal trays 1.5 hours after breakfast was scheduled- due to staff being unavailable to help pass trays and/or assist residents with eating. *On 03/31/2025, The Facility's schedule documented residents were unable to be rounded on, due to staffing. Findings include: On 04/15/2025, at 12:46 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-W. Surveyor asked CNA-W how the staffing is at the Facility. CNA-W indicated horrible. Surveyor asked CNA-W to elaborate on what horrible means. CNA-W informed Surveyor that there is only CNA on TV1 (Terrace view 1), the second shift nurse doesn't help on TV1 and has expressed these concerns to DON-B and NHA-C. CNA-W indicated that CNA-W was not able to get residents up due to being alone on unit with 8 residents requiring hoyer lifts that need 2 people. CNA-W indicated CNA-W was able to get 2 residents up with hoyer's, with the help of staff from another unit, but 4 residents are not able to get up who require hoyer lifts. On, 04/17/2025, at 09:09 AM, Occupational Therapist (OT)-E requested Surveyor come to the dining room. OT-E informed Surveyor that there were not enough staff to assist passing trays and assist residents with eating in dining room on first floor. Surveyor went to the first-floor dining room and noted no aides were in the dining room. On 04/17/2025, at 09:13 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-II. LPN-II indicated this is the first day the dining room is open again and that breakfast starts at 08:15 AM. LPN-II indicated CNA's will start passing room trays from the hall cart first and then aides will come to the dining room. On 04/17/2025, at 09:41 AM, Surveyor observed 14 residents in the dining room, 2 residents being assisted with feeding. On 04/17/2025, at 09:43 AM, Surveyor observed the last resident receive a meal tray in the dining room. Surveyor noted trays were still being made and delivered to the halls for the residents who did not come to the dining room. Surveyor reviewed the Facility's Assessment and noted for staffing the following, for Nurses- AM shift- 5, PM shift -5 and night shift- 4. For CNA's AM shift- 8, PM shift- 8 and night shift- 4. Surveyor reviewed staff schedules from February 2025 to current. Surveyor noted on 03/31/2025 during night shift, a note on the schedule documents . Help with TV2 (Terrace view 2)/ this is how it was on the schedule when writer got here; CNA was no where to be found after 23:00; did not do rounds on TV2. On 04/21/2025, at 03:28 PM, Surveyor interviewed Staff Coordinator-RR. Staff Coordinator-RR indicated that Staff Coordinator-RR does the schedule and schedules staff based on the Facility's census, but will usually schedule the following, AM and PM shift CNA's- 13 to 14, and on night shift 8 CNA's. Staff Coordinator-RR indicated AM and PM shift for Nurses is 9 and on night shift 6, not including a supervisor. Staff Coordinator-RR informed Surveyor that the Facility does utilize agency staff for nurses but not for CNA's, but when there is a call in, supervisors will send out an email to staff, supervisor or Staff Coordinator-RR will call for people to pick up. Staff Coordinator-RR indicated staff concerns, that staff get upset about call ins, especially on units with higher acuity residents and sometimes they must pull from a different unit or Staff Coordinator-RR will help. Staff Coordinator-RR indicated that unit TV1 on 4/15/2025 had to split the hall to add some residents to the workload of the 2 CNA's on unit PV1 (Parkview 1). Staff Coordinator-RR expressed that it is terrible, but the staff really try to work together to get things done. Staff Coordinator-RR was not sure who wrote the comment on the 03/31/2025 schedule. On 04/22/2025, at 10:57 AM, Surveyor interviewed DON-B regarding staffing. DON-B indicated that staffing depends on the unit, census of unit and acuity of residents on the unit. DON-B was unsure about the comment left on the 03/31/2025 schedule but would look into it. Surveyor asked DON-B about how the Facility Assessment was determined for the staffing portion, DON-B informed Surveyor that Previous NHA-C is the one who created the Facility Assessment. On 04/22/2025, at 03:26 PM, Surveyor informed the Facility regarding concerns that staff was unable to round on residents or get residents out of bed due to not having enough staff on 04/15/2025 and 03/31/2025. On 04/23 and /2025, at 03:51 PM, Surveyor spoke with Director of Clinical Operations-D regarding the Facility Assessment due to Previous NHA-C no longer being at the Facility, Director of Clinical Operations-D indicated to Surveyor to speak with Chief Clinical Officer (CEO)-A. On 04/24/2025, at 09:08 AM, Surveyor interviewed CEO-A. CEO-A indicated that CEO-A was not part of the specific conversations regarding staffing numbers in the Facility Assessment, and indicated that was discussed with leadership with minimum staffing regulations in mind and the consensus was to keep it conservative. CEO-A shared the very recent shift in NHA responsibilities in the facility and would further discuss staffing and the Facility Assessment moving forward.

2.) R73's nurses note dated 2/28/25 at 4:05 a.m. indicates R73 was transferred to the hospital for a change in condition. Note indicates unit nurse will update POAH (power of attorney health) and will call the hospital for nurse to nurse report. R73's nurses note dated 3/1/25 at 12:35 a.m. by Registered Nurse (RN)-X documents F/U (follow up): Call place to [hospital initials], update; pt (patient) admit w/ (with) acute Hypoxia 2/2 (secondary to) Chronic Resp (respiratory) failure. R73 was readmitted on [DATE]. Surveyor was unable to locate in R73's medical record R73 or R73's representative had been notified of the hospital transfer in writing. On 4/17/25, at 1:00 p.m., Surveyor asked Licensed Practical Nurse (LPN)-JJ who would notify a resident or their resident representative of a transfer to the hospital in writing. LPN-JJ replied I don't know and informed Surveyor if the resident was their own person she would tell them if not she would verbally tell their family. On 4/17/25, at 3:00 p.m., during the end of the day meeting, Surveyor informed Previous Nursing Home Administrator (NHA)-C Surveyor is unable to locate a written transfer notice for R73 when R73 was transferred to the hospital on 2/28/25 and requested the transfer notice. On 4/21/25, at 12:41 p.m., Surveyor informed Previous NHA-C Surveyor has not received a written transfer notice for R73's discharge on [DATE]. On 4/21/25, at 2:40 p.m., during the end of the day meeting, Surveyor informed Previous NHA-C Surveyor has not received a written transfer notice for R73's discharge on [DATE]. On 4/22/25, at 7:38 a.m., Surveyor asked Previous NHA-C if she has the written transfer notices provided to residents and their representatives for the residents the surveyors have been asking for. Previous NHA-C informed Surveyor she thought accounting would have them and then stated no we don't have them. On 4/22/25, at 7:38 a.m., Surveyor asked Previous NHA-C if she has the written transfer notices provided to residents and their representatives for the residents the surveyors have been asking for. Previous NHA-C informed Surveyor she thought accounting would have them and then stated no we don't have them. 4.) R78's nurses note dated 12/8/24 at 5:47 a.m. documents Nursing routine care notes: Received call from on call APNP (Advanced Practice Nurse Prescriber) and order obtained to send [R78's first name] to the Emergency Room. I left a message for [Name] regarding [R78's first name] impending transfer to [Hospital initials]. [Name] Ambulance summoned and report called to [Hospital initials] Emergency Room. R78 was readmitted on [DATE]. R78's nurses note dated 1/12/25 at 10:18 a.m. written by Licensed Practical Nurse (LPN)-MMM documents . Writer contacted his daughter and left a message and then called his son and talked directly with him. R78 was readmitted to the facility on [DATE]. R78's nurses note dated 2/23/25 at 8:06 p.m. by Quality & Clinical Support Nurse-NNN documents .decision was made to send resident out for eval (evaluation) due to need for timely chest xray and labs. [Name] made aware of above and agrees to transfer to [Hospital name]. R78 was readmitted on [DATE]. R78's nurses note dated 3/26/25 at 2:12 p.m. written by LPN-NNN documents . contacted NP who advised to send him out. He was sent to [hospital initials] . R78 was readmitted on [DATE]. Surveyor was unable to locate in R78's medical record R78 or R78's representative had been notified of the hospital transfer in writing when R78 was discharged to the hospital on [DATE], 1/12/25, 2/23/25, & 3/26/25. On 4/17/25, at 1:25 p.m., Surveyor asked Registered Nurse (RN) Supervisor-AA who provides the resident and their representative in writing a transfer notice when a resident is transferred/discharged to the hospital. RN Supervisor-AA informed Surveyor he didn't know there was anything in writing and usually just calls them. On 4/17/25, at 3:00 p.m., during the end of the day meeting, Surveyor informed Previous Nursing Home Administrator (NHA)-C Surveyor is unable to locate a written transfer notice for R78 when R78 was transferred to the hospital on [DATE], 1/12/25, 2/23/25, & 3/26/25 and requested the transfer notices. On 4/21/25, at 12:40 p.m., Surveyor informed Previous NHA-C Surveyor has not received any written transfer notice for R78's discharges on 12/8/24, 1/12/25, 2/23/25, & 3/26/25. On 4/21/25, at 2:40 p.m., during the end of the day meeting, Surveyor informed Previous NHA-C Surveyor still has not received a written transfer notice for R78's discharge on [DATE], 1/12/25, 2/23/25, & 3/26/25. On 4/22/25, at 7:38 a.m., Surveyor asked Previous NHA-C if she has the written transfer notices provided to residents and their representatives for the residents the surveyors have been asking for. Previous NHA-C informed Surveyor she thought accounting would have them and then stated no we don't have them. Based on interview and record review, the facility did not ensure 7 (R11, R28, R38, R72, R73 , R78 and R94) of 7 sampled residents reviewed for a facility initiated discharge received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. * R11 was transferred to the hospital on [DATE] and 3/22/25 R11 and/or their representative was not given a transfer notice. * R28 was transferred to the hospital on 3/24/25, 4/5/25 and 4/10/25. R28 and/or their representative was not given a transfer notice. * R38 was transferred to the hospital on 1/7/25 and 2/4/25. R38 and/or their representative was not given a transfer notice. * R72 was transferred to the hospital on 3/23/25 and 4/3/25. R72 and/or their representative was not given a transfer notice. * R73 was transferred to the hospital on 2/28/25. R73 and/or their representative was not given a transfer notice. *R78 was transferred to the hospital on [DATE], 1/12/25, 2/23/25 and 3/26/25. R78 and/or their representative was not given a transfer notice. * R94 was transferred to the hospital on 4/7/25. R94 and/or their representative was not given a transfer notice. Findings include: On 4/23/25 at 12:56 PM Director of Clinical Operations-D was interviewed and indicated they could not find and policy and procedure for issuing transfer notices. 1.) On 4/21/25, the Surveyor reviewed R38's medical record and it indicated R38 was transferred to the hospital on 1/7/25 and 2/4/25. R38's medical record did not include documentation that a transfer notice had been given to the resident and/or their representative for the hospitalization. On 4/22/25 at 1:30 PM Previous Administrator-C was interviewed and indicated no transfer notice could be found for R38's hospitalizations on 1/7/25 and 2/4/25. On 4/21/25 at 3:00 PM, the above findings were shared with Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided as to why a transfer notice was not given to R38 and/or their representative for their hospitalizations on 1/7/25 and 2/4/25. 5.) R11 was initially admitted to the facility on [DATE], R11 was their own person. On 12/7/2024, R11 was transferred and admitted to the hospital. On 3/22/2025, R11 was transferred and admitted to the hospital. Surveyor reviewed R11's medical record and was unable to locate the transfer notices for when R11 went out to the hospital and was admitted on [DATE], and 3/22/2025. On 4/17/2025, at 1:47 PM A Surveyor interviewed registered nurse (RN) supervisor (RN sup)-AA who stated the nurses give the bed holds and then gives them to the director of nursing (DON)-B, but RN sup-AA was not sure what staff was in charge of doing the transfer notice when someone goes out to the hospital. RN sup-AA stated that usually the resident's emergency contact is notified by staff calling and telling them and was not aware if there is anything in writing. On 4/21/2025 Surveyor requested the transfer notices for when R11 went out to the hospital and was admitted on [DATE], and 3/22/2025. On 4/22/2025 at 7:38 AM A Surveyor asked previous nursing home administrator (NHA)-C if NHA-C had the transfer notices for the residents that have been requested. NHA-C stated that NHA-C thought accounting would have them, but accounting does not have them. NHA-C stated that the facility does not have transfer notices. Surveyor requested the transfer notice policy for the facility. Surveyor shared concerns with NHA-C that the transfer policies for when R11 went out to the hospital and was admitted on [DATE] and 3/22/2025 are not readily available for review and that the resident and/or resident representative were not notified of the transfer in writing. On 4/23/2025, at 7:18 AM, Surveyors requested the transfer policy again from director of clinical operations (DCO)-D who stated that there was absolutely a policy for transfer notices, can not say it was being followed, but would get it to the Surveyors. On 4/23/2024 at 12:56 PM, DCO-D stated a policy for transfer notification could not be found, there is no policy. 6.) R72 was admitted to the facility on [DATE] and was their own person. On 3/23/2025, R72 was transferred and admitted to the hospital. On 4/3/2025, R72 was transferred and admitted to the hospital. Surveyor reviewed R72's medical record and was unable to locate the transfer notices for when R72 went out to the hospital and was admitted on [DATE], and 4/3/2025. On 4/17/2025, at 1:47 PM A Surveyor interviewed registered nurse (RN) supervisor (RN sup)-AA who stated the nurses give the bed holds and then gives them to the director of nursing (DON)-B, but RN sup-AA was not sure what staff was in charge of doing the transfer notice when someone goes out to the hospital. RN sup-AA stated that usually the resident's emergency contact is notified by staff calling and telling them and was not aware if there is anything in writing. On 4/21/2025 Surveyor requested the transfer notices for when R72 went out to the hospital and was admitted on [DATE], and 4/3/2025. On 4/22/2025 at 7:38 AM A Surveyor asked previous nursing home administrator (NHA)-C if NHA-C had the transfer notices for the residents that have been requested. NHA-C stated that NHA-C thought accounting would have them, but accounting does not have them. NHA-C stated that the facility does not have transfer notices. Surveyor requested the transfer notice policy for the facility. Surveyor shared concerns with NHA-C that the transfer policies for when R72 went out to the hospital and was admitted on [DATE] and 4/3/2025 are not readily available for review and that the resident and/or resident representative were not notified of the transfer in writing. On 4/23/2025, at 7:18 AM, Surveyors requested the transfer policy again from director of clinical operations (DCO)-D who stated that there was absolutely a policy for transfer notices, cannot say it was being followed, but would get it to the Surveyors. On 4/23/2024 at 12:56 PM, DCO-D stated a policy for transfer notification could not be found, there is no policy. *) R28 was admitted to the facility on [DATE], with diagnoses which include Chronic Kidney Disease, Chronic diastolic heart failure, Urinary tract infections and morbid obesity. R28's Annual Minimum Data Set (MDS), dated [DATE], documents R28 is able to understand and be understood, and has a Brief Interview for Mental Status (BIMS) of 15 indicating R28 is cognitively intact. On 03/24/2025, 04/05/2025 and 04/10/2025 R28 was transferred to the hospital. Surveyor could not locate transfer notices in R28s chart and requested transfer notifications from the Facility. R94 was admitted to the facility on [DATE], with diagnoses which include Cerebral Infarction, Chronic Kidney Disease, and muscle weakness. R94's admission MDS, dated [DATE], documents R94 is able to understand and be understood, and has a BIMS score of 11indicating R94 has moderately impaired cognition. On 04/21/2025, at 11:07 AM, Surveyor received an email from NHA-A with a blank form titled DISCHARGE TRANSFER NOTICE BEDHOLD NOTIFICATION via email. As of time of write up, no further information was provided by the Facility.

Based on observation and interview the facility did not ensure a safe, clean, comfortable, and homelike environment for 5 (R34, R105, R78, R73, & R38) of 6 residents. The base of R34, R105, R78, R73, & R38's tube feeding poles were observed with dried feedings on multiple days. Findings include: Surveyor requested facility policy regarding cleaning resident equipment. Surveyor was provided with the facility's policy titled Wheelchair and [NAME] Cleaning and Maintenance reviewed 4/25. This policy does not address resident's tube feeding poles. No other policy was provided. On 4/21/25, at 11:40 a.m., Surveyor asked Housekeeping Aide (HA)-GG, who was working on the vent unit, if she is responsible for cleaning resident's tube feeding poles. HA-GG replied ya but we just started this vent unit. Surveyor asked when they started cleaning the vent unit. HA-GG informed Surveyor a month ago and explained those poles were on SunnyView 2. HA-GG stated I'll start cleaning its all stuck on there. Surveyor asked HA-GG in the last month has she cleaned any of the tube feeding poles. HA-GG replied no, to be honest with you, I'm really not sure if it's my job or the CNAs (Certified Nursing Assistants). I would think it would be mine, technically they are suppose to clean and we go after them. On 4/22/25, at 8:46 a.m., Surveyor asked Registered Nurse (RN) Supervisor-AA who is responsible for cleaning resident's tube feeding poles. RN Supervisor-AA replied housekeeping but all staff can do it. On 4/22/25 at 8:51 AM Administrator-A was interviewed and indicated housekeeping is responsible for cleaning gastrostomy tube feeding poles. 1.) On 4/15/25, at 3:16 p.m. Surveyor observed R34's tube feeding pole has multiple areas of dried feeding on the base of the pole. On 4/16/25, at 9:50 a.m., Surveyor observed R34's tube feeding is not running. The base of the tube feeding pole has splattered dried feeding on three of the four legs of the tube feeding pole. On 4/17/25, at 1:12 p.m. Surveyor observed the base of R34's tube feeding pole continues to have multiple dried feeding on three of the four legs. On 4/21/25, at 11:45 a.m. Surveyor observed the base of R34's tube feeding pole continues to have multiple areas of dried feeding on three of the four legs. Surveyor noted on one of the legs there is a clump of what appears to be R34's tube feeding. 2.) On 4/16/25, at 9:38 a.m., Surveyor observed R105's tube feeding of Isosource 1.5 is running at 60 ml/hr (milliliter per hour). Surveyor observed the base of R105's tube feeding pole has multiple areas of dried feeding covering approximately two thirds of the legs on two of the four legs. On 4/17/25, at 1:07 p.m. Surveyor observed the base of R105's tube feeding pole has multiple areas of dried feeding on three of the four legs. On 4/21/25, at 11:42 a.m. Surveyor observed the base of R105's tube feeding pole has multiple areas of dried feeding on three of the four legs with one of the legs of the tube feeding pole has half of the leg covered with dried feeding. 3.) On 4/16/25, at 9:42 a.m., Surveyor observed the base of R78's tube feeding pole has multiple areas with dried feeding. On 4/17/25, at 1:11 p.m. Surveyor observed the base of R78's tube feeding pole has dried feeding on all four legs of the base. Surveyor noted three of the four legs are 75% covered with dried feeding. On 4/21/25, at 11:43 a.m., Surveyor observed the base of R78's tube feeding pole continues to have dried feeding on all four legs. Surveyor noted three of the four legs continue to be over 75% covered with dried feeding. 4.) On 4/17/25, at 1:04 p.m. Surveyor observed the base of R73's tube feeding pole has dried splattered feedings on two of the four legs. On 4/21/25, at 11:39 a.m. Surveyor observed the base of R73's tube feeding pole continues to have dried splattered feedings. On 4/21/25, at 3:14 p.m. during the end of the day meeting with Previous Nursing Home Administrator (NHA)-C, NHA-A, and Director Clinical Operations-D were informed the base of R34, R105, R78, R73 tube feeding poles were dirty with dried feedings on multiple days. No information was provided to Surveyor as to why these tube feeding poles were not being cleaned. 22692 5.) On 4/16/25 at 10:32 AM, R38's gastronomy tube pole was observed to be covered with what appeared to be dry gastrostomy feeding solution on the pole and base. On 4/17/25 at 8:32 AM, R38's gastrostomy tube pole was observed to be covered with what appeared to be dry feeding solution on the pole and base. On 4/21/25 at 10:32 AM, R38's gastrostomy tube pole was observed to be covered with what appeared to be dry feeding solution on the pole and base. Family member-LLLL was in the room during the observation and indicated the gastrostomy tube pole has been like that for months. Family member-LLLL indicated it is hard to raise or lower the pole because it sticks because of all the dried feeding solution on it. The above findings were shared with Former Administrator-C and Director of Nurses (DON)-B on 4/22/25. Additional information was requested if available as to why R38's gastrostomy feeding pole was dirty for the above observations. None was provided.

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary medication for 4 (R93, R514, R8 & R72) of 6 Residents reviewed. * R93 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. * R514 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. * R8 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. * R72 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. Findings include: On 4/22/2025, at 3:17 PM, Surveyor was informed by Nursing Home Administrator (NHA)/ Chief Executive Officer (CEO)-A, that the facility does not have a policy for anticoagulation or high-risk medication. 1) R93's was admitted to the facility on [DATE] with diagnoses that includes pulmonary embolism without acute cor pulmonale, chronic obstructive pulmonary disease, repeated falls and weakness. R93's quarterly Minimum Data Set (MDS) assessment, dated 1/28/2025, documents a Brief Interview Mental Score (BIMS) of 15, which indicates R93 is cognitively intact. R93's blood thinner care plan, dated 7/12/2024, documents under the intervention section, monitor for presence or absence of active bleeding such as hematuria, petechiae, bruising, bloody stools, or nosebleeds at least daily. R93's current physician order is: Eliquis tablet 2.5 milligrams,1 tablet, orally, twice a day. On 4/17/2025, at 8:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-O, who indicated that the facility changed the matrix program (CNA's program used to chart resident care)and that the new program no longer indicates to staff if someone is to be monitored for side effects of medications. CNA-O stated that the facility also had older, printed packets that staff could carry with them, that would have information on them for monitoring for bleeding, but the facility took them away when the facility switched to the new program. On 4/21/2025, at 11:18 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-KKK, who stated that if a resident is on blood thinners, that something should be in place for monitoring for bleeding, if a resident is on blood thinners, then they should be getting monitored. On 4/21/2025, at 11:40 AM, Surveyor interviewed Director of admissions-FF, who stated to be the person responsible for entering physician orders, but not the person who enters monitoring for side effects to medications. Director of admissions-FF stated the unit supervisors will put in orders for monitoring if they are needed. On 4/21/2025, at 3:57 PM, Surveyor interviewed Registered Nurse (RN) Supervisor-QQ who acknowledged that residents on blood thinners don't have an order to monitor for bleeding, but that it's a good idea, and will be looking into this. Registered Nurse (RN) Supervisor-QQ indicated it is in the care plan only but not getting documented on. On 4/22/2025, at 11:59 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated the facility does not have monitoring for side effects in current orders on the CNA care plan but that information on blood thinners is in R93's nursing care plan. Surveyor asked if there is any documentation that monitoring is occurring and DON-B stated no, it only needs to be in the care plan. On 4/24/2025, at 7:55 AM, Surveyor interviewed Director of Clinical Operations-D, who stated that pharmacy explained to the facility, that they don't need to monitor this drug for bleeding and that's the beauty of this drug, it just must be on the care plan. Surveyor explained the care plan is where it is documented that monitoring daily should be occurring. On 4/24/2025, at 2:30 PM, Surveyor informed NHA (CEO)-A, DON-B, and Director of clinical operations-D, of the concern that no monitoring of the side effects of anticoagulation medication is occurring for R93, even know it is in R93's care plan. No additional information received as to why R93 has no monitoring of side effects to anticoagulation medication. 2) R514 was admitted to the facility on [DATE] and has diagnoses of permanent atrial fibrillation, diverticulitis of large intestines, enterocolitis due to clostridium difficile, long-term use of anticoagulants. R514's admission, Minimum Data Set (MDS) assessment, dated 3/28/2025, had a Brief Interview Mental Score (BIMS) of 00, which indicates R514 is not cognitively intact. Under section B, the hearing, speech, and vision section, it documents a 2, which indicates that R514 sometimes is understood/understands. R514's care plan for blood thinner, dated 3/25/2025 documents, if side effects are noted, a nurse note should reflect this issue with immediate follow up notification to the physician via phone call. Monitor for presence or absence of active bleeding such as hematuria, petechiae, bruising, bloody stools, or nosebleeds at least daily, every shift: day, evening, night. R514's current order for Eliquis is: Eliquis 5 milligram tablet, take orally for blood clot prevention, twice a day. On 4/17/2025, at 8:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-O, who indicated that the facility changed the matrix program (CNA's program used to chart resident care). CNA-O stated that the new program no longer indicates to staff if someone is to be monitored for side effects of medication. CNA-O stated that the facility also had older, printed packets that staff could carry with them, that would have information on them for monitoring for bleeding, but the facility took them away when the facility switched to the new program. On 4/21/2025, at 11:18 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-KKK, who stated that something should be in place for monitoring for bleeding, if a resident is on blood thinners they should be getting monitored. On 4/21/2025, at 11:40 AM, Surveyor interviewed Director of admissions-FF, who stated to be the person responsible for entering physician orders, but not the person who enters monitoring for side effects to medications. Director of admissions-FF stated the unit supervisors will put in orders for monitoring if they are needed. On 4/21/2025, at 3:57 PM, Surveyor interviewed Registered Nurse (RN) Supervisor-QQ who acknowledge that residents on blood thinners don't have an order to monitor for bleeding, but that it's a good idea, and will be looking into this. Registered Nurse (RN) Supervisor-QQ indicated it is in the care plan only but not getting documented on. On 4/22/2025, at 11:59 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated the facility does not have monitoring for side effects in current orders or on the cna care plan, that information is just in R93's nursing care plan. Surveyor asked if there is any documentation that monitoring is occurring and DON-B stated no, it is only in the care plan. 04/24/25 07:55 AM Surveyor interviewed Director of Clinical Operations-D, who stated that pharmacy explained to the facility, that they don't need to monitor this drug for bleeding and that's the beauty of this drug, it just must be on the care plan. Surveyor explained the care plan is where it is documented that monitoring daily should be occurring. On 4/24/2025, at 2:30 PM, Surveyor informed NHA (CEO)-A, DON-B, and Director of clinical operations-D, of the concern that no monitoring of the side effects of anticoagulation medication is occurring for R514, even know it is in R514's care plan. No additional information received as to why R514 has no monitoring of side effects to anticoagulation medication. 42037 3.) R8 was admitted to the facility on [DATE] with diagnoses including chronic embolism (A blockage in a blood vessel caused by a foreign substance, often a blood clot.) and heart disease. R8's Quarterly MDS (Minimum Data Set) Assessment with an assessment reference date of 3/18/2025 indicates R8 received an Anticoagulant medication during the assessment period. R8's medical record was reviewed including physician orders, MARs (Medication Administration Records) TARs (Treatment Administration Records) and comprehensive care plans. R8's physician orders document the following: . 9/20/2021 .Eliquis Tablet (Apixaban), Give 5 mg (milligrams) by mouth every 12 hours . Surveyor noted R8 has been receiving Eliquis (an anticoagulant medication) on a scheduled basis since September 2021. Surveyor reviewed R8's comprehensive care plan. R8's comprehensive care plan with an initiation date of 10/24/2024 documents the following: (R8) is at risk for complications from blood thinning medications. List name of medication(s): Eliquis . R8's care plan interventions include the following: . Monitor for presence or absence of active bleeding such as hematuria, petechiae (tiny brown-purple spots from bleeding under the skin), bruising, bloody stools, or nose bleeds at least daily. Surveyor reviewed R8's MARs and TARs for November 2024-April 2025. Surveyor was unable to locate any medication monitoring related to R8's use of the anticoagulant medication Eliquis. On 4/23/2025 on 2:16 PM, Surveyors conducted interview with Director of Clinical Operations-D regarding expectation for side effect monitoring for a resident receiving the medication Eliquis. Director of Clinical Operations-D replied that Eliquis does not have a standard to monitor for bleeding but there should be a care plan in place for those residents that receive Eliquis. On 4/23/2025 at the daily exit meeting, Surveyors informed DON-B that Surveyor was unable to locate any medication monitoring for R8's use of Eliquis, an anticoagulant medication, in their medical record. No additional information was provided by facility at this time. 3.) R72 was admitted to the facility on [DATE] with diagnoses including acute embolism (a sudden blockage in a blood vessel caused by a foreign substance, often a blood clot) and Congestive Heart Failure (the inability of the heart to adequately pump leading to side effects such as cough and a build up of fluid in the body.) R72's Quarterly MDS (Minimum Data Set) Assessment with an assessment reference date of 2/11/2025 indicates R72 received an Anticoagulant medication during the assessment period. Surveyor reviewed R72's electronic medical record and could not locate a person-centered care plan addressing the need to monitor for adverse side effects related to the use of an anticoagulant. R72's medical record was reviewed including physician orders, MARs (Medication Administration Records) TARs (Treatment Administration Records) and comprehensive care plans. R72's physician orders document the following: . 4/9/2025 .Eliquis Tablet (Apixaban), Give 5 mg (milligrams) by mouth every 12 hours . Surveyor noted R72 has been receiving Eliquis (an anticoagulant medication) on a scheduled basis since April 2025. Surveyor reviewed R72's MARs and TARs for April 2025. Surveyor was unable to locate any medication monitoring related to R72's use of the anticoagulant medication Eliquis. On 4/23/2025 on 2:16 PM, Surveyors conducted interview with Director of Clinical Operations-D regarding expectation for side effect monitoring for a resident receiving the medication Eliquis. Director of Clinical Operations-D replied that Eliquis does not have standard to monitor for bleeding but there should be a care plan in place for those residents that receive Eliquis. On 4/23/2025 at the daily exit meeting, Surveyors informed DON-B that Surveyor was unable to locate any medication monitoring for R72's use of Eliquis, an anticoagulant medication, in their medical record. No additional information was provided by facility at this time.

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 3 of 6 medication carts and 2 of 2 medication refrigerators located in the nurses station. Concerns include: * An expired Basaglar insulin pen for R22 with an open date of [DATE]. * Used Lantus Solostar insulin which was not labeled with a resident's name and an expired bottle of Humalog insulin for R42 with an open date of ,d+[DATE]. * A bottle of Extra Strength Rapid Release Tylenol 500 mg (milligrams) with the expiration date of ,d+[DATE]. * A used Semglee insulin pen for R13 that was not dated when opened and a used bottle of Lispro insulin for R13 that was not dated when opened. * Inside a plastic bag marked with R1's name is a bottle of used Lispro insulin that is not labeled with a resident's name or dated when opened. Inside R1's bag there is also a bottle of Lispro insulin for R13. R13's Lispro insulin was not dated when opened. * A used bottle of Lispro insulin for R49 that was not dated when opened. * A used bottle of Glargine insulin for R13 that was not dated when opened. * A used bottle of Novolin N insulin for R216 that was not dated when opened. * A used Levemir flextouch insulin pen that is not labeled with a resident's name or date when the pen was opened located in the TerraceView 2 medication refrigerator. * A used bottle of Lispro insulin for R48 that was not dated when opened located in the TerraceView 1 medication refrigerator. Findings include: The facility's policy titled, Subcutaneous Insulin and dated ,d+[DATE] under procedure documents 6. Date vial or device after first use. The facility's policy titled Medication Administration General Guidelines and dated ,d+[DATE] under the section Medication Administration documents 8c. Certain products or package types such as multi-dose vials and ophthalmic drops have specified shortened end -of-use dating, once opened, to ensure medication purity and potency (Refer to Section ,d+[DATE] - Medications With Shortened Expiration Dates). When date open expiration dating is not available from the manufacturer, the following may be considered in determining facility policy: * Multi-dose vials: 28 days after open date or per manufacturer's guidelines. * Ophthalmic preparations (solutions, suspensions, ointments): discard per manufacturer's guidelines or may implement a facility specific policy for shortened expiration dates (see customizable form in 12.3 Optional P/P (policy/procedure) Templates). 1.) On [DATE], at 9:24 a.m., Surveyor observed in the 3rd drawer on the left side of the Parkview 1 medication cart an expired Basaglar insulin pen for R22 with an open date of [DATE]. 2.) On [DATE], at 9:27 a.m., Surveyor observed in the 3rd drawer on the left side of the Parkview 1 medication cart a bottle of used Lantus Solostar insulin which was not labeled with a resident's name and an expired bottle of Humalog insulin for R42 with an open date of ,d+[DATE]. On [DATE], at 9:30 a.m., Surveyor asked Licensed Practical Nurse (LPN)-JJ after an insulin bottle has been dated with the open date does she know how long can the insulin be used before it is expired. LPN-JJ replied No don't know off top of my head. Surveyor showed LPN-JJ the expired insulin. LPN-JJ informed Surveyor she will dispose the insulin. 3.) On [DATE], at 9:32 a.m., Surveyor observed in the top right drawer of the Parkview 1 medication cart a bottle of Extra Strength Rapid Release Tylenol 500 mg (milligrams) with the expiration date of ,d+[DATE]. On [DATE], at 9:33 a.m., Surveyor asked LPN-JJ who checks the medication cart for expired medication. LPN-JJ informed Surveyor the nurses are suppose to check every month and then they have them do random audits. 4.) On [DATE], at 9:55 a.m., Surveyor observed in the 3rd draw of the front half medication cart on the SunnyView 2 unit a used Semglee insulin pen for R13 that was not dated when opened and a used bottle of Lispro insulin for R13 that was not dated when opened. On [DATE], at 10:01 a.m., Surveyor asked Licensed Practical Nurse (LPN)-HH if there should be an open date after insulin has been opened. LPN-HH informed Surveyor there should be. 5.) On [DATE], at 10:02 a.m., Surveyor observed in the 3rd draw of the front half medication cart located on the SunnyView 2 unit a plastic bag marked with R1's name. Inside R1's bag is a bottle of used Lispro insulin that is not labeled with a resident's name or dated when opened. Inside R1's bag there is also a bottle of Lispro insulin for R13. R13's Lispro insulin was not dated when opened. 6.) On [DATE], at 10:07 a.m., Surveyor observed in the 3rd draw of the front half medication cart located on the SunnyView 2 unit a used bottle of Lispro insulin for R49 that was not dated when opened. 7.) On [DATE], at 10:09 a.m., Surveyor observed in the 3rd draw of the front half medication cart located on the SunnyView 2 unit a used bottle of Glargine insulin for R13 that was not dated when opened. On [DATE], at 10:14 a.m., Surveyor showed LPN-HH R13's Lispro insulin which is in a plastic bag labeled with R1's name. LPN-HH informed Surveyor she's going to take a picture of it as she is not usually on this medication cart. 8.) On [DATE], at 10:20 a.m., Surveyor observed in the third medication cart located on the SunnyView 2 unit in the top drawer a used bottle of Novolin N insulin for R216 that was not dated when opened. On [DATE], at 10:25 a.m., Surveyor asked Licensed Practical Nurse (LPN)-DD if insulin bottles should be dated when opened. LPN-DD informed Surveyor it should be dated. Surveyor showed LPN-DD R216's Novolin N insulin bottle that was not dated when opened. 9.) On [DATE], at 8:03 a.m., Surveyor observed in the TerraceView 2 medication refrigerator located in the nurses station. Inside the refrigerator there is a beige box with a used Levemir flextouch insulin pen that is not labeled with a resident's name or date when the pen was opened. On [DATE], at 8:04 a.m. Surveyor asked Registered Nurse (RN) Supervisor-AA when a nurse opens an insulin bottle or pen what should the nurse do. RN Supervisor-AA replied should be dated. Surveyor asked if there is a resident's name on the insulin bottle or pen. RN Supervisor-AA informed Surveyor they come from the pharmacy that way. Surveyor asked RN Supervisor-AA if anyone checks to make sure insulin is dated when opened. RN Supervisor-AA informed Surveyor the floor nurse or unit nurse. Surveyor asked when the insulin bottles or pens should be checked. RN Supervisor-AA replied I would hope they would do it on a daily basis. Surveyor showed RN Supervisor-AA the used Levemir flextouch insulin pen that was not labeled with a resident's name or date when opened. 10.) On [DATE], at 8:13 a.m., Surveyor observed in the TerraceView 1 medication refrigerator located in the nurses station a used bottle of Lispro insulin for R48 that was not dated when opened. On [DATE], at 8:20 a.m., Surveyor asked Licensed Practical Nurse (LPN)-II when an insulin bottle is opened should the bottle be dated. LPN-II replied yes. Surveyor informed LPN-II R48's Lispro insulin was not dated when opened. LPN-II replied that's weird, I'll throw it in the trash, I wouldn't use it.

Based on observation, interview, and record review the facility did not ensure the necessary Respiratory Therapy services to provide respiratory care consistent with professional standards of practice to 2 (R7 and R1) of 3 residents reviewed for respiratory cares/ services. The facility did not ensure staff were trained, knowledgeable and competent to provide respiratory care to 9 residents who are ventilator dependent and 7 residents who are not ventilator dependent but have tracheostomies (trach). *On 01/25/2025, R7 was not put on R7's ventilator at night due to the Facility not having a Respiratory Therapist at the Facility. R7 did not have Respiratory orders relating to R7's ventilator. R7 did not have a documented Respiratory Assessment for every shift, between 01/06/2025 through 02/04/2025. *On 2/1/2025 R1's family member had to hook up R1's trach mask to oxygen due to scheduled facility staff not having the knowledge/competencies to hook R1's trach mask up to oxygen. R1's family provided suctioning to R1 due to staff not having the competency to provide suctioning for R1. *The facility does not ensure nursing staff have competencies to care for vulnerable residents requiring Respiratory Therapy Services when Respiratory therapists are not in the building or that licensed practical nurses (LPN's) scheduled to care for the residents with respiratory needs are not working outside their scope of practice and if delegated to, they are competent to carry out delegated tasks with supervision from competent registered nurses (RN). Facility failure to provide nursing staff with Respiratory Therapy Services competencies to vulnerable residents on the ventilator unit created a finding of immediate jeopardy that began on 1/25/2025. Surveyors notified the nursing home administrator (NHA)-A, Director of nursing (DON)-B of the immediate jeopardy on 2/6/2025 at 10:53 AM. On 2/13/25 Surveyors retuned to the facility to verify removal of the immediate jeopardy and complete the partial extended survey tasks. Based upon observation, interview and record review on 2/13/15 it was determined the immediate jeopardy was not removed upon exit from the facility. Findings include: The facility policy titled Respiratory Therapy Policy and Procedure: Respiratory Assessment reviewed on 7/2024 and applies to Nursing Services and Respiratory Therapy documents: POLICY: A respiratory assessment will be performed on the following residents to ensure proper respiratory treatments, equipment, and modalities are ordered to meet the resident's needs. 1. New admissions and re-admission to Respiratory Unit. 2. New admissions and re-admissions of resident's underlying pulmonary diagnosis, respiratory treatments, oxygen therapy, or a tracheostomy (Trach), by physician order. 3. Any resident with a change in condition requiring respiratory treatments or oxygen therapy, or with signs and symptoms of respiratory infection, by physician order. Procedure: 1. List cardiopulmonary history. 2. Document heart rate, respiratory rate, oxygen saturation, fraction of inspired oxygen/ liters per minute (FiO2/LPM, amount of oxygen in the air that a person inhales), breath sounds, sputum (saliva/mucus coughed up from the respiratory tract) color/ consistency/volume, expiratory time, breathing pattern, and ability to cough effectively. 3. If a trach resident, document the trach size and type, insertion or change date, and stoma site integrity. 4. If a ventilator (vent) resident, document the ventilator setting including the mode, tidal volume, respiratory rate, peep, FiO2, the amount of pressure support and any weaning plans. 5. Check the planned modalities of treatment for the resident. 6. List any pertinent comments vital to their (resident's) treatment. The facility policy entitled Respiratory Therapy Policy and Procedure: Ventilator Alarms and Call Lights Response reviewed on 7/2024 and applies to Nursing and Respiratory Therapy documents: Policy: Ventilator alarms will be responded to immediately by all staff. Alarms notify staff of life-threatening situations. Call lights will be responded to by all staff and care will be provided within the scope of the caregiver or reported to the caregiver needed to provide the care needed. The care provided will be documented appropriately. Procedure: 1. Determine if alarm is respiratory related. a) Respiratory related alarms include but not limited to: i. Patient needs suctioning. ii. Continual high pressure without cares. iii. Alarming after cares. iv. Patient disconnect. v. Unwitnessed alarms of unknow origin. vi. Call light from tracheostomy needing respiratory care. b) If the alarm is respiratory related provide emergency care as needed. c) Assess residents and provide needed care. d) Reassess residents and provide any care indicated. e) Document assessment and cares provided using respiratory assessment form in MatrixCare or on paper respiratory assessment form. f) Completed paper forms are to be placed in respiratory basked located near the Director's office. The facility policy entitled Respiratory Therapy Policy and Procedure: Suctioning (oral cavity) reviewed on 7/2024 and applies to Nursing Services and Respiratory Therapy documents: Policy: Oral suction will be performed according to proper practice standards. General Information: 1. Oral suctioning removes secretions from the oral cavity by means on a Yankauer inserted in the mouth. The procedure is used to: 1.1 Prevent aspiration 1.2 Decrease the potential for infection that may result from accumulated oral secretions. 2. Procedure to be performed by the respiratory therapist (RT), registered nurse (RN), licensed practical nurse (LPN), or certified nursing assistant (CNA). 3. Emergency suction machines are kept at kept on all nursing units. 4. For frequent suctioning, assign a machine to the resident and keep at bedside. The facility policy entitled Respiratory Therapy Policy and Procedure: Suctioning (oral/nasopharyngeal) reviewed on 7/2024 and applies to nursing services and respiratory therapy documents: Policy: Oral-Nasopharyngeal suction will be performed according to best practice. General information: 1. Oral-nasopharyngeal suction removes secretions from the pharynx by means of a suction catheter inserted through the mouth or nose. This procedure is used to: a) Maintain airway patency-prevent aspiration. b) Decrease the potential for infection that may result in accumulated secretions. c) Stimulate an effective cough and expectoration. 2. Procedure to be performed by RTs, RN, or LPN. The facility policy entitled Respiratory Therapy Policy and Procedure: Tracheostomy- Care and Maintenance reviewed on 6/2024 and applies to nursing and respiratory services documents: Policy: Tracheostomy care will be provided according to proper practice standards. General Information: . Safety: . 2. Keep an ambu bag visible in room. Take ambu bag with resident when off unit. The facility policy entitled Respiratory Therapy Policy and Procedure: Treatments- Administration/ Documentation reviewed 7/2024 and applies to nursing services and respiratory services documents: Policy: To administer and the document all treatments on the Treatment Administration Request (TAR) or Respiratory Medication Administration Record (MAR) in the Electronic Medical Record (EMR). General Information: 1. Treatments and medications administration records are to be kept in the EMR. 2. All treatments including directions, sites, etc. will be transcribed in the EMR according to physician orders by . nurse, or RT and verification will be done by RN/LPN/RT. 3. All treatments performed by RN's, LPN's, RT's, and CNA's will be documented in the EMR. Surveyor notes that all the policies and procedures noted above are based on Lippincott Nursing procedures. Surveyor also notes that the above policies and procedures do not differentiate who does what. (Nursing services versus therapy services). There is no delegation of responsibilities for the specialized care on the ventilator/ tracheostomy unit. R1 RESPIRATORY SERVICES CONCERNS: * R1 was admitted to the facility on [DATE] and has diagnoses that include acute on chronic respiratory failure with hypoxia, ataxia following cerebral infarction, quadriplegia, legal blindness, anoxic brain injury, and epileptic seizures. R1 has a tracheostomy (non-ventilator dependent/requires trach mask hooked up to oxygen), gastrostomy and jejunostomy tube, R2 is non-verbal and not able to make needs known. On 1/27/2025, 1:46 PM, in the progress notes licensed practical nurse (LPN)-N documented . R1's family at bedside with concern that R1 has increased secretions and reports R1 had vomited. Per assessment R1 did not vomit and had normal amount of yellow tinged sputum and (sic) trach site. LPN-N provided oral care. R1's family member reports suctioning R1 themself without staff assistance or oversight. On 1/30/2025, at 10:25 AM, Surveyor observed R1's family at R1's bedside. Family member-J stated that the facility taught them how to suction R1 because R1 is getting ready to go home. Surveyor asked if family was allowed to suction R1 without staff present. R1's family member-J stated that there is never staff around or staff that know how to do it, so family member-J does it. Family member- J stated that on 1/27/2025 family member-J suctioned R1 because R1 had some emesis and there was not a respiratory therapist (RT) in the facility and R1's nurse did not know how to suction R1. On 2/3/2025, at 10:39 AM, Surveyor interviewed LPN-N who stated family member-J told LPN-N that family member-J was suctioning R1. LPN-N stated that R1's family member-J stated R1 has emesis and was suctioning R1's mouth out. LPN-N stated that R1 was not having emesis, and it was normal drainage. LPN-N stated that LPN-N normally does not work on the vent unit so got another nurse to help suction R1 because there was not a RT in the facility at that time. LPN-N stated LPN-N does not suction or do any trach cares for the residents on the vent unit, so LPN-N will call the nursing supervisor or get another staff member to do those tasks if they were needed. Surveyor asked LPN-N what LPN-N would do if there was an emergency with a resident that had a Trach. LPN-N stated LPN-N would call the supervisor, call the doctor/nurse practitioner (NP), or send the resident out to the hospital. On 2/3/2025, at 2:45 PM, Surveyor was called into R1's bedroom by R1's family member-J. Family member-J stated that R1 went to the hospital on 1/31/2025 and came back to the facility on [DATE] early in the morning. When R1 and Family member-J arrived back at the facility around 5:00 AM on 2/1/2025 there was no RT in the building and the nurse on the unit did not know how to hook R1's trach mask up to the oxygen and asked family member-J to do it. Surveyor reviewed R1's progress notes and noted that there was no progress notes documented of R1 returning to the facility on [DATE]. Surveyor reviewed the schedule for 1/31/2025 night shift (10:00 PM- 6:30 AM 2/1/2025). Surveyor notes that there was not a RT assigned during the night shift and 1 registered nurse (RN) and 1 LPN nurse, both from an agency, were assigned to work the ventilator unit. On 2/3/2025, at 3:15 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R1's family member was suctioning R1 and hooked R1's trach up to oxygen because staff were not available that had competencies in completing those tasks/cares. DON-B stated it would get looked into. VENT UNIT NURSING COMPETENCY/ STAFFING CONCERNS: * The facility has a total of 59 beds available for residents requiring a ventilator. Currently the facility has 9 ventilator dependent and 7 non-ventilator dependent residents with tracheostomies with schedules of receiving oxygen via a trach mask requiring respiratory cares/ services. The Facility advertises on the facility website at https://www.vmpcares.com/healthcare/ventilator-care/ and through brochures that it has 24/7 respiratory therapists and ventilator certified nurses. On 1/30/2025, at 1:13 PM, Surveyor interviewed Scheduler-P who stated depending on facility census scheduler-P tries to schedule 2 respiratory therapists (RT's) on the ventilator unit for day (6:00 AM- 2:30 PM) and Evening (2:00 PM- 10:30 PM) shift; for night shift (10:00 PM- 6:30AM) 1 RT is to be scheduled. Surveyor asked what happens to the schedule if a RT is not available. Scheduler-P replied that requests to work go out to other facility RT's or ask for RTs to stay on shift for incentive. Scheduler-P stated that if an RT is not available then an agency RT is called in. Surveyor asked how it is determined when an RT is not available to work that nursing staff have the competencies to care for residents on the ventilator unit. Scheduler-P stated that all nursing is able to perform suctioning for residents. Surveyor asked about nursing competencies for the ventilator and tracheostomy cares. Scheduler-P stated that Director of Nursing (DON)-B has a list of nurses that have training with the ventilator and DON-B will communicate with Scheduler-P who to schedule if RT is not available. Scheduler-P stated that DON-B has that list. On 2/3/2025, at 3:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who stated that the facility has experienced some changes recently with staffing RT's. DON-B stated RT staff have been leaving for other opportunities and administration noted that they had to do something. DON-B stated that on 1/9/2025 several nursing staff attended a ventilator certification course. DON-B stated that if an RT is not scheduled then they make sure to have one of the nursing staff that attended the course on the unit. DON-B stated that RT's used to make up their own schedules and primarily report to the pulmonologist but with the RT's leaving, the scheduling and reporting has changed to Scheduler-P and RT's now report to DON-B. NHA-A stated that there has been discussion on transferring all the residents with ventilators to the same unit and all the residents with tracheostomies will be on another unit. NHA-A stated that way they could have all the ventilators together and plan on having 1 RT, 1 nurse and 2 CNAs scheduled to that unit. NHA-A also stated that there is a plan to get all nurses to the ventilator certification course. On 1/30/2025, at 1:37 PM, Surveyor interviewed licensed practical nurse (LPN)-O who stated LPN-O received training on how to suction, perform trach cares, and trach ties when hired. LPN-O stated there was no ventilator training on hire and that LPN-O was not authorized to touch the ventilator or change settings. Surveyor asked LPN-O if a ventilator alarm went off and an RT was not available what would nursing do. LPN-O stated that if an alarm on the ventilator went off it could mean that the resident was in distress, so LPN-O would assess the situation and call the supervisor, on call doctor/ nurse practitioner (NP), or pulmonary on call. Surveyor asked what would happen in event of emergency and no one was available right away when called. LPN-O stated 911 would be called and send the resident out for further evaluation. On 2/3/2025, at 8:04 AM, Surveyor interviewed Anonymous staff-D who stated education was provided on how to suction, give treatments, and trach cares. Anonymous staff-D stated that if there was no RT on the unit and there was a concern that nursing would call the pulmonologist, and if there was concern or a resident was noted to be in distress, then nursing would send out to get further evaluation. Anonymous staff- D stated that nursing can touch the vent to a point, but does not touch settings or change anything, usually it is just to silence an alarm that may be going off. On 2/3/2025, at 10:45 AM, Surveyor interviewed RT-Q who stated RTs provide suctioning, trach cares, and oral cares to residents on the ventilator unit. RT-Q stated that not all of the residents have the pulmonary oversight like all the ventilator dependent residents do and technically nursing staff can do the suctioning and trach cares, but RT will do the cares if nursing staff ask them to because not all the nursing staff is sure on how to do suction or trach cares or has not done it for a long time. On 2/3/2025, at 11:02 AM, Surveyor interviewed RN supervisor-M. Surveyor asked RN-Supervisor-M how it is assured that the nurses scheduled on the vent unit have the competencies to care for the residents if RT is not in the building. RN supervisor-M stated he would need to get back to surveyor with that information since RN supervisor-M does not make up the schedule. Surveyor asked what the expectation of nursing staff is if a resident on a ventilator needed assistance, and no RT was available. RN supervisor-M stated that the doctor/NP, and pulmonary NP are on call 24/7 to get direction. RN supervisor-M stated that currently the facility is working on getting the nursing staff ventilator certified, but only a handful has been through the certification so far. On 2/4/2025, at 8:37 AM, Surveyor interviewed anonymous staff-C who stated that the RN supervisor is not directly assigned a unit but oversees the whole building. Anonymous staff-C stated that the RN supervisor is not always available for supervision of staff because they get pulled everywhere, whether it involves taking on a unit due to a call in, working with an admission, working on a discharge, or other tasks. The RN manager does not always have time to directly supervise someone. Surveyor asked what kind of cares nursing provides to the residents that are ventilator and non-ventilator dependent on the vent unit. Anonymous staff-C stated that the RT does most of the trach suctioning, trach cares, and vents. Anonymous staff-C stated they would be hesitant to hook up a resident to oxygen if they had a trach mask because they have never done it before and anonymous staff-C stated they do not touch or do anything with the ventilators and has never had any training on what to do. Surveyor asked anonymous staff-C what nursing staff would do in the event of an emergency or someone on a ventilator needed assistance. Anonymous staff- C stated that they would call the on-call doctor or send the resident out but would not be comfortable doing anything with the ventilators. Surveyor requested to look at what competencies nursing (LPN and RN) are expected to be able to perform at the facility. The following competencies were documented that pertain to the ventilator/trach unit: - Oral Hygiene - Oxygen - Trach care/ inline suctioning. Surveyor notes that there are no ventilator competencies. On 2/4/2024, at 3:23 PM, Surveyor interviewed NHA-A and DON-B. Surveyor asked how it is determined that the ventilator unit has staff that are competent and how do they ensure agency staff have the competencies to a care for the vulnerable residents that require ventilator/trach cares. DON-B stated that when an RT is not scheduled, they always make sure a nurse that went to the vent certification course is scheduled to the unit. Surveyor asked how are the LPN's that were certified supervised and delegated on the unit with such vulnerable residents. DON-B stated that there is a nursing supervisor on the schedule, 24/7 on call doctor/NP, and pulmonary doctor/NP are always available by phone 24/7. DON-B stated that DON-B is always available by phone as well. Surveyor asked what if there was a situation that required emergent care for the resident, and no one was available. DON-B stated that staff would call 911 and send the resident out to be further evaluated. Surveyor requested to review the education provided in the ventilator certification class and what staff attended the class and the check off competencies for trach care/ in line suctioning provided to nursing staff upon hire. DON-B stated that there is not a check off competency and the DON-B will go over it with staff. Surveyor requested to see what DON-B goes over with nursing staff. DON-B stated she will write something up. On 2/5/2025, at 9:18 AM, Surveyor was provided the Ventilator Certification course material and DON-B stated that the facility staff that attended the course on 1/9/2025 included: DON-B, Staff development Coordinator, and 5 LPN's. DON-B stated the next class offered will be in March 2025. Surveyor asked if any of the RN supervisors were educated on the ventilator. DON-B stated that no RN supervisors attended the course, but RT gave some education to nursing staff. Surveyor requested to see what the RT went over with staff, and who RT went over it with. Please note, Surveyor has not received a list of staff or education RT went over with facility staff on the ventilator unit or what DON-B goes over with staff regarding suctioning, and trach cares at time of write up. Surveyor reviewed the course material for the ventilator certification course. The Adult Ventilator Care Certification course was provided through [Hospital] and the instructors were Respiratory care practitioners employed at [Hospital]. The class was eight hours and included handouts, lecture, return demonstrations and a 50 question exam. The class objectives included: 1. Verbalize the components of routine pulmonary assessment including: a. Ventilatory pattern. b. Breath sounds. c. Sputum characteristics. d. Oxygenation. 2. Ability to discuss the components of oxygenation systems and auxiliary oxygen delivery devices. 3. Demonstrate tracheostomy tube change, site care, and suctioning. 4. Ability to recognize and react to tracheostomy emergency situations. 5. Ability to adjust ventilator settings according to physician orders. 6. Ability to troubleshoot ventilator settings and alarms. Surveyor notes that 2 staff members that attended the ventilator certification course (LPN-O and Anonymous staff-D) stated that the nursing staff do not touch the ventilator and just verify settings and would call the on-call supervisor, doctor/ NP, pulmonary doctor, and call 911 in event of an emergency. That does not match up with what was taught in the ventilator certification course on 1/9/2025 for staff to complete. During interviews, there were staff, (despite possibly attending the 1/9/25 training) that still do not feel comfortable providing respiratory cares. Surveyor reviewed the staff schedules for January 2025, the following dates/ shifts had the following staff scheduled without a RT scheduled: (note shift hours - Day shift: 6:00 AM - 2:30PM, Evening shift: 2:00 PM- 10:30 PM, Night shift 10:00 PM - 6:30 AM). 1/5/2025: Day shift- no RT scheduled; 2 LPNs scheduled both vent certified Evening shift- RT scheduled for 6:30 PM - 10:30 PM, 2 LPNs scheduled both vent certified Night shift- no RT scheduled, 1 agency LPN, 1 LPN vent certified. 1/6/2025: Evening shift- RT scheduled for 6:30 PM- 10:30 PM, 1 agency LPN, 1 LPN vent certified. 1/7/2025: Evening shift- no RT scheduled, 1 LPN scheduled 2:00PM - 6:30PM, 1 LPN scheduled 6:30PM- 10:30PM, 1 LPN vent certified. Night shift- no RT scheduled, 1 agency RN, 1 LPN vent certified. 1/8/2025: Evening shift- RT scheduled from 6:30PM- 10:30PM, 1 LPN schedule for 2:30PM - 6:30PM, 1 LPN, 1 LPN vent certified. 1/10/2025: Evening shift- RT scheduled until 7:00PM, 1 LPN, 1 agency LPN Night shift- no RT scheduled, 1 agency LPN, 1 LPN vent certified. 1/13/2025: Evening shift- No RT scheduled until 6:30PM, 2 LPN both vent certified 1/23/2025: Night shift- no RT scheduled, 1 LPN, 1 LPN vent certified 1/25/2025: Evening shift- No RT scheduled for 6:30 PM- 10:30PM, 1 LPN, 1 agency LPN 1/27/2025: Day shift- no RT scheduled, 1 agency LPN, 2 LPN vent certified 1/31/2025: Night shift- no RT scheduled, 1 agency RN, 1 agency LPN, no RN supervisor listed 2/1/2025: Night shift- no RT scheduled, 1 agency RN, 1 LPN vent certified, no RN supervisor listed Surveyor notes that according to chapter N6: Standards of Practice for Registered Nurses and Licensed Practical Nurses documents the following: N 6.04 Standards of practice for licensed practical nurses: (1) PERFORMANCE OF ACTS IN BASIC PATIENT SITUATIONS. 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: (a) Accept only patient care assignments which the L.P.N. is competent to perform. (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data. (2) PERFORMANCE OF ACTS IN COMPLEX PATIENT SITUATIONS. In the performance of acts in complex patient situations the L.P.N. shall do all of the following: (a) Meet standards under sub. (1) under the general supervision of an R.N., physician, podiatrist, dentist or optometrist. (b) Perform delegated acts beyond basic nursing care under the direct supervision of an R.N. or provider. An L.P.N. shall, upon request of the board, provide documentation of his or her nursing education, training or experience which prepares the L.P.N. to competently perform these assignments. On 2/5/2025, at 10:35 AM, Surveyors shared concerns with NHA-A and DON-B of the oversight of the vulnerable residents residing on the ventilator unit and staff having the ability to assess and treat residents when necessary. Surveyor shared concern with NHA-A and DON-B that the ventilator unit is specialized, and the RT's have their tasks and expertise, however RT's do not have the ability to delegate tasks to LPN's. Surveyor shared concerns that there is no direct oversight of an RN over the LPNs on the unit and that no RN's are vent certified that would oversee the LPN's. Surveyor asked how the tasks are delegated to the LPN if there is no RN supervision over the LPN staff that is scheduled especially if the RN did not have ventilator training. DON-B stated that there is always an RN supervisor on each shift and they can contact DON-B if not in the building, doctor/NP on call, or the pulmonary on call. Surveyor asked to clarify the RN supervisor role. DON-B stated that the RN Supervisor oversees the whole facility. On day and evening shift there is 1 RN supervisor for 2nd floor, 1 RN supervisor for 1st floor, and night shift there is 1 RN supervisor for the whole building. Surveyor asked if a RN supervisor is directly assigned only for the ventilator unit. DON-B stated there is not an RN supervisor assigned only to the ventilator unit. Surveyor shared concern that facility staff do not have all the competencies or direct oversight to care for residents that are ventilator and non-ventilator dependent residing on the ventilator unit when a RT is not in the building. Surveyor shared concerns with DON-B that not all RN supervisor staff have the competencies or feel confident about caring for residents on the ventilator unit. 49845 * R7 was admitted to the facility on [DATE] with diagnoses that include Acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood stream), dependence on respirator (ventilator, Pneumonitis due to inhalation of food and vomit, and Chronic obstructive pulmonary disease with exacerbation. R7's Admission Minimum Data Set (MDS), dated [DATE], documents in part that R7 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R7 is cognitively intact. R7's MDS documents R7 has Respiratory treatments documented as: continuous oxygen therapy, suctioning as needed, tracheostomy care, invasive mechanical ventilator, and had 7 days of respiratory therapy for at least 15 minutes a day in the last 7 days. On 02/04/2025, at 10:18 AM, Surveyor interviewed R7, who indicated having no concerns. Surveyor reviewed R7's Facility provided document, titled Care Plan for R7. Surveyor noted, R7's care plan documents the following problem category, Pulmonary and documents R7 has alteration in respiratory status related to ventilator/trach use. Surveyor noted R7's care plan documents in part the following: . Change trach Q (every) 6 weeks & as needed (PRN) . Change tubing, masks, cannula & other equipment, per protocol . Check O2 (oxygen) settings Q4H (every 4 hours) & PRN . Elevate HOB (head of bed) to 30 degrees . Encourage pursed lip breathing . Humidifier, per MD order . Lab/Diagnostic work, per MD orders . Maintain patent airway . Maxorb 2 Ag+ Alginate wound Dressing with silver placed under Tracheostomy dressing TID (three times daily) for wound . Mechanical Vent Support, per MD orders . Monitor and report signs of hypoxia (cyanosis (blue skin), tachypnea (fast breathing), dyspnea (shortness of breath), confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) . Monitor for S/Sx (signs/symptoms) of respiratory infection, shortness of breath . Monitor O2 sats, Q4H & PRN . Monitor oxygen saturation via pulse oximetry Q4 hours & PRN when on continuous oxygen therapy . Monitor Respiratory status, per MD orders or PRN . Oral Hygiene Q Shift & PRN . Provide calm environment free of stimuli to reduce /prevent anxiety . Resident will require a minimum of 7 hours each night of ventilator support chronic respiratory failure with hypercarbia. This will be continuous. Resident to be on ventilatory support each night and PRN during the day. Sip/puff call light . Stonghold device to be placed to prevent accidental ventilator disconnection. Suction PRN per MD orders . Trach care Q Day & PRN . Vent Settings: ACVC 450/18/5+ FiO2 to keep SpO2 at or above 92% . R7's respiratory care plan with a problem start date of 11/23/2024 includes an intervention with an approach Start Date of 12/19/2024. Respiratory therapy: ___ (specify plan -nebulizers, inhalers, etc.). Surveyor noted this was not individualized or complete for R7. On 02/04/2025, Surveyor reviewed R7's document titled, Physician Order dated 02/04/2025, and noted orders related to R7's medications, treatments, and enhanced barrier precautions and no orders related to ventilator care and/or management is documented. Surveyor reviewed the Facility provided document titled, Physician Order Report, dated 01/01/2025-01/31/2025, which documents R7 had documented Respiratory orders with a start date of 11/21/2024 and discontinued on 01/06/2025. Surveyor reviewed the Facility provided document titled, Physician Order Report, dated 12/18/2024-12/31/2024, which documents R7 had Respiratory orders documented with a start date of 11/21/2024 and discontinued on 01/06/2025. ORDER INTERVIEWS On 02/04/2025, at 10:25 AM, Surveyor asked Respiratory Therapist (RT)-R to show Surveyor what R7 has for Respiratory Therapy while in R7's room. RT-R indicated R7 is on a ventilator at night and switched to an aerosol, T-piece valve (a specialized adaptor used to safely deliver aerosolized medications to an individual who is on a ventilator) during the day, which R7 currently had on. RT-R indicated that nurses are responsible for ensuring R7 is on the ventilator at night and taken off the ventilator in the morning when RT is not at the Facility. Surveyor asked RT-R how nursing staff or agency staff would know of R7's ventilator orders, RT-R indicated that RT orders are separate from the nursing orders and was not sure if nursing staff could see the RT orders for R7. RT-R indicated that report would be given to the next shift from RT or RN supervisor. RT-R indicated that RT-R was the lead RT until recently when he was demoted after a meeting with NHA-A and DON-B regarding RT to resident ratios. On 02/04/2025, at 10:30 AM, Surveyor [TRUNCATED]

Based on interview and record review, the Facility did not ensure a resident received treatment and care in accordance with professional standards of practice to include individual assessment and reporting when experiencing a medical change of condition, per standards of practice for respiratory therapists. This was discovered with 1 (R2) of 1 resident reviewed that had a medical change of condition while on a ventilator. On [DATE], at 11:12 PM, there was a progress note written by the Respiratory Therapist (RT)-T that indicated shortness of breath was present for R2 and that this was new, not chronic. RT-T raised R2's oxygen flow rate from 5 lpm (liters per minute) to 8 lpm. There is no evidence that any further assessment was completed indicating why to increase the flow rate or to help determine why R2 was newly short of breath. There is no evidence of further assessment to determine if increasing the oxygen flow rate improved the shortness of breath symptoms. There is no evidence this change of condition was communicated to the Registered Nurse working the same shift or to staff working the next shift. There is no evidence the change of condition was reported to R2's physician for consultation and treatment. R2 passed away in the Facility and was found deceased for several hours on [DATE] and pronounced dead at 8:40 AM by the Pulmonary Doctor. The Facility's failure to provide assessment and follow up created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A of the immediate jeopardy on [DATE], at 10:53 AM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The Facility Policy titled Notification of Changes last reviewed ,d+[DATE], documents (in part) . Policy: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident . Procedure: 1. The nurse will immediately notify the resident, resident's physician, and the resident representative(s) for the following (list not all inclusive): An SBAR (situation, background, assessment, recommendation) will be completed in the EMR (electronic medical record) to reflect pertinent info to notify the physician of . B. A significant change in the resident's physical, mental, or psychosocial status. C. A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. D. A need to alter treatment significantly . 2. The nurse will notify the resident, resident's physician, and the resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician . The Facility Policy titled Respiratory Assessment last reviewed ,d+[DATE], documents (in part) . Policy: A Respiratory Assessment will be performed on the following residents to ensure proper respiratory treatments, equipment, and modalities are ordered to meet the resident's needs . 3. Any resident with a change of condition requiring respiratory treatments or oxygen therapy . General Information: The Respiratory assessment is performed one time for each of the above and charted in the EMR (Electronic Health Record). Procedure: 1. List Cardiopulmonary history. 2. Document heart rate; respiratory rate; O2 (oxygen) Saturation; FiO2/LPM (fraction of inspired oxygen/liters per minute); breath sounds, sputum color, consistency, and volume; expiratory time, breathing pattern; and ability to cough effectively. 3. If a trach resident, document the trach size and type; insertion or change date; and stoma site integrity. 4. If a vent resident, document the ventilator settings including the mode, tidal volume, respiratory rate, peep, FiO2; the amount of pressure support; and any weaning plans. 5. Check the planned modalities of treatment for the resident. 6. List any pertinent comments vital to their treatment. According to the American Association for Respiratory Care, The practice of a respiratory therapist is directed by a licensed independent practitioner and is determined by state licensure laws where applicable. The practice typically focuses on: . o Direct and indirect patient observation and monitoring of signs, symptoms, reactions, general behavior and general physical response to respiratory care and diagnostic interventions. o Implementation of respiratory therapy procedures, medical technology, and diagnostic procedures necessary for disease prevention, treatment management, and pulmonary rehabilitation . The responsibilities of a respiratory therapist include, but are not limited to: 1. Performance and collection of diagnostic information . https://www.nbrc.org/wp-content/uploads/,d+[DATE]/AARC-Scope-of-Practice.pdf R2 was readmitted to the facility on [DATE]. R2's pertinent diagnoses include chronic respiratory failure with hypoxia, chronic kidney disease-stage 4, dependence respirator (ventilator) status, major depressive disorder, generalized anxiety disorder, insomnia, hypertensive chronic kidney disease, acute on chronic systolic (congestive) heart failure. R2's Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE] indicated R2 had a Brief Interview for Mental Status score of 14 (cognitively intact). R2 is responsible for self. R2 is listed as full code for resuscitation. R2's MDS showed that oxygen therapy, suctioning, tracheostomy care and invasive mechanical ventilator were used for respiratory treatment. R2 is assessed as having no impairment to upper or lower extremities and R2 uses a wheelchair for mobility. R2 is assessed as occasionally incontinent of bladder and frequently incontinent of bowel. R2 has a pulmonary care plan which documents R2 has potential for complications from COPD (chronic obstructive pulmonary disease), respiratory failure, CHF (chronic heart failure). Pertinent interventions include: Monitor for complications such as dyspnea, shortness of air, cyanosis or tachypnea. Start Date [DATE] Monitor Oxygen saturation and administer Oxygen per physician orders. Start Date [DATE] Provide treatment per physician's orders and monitor for response. Observe for side effects and inform physician. Start Date [DATE] Administer medications per orders and monitor for response. Observe for side effects and inform physician prn. Start Date [DATE] R2 has an alteration in respiratory status vent/trach care plan which reads R2 has alteration in respiratory status related to ventilator/trach use. Pertinent interventions include: Monitor and report signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) Start date [DATE] Monitor O2 (oxygen) sats (saturation). Q (every) shift & PRN Start Date [DATE] Monitor for signs and symptoms of respiratory infection, shortness of breath. Start Date [DATE] RT (respiratory therapist) consult as needed Start Date [DATE] Monitor oxygen saturation via pulse oximetry Q shift and PRN when on continuous oxygen therapy. Start Date [DATE] Check O2 settings Q shift and PRN Start Date [DATE] Maintain patent airway Start Date [DATE] Suction PRN per MD (medical doctor) orders Start Date [DATE] Airway checks, q shift and PRN Start Date [DATE] FiO2 (fraction of inspired oxygen) to keep SpO2 (oxygen saturation) at/above 90% Start Date [DATE] Surveyor reviewed the electronic medical record (EMR) and found physician orders related to R2's ventilator (vent) and tracheostomy (trach) care which included: Vent Settings: PC (pressure control) ,d+[DATE] / RR (respiratory rate) 18 / FIO2 TO KEEP SPO2 AT / ABOVE 90%, Every Shift, effective [DATE] RT change trach Q12 weeks, Once A Day on Monday, effective [DATE] Surveyor notes a review of charting showed resident oxygen was kept at 5 liters leading up to the night of the incident. On [DATE], a respiratory progress note written by RT-T with time of 11:12 PM was entered with the notation of Recorded as Late Entry on [DATE] 03:15 AM. The progress note reads: Lung Sounds: diminished Respirations Rhythm/Pattern: Regular/Unlabored Cough present?: No Shortness of Breath present?: Yes (New or Chronic) New Fever present?: No Oxygen in use?: Yes (Liter Flow) 8 lpm Oxygen delivered by: Not Applicable Isolation Precautions in place?: Not Applicable Restlessness present?: No Anxiety present?: No Fatigue present?: No Comments: Vent settings: PC mode 25 PIP, 5 of PEEP, 18 RR, 5 lpm Actual PT: 25 PIP, 7.2 MVE, 386TV, 18 RR, Breath sounds: diminished Trach care: Gauze changed, and site cleaned Oral Care: mouth and gums brushed Secretions: PT (patient) didn't need suctioning Vital Signs: 84 HR (heart rate), RR (respiratory rate) 18, SPO2 97% Surveyor notes the progress note written by RT-T indicates R2 was having shortness of breath, which was new. The oxygen in use was recorded as 8 lpm. The vital signs were 84 for heart rate, 18 for respiratory rate, spo2 97%. There is no indication if these vitals were before or after the oxygen was increased. There is no subsequent follow up by RT-T. Based on interviews of staff working that shift (as shown below), there is no evidence RT-T communicated this change to other staff. No SBAR was completed and there was no communication with the physician. The next progress note was written by Registered Nurse (RN)-U on [DATE], at 05:10 AM. It documents writer went into room at 0500 to give resident her prn APAP (Tylenol) that she requests each morning. Resident was sleeping comfortably. Color was baseline and lips were pink. No complaints from either residents (sic) in that room all shift. Surveyor notes the last PRN dose of Tylenol recorded as administered on the MAR (Medication Administration Record) was at 12:27 AM, on [DATE], by RN-U. The next respiratory progress note was written on [DATE], by RT-S with time of 8:20 AM, which documents: Lung Sounds: N/A Respirations Rhythm/Pattern: Regular/Unlabored Comments: Vent Settings: Received on ACPC ,d+[DATE]+ R 18 on 10L (liters) Vent Actuals: VT 80 MVE 1.9 PIP 24.3 PMAP 5.3 I/E 1:1.1 Vital Signs: HR POX RR unable to obtain Breath Sounds: Unable to obtain Secretions: N/A Trach Care: N/A Oral Care: N/A Tx: N/A Misco: N/A Resident unresponsive between approx. ,d+[DATE]. RT bagged PT on 15L, nurse present, supervisor arrived. RT unable to obtain POX (pulse oximetry) and HR (heart rate) with POX device. BS (breath sounds) unable to be heard. Bilateral chest rise present from ventilation assistance. NP (nurse practitioner) present, nurse and nursing supervisor. Surveyor notes there is no documentation as to when oxygen was increased from 8 to 10 liters per minute. On [DATE], at 8:45 AM, a progress note was written by Nurse Practitioner (NP)-V that documents . evaluated at bedside this AM 0825, mottled/cyanotic/pupils fixed. No pulse/audible HR/ no BP/no respirations. Extremities stiff c/w (consistent with) rigor mortis. By estimation, pt likely expired at least several hours prior .reviewed with (Pulmonary Doctor) via phone, concurs, pronounced dead @ (at) 0840am. On [DATE], at 8:46 AM, Surveyor interviewed R8, the roommate of R2, and was told that R2 put the call light on that night and said something about breathing, roommate heard RT-T tell R2 that they turned up the oxygen. The Facility did an investigation after the incident and the statement Nursing Home Administrator (NHA)-A wrote as a statement from R8 indicates R8 reported that around 9pm she heard (R2) on the phone with her grandsons, playing a virtual game. Later, during the 3rd shift around 11pm, (R2) called the CNAs (Certified Nursing Assistants) to warm up her usual snack, hot pockets. (R8) stated that both she and (R2) received their breathing treatments close to midnight from the night (RT-T) and (R2) was fine at that time. (R8) also mentioned that she heard staff in the room about 3 times throughout the night . On [DATE], at 11:51 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-W who stated they were not her (R2's) nurse that day but NP-V went into R2's room and came out and said R2 was not breathing. During walk around between 6:,d+[DATE]:00 AM, R2 and roommate were sleeping which was not unusual. Later when LPN-W went into the room with NP-V, R2 was ashen in color and looked like she was sleeping. On [DATE] at 1:50 PM, Surveyor interviewed CNA-Z who stated they rounded at around 7am and thought R2 was sleeping at that time. On [DATE], at 2:11 PM, Surveyor interviewed RT-AA who worked the next shift after the incident. RT-AA stated that the incident could be attributed to poor communication, there was a change in condition that was not reported or passed on. Surveyor asked what that change was and was told by RT-AA it was that the oxygen had been increased on the night shift. On [DATE], at 2:52 PM, Surveyor interviewed LPN-X via phone and was told at around 7am LPN-X went into the room as the roommate's vent lights were going off, LPN-X turned off the vent lights and looked over both patients and they were both in their sleeping positions. On [DATE], at 10:44 AM, Surveyor interviewed RT-T via telephone who was on the night shift and increased the oxygen level for R2. When asked if R2 was experiencing a change of condition RT-T stated the oxygen was at 5 liters and that they did raise it to 8 liters. RT-T stated this is common to do. R2's pulse ox was at 91% but R2 was not having trouble breathing. RT-T saw resident in no distress and R2 did not tell RT-T there was a problem. Surveyor notes this shows discrepancy from the progress note written the night of the incident that indicates R2 was experiencing a new change in condition of shortness of breath and does not follow physician order to raise SPO2 to keep saturation above 90%, R2 was above 90% according to RT-T's statement. The Facility investigation after the incident included a statement NHA-A wrote from their interview with RT-T. (RT-T) stated that (R2's) vital signs were normal throughout the night and that he was able to administer treatments as scheduled. He stated he performed (R2's) breathing treatment around 11 pm, closer to midnight. (RT-T) last checked on her around ,d+[DATE]am, describing her as seemingly fine and possibly asleep. He stated that (R2) had not complained of any shortness of breath or distress during their interactions that night. (RT-T) noted that (R2) appeared stable and routine, with no indications of distress observed during their rounds. He expressed surprise at the news of her passing, stating that nothing seemed abnormal during the shift. Surveyor notes documentation of respiratory therapist administered treatments were requested starting with the night of [DATE] and Surveyor was provided the Medication Administration Record (MAR) for a nebulizer treatment done by nursing twice a day that was last done on the [DATE] second shift by Licensed Practical Nurse (LPN)-BB. Surveyor noted there was no documentation of a breathing treatment done by RT-T. Surveyor notes the discrepancy of RT-T's interview with Surveyor and statement of interview with RT-T from NHA-A. On [DATE], at 11:21 AM, Surveyor interviewed RN-U, via telephone, who was working on the night shift before R2 passed. RN-U stated that R2 was alert and oriented times 4, so would alert staff if there was an issue. RN-U stated she saw R2 at midnight, R2 was on her tablet and there were no complaints. When asked about the oxygen being increased RN-U stated that if there had been an issue RT-T would have let RN-U know and RN-U was not alerted of any change. On [DATE], at 1:43 PM, Surveyor interviewed LPN-BB, via telephone, who worked the PM shift before the oxygen level was increased. Surveyor asked if there was any indication of a change of condition for R2 to which LPN-BB responded no, R2 was vocal and would have been taken care of as needed, R2 was alert and oriented times 4 and would let RT, Nurse or aide know if there was any discomfort. On [DATE], at 8:23 AM Surveyor interviewed Pulmonary NP-V via telephone. NP-V could not remember the exact numbers but thought R2 was normally on ,d+[DATE] liters of oxygen and that the oxygen was increased to ,d+[DATE] liters. NP-V let Surveyor know that only the RT can increase the oxygen level, the resident cannot. NP-V stated that if the oxygen is increased that would suggest something is happening. NP-V remembers R2 looked like they were sleeping, NP-V checked on R2's roommate first, the room was dark. It was 8:,d+[DATE]:30ish in the morning and the curtain was closed between the two residents. When NP-V went to R2 their eyes were closed and they did not respond to verbal stimuli. R2 had no pulse or blood pressure, pupils were fixed and dilated, R2's body was cold and stiff when found so best estimate was R2 had been gone a few hours. On [DATE], at 10:23 AM, Surveyor interviewed RT-S, via telephone, who was on the shift that R2 was found deceased . RT-S did not check on R2 between the start of shift and time R2 was found deceased , they started the shift and had multiple issues to deal with before this occurred. RT-S was told the nurse and Certified Nursing Assistant on the shift thought R2 was sleeping when they rounded. R2 did not have any medications due from RT-S until 9 am. RT-S stated that NP-V found R2 deceased and determined this had been for hours due to the condition of R2's body. RT-S stated there was wrongdoing on the part of the night shift (NOC) RT-T, R2 was not tended to properly when they complained they could not breathe, and RT-T increased the oxygen flow rate. The NOC RT (T) reported no changes even though the RT (T) had raised the oxygen flow rate. RT-S told Surveyor that the NOC RT (T) raised the oxygen flow per the roommate because R2 told RT-T that R2 could not breathe. When RT-S responded to the call for help R2's oxygen was at 10 liters and 5 liters is the norm for R2. RT-S stated the raising of the oxygen liters was a change of condition that should have been reported. RT-S stated that it is in the scope of practice for an RT to increase oxygen flow level but need to assess what is going on. If the pulse ox is low need to determine if resident needs to be suctioned, if the inner cannula has a mucus plug or if resident needs a PRN breathing treatment. The RT needs to figure out why a resident cannot breathe, not just turn up the oxygen. On [DATE], at 1:27 PM, Surveyor spoke to RN-U, via telephone, to clarify when Tylenol was brought to R2's room around 5am how RN-U could tell R2 was sleeping, per RN-U R2 was upright in bed, breathing and when RN-U touched R2's arm, R2 moved a bit and was warm. Surveyor asked RN-U if a pain assessment or any assessment had been done at this time as RN-U was bringing in a PRN medication. RN-U shared there was no assessment of R2 at this time. Surveyor noted there is no indication of a nursing assessment throughout the shift. On [DATE], at 1:49 PM, Surveyor interviewed RT-Y who works PRN for the Facility. When asked about increasing a resident's oxygen level Surveyor was told an assessment would be needed in addition to checking the pulse ox. RT-Y stated you need to look and touch resident. An increase in oxygen would be considered a change in condition because it is not the normal for the resident. Communication of the change would be expected and did not happen in this case. RT-Y felt this was a failure on RT-T's part. On [DATE], at 2:38 PM, Surveyor followed up with NP-V and asked what should be done before increasing oxygen on a resident and was told the RT should assess for suctioning and assess the situation. Surveyor then asked what should be done after the oxygen is increased and was told if the resident remains hypoxic it means they could need suction, do not have good profusion, and need to check for a fever. If the problem persists RT would need to again contact the provider and get an order for a chest x-ray. Overall, the RT needs to do an assessment to figure out why the resident needs more oxygen, need to troubleshoot. NP-V agreed with Surveyor that not reporting an increase in the oxygen needs of a resident is a problem as this is a change of condition all team members should be aware of. Surveyor notes 3 interviews with RT's that work with R2 (RT-S, RT-Y, RT-AA) stated a need to increase oxygen would be a change of condition that should be assessed and reported to the physician for consultation. RT-S stated that it is within the scope of practice for an RT to increase oxygen flow level but need to assess what is going on. On [DATE], at 3:21 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding the NOC shift of [DATE] and R2's oxygen being increased from 5 to 8 liters. They stated that this would be part of the RT's job. Their assessment would include taking a pulse oximetry which would indicate the need for more oxygen. They also stated that there was a lack of checks on R2 because R2 was not a resident that needed to be checked for incontinence or needed to be changed on a schedule. They stated R2 was a highly functioning resident. Surveyor notes R2's care plan states R2 should be monitored for incontinence every ,d+[DATE] hours prn, staff should offer to assist with toileting with each encounter and whenever observed to be awake at night and supervision is required with transfer with a walker and gait belt. On [DATE], at 10:34 AM, Surveyor followed up with NHA-A and DON-B to find out what the rounding schedule should be on the unit, to which it was stated, for Certified Nursing Assistants and Nurses should be every 2 hours, there is not a set rounding requirement for RT's. NHA-A and DON-B went on to discuss RT-T's assessment the night of the oxygen increase showed R2's respiratory rate and rhythm were fine, and no treatment was needed, they stated that the documentation showed no physiological signs the patient was in distress. Surveyor asked DON-B if an assessment should be completed after a resident's oxygen is increased to which DON-B stated yes, that would be advised as best practice. They stated that because the charting says R2 was at 97% oxygen, R2 was not in distress. They stated that it must be factored in that R2 was a highly functioning resident, that R2 could suction themselves. When asked how oxygen got from 8 liters to 10 liters, NHA-A and DON-B did not have an answer. Surveyor again noted the vitals RT-T documented do not indicate if they were before or after R2's oxygen was increased and whether R2's shortness of breath had been resolved throughout the shift as no additional assessments or monitoring had been completed. Surveyor notes the physician orders state to increase the oxygen if below 90%. Surveyor has an interview with RT-T where RT-T stated R2 was at 91%, which was not within the parameter to increase the oxygen and that the 91% was never charted. Surveyor notes nowhere in the care plan is it stated R2 had been assessed and could suction themselves as indicated by NHA-A and DON-B. Surveyor notes there is no documentation on how the oxygen lpm got to 10. The conclusion to the Facility investigation includes Throughout the prior shift, staff were consistently attentive and frequently checked on (R2), as confirmed by interviews. (R2) was independent in most of her functional abilities and would call staff for any assistance. (R2) had a routine for most of her cares and typically requested assistance around 9am. During all staff visits to (R2's) room throughout the shift, nothing out of the ordinary was observed. (R2) had a recent hospitalization in November due to chronic heart failure (CHF) and it is likely that she experienced sudden cardiac arrest, a possibility supported by her medical history. It is important to note that the ventilator was set to assist control pressure support (ACPC) which means that while the machine was providing respiratory support, it would not have alarmed in the event of a sudden cardiac arrest . During this investigation, we identified areas for improvement and have since implemented walking rounds to exchange reports. Staff were educated on this new process to enhance communication and patient monitoring. The facility exercised due diligence in providing care for (R2) and responded appropriately to all her needs. Surveyor notes the care plan and assessments including the MDS do not support the statement that R2 was independent in functional abilities. Surveyor notes a new diagnosis of CHF would make R2 frailer and needing more assessment with a change of condition. It was also noted by Surveyor R2 had only been using a vent since late 2024. Surveyor notes that R2 had a change of condition that was not assessed appropriately or reported to other staff. R2's physician was not consulted with regarding the change in condition of shortness of breath leading to increasing R2's oxygen setting. R2 was not assessed/monitored during the shift by RT or nursing staff. R2 was found with their oxygen level raised to 10 lpm and deceased by the respiratory nurse practitioner-V. who indicated R2 had been deceased for a length of time based upon R2's physical condition at the time of finding R2 deceased . The Facility failed to take immediate action by not having follow up on the care provided to R2 following a change in condition the night before R2 passed. These actions created a reasonable likelihood for serious harm, thus leading to the finding of immediate jeopardy starting [DATE]. The facility removed the immediate jeopardy on [DATE] when the facility implemented the following: The Director of Nurses along with a consulting respiratory therapist will provide education to all nurses and RT's who will be delegated to the respiratory unit related to recognition of all respiratory changes of condition to include policies and procedures related to same and or other physiological changes of condition. Education included the following: Staffing expectations for all shifts related to the respiratory unit Change of condition policy and procedures titled: Physician Notification Respiratory policy and procedures which include: Mechanical Ventilation: Set up and Monitoring Oxygen Administration Pulse Oximetry Tracheostomy Care Notification and documentation expectations with change of condition Where to look for a comprehensive list of orders and treatment within the EHR Shift to shift report expectations and use of 24 hour report board Competency exercises - competency will include a return demonstration on care for a resident with a ventilator and or other open airway that includes verbal affirmation of what, when and whom to report any changes in condition. Nursing and respiratory staff will collaborate and communicate any change in condition as a team, implementing appropriate interventions as ordered by provider. Signs were posted at the clinical hub on the vent unit to inform clinical staff that if they have not received the competency, they are not permitted to work on the unit until they've received the training. All nurses and RT's will be required to view the in-service prior to their next working shift. Once present for their scheduled shift a competency will be provided by a DON or a verified competent facility designee. Education was started on [DATE] with PM shift. Education will continue on [DATE]. All nurses and RT's will be trained prior to their next working shift. Oxygen Administration Pulse Oximetry Tracheostomy Care Notification and documentation expectations with change of condition Where to look for a comprehensive list of orders and treatment within the EHR Shift to shift report expectations and use of 24 hour report board Competency exercises - competency will include a return demonstration on care for a resident with a ventilator and or other open airway that includes verbal affirmation of what, when and whom to report any changes in condition. Nursing and respiratory staff will collaborate and communicate any change in condition as a team, implementing appropriate interventions as ordered by provider. A competent RN will be designated to respond to all emergency situations for ventilator and tracheostomy residents at all times. The RN will be delegated and present and available to ensure timely and comprehensive assessments to any resident demonstrating a potential change in condition. This scheduling pattern will begin on [DATE] pm shift. The unit will be staffed with an RN who has demonstrated competency in caring for ventilator residents. CNAs will be scheduled to meet residents, and RT's scheduled as necessary. The Change of Condition policy, Physician Notification has been reviewed and modified to include; Examples of Change of Condition Notification expectations with change of condition Documentation of a change of condition Vital sign expectations All changes in condition will be listed on the 24-hour report board Facility standard of practice policies from [NAME] have all been reviewed, and implemented to include: Mechanical Ventilation: Set up and Monitoring, Oxygen Administration, Pulse Oximetry,Tracheostomy Care Shift to shift report expectations protocol has been developed to use with 24 hour report board Medical Director-EE consulted during the development of this corrective action plan. The DON and or designee will review progress notes and 24-hour report board daily for 1 month for any changes of condition to ensure all condition changes have been recognized and appropriate for the residents status. An audit tool has been developed to support identification of any condition change. Audits will continue daily for 1 month with ad hoc training provided as necessary for any missed opportunities. Audits will continue 3x per week for 2 months. The DON and or designee will observe the delivery of respiratory care assigned by nurse or RT 3x per week for two weeks and weekly observations for two months. All audits will be brought to the Quality Improvement Committee for review and recommendations.

Based on interviews and record reviews, the facility failed to implement interventions when 1 of 6 residents (R5) reviewed for elopement out of a total sample of 11 was assessed as being at risk for elopement. R5, who was described as extremely confused, was assessed as being high risk for elopement on 12/14/23 and should have had a departure alert bracelet in place at that time. R5 was last seen on 12/16/23 between 4:00 PM and 4:15 PM. Staff identified that R5 was not in the building at 4:30 PM. R5 crossed a heavily traveled 4 lane street and was found by a neighbor in their yard at 4:50 PM. The resident was outside unsupervised and without the staff's knowledge of the resident's whereabouts for approximately 20 minutes. R5 did not have a wanderguard placed until after the elopement. Failure to implement interventions for a person who was at high risk for elopement created a finding of immediate jeopardy, which began on 12/16/23. NHA A (Nursing Home Administrator) DON B (Director of Nursing) CCO (Chief Clinical Officer) and COO (Chief Operating Officer) were notified of the immediate jeopardy on 01/10/2024 at 4:23 PM. The immediate jeopardy was removed on 12/18/23; however, the noncompliance continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: A review of a facility policy titled Wanderer Care, revised in January 2023, revealed, Policy: Measures will be taken to make every effort to be aware of the location of all residents and to provide safety for the identified wanderers . 2. Residents who are identified at risk to wander and high risk to wander must have an individualized plan of care completed by Social Services. 3. Wandering Risk Scale Directions and Use specified, d) Assess Resident in the following areas: i. Mental status, ii. Mobility, iii. Speech patterns, iv. History of wandering, v. Diagnosis of dementia e) Check the most appropriate box in each section. f) The score will total on the bottom right-hand side of the assessment. Scores of: 0-8 Low Risk to Wander; 9-10 At Risk to Wander; and 11 and above High Risk to Wander . b) If the resident is identified as At Risk to Wander. Initiate interdisciplinary care plan accordingly and follow plan of care. c) If the resident is identified as High Risk to Wander, the following actions must be taken: i. Initiate interdisciplinary care plan including specific approaches/interventions and time-measured goals. Review and update as needed, but no less than quarterly. ii. Inform patient representative of the identification methods being taken. iii. Apply [departure alert bracelet], provide name band, and label all clothing. iv. Once determined resident is a wanderer this information will be communicated to other departments via email. a. Resident's name and room number will be added to the wander list. b. Wander list will be updated by Social Services ongoing and reviewed weekly. c. Changes and updates as they occur will be forwarded to all departments by Social Services. v. The list of wanderers will be kept in a purple binder in all departments along with a picture and room number of each resident identified as a wanderer. R5 was admitted on [DATE] with diagnoses that included cerebral infarction (stroke), cerebrovascular disease, paroxysmal atrial fibrillation, and aphasia (a language disorder that affects a person's ability to communicate). R5's Wandering Risk Scale assessment, dated 12/12/23 completed by LPN Q (Licensed Practical Nurse) revealed as assessment score of 9. This indicates R5 is at risk to wander. R5's Wandering Risk Scale assessment, dated 12/14/23 recompleted by RN T (Registered Nurse)revealed a score of 11. This indicated R5 was at high risk to wander. R5's Care Plan revealed a Category initiated on 12/12/2023 that indicated R5 had impaired decision-making. Interventions directed staff to provide daily orientation to the facility routines and activity schedules, use environmental cues to stimulate memory and promote appropriate behavior, and provide a consistent physical environment and daily routine. The care plan did not address R5's elopement/wandering risk. Based on the facility's policy and procedure, staff should have developed and implemented a care plan and placed a departure alert bracelet on R5 among other interventions. There is no evidence this was completed. R5's Interdisciplinary Notes included the following entries: ~Documented by LPN Q and dated 12/16/2023 at 6:15 PM, R5 was noted to be missing from the unit at 4:30 PM. The note revealed the supervisor was notified, and staff searched all units' rooms, including the assisted living area. According to the note, staff also searched the outside facility perimeters. The note revealed that at 4:50 PM, the supervisor received a call from a staff member who lived across the street, who stated that the resident was found outside their house. Per the note, the resident was taken to the hospital for a medical evaluation. ~Documented by RN V and dated 12/16/2023 at 6:48 PM, RN V was notified at 4:35 PM that staff could not find R5. According to the note, the last known time the resident was seen was at 4:30 PM. The note revealed staff searched all the rooms on the unit, around the hallways, the front entrance area, the assisted living area, and the area outside the facility but could not locate the resident. Per the note, RN V immediately called DON B, who instructed the RN to call a code. The note revealed after RN V got off the phone with DON B, they received a phone call from someone who lived across the street from the facility, who stated that they found a resident who was extremely confused. The note revealed the caller reported they asked the person's name, but the person could not answer. According to the caller, it appeared that the resident had sustained a fall due to a skin tear on their hand. The note indicated they were able to confirm the person was, in fact, R5 after the caller described the individual's clothing. The police and ambulance were called to the scene. The note further indicated the resident would be evaluated at the emergency room (ER), and upon return to the facility, a departure alert bracelet would be placed. During an interview on 01/09/2024 at 2:29 PM, RN V stated they were notified by LPN Q at 4:35 PM that R5 was missing and was last seen between 4:00 PM and 4:15 PM. RN V indicated they called DON B and were told to call a missing persons code. RN V said that immediately after the call with DON B, a therapy employee who lived across the street from the facility called to see if the facility had a missing resident because an individual was found between the caller's garage and their neighbor's garage. RN V said the caller described what the person was wearing, and at that time, it was confirmed the person they found was R5. RN V said that the caller reported R5 appeared to have fallen because they had a skin tear on their hand, and the caller had already contacted emergency medical services (911) because they did not recognize the individual as a resident of the facility. RN V said on the day of the incident, R5 was wearing brown pants, a flannel shirt, socks, and shoes and indicated the resident could walk unassisted around their room. RN V stated R5 was not at risk for wandering according to their information in their electronic health record (EHR) and had not exhibited any exit-seeking behaviors prior to the event. RN V said they did not know R5's wander risk score but indicated if a resident was identified as a wander risk, this should be documented in their EHR and listed on the 24-hour board kept at the nurses' station on each unit (a method used to communicate information from shift to shift). RN V denied knowledge of a book with information about residents identified as at risk for wandering and stated the care plan should be updated for any resident identified as at risk for wandering. During an interview on 01/09/2024 at 3:15 PM, LPN Q said that during the medication pass on 12/16/23 at 4:30 PM, she noticed R5 was not in their room. LPN Q indicated that the resident was last seen at 4:15 PM. LPN Q said after she realized R5 was missing, she alerted staff and the RN supervisor, who called a missing person code. LPN Q stated they looked on the first, second, and basement floors and outside the facility but were unable to find the resident. LPN Q stated RN V then received a call from a therapy employee who lived across the street from the facility, who said she had found an individual and she was unsure if they were one of the facility's residents but had already contacted 911 and the resident was sent to the ER. LPN Q stated that R5 had a skin tear on their left hand and forearm before they went missing. LPN Q said the resident must have left the facility through the front door. LPN Q explained that based on the location of the resident's room, R5 would have turned left out of their room and then left at the lobby and out the front door. LPN Q said she felt the resident was able to leave out the front door because there was no receptionist at the time the resident left, and the door only alarmed if a resident wearing a departure alert bracelet approached the door. LPN Q said there was usually a receptionist until 8:00 PM each day. LPN Q stated she had conducted the resident's wandering risk scale on 12/12/2023 and determined the resident had a score of 1 or 2, which would indicate not at risk for wandering, but she was later told by the Quality and Clinical Support nurse she did it incorrectly and to correct it. LPN Q indicated that after she corrected the assessment, R5 scored a 9, which indicated the resident was at risk for wandering; however, she did not correct the assessment and identify the resident was at risk for wandering until after the resident eloped. LPN Q said once a resident was identified as at risk for wandering, the care plan was updated, and the 24-hour report board would list the resident as a wanderer. LPN Q said if these things had been done, it was possible R5's elopement could have been prevented. During an interview on 01/09/2024 at 3:30 PM, the Director of Admissions, who oversaw the receptionist, said the receptionist usually manned the front desk at the facility entrance from Monday through Friday from 8:00 AM to 8:00 PM and on Saturdays and Sundays from 9:00 AM to 5:00 PM. She said the doors automatically locked at 8:00 PM on Monday through Fridays and at 5:00 PM on the weekends but were only locked for entry from outside, not for exiting from the inside. The Director of Admissions indicated that on the day of R5's elopement, there was no receptionist on duty due to an emergency call-in, which left the front entrance unmanned. During an interview on 01/10/24 at 9:48 AM, RT W (Rehabilitation Technician), who found R5 at their house on 12/16/23, said that they lived less than a mile from the facility across a 4-lane busy street with a median in between the lanes. RT W indicated that crossing that street would be dangerous for someone with R5's mental status. RT W stated she found R5 in an alley between their garage and their neighbor's garage. RT W said at first, she did not recognize the individual they found as a resident of the facility, so she called 911. She said once the ambulance arrived, they asked if she knew who the individual was, and at that time, she noticed a bandage on the individual hand that looked to be a bandage typically used at the facility. RT W said the ambulance transported the individual to the ER, and she called the facility and spoke to an RN supervisor, who confirmed they had a missing resident. RT W recalled R5 was wearing a red plaid flannel shirt with a long-sleeved shirt under the flannel one, blue jeans, socks, and shoes. RT W stated they did not remember what the temperature was that day, but it was kind of misty outside. According to Weather Underground, the weather in [NAME] on 12/16/23 at 4:40 PM was 44 degrees Fahrenheit, winds out of the south/southeast at 16 miles per hour, and there was light rain. During an interview on 01/10/24 at 10:10 AM, the QCSN (Quality and Clinical Support Nurse) stated that the wander risk assessment done on admission for R5 was scored incorrectly with a score of 2 because the nurse initially checked the resident as being able to move without assistance in a wheelchair, was able to follow instructions, and could communicate. The QCSN stated R5 was ambulatory, could not follow instructions, and could not communicate. The QCSN said if the assessment had been accurate, R5 would have scored a 9 and a care plan addressing wandering would have been developed, and interventions would have been implemented. The QCSN stated the risk assessment conducted on 12/14/23 was inaccurate because it had both no history of wandering and history of wandering marked and stated the resident should have had a departure alert bracelet placed as an intervention with detailed, appropriate interventions regarding their wandering risk. During an interview on 1/13/2024 at 12:58 PM, NHA A stated they expected residents who were deemed as at risk for wandering/elopement were safeguarded by implementing increased observation, listing the resident on the 24-hour board, and staff on the unit conducting huddles to ensure all staff were aware of the potential for wandering and/or elopement. NHA A said if a resident was at risk for wandering, they were to place a departure alert bracelet on the resident, and/or staff were to provide one-to-one supervision as the very highest safeguard. NHA A said they had updated their policy and it now specified that any resident that scored a nine or above for their wander risk score would have a departure alert bracelet implemented. The immediate jeopardy that began on 12/16/23 was removed om 12/18/23 when the facility implemented the following actions: 1. R5 was sent to the ER and did not return 2. Wander Risk assessments were completed and behavior care plans were reviewed and updated as needed. 2. Changes were communicated by supervisors or at bottom of 24 hour board 3. Review and monitoring of residents upon admission and with change of environment or medical status for risk of change in behavior 4. Re-education of nursing staff on the following: - Difficult Behaviors, Management - Elopement precautions, Management - Monitoring of change of conditions and subtle behaviors that may precipitate behavior changes - Documentation and Care Planning 5. Mock Missing Resident Search to be scheduled next quarter 6. Audits will be completed weekly for 8 weeks to ensure the following: - Residents with change of conditions are on 24-hour board and discussed at clinical meeting. - Bi-monthly Behavior Meeting 7. Results will be analyzed and reported to QAPI (quality assurance and performance improvement) monthly for further recommendations.

Based on observation, interview and record review the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 (R15) residents reviewed for choking. R15's Minimum Data Set (MDS) indicated she was to receive 1 person physical assist with meals, which was not care planned. R15 was served pieces of solid meat for lunch instead of the sliced roast beef that was on the menu, the pieces of the solid meat were the approximate size of 2 inches. There was no evidence the meat was cut when served to the resident as indicated on her meal ticket. R15 sustained a witnessed choking episode during the meal. 911 was not immediately called resulting in a delay of emergency medical services (EMS) arrival to provide medical assistance. Findings include: R15 admitted to the facility on [DATE] and had diagnoses that included Parkinson's disease, chronic pain syndrome, neurocognitive disorder with Lewy Bodies, Dementia, Degenerative Joint Disease, Depression and Hypertension. R15's admission MDS dated [DATE], section G0110: Activities of Daily Living (ADL) Assistance documented: Eating - how resident eats and drinks, regardless of skill as supervision - oversight, encouragement or cueing as one-person physical assist. R15's care plan for nutritional status documented: General diet, thin liquids. Provide set up, assist as needed. Surveyor noted 1-person physical assist was not care planned as indicated on the admission MDS. The facility policy Emergency Response - Nursing Code One revised ,d+[DATE] and reviewed ,d+[DATE] documents: Policy: Immediate first aid procedures will be initiated for residents who have been injured or who have suddenly become ill. Procedure: 1. Staff discovering an individual in need of immediate emergency care is to call a Code One to request assistance. 2. Nursing staff should respond to call Code One - Nursing with emergency cart. 3. First aid procedures, according to American Red Cross guidelines, will be administered by trained personnel until emergency medical personnel (if applicable) arrive to assess for and/or complete further intervention. On [DATE] R15 was eating lunch in the dining room when staff witnessed the resident choking. Camera footage of the event revealed a CNA (Certified Nursing Assistant) rushing from dining room at 1:03 PM. Code 1 was called at 1:04 PM. Supervisor entered dining room at 1:04 PM. Medical Doctor-DD entered the dining room at 1:04 PM. Respiratory Therapist (RT)-BB entered the dining room at 1:05 PM. On [DATE] Surveyor spoke with MDS Nurse-KK. Surveyor advised R15's admission MDS indicated she required 1-person physical assist with eating, which was not care planned. MDS Nurse-KK reviewed the look back period information which documented 1 indicating set up help only. MDS Nurse-KK reported she did not know why she coded it wrong and maybe just clicked the wrong button. MDS-Nurse-KK completed a correction to the MDS. Surveyor identified concern the MDS indicated 1-person physical assist with meals, which was not care planned and it was not identified until Surveyor brought it to the attention of the facility. R15's meal ticket for lunch on [DATE] documented: Roast beef with gravy 3 oz (ounces). Baked potato ,d+[DATE] ea (each), green beans 3 oz., cookies and cream pie 1 slice, hot chocolate 6 oz., white soda 1 can. West [NAME] Fire Department Full Run Form dated [DATE] included a picture of R15's meal plate after the choking episode. The plate consisted of 4 different sized pieces of solid meat, 4 pieces of cut up baked potato and cut green beans. Surveyor verified the utensils provided to residents for use to eat included only 1 sized fork. Surveyor measured the fork from the end of the tine to the base of the fork to be 2 inches. Surveyor verified the 4 pieces of solid meat (in the picture) served to R15 to be of various sizes, two of which appeared to be the length of the fork measurement of 2 inches. On [DATE] at 9:19 AM Surveyor spoke with Food Service Director-CC. Surveyor asked how the roast beef was served on [DATE]. Food Service Director-CC reported the roast beef is sliced into 3 oz. slices. Surveyor advised R15 was served solid meat chunks and asked if the menu was changed. Food Service Director-CC reported the meat slicer was malfunctioning that day, and some of the meat needed to be cut by hand in the kitchen, so some residents were served meat that was cut by hand. Surveyor advised R15's meal ticket documented: Set up. Open containers/packages. Cut meat. Assist as needed. Food Service Director-CC reported the clinical staff serving the meal is responsible for following the directions on the meal ticket for set up, open containers/packages, assist as needed and cut meat - if further cutting of the meat is needed. On [DATE] at 1:00 PM Surveyor spoke with Chief Clinical Officer-C and asked if the facility investigated who provided R15 her tray and if her meat was cut up as indicated on her meal ticket. Chief Clinical Officer-C stated: Yes. I immediately looked at her plate and the meat was cut up. I felt there was an opportunity there, after, to educate staff on cutting food into smaller bite sized pieces. Surveyor asked why. Chief Clinical Officer-C stated: Because although the meat was cut, I felt it could have been cut smaller. Unfortunately, no-one would come forward and say they provided the tray. There were several staff assisting with passing trays that day, but I did look at her plate and saw that the meat was cut up. Could it have been smaller, possibly, that's why I took it as an opportunity to do further education. The facility was not able to determine which staff member provided R15 her meal tray that day and if anyone assisted with further cutting of the solid meat as indicated on her meal ticket. When R15 was identified to be choking, staff intervened with the Heimlich Maneuver, which was unsuccessful, until R15 lost consciousness. R15 was then moved to the floor and Cardiopulmonary Resuscitation (CPR) was initiated. On [DATE] at 10:10 AM Surveyor spoke with Medical Doctor-DD. Medical Doctor-DD reported after R15 lost consciousness and was moved to the floor, she didn't know, and didn't think 911 was called, so she told (Nurse Technician-LL) to call 911. Surveyor confirmed 911 was called at 1:08 PM - 5 minutes after camera footage showed the CNA rushing out of the dining room and 4 minutes after Code 1 was called. Medical Doctor-DD reported when CPR was initiated, she asked a nurse to verify her code status. The nurse returned a minute or two later and said she was a DNR (Do not resuscitate) so Medical Doctor-DD instructed CPR to stop. (Cross-reference F578). On [DATE] at 9:20 AM Surveyor spoke with DON-AA and asked who is responsible for calling a code and 911. DON-AA stated: Typically the nurse in charge at the scene will delegate to someone else to call the code and 911 because she is busy either performing CPR or attending to the resident. It can be anyone in charge at the scene, an RN (Registered Nurse), RT, whoever is taking charge delegates to call 911. Surveyor advised the facility code 1 policy does not specify to call 911 and asked what the facility expectation is. DON-AA stated: I would expect if Code 1 is called, then 911 should also be called. Emergency measures including the Heimlich Maneuver and CPR were unsuccessful and R15 was pronounced dead at the scene at 1:12 PM. Emergency Medical Services arrived at 1:12 PM after R15 was pronounced dead. The facility investigation documented the autopsy revealed a food bolus in the hypopharynx (the bottom part of the throat). On [DATE] at 12:10 PM Surveyor advised Nursing Home Administrator (NHA)-A, President/CEO-B, Chief Clinical Officer-C and DON-AA of the following concerns: R15's MDS indicated 1-person physical assist with meals, which was not care planned. R15's meal ticket indicated her meat was to be cut. R15 was served at least 4 pieces of solid meat which was cut by hand in the kitchen. 2 of the 4 pieces appeared to be 2 inches in length. There was no evidence staff assisted with cutting of the meat after it was served to R15. 911 was not immediately called when the code was announced. Medical Doctor-DD advised staff to call 911, which was not done until 4 minutes after the code was called, resulting in a delay of EMS arrival to the scene to provide emergency support. R15 passed away as result of the events that occurred.

Based on observation, interview, and record review the facility did not ensure the residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R5 and R12) of 5 residents reviewed for pressure injuries. * R5 did not have a comprehensive assessment with measurements or treatment in place when a new open area was observed on [DATE] until [DATE] which allowed the open area to worsen to an unstageable, facility acquired pressure injury. * R12 did not have a comprehensive assessment of an open area when returned from the hospital. On [DATE] R12's open area healed; the facility continued to do R12's treatment on the healed open area. Findings include: The facility policy, entitled Pressure Ulcer Prevention, states: . Risk Factors- All individuals regardless of mobility, must be assessed for pressure ulcer development on admission, weekly for the first four weeks after admission, then quarterly and with any significant change in condition using the Braden Scale for Predicting Pressure Ulcer Risk. The risk assessment should identify which factors can be removed or modified. All risk factors should be addressed even if the total risk scores does not place the resident at risk for developing pressure ulcers. Primary Risks- Impaired or decreased mobility and deceased functional ability are the primary risk factors for pressure ulcers. Secondary Risks- after identifying residents who are bedfast or chairfast, the following characteristics further increase the risk of pressure ulcer development: - Advanced age - Decreased sensory perception . - Impaired diffuse or localized blood flow (generalized atherosclerosis or lower extremity arterial insufficiency) or other factors that affect perfusion and oxygenation (hypertension, diabetes, edema) - Exposure of skin to urinary and fecal incontinence, under nutrition, malnutrition, and hydration deficits. - Altered level of consciousness or cognitive impairment - Comorbid conditions such as diabetes mellitus, end-stage renal disease, thyroid disease . - History of healed pressure - Friction and shearing - Body temperature (fever or hypothermia) Skin Care and Early Treatment: Complete Skin Assessment- The complete skin assessment is an integral part of the Pressure Ulcer Prevention Program. It is through these inspections that early skin problems can be identified and interventions implemented. The complete skin assessment begins on admission to identify pre-existing signs suggesting that deep tissue damage has already occurred, and additional deep tissue loss may occur. Assessments should continue daily for residents at risk for skin breakdown. A weekly assessment should be completed on all residents. Accurate Documentation- Accurate documentation is needed to ensure continuity of care. The plan of care should address efforts to stabilize, reduce, or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate. The care plan should specifically address risk factors including pressure points, under nutrition, hydration deficits, and the impact of moisture. 1.) R5 was admitted to the facility on [DATE] and has diagnoses that include cerebral atherosclerosis, type two diabetes mellitus, congestive heart failure, chronic kidney disease, dementia, major depressive disorder, mild protein-calorie malnutrition, and was on Hospice. The facility assessed R5 needing limited assist with bed repositioning and extensive assist with dressing, toileting, and hygiene. R5 required a Hoyer lift for transfers and on [DATE] R5 was assessed to be a moderate risk for developing pressure injuries with a Braden score of 14. R5 was incontinent of bowel and bladder and was on a repositioning schedule when R5 was in bed. R5's skin care plan was initiated on [DATE] with the following interventions: - Monitor skin daily with cares, during baths, and weekly. Update medical doctor (MD) if indicated. - Apply lotion to arms and legs ever morning, night, and as needed - Assess for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. - Encourage physical activity, mobility, and rand of motion to maximum potential. - Assist with repositioning every two hours and as needed when in bed. Utilize draw sheet when available to minimize friction/ shear. Encourage side to side positioning when in bed. - Float heels with pillow under calves when in bed as tolerated. - Nursing will assess skin- upon admission, weekly on scheduled bath days, as needed, and with change in condition. Abnormalities will be reported to primary physician and wound team for follow-up. - Address pain as needed to promote resident comfort and to encourage adherence to interventions to maintain skin integrity. - Provide incontinence care as needed to keep skin clean as clean and dry as possible. Utilize barrier cream as needed to protect skin from incontinence. Change linens and clothing when wet to prevent prolonged exposure to moisture. - Moisture management- insure abdominal, groin, and chest folds are cleaned and thoroughly dried twice daily with morning and night cares. - Gel cushion to wheelchair to reduce pressure when up in wheelchair. - Tubi grip to bilateral upper arms for protection. On in the morning and off at bedtime. On [DATE] at 12:37 AM in the progress notes nursing charted R5 had a new open area, purplish in color, pinpoint size in sacral region. Barrier cream was applied and R5 was repositioned off back and onto side. On [DATE] R5 had an initial visit with the wound physician (Wound MD)-D and gave the following assessment: - Coccyx- full thickness, pressure: unstageable necrosis, 1.0 cm X 1.0 cm X 0.1 cm, moderate serous drainage, 100% slough - Treatment: Xeroform gauze with foam border gauze, change daily. - Palliative care goals: debridement not indicated - Objective: maintain healing phase, unavoidable secondary to general decline, R5 already has air mattress in place. Wound MD-D's following wound assessments are as follows: [DATE]- coccyx- pressure, unstageable necrosis, 1.0 cm X 1.0 cm X 0.1 cm, moderate serous drainage, 100% slough. -Chronic stable wound with insignificant amount of necrotic tissue and no signs of infection, monitor closely for now. [DATE]- coccyx- pressure, unstageable necrosis, 1.0 cm X 1.0 cm X 0.1 cm, moderate serous drainage, 100% slough. -treatment changed to apply Santyl to wound base once daily and cover with foam border dressing. On [DATE] at 1:48 PM Surveyor interviewed registered nurse supervisor (RN sup)-M who stated RN sup-M recalled R5 slightly but did not recall issues involving pressure injuries. Surveyor asked what the expectation is of staff when an area of concern or open area is identified on the resident. RN sup-M replied that the expectation is to notify the nurses (specifically a RN) so an initial assessment can be done that included measuring and description of the concerned area, then the physician should be notified for further direction on how to pursue, and then notification of the family or representative for the resident. On [DATE] at 10:00 AM Surveyor interviewed Wound MD-D who stated Wound MD-D did not recall R5 but would look at the notes written. Wound MD-D stated they were first made aware R5 had an opening on R5's coccyx on the initial visit on [DATE]. Surveyor asked Wound MD-D if a delay in treatment could cause a wound to worsen. Wound-MD-D stated most likely depending on the situation. Reading through R5's chart Wound-MD-D stated R5 had a lot of contributing factors that increased risk for skin breakdown such as R5's diagnoses, R5 having decreased mobility, and type two diabetes being main contributors. Wound MD-D stated that they did not see R5 for many visits, but wound was maintained once they got a treatment on it and did not decline with the three visits. Wound MD-D assessed R5 and with R5 being on hospice, it would be about maintaining that comfort level for R5. On [DATE] at 11:38 AM Surveyor spoke with Hospice RN-L who stated according to her notes, RN-L noted redness to R5's buttock area on [DATE] and encouraged facility staff to make sure R5 was being repositioned. RN-L stated RN-L was notified on Friday [DATE] by R5's family that R5 had an opening on R5's buttocks. RN-L stated RN-L went to the facility to assess R5 on [DATE] and noted an open area on R5's coccyx that measured 2.0 cm X 2.0 cm, red, a little slough with new tissue growth. RN-L stated RN-L put calcium alginate on R5's open area and covered with a border gauze. RN-L stated RN-L notified facility nursing staff, RN-L could not recall who was notified, and made facility staff aware that a dressing has been applied to R5's coccyx area and supplies were left. Surveyor asked RN-L if an order was obtained or if RN-L notified a physician. RN-L stated RN-L had not because RN-L was under the impression R5 was going to be seen by the wound care physician the following day (Saturday [DATE]). RN-L stated RN-L did a visit on R5 on [DATE] and changed R5's coccyx bandage again using the calcium alginate to the open area and applied border dressing over. RN-L stated RN-L got orders for the dressing and to follow wound MD recommendations after R5 was seen on [DATE]. Surveyor noted that there was no notification to physician or treatment ordered with a schedule of application for the new open area to R5's sacral region from [DATE] - [DATE]. On [DATE] at 12:17 PM Surveyor interviewed the Chief Clinical Officer (CCN)-C who stated CCN-C did not recall a coccyx wound for R5 but was familiar with R5. Surveyor asked CCN-C was the expectations of facility staff were when an area of concern or an open area is identified on a resident. CCN-C stated that facility staff know to get an assessment of the area by the wound nurse or an RN if the wound nurse is not available, the Physician will be notified and if orders given the orders are initiated, family/ resident representative is contacted. CCN-C stated the assessment consists of measurement of the area, description of area, what was done, and monitor. Surveyor expressed concerns that R5's open area was not comprehensively assessed until [DATE] and no treatment was put in place for nine days. CCN-C agreed with Surveyors concern and stated CCN-C would see if any information was available for the days [DATE] through [DATE]. On [DATE] at 2:20 PM CCN-C and RN-P stated they could not find documentation or assessments for R5 regarding the open area on the coccyx from [DATE] - [DATE] when the Wound MD-D saw R5. CCN-C and RN-P stated there was a communication breakdown and protocol was not followed for R5's coccyx wound that was first observed on [DATE]. No further information was provided at this time. 20483 2.) R12's diagnoses includes multiple sclerosis, hypertension, diabetes mellitus, chronic respiratory failure, and dependence on ventilator. The at risk for alterations in skin integrity care plan, not dated when implemented, documents the following approaches: * Monitor skin daily with cares, during baths, and weekly. MD (medical doctor) update if indicated. Start dates of [DATE], [DATE], & [DATE]. * Apply lotion to arms and legs every am (morning) and hs (hour sleep). Start dates of [DATE], [DATE], & [DATE]. * Assess for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. Start dates of [DATE], [DATE], & [DATE]. * Encourage physical activity, mobility and range of motion to maximum potential. Start dates of [DATE], [DATE], & [DATE]. * Air mattress to bed, check function every shift. Start dates of [DATE], [DATE], & [DATE]. * Provide incontinence care as needed to keep skin as clean and dry as possible. Utilize barrier cream as needed to protect intact skin from incontinence. Change linens and clothing when wet to prevent prolonged moisture to skin. Start dates of [DATE], [DATE], & [DATE]. * Provide [R12's first name] with repositioning every 2 hours & as needed, side to side only, when in bed. Utilize draw sheet when available for repositioning to reduce risk of friction/shear. Start dates of [DATE], [DATE], & [DATE]. * Limit time up in wheelchair to 2 hours once a day. Assist resident to shift weight while up in chair at least once an hour. Start dates of [DATE], [DATE], & [DATE]. * Barrier cream to be applied to buttocks and peri-area every shift. Start dates of [DATE], [DATE], & [DATE]. * Nursing will assess skin upon admission, weekly on day of scheduled shower, PRN (as needed), and with any change in condition. Any abnormalities will be documented in chart, and reported to primary physician and Wound Care Team for follow up. Start dates of [DATE], [DATE], & [DATE]. * Moisture management-- insure abdominal, groin and chest folds are cleaned and thoroughly dried twice daily with AM/PM cares. Check and change Q2hours (every two hours) and PRN. Start dates of [DATE], [DATE], * No brief when in bed. Start dates of [DATE], [DATE], & [DATE]. * Bilateral off-loading boots when in bed, as tolerated. Start dates of [DATE], [DATE], & [DATE]. * Address pain prior to treatment to improve resident tolerance/acceptance of wound care. Start dates of [DATE], [DATE], & [DATE]. * Wound treatments to be performed by nursing, as ordered by MD/NP (medical doctor/nurse practitioner). Nursing to monitor integrity of drsgs (dressings), with each encounter, and replace drsgs if soiled, loose or missing. Start dates of [DATE], [DATE], & [DATE]. * Wound assessment/measurement performed weekly by wound care team. If resident unavailable, assessment to be completed at earliest availability. Start dates of [DATE], [DATE], & [DATE]. * Place pillow between knees, legs, & feet, when lying on her side. Start dates of [DATE], [DATE], & [DATE]. R12 had an unstageable pressure injury on the right buttocks which resolved on [DATE]. The nurses note dated [DATE] documents no diaphoretic episode noted this shift. Residents VS (vital signs) stable this shift. Resident noted to have open area to left buttock, Supervisor made aware, [Name] NP (Nurse Practitioner) made aware. Xerofoam placed over wound, secured with border foam. Resident BS (blood sugar) at 1200 (12:00 p.m.) 453, [Name] made aware, order to give 54 units. New order for Lantus 42 units at HS (hour sleep), labs to be drawn in AM (morning). Husband at bedside visiting and aware of changes. Residents Foley changed 20 FR (french) 30 ml (milliliter) with new drainage bag d/t (due to) attempt to reduce contamination for UA (urinalysis) ordered. Resident had large loose BM (bowel movement) this shift. No signs of pain this shift. This note was written by a LPN (Licensed Practical Nurse) and there is no comprehensive assessment of the open area. The nurses note dated [DATE] documents Area to L (left) buttocks 1 cm (centimeter) x 1 cm x 0.1 cm over scar tissue from previous breakdown. This note was written by a RN (Registered Nurse) but is not a comprehensive assessment as there is no description of the wound bed. This open area to R12's left buttock was not comprehensively assessed until [DATE] when R12 was examined by MD (Medical Doctor)-D, who is the wound doctor for the Facility. The nurses note dated [DATE] documents L Buttock MASD (moisture associated skin damage) 1 cm x 3 cm x 0.1 cm New. Resident seen by [Physician name] today. Please refer to his notes for more information/description. Writer reviewed notes and agrees with [Physician name] assessment. Primary made aware of current status. Treatment to wound assessed by [Physician's name] completed per [Physician's name] orders. R12 was hospitalized from [DATE] to [DATE]. The nurses note dated [DATE] under wound care documents none. The nurses note dated [DATE] documents Pt (patient) re/admit to previous Rm (room), tx (treatment) for UTI (urinary tract infection) ,d+[DATE] (secondary to) Foley cath. (catheter). Pt seen in bed w/ (with) family in Rm. Vitals T (temperature) 98.2 P (pulse) 88, reg (regular), R (respirations) 22, improved post arrival, BP (blood pressure) ,d+[DATE]. D/C (discontinued) rpt (report) pt (patient) to cont (continue) on abt (antibiotic) Augmentin. Pt/family/ re/orientated to Rm. The nurses note dated [DATE] documents Resident being mx (monitored) for readmission. She is positive for loose stools. Will obtain a stool sample for possible C-diff. Augmentin has been d/c (discontinued) by [Name] NP. Order for a midline to be placed and IV (intravenous) ABT (antibiotic) to start for UTI (urinary tract infection). [Name of company] RN called to place midline. Resident is resting comfortably. She will open her eyes with verbal stimuli. Resident is noted to have three O/A (open areas) to her right buttock. Wound care completed. Will continue to mx (monitor). This note was written by a LPN. The nurses note dated [DATE] documents RN assess of skin upon admit. 2 wounds to R (right) buttock on admit, both unstageable PU. R proximal buttock wound is 8 x 4 x 0.1, R distal buttock is 6 x 3 x 0.1. Updated wound nurse. Surveyor noted this is not a comprehensive assessment of R12's pressure injuries as there is no description of the wound bed. This nurses note was written by RN-P. The nurses note dated [DATE] documents Patient has 2 wounds on her right buttock and I assessed and measured them: Right proximal is unstageable and measured 4.2 x 3.5 x 0.1. Right distal is unstageable due to 50% od sic (of) slough with measurement of 3 x 3.7. She is added in the wound doctor's list for Thursday. Patient's periwound has pink scar tissue that looks like from a healed stage 4 ulcer. Her current treatment is appropriate till the wound doctor sees her on Thursday. This note was written by Wound RN-R. Surveyor noted this is not a comprehensive assessment as there is no description of the right proximal pressure injury and the right distal wound bed is 50% slough but does not describe the remaining 50% of the wound bed. R12's right buttocks pressure injuries were not comprehensively assessed until [DATE]. MD-D's wound evaluation & management summary dated [DATE] documents unstageable (due to necrosis) of the right proximal buttocks full thickness. Under etiology documents pressure, wound size (L x W x D) (length times width times depth) documents 4 x 2.5 x 0.1 cm (centimeter), slough is 10% & granulation tissue 90%. The unstageable (due to necrosis) of the right, distal buttock full thickness for etiology documents pressure, wound size is 6 x 3 x 0.1 cm. Slough is 30%, granulation tissue is 40% and skin is 30%. R12 was hospitalized from [DATE] to [DATE]. The nurses note dated [DATE] under wound care documents Stage 2 R (right) ischium, abrasions to bilateral buttocks. The nurses note dated [DATE] documents Right 1st gluteal wound appeared with red bleeding measured 2.2 x 1.5 x 0.1; 2nd r gluteal wound with yellow subQ (subcutaneous) tissues in the wound measured 3 x 1.5 x 0.2. Left gluteal/coccyx wound with red bleeding from wound measured 5 x 2.5 x 0.1. All wound wounds were cleansed with NS (normal saline), pat & dried by gauze. Then foam dressing was applied. The resident had discomfort and unit nurse f/u (followed up) with PRN (as needed) analgesic. This note was written by RN Supervisor-O. Surveyor noted this is not a comprehensive assessment of R12's pressure injuries as there are no description of the wound bed and the areas are not staged. The nurses note dated [DATE] documents Patient's (sic) is assessed and I noted that her left shoulder abrasion is completely healed. She still has the 2 ulcers on her right buttock; The proximal measured 2 x 1.5 x 1. The distal is 3 x 1.6 x 0.2 with 50% slough. She came back from the hospital with a left buttock ulcer that was not present went sic (when) we sent her out and it measured 3.5 x 5 x 0.1. We will continue with the Santyl application F/B (followed by) calcium AG (silver) and foam dressing daily till [Physician's name] sees her tomorrow. This nurses note was written by Wound RN-R. Surveyor noted this is not a comprehensive assessment as there is no description of R12's proximal right buttocks & left buttocks pressure injury and the distal right buttocks only describes 50% of the wound bed. MD-D's wound evaluation & management summary dated [DATE] documents unstageable (due to necrosis) of the right, proximal buttock full thickness. For etiology documents pressure, wound size is 2 x 2 x 0.1 cm, slough is 10% and granulation tissue is 90%. Unstageable (due to necrosis) of the right, distal buttock full thickness for etiology documents pressure, wound size is 2.5 x 2 x 0.1 cm, slough is 40% and granulation tissue is 60%. Unstageable (due to necrosis) of the left buttock full thickness for etiology is pressure, wound size is 4.5 x 4 x 0.1 cm, slough is 30% and granulation tissue is 70%. Under the dressing treatment plan documents for Primary Dressing(s) Alginate calcium apply once daily for 30 days, Santyl apply once daily for 30 days. Secondary Dressing(s) documents Foam with border apply once daily for 30 days. The physician orders with a start date of [DATE] documents Tx (treatment) to R (right) and L (left) buttocks, cleanse with soap and water, pat to dry, apply Santyl to the wound bases, f/b Calcium Alginate and cover with border foam daily and PRN. MD-D's wound evaluation & management summary dated [DATE] documents unstageable (due to necrosis) of the right, proximal buttock full thickness. For etiology documents pressure, wound size is 1 x 0.3 x 0.1 cm, slough is 10% and granulation tissue is 90%. Unstageable (due to necrosis) of the right, distal buttock full thickness for etiology documents pressure, wound size is 2.5 x 1.5 x 0.1 cm, slough is 40% and granulation tissue is 60%. Unstageable (due to necrosis) of the left buttock full thickness for etiology is pressure, wound size is 3.5 x 4 x 0.1 cm, slough is 10% and granulation tissue is 90%. MD-D's wound evaluation & management summary dated [DATE] documents for unstageable (due to necrosis) of the right, proximal buttock (Resolved on [DATE]). Unstageable (due to necrosis) of the right, distal buttock full thickness for etiology documents pressure, wound size is 1.5 x 1 x 0.1 cm, and slough is 100%. Unstageable (due to necrosis) of the left buttock full thickness (Resolved on [DATE]). The dressing treatment plan for the right distal buttocks documents Primary Dressing(s) Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days. Secondary Dressing(s) Foam with border apply once daily for 30 days. The right proximal buttocks & left buttocks pressure injures have no treatment as these areas have healed. On [DATE] at 9:57 a.m. Surveyor observed R12 in bed on left side with the head of the bed elevated, tube feeding of Glucerna 1.5 is running at 50 cc (cubic centimeters), is on a ventilator, has an air mattress, and is wearing bilateral pressure relieving boots. On [DATE] at 12:15 p.m. Surveyor observed R12 has been repositioned and is now on the right side. R12 continues to be wearing the pressure relieving boots. On [DATE] from 7:11 a.m. to 7:37 a.m. Surveyor observed morning cares for R12 with CNA (Certified Nursing Assistant)-I. During this observation CNA-I removed two border foam dressings. No concerns were identified during this observation. At 7:41 a.m. Surveyor observed CNA-I inform LPN-E she removed R12's dressings. On [DATE] at 7:43 a.m. Surveyor asked LPN-E what time she would be doing R12's pressure injury treatment. LPN-E informed Surveyor she wanted to complete her medication pass and would be doing the treatment around 9:00 a.m. On [DATE] at 9:08 a.m. Surveyor observed LPN-E & CNA-I place PPE (personal protective equipment) on and enter R12's room. Surveyor observed R12's treatment supplies are on a barrier on the over bed table. LPN-E turned off R12's tube feeding, removed her gloves, cleansed her hands and placed new gloves on. CNA-I lowered the head of the bed down, removed a quilt from under R12's hand, a pillow under R12's upper right side and R12 was positioned on the side. Surveyor observed R12 is not wearing an incontinence product and Surveyor inquired about this. CNA-I explained to Surveyor the incontinence product would do more harm than good and placed a disposable chuck on the bed. LPN-E indicated R12 has a little BM (bowel movement). LPN-E washed R12's rectal area, removed her gloves, cleansed her hands, and placed gloves on. R12 continued to have thin bowel movement. LPN-E washed R12's buttocks and rectal area with disposable wipe, removed her gloves, cleansed her hands and placed gloves on. LPN-E placed Santyl on a cotton applicator, placed the Santyl on R12's right distal buttocks pressure injury, calcium alginate over the Santyl, sprayed skin prep around the periwound and placed a border foam dressing over R12's right distal buttock pressure injury. LPN-E removed her gloves, cleansed her hands, placed gloves on and then informed Surveyor to move back as R12 can spray, referring to the liquid stool. CNA-I washed R12's rectal area, buttocks, urinary catheter tubing to remove BM and removed the dressing. CNA-I removed her gloves, washed her hands, and placed gloves on. At 9:22 a.m. LPN-E sprayed bedside care spray on R12's right distal pressure injury, removed her gloves, cleansed her hands and placed gloves on. LPN-E placed Santyl on a cotton applicator, placed the Santyl on the wound bed and Calcium Alginate over the Santyl. LPN-E sprayed skin prep around the pressure injury and covered the right distal pressure injury with a border foam dressing. At 9:24 a.m. LPN-E removed her gloves, cleansed her hands, placed gloves on and informed Surveyor once scabbed area falls off will be resolved. Surveyor noted MD-D had resolved the left buttock pressure injury on [DATE]. LPN-E dated the dressing, sprayed bedside care spray on the left buttocks dried skin/scabbed area, removed her gloves, cleansed her hands and placed gloves on. LPN-E placed Santyl on the end of a disposable wipe, placed the Santyl over the left buttocks dried skin/scabbed area, calcium alginate, and sprayed skin prep around the periwound. LPN-E placed a border foam dressing, removed her gloves and cleansed her hands. Surveyor reviewed R12's [DATE] TAR (treatment administration record) and noted a treatment with a start date of [DATE] and end date of [DATE] which documents Tx (treatment) to R (right) and L (left) buttocks, cleanse with soap and water, pat to dry, apply Santyl to the wound bases, f/b (followed by) Calcium alginate, and cover with border foam daily and PRN. Surveyor noted the treatment to R12's left buttock was not initiated until [DATE], 3 days after R12 was admitted . Surveyor noted this treatment is initialed as being completed on ,d+[DATE], ,d+[DATE], ,d+[DATE], & ,d+[DATE]. R12's left buttocks pressure injury is documented as being resolved on [DATE] by MD (Medical Doctor)-D who is the Facility's wound MD. R12's physician orders with an order date & start date of [DATE] documents Tx (treatment) to R(right) distal buttock, cleanse with soap and water, pat to dry, apply Santyl to the wound bases, f/b (followed by) Calcium Alginate, and cover with border foam daily and PRN (as needed) every day. On [DATE] at 1:53 p.m. Surveyor asked LPN (Licensed Practical Nurse)-E how does she know what treatment she needs to do for R12. LPN-E informed Surveyor she goes by the TAR (treatment administration record). LPN-E explained the wound nurse goes with MD-D and the wound nurse is the one that puts the orders in. On [DATE] at 2:33 p.m. Surveyor asked Wound RN-R to explain the system at the Facility regarding pressure injuries. Wound RN-R informed Surveyor they have a wound doctor, MD-D, who does wound rounds every Thursday. Wound RN-R explained sometimes MD-D changes treatment then she will change the treatment in the system. If the treatment stays the same, she puts an ID (interdisciplinary) note in with no new orders and if the wound has healed MD-D will do the last assessment and resolve the treatment. Surveyor inquired who discontinues the treatment in the [Name] of computer program & when is the treatment discontinued. Wound RN-R informed Surveyor she discontinues the treatment and the treatment is discontinued on Thursday. Surveyor asked Wound RN-R if R12's left buttocks & right proximal buttocks pressure injuries were resolved on [DATE] why wasn't the treatment discontinued until [DATE]. Wound RN-R replied not sure why we missed it. Wound RN-R informed Surveyor when R12 went to the hospital she had only the two right buttock pressure injuries and when she came back with the left one. Surveyor informed Wound RN-R of the observation with LPN-E completing the treatment on R12's left buttocks which healed on [DATE]. On [DATE] at 9:31 a.m. Surveyor asked Wound RN-R when a Resident is admitted or returns from the hospital with a pressure injury who assesses the pressure injuries. Wound RN-R informed Surveyor she works at the Facility 3 days a week and if she is here she will assess the pressure injury. If she is not here the RN on the floor should assess and measure, they should have a baseline. Surveyor asked Wound RN-R after MD-D examines the Resident does the Facility use his assessment as the Facility's assessment. Wound RN-R replied yes. On [DATE] at 9:34 a.m. Surveyor accompanied Wound RN-R to R12's room. Surveyor observed R12 is on the left side wearing bilateral pressure relieving boots. At 9:34 a.m. CNA-I entered R12's room to assist Wound RN-R. During this observation, Wound RN-R showed Surveyor where R12's left buttocks and right proximal buttocks were before they healed and completed the treatment according to physician orders. Wound RN-R verified with Surveyor the only pressure injury R12 currently has is the right distal buttocks. On [DATE] at 12:50 p.m. Surveyor informed CCO (Chief Clinical Officer)-E of the above. On [DATE] CCO-E emailed Surveyor a link for an article from the National Library of Medicine titled Collagenase Santyl Ointment: a selective agent for wound debridement.

Based on observation, interview and record review, the facility did not ensure that 1 (R32) of 12 residents at high risk for elopement were not provided with safety measures, interventions and assessments to prevent elopement; 1 (R329) of 5 residents with falls followed Care Plan to prevent falls; 12 (R80 and R11) of 24 residents reviewed for environment were provided with a safe environment; and 1 (R40) of 1 resident who smoked was assessed to be a safe smoker. 1. R32 was assessed as a high elopement risk and demonstrated active wandering behavior and desire to leave facility starting on 10/2/22. Facility placed a Wanderguard on and initiated a Care Plan. Facility stated they initiated 1:1 monitoring but that was not put in place until 11/6/22. R32 continued to have wandering behaviors. On 10/20/22 R32 was moved to the 1st floor more secure unit but R32 continued to wander and eloped on 10/24/22 and was found in the Aurora Clinic in basement of complex. R32 was not assessed and the Care Plan was not updated with any added interventions. R32 had ongoing documentation of trying to leave. On 11/5/22, R32 exits the facility after she pulled the fire alarm and exited the posterior exit door on the unit. R32 had fallen and sustained facial fracture. R32 continued to pull fire alarm, attempt to leave unit and wander. Care Plan was updated with interventions that were already in place or not effective. Facility indicated 1:1 initiated 11/6 however is not consistently implement particularly on third shift where 1:1 monitoring was left to discretion of nursing. 2. R329's care plan stated resident was to be a 2 person assist with cares. Resident was being assisted with cares in bed by 1 CNA and suffered a fall out of bed and sustained a hematoma, bruising and skin tear. A root cause analysis was not done and not following the Care Plan was not identified as the cause of the fall. 3. R80 utilizes an air mattress which should be set according to R80's weight. The facility did not ensure R80's air mattress was set correctly which posed a safety/hazard risk for R80. 4. R11 utilizes an air mattress which should be set according to R11's weight. The facility did not ensure R11's air mattress was set correctly which posed a safety/hazard risk for R11. 5. R40 was a smoker and was not assessed for safe smoking status or if they were able to independently smoke or needed supervision. The facility's failure to properly monitor, assess and intervene on previous elopements of R32 created a finding of Immediate Jeopardy (IJ) that began on 10/3/22. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Director of Clinical Operations (DCO)-C of the IJ on 12/21/22 at 12:51 PM. The IJ was removed on 12/21/22, however; the deficient practice continues at a scope/severity level of E (No Actual Harm/Pattern). Findings include: Surveyor reviewed facility's Wanderer Care policy with a reviewed date of 7/18. Documented was: POLICY: Measures will be taken to make every effort to be aware of the location of all residents and to provide safety for the identified wanderers. GENERAL INFORMATION: 1. Wandering most likely results from a combination of factors including organic brain changes, but also can be predisposed by psychosocial and cultural patterned or determinants based on occupation, interests, living arrangements, marital status and social habits. 2. Factors in the facility that may promote wandering are confusion from noise, people gathering or disorganization. 3. Wandering may increase at certain times of the day. Late afternoon or early evening is prime time for increased wandering. 4. Wandering may also happen when there is an unmet need i.e. hungry, tired, pain, thirsty, needing to use the bathroom. PROCEDURE: 1. As part of the admission assessments, all newly admitted residents' clinical status will be assessed by nursing to determine their risk for wandering using the Wandering Risk Scale Form (see attached). 1.1 Reassessment as follows: A. After 72 hours by Social Services B. Whenever there is change in condition and/or Quarterly review, to be completed by Social Services . Scores of: 0-8 Low Risk to Wander 9-10 At Risk to Wander 11-above High Risk to Wander 5. Action required bases on Wandering Risk Scale Score: 4.1 If the resident is identified as Low Risk to Wander, no intervention to prevent wandering is needed. 4.2 If the resident is identified as At Risk to Wander. Initiate interdisciplinary care plan accordingly and follow plan of care. 4.3. If the resident is identified as High Risk to Wander, the following actions must be taken: A. Initiate interdisciplinary care plan. A.1 Including specific approaches/interventions and time-measured goals. Review and update as needed but no less than quarterly. B. Inform patient representative of the identification methods being taken. C. Apply wander guard bracelet, provide name band, and label all clothing. D. Once determined resident is a wanderer, this information will be communicated to other departments via email. D.1 Resident's name and room number will be added to the wander list. D.2 This list will be updated by Social Services ongoing and reviewed weekly. D.3 Changes and updates as they occur will be forwarded to all departments by Social Services. E. The list of wanderers will be kept in a purple binder in all departments along with a picture and room number of each resident identified as a wanderer. E.1 The binders will be updated by each department as the changes and updates are communicated by Social Services. 6. Encourage participation in unit activities, both physical and social. 7. Initiation of Code Purple when applicable. Refer to EMERGENCY CODE-PROCEDURE Policy. Surveyor reviewed facility's FALLS - PREVENTION/ FALLING STAR policy with a revision date of 7/20. Documented was: POLICY: MP maintains the responsibility to assess each resident as to the risks of injury from falling, implement an individualized interdisciplinary care plan that addresses those risks in a proactive manner and evaluates the effectiveness on a routine basis. In addition to addressing the issue of individual fall incidents, VMP takes seriously its responsibility to be at the forefront in fall prevention efforts by tracking and trending of fall incidents to identify extrinsic as well as intrinsic causes and implementing fall prevention interventions. Fall Prevention (Falling Star Program) Incidence of falls and falls resulting in injury increase with age, use of certain Medications or if balance or gait problems exist. The goal of this protocol is to include the Interdisciplinary Team (Resident, Resident representative, Nursing, Social Services, PT/OT, Physician, Activities, Dietary, Pharmacy and Speech Therapy) in fall prevention by: 1. Identifying specific fall risk factors for each resident; 2. Increasing the team's awareness of these residents and their risk factors; 3. Discussing and documenting strategies initialized for each resident and eliciting the team's cooperation in attempting to minimize the risk factors identified, without compromising mobility and functional independence, whenever possible; 4. Reporting and recording falls and near falls so that new risk factors or residents that are high risk can be identified; 5. Ultimately, decreasing risks and preventing falls to the degree possible. 6. Trending and tracking of extrinsic as well as intrinsic causes of fall occurrences. 7. Falling stars criteria: 2 falls in 30 days; 3 falls in 90 days. 8. A falling star list will be maintained and updated for all units/departments, to identify residents at high risk for falls and heighten awareness of all staff. 9. A resident will be removed from the Falling Star program after three consecutive months of no falls, unless the IDT decides that a high risk safety concern remains. GENERAL INFORMATION: Fall Definition: A fall is a sudden unexplained change in position to a next lower surface, (i.e. chair to floor, bed to mat, etc.). A fall is also an episode where a resident loses his or her balance and would have fallen were it not for staff intervention. In other words, an intercepted fall is still a fall. PROCEDURES: I. Proactive: To prevent the first fall: 1. All residents are assumed to have some risk of falls and staff is aware of the potential for a fall of any resident at any time and takes precautions when transferring/ambulating all residents. 1.1 At admission a discussion is conducted with each resident. It includes call light usage and the procedure for obtaining assistance for transfer or ambulation. 2. All residents will have a Fall Risk Assessment completed upon admission, quarterly with a significant change per Resident Assessment Instrument (RAI) process and immediately following the fall incident. 3. Care Plan will be updated to reflect changes in- interventions that are necessary to maintain resident's safety. Residents that have a Score of 18 or higher on Fall Risk Assessment, or residents that experience a fall incident, will have one or more interventions implemented immediately following each fall incident/ admission. The decision as to which if any measure to use will be based on history/observation and/or nurse's judgement. Refer to the following list of potential interventions that may be implemented. Il. Assessing Risk Potential 1. The Fall Risk Assessment will be completed by nursing personnel upon admission, annually quarterly, with a significant change and with any fall. Included in the assessment are risk factors and a health history as they relate to falls. Assessment care planning and monitoring of residents related to fall issues will be initiated by the primary nursing staff along with input from Team Meetings, observation and/or staff report. 3. A review of resident's medications should be completed for possible effects/side effects relating to falls, with a focus on medications which could predispose to falls (i.e. diuretics, cardiovascular, antihypertensive, antipsychotic agents, hypnotics, antidepressants, sedatives, analgesics, and laxatives. Consider not only the class of drugs, but the number of drugs (polypharmacy), and the potential for addictive effects when the accumulate in the body that also increases risk. Nursing Policy & Procedure Falls - Prevention and Intervention 4. Assess adaptive equipment walker, w/c, hearing aids, glasses etc. 5. Assess for vision/hearing problems. 6. Assess and encourage the use of proper footwear. 7. Assess for orthostatic hypotension, if able. 8. Assess the environment in which the fall occurred. IV. Interventions to Prevent Falls (The following is not meant to be all inclusive) Interdisciplinary team members will discuss and initiate appropriate interventions for identified risk factors. Interventions will be designed in relation to diagnosis and need: 1. Impaired Mobility - assess potential for PT/OT or Restorative Nursing Program - consider need for assistance with ambulation and/or transfer - consider need for assistive devices (cane, walker, etc.) - encourage use of call light to request assistance and ask resident to wait until assistance arrives. - contact housekeeping if room clutter/floor condition is a concern and consider reorganizing room. - evaluate adequate lighting, need for night light. - evaluate supportive equipment W/C and/or walker fit, bed height, etc. - consider bedside commode. 2. General Debility - encourage mid day nap or rest period, if appropriate. - avoid complete bed rest, unless absolutely necessary and remove bed rest orders as soon as possible. - consider increasing the frequency of observation or keeping in public area when up. - assess need for attention to decrease pain, anxiety or agitation. - assess adequacy of nutrition and hydration. - assist with activity at regular intervals to increase stamina and balance. - encourage participation in exercise program, if possible. - assess need for assistance with ADL's, ambulation or toileting. 3. Incontinence - assess need for regular toileting schedule. - assess need for incontinence under padding/under garments. - consider a urological consultation with a specialist. 4. Visual/Auditory Impairment - check hearing aid for proper function and battery, if applicable. - complete a preliminary vision screening and/or refer to Optometrist if need for glasses is assessed. Nursing Policy & Procedure Falls - Prevention and Intervention 5. Improper Shoe Fit - Assess footwear including shoes and slippers. - request purchase of proper shoes/slippers, if necessary. 6. Restraints/Alternatives - consider motion detectors - Monitor all interventions to be sure the least restrictive intervention is being used. 7. Consultation - consult with MD, Pharmacist or Psychiatrist, as needed, for repeat falls - Resident/resident representative/staff education will be done by Social Service and/or Nursing to increase their awareness and cooperation with proposed interventions, as needed. V. Documentation 1. All fall interventions will be care planned and recorded on Care Plan and on CNA Care Card as appropriate. 2. All risks and benefits will be provided to the resident/resident representative/POA-HC/Guardian. 3. Interdisciplinary review of fall incident will be completed in EHR. VI. Post Fall Incident: After caring for the immediate physical/psychological needs of the resident the Nurse will: 1. Complete Incident Report, Fall Evaluation, Fall Risk, ID Note and any other necessary documentation in EMR. 2. Complete Notes of interview 3. Send appropriate paperwork to DON/Designee. 4. Determine and implement an immediate intervention to prevent another fall with guidance from Fall program Coordinator or designee. 5. Update POA-HC/Resident/ Resident Representative/Guardian after each fall. 6. Call Fall Program Coordinator with fall details. VII. Nurse Manager to review fall incident within 24 hours of fall (Next business day). The following shall occur: 1. Resident incident will be reviewed with Interdisciplinary Team (IDT)/ Fall Program Coordinator. 2. Fall intervention recommendations from the meeting will be added to the Resident Care Plan and CNA Care Card (as appropriate, this is the responsibility of the Nurse Manager or designee.) 3. The Care Plan will be reviewed and modified as needed. * Note: Upon reviewing the resident fall at the Falls Review meeting, the Interdisciplinary Team will complete the Investigation Section of the Incident Tracking form in AOD. All interventions and modifications to the Resident Care Plan and CNA Care Card will be recorded in the EHR. 1. R32 was admitted to the facility on [DATE] with diagnoses that included stenosis of other cardiac prosthetic device, syncope, heart valve replacement, diastolic heart failure, aortic valve stenosis, unspecified dementia without behaviors/psychosis/mood/anxiety, anxiety and urinary tract infection (UTI). R32's room was on the second floor in an unlocked, unsecured unit. Surveyor reviewed Wandering Risk Scale assessment for R32 with assessment dates of 9/21/22 and 9/26/22 with assessments of Low Risk of Wandering. Surveyor reviewed R32's Progress Notes and documented on 10/2/22 8:20 PM was Resident was yelling out of window. Help, Help. I have been kidnaped. Gave resident a cup of tea, tried to calm resident down. Documented on 10/2/22 at 9:17 PM was Wandergaurd put on right ankle. Resident stated she was going to leave. Has been walking out in the hall, walking towards door. Documented on 10/2/22 at 10:32 PM was Exit seeking: [patient (Pt)] attempt to leave unit via elevators [times (X)] 2, made to lower floor on 2nd attempt. Staff safely [returned] to proper unit [with] incident. When asked states, I am leaving just waiting for my ride. Staff re/oriented to [room]/unit. Update to On-call provider/family. Wandergaurd apply to [right (R)] ankle, 24hr [continuous] monitoring initiated. Surveyor reviewed Wandering Risk Scale assessment for R32 with assessment dates of 10/2/22. Documented was: Mental Status - cannot follow instructions Mobility - can move [without (w/o)] assistance in [wheelchair (w/c)] Hx of Wandering - with [history (hx)] of wandering (hx of res/family or noted on hospital paperwork) [Diagnoses (Dx)] - with dx dementia . SCORE: 11. Score of 11 indicated a High Risk for Wandering. Surveyor reviewed R32's Comprehensive Care Plan with an initiation date of 10/3/22. Documented was: [R32] will maintain safety though review date. Wanderguard in place with monitoring per facility protocol. Intervene as necessary to ensure safety of resident. Stay with resident if they leave unit in a wandering episode. Watch for these signs: pacing, packing belongings, talking about leaving, putting on a coat. Redirect resident from stimulus with activity of their choice. When resident is exit seeking, offer toileting, food and drink. Utilize [one to one supervision (1:1)] [as needed (PRN)]. Do not argue with [R32] about the correctness of their beliefs. Surveyor reviewed schedules for Certified Nursing Assistant (CNA) staff who would be assigned 1:1 monitoring for R32. There was no 1:1 aide scheduled from 10/3/22 through 11/5/22. Surveyor reviewed R32's Progress Notes and documented on 10/6/22 at 1:38 AM was Resident attempted to wander from unit twice, she stated I heard a loud crash, I have to find out where its coming from. Resident was redirected and brought back to unit, writer reorientated resident on date, time, and place. Although confused resident was pleasant and nonconfrontational, 1:1 sitter initiated until resident fell back to sleep, and q15 minute checks thereafter. There was no 1:1 sitter initiated, no added interventions put in place and no assessment of elopement risk. On 10/6/22 a psych referral was completed for R32 and on 10/10/22 R32 was seen by psych services and medication changes were made. On 10/7/22 R32 was moved from room [ROOM NUMBER] to 2410 on the second floor to be closer to the nurses' station for monitoring although R32 was supposed to be on 1:1 monitoring. Surveyor reviewed R32's Progress Notes and documented by Music Therapy on 10/12/22 was .distressed phone calls from [R32], saying she wanted to call police as she was being held here against her will . [R32] accepted visit, presenting as grumpy and anxious to leave, with bags packed next to her on the bed, looking through book to find numbers for a ride . took opportunity to remove [R32] to go for a walk, quickly moving bagged belongings to the closet . Surveyor reviewed R32's Progress Notes and documented on 10/15/22 at 6:11 AM was Resident did wander once on shift, she stated I am going to the bathroom on the second floor. Resident was assisted to her room where she was toileted and went back to bed. Documented on 10/17/22 at 6:05 AM was Resident out wandering in hall. Reports I heard my son knocking on my door. Reassured resident that she is safe and her son is not here. Easily redirected to room. On 10/7/22 R32 was moved from room [ROOM NUMBER] to 1315A on the first floor. Documented in Progress Notes on 10/20/22 at 9:57 AM was [R32] will - transfer from 2404 to 1315A on this date. Both [R32] and her [daughter in-law] are in agreement with transfer. [Daughter-in-law] agrees that [R32] needs a more secure unit due to her wandering. [R32] will also benefit from the structured activities on the unit and keep her busy. Surveyor noted that first floor unit has no locked doors and was not secure as the units' doors were closed with signs to Keep Doors Closed but not locked. Wanderguard alarms on the posterior exit door at the end of the hallway, the elevators and in the front lobby. The posterior exit door was also alarmed as a fire door. Surveyor reviewed MD orders for R32. Documented with a start date of 10/23/22 was Record number of episodes of wandering behaviors such as pacing, packing belongings, talking about leaving, putting on a coat. If 1 or more, document incident and interventions in EMR. Notify supervisor as indicated. Surveyor reviewed R32's Progress Notes and documented on 10/24/22 at 11:42 PM was [7:15 PM] Staff respond to unit posterior door alarm, noted pt left out of unit. Elopement protocol activated, Pt found in Aurora facility basement w/ clinic staff. 3 women's hand bags seen to R shoulder w/ pt belongings, when asked, states I am leaving. Staff escorted safely back to proper unit s/ incident. Post elopement assessments completed, no findings noted. Pt calm, [vital signs stable (VSS)], in no acute distress, Wandergaurd in place R ankle/activated. Update to provider & family, voice msg left for pt contact to call facility for pt update. 24hr f/u monitoring initiated. There was no 1:1 aide scheduled for 24 hour monitoring. There was no update to the care plan or added interventions after elopement and no post elopement assessments completed. On 10/28/22 R32 was moved from room [ROOM NUMBER]A to 1312B on the first floor after an altercation with her roommate. Surveyor reviewed R32's Progress Notes and documented on 10/28/22 at 12:25 PM was Resident reports to staff and MD that her son is being chased and in danger. MD contacted daughter, who states that resident son is not in danger and is safe. Staff to closely monitor resident for behavior and wandering behaviors. Documented on 10/30/22 at 10:31 PM was At [10:30 PM] yelling -screaming about son trying to leave Unit. Documented on 10/31/22 at 6:18 AM was Around [10:30 PM] the resident was staying by exit doors on [R32's unit (SV1)] stating she wants to go home next door. She was difficult to redirect. It took several staff members to redirect. She asked for phone to call her [son], and it was provided. Also tried go to the door to leave, and again was redirected X3 . Documented on 10/31/22 at 10:56 AM was Resident found wandering in hallway X3, attempted to exit unit X1. Not easily redirected. Daughter-in-law in this unit, redirected resident, focused on crafts. Documented on 11/02/22 at 4:36 AM was Resident attempted to leave unit X2. Said that she will be killed if she does not leave. When attempting to redirect, resident became combative, pushing and hitting staff. Resident eventually settled and is currently sleeping. Will continue monitoring. Documented on 11/02/22 at 9:42 AM was Later in shift kept trying to leave unit Needed help, from all to keep on floor. Documented on 11/03/22 at 2:13 AM was [2:00 AM] While staff assisting in a room, resident exited the [posterior exit fire door]. She saw there was stairs going up and down, so did not attempt to go further. Staff heard door alarm go off and immediately got her back onto unit. She was walking around as staff assisted other residents and went towards [another unit] around [2:15 AM]. Will watch at nursing office for closer monitoring. Documented on 11/05/22 at 5:27 AM was Resident noted to be wandering X1, no behaviors this shift. R32 eloped from the facility at 4:16 PM on 11/5/22. Documented at 4:59 PM was 16:16 Fire Code called to SV1 unit, several responded to scene, no fire findings. Staff [instructed] to initiate Res head count, immediately found pt missing from unit. Code purple activated, all on different unit complete. Documented on 11/5/22 at 7:54 PM was To add to previous note, resident was noted to not be in her room or in common areas on unit around [4:15 PM]. Code purple was called for resident and a dozen staff from multiple departments responded to search for resident. Search was initiated on SV1 while we waited for responders and resident was not found in any bedroom, utility area, or bathroom on unit. Back stairwell was searched and resident was not found. Staff searched both floors of Maplewood and the basement including clinic hall. Within 10 minutes it was determined that she was not likely inside the building or in the parking lots so search was expanded to include sidewalks around campus. Resident was then located on Oklahoma about 40 feet west of driveway to Maplewood. She had with her a purse and two cloth bags containing picture frames and other belongings. She was wearing a blouse with a sweater over it, 3/4 length pants and shoes. She was being attended to by a good samaritan who noticed her in distress. She had fallen outside apparently hitting her head on the curb. Fire Dept responded to a call from the good samaritan. Resident noted to have facial bleeding and swelling including damage to her forehead, nose, left cheek as well as abrasions to both knuckles. Resident was upset but seemed to be comforted and calmed by the fire dept staff. First aid was provided by the fire dept on the scene and she was taken by ambulance to the ER. Family updated by Supervisor. Awaiting update as to what hospital resident is being evaluated at and possible readmit. Anticipating the need for 1:1 supervision until safety can be established if resident re-admits this weekend. On 11/6/22 at 1:35 AM R32 returned to the facility from the hospital. R32 had sustained a facial fracture. Documented at 11/6/22 at 1:42 AM was Around [11:00 PM] on 11/05/2022 received a call from ED nurse regarding the resident's returning to the facility with hairline facial [fracture (Fx)]. She was given analgesics, and will be returning to [facility] . She was given call light and put to bed with staff to monitor. Documented on 11/6/22 at 6:27 AM was Resident returned from hospital pleasant and cooperative . Slept for a few hours then was found wandering the halls X2, asking where her sons were. Resident was brought out to common area for close monitoring. There was no 1:1 monitoring put in place when R32 returned from the hospital. On 11/7/22 at 4:45 PM, R32 rang the fire alarm again. Documented at 5:03 PM was [4:45 PM] resident who had been in room rang the fire alarm Did not leave unit on 15min checks 1;1 tonight. There was no documentation stating whether R32 was on 1:1 or 15 minute checks. Surveyor reviewed R32's Comprehensive Care Plan with a revision date of 11/7/22. Added to the Wandering Care Plan was: Psych consult made. Referral to pastoral care. Q15 min checks. Encourage family involvement/visits. Surveyor noted that Psych had already consulted and had seen R32 on 10/10/22. Surveyor also noted that R32 was supposed to be on 1:1 monitoring and was unsure why 15 minute checks were added to the care plan. Surveyor reviewed R32's CNA Kardex to direct cares for CNA's. Documented with a start date of 11/6/22 was: Provide 1:1 visits PRN. Especially when wandering and anxious, provide validation and engage [R32] in the moment (i.e. constructive discussions about what you can do now to help, refer her to daily routine schedule binder, invite to activity, meet basic needs as able, remind her and engage her in independent leisure, talk about her likes and interests and fond memories of her youth). Documented under Progress Notes on 11/10/22 at 2:21 AM was Resident made multiple attempts to leave the unit. Took multiple staff to redirect as resident became combative, scratching and pinching staff. Once in bed resident began to punch the walls and snatch down blinds on window next to bed. 1:1 monitoring initiated and resident continued to yell out help, I'm being held hostage. This lasted for about 2 hours before resident eventually settled down. 1:1 monitoring was not in place on this shift. Documented under Progress Notes on 11/13/22 at 11:22 PM was The resident tried multiple times to leave the unit stating there is someone in the car is waiting for her. She was going to the exit door, and setting alarms out tried get through the doors going outside. It took several staff members to be able to redirect the resident. Also the resident was combative and hitting the staff. Documented on 11/14/22 at 7:48 AM was Resident awake and wandering hallway since beginning of shift, has two bags packed and attached to walker. Resident states she has to go home and take care of her house, asked this writer which door leads out . Documented on 11/14/22 at 8:57 PM was Resident pulled fire alarm near door trying to get out door. Documented on 11/16 at 3:32 AM was No 1:1 supervision available overnight . Documented on 11/23/22 at 2:12 PM was Attempted to elope off unit X1 . Documented on 11/26/22 at 11:14 AM was .3 attempts to elope this shift . Documented on 11/30/22 at 1:45 PM was [6:50 PM] Exit seeking: Pt disruptive, calling staff names, demand to leave unit. Re/directing unsuccessful, able to walk out of unit double doors out in hallway w/ staff stand by assist. Staff walked w/ pt to [another unit] before pulling fire alarm. Staff provided guidance until pt safely ret to proper unit. Assistance w/ phone call to family provided, offered snack/fluids, helpful. During survey on 12/19/22 at 10:12 AM, 1:04 PM and 3:52 PM, Surveyor observed R32 in room alone with no 1:1 supervision. On 12/20/22 at 8:14 AM, Surveyor observed R32's door closed and knocked. Surveyor entered room and noted R32 was sitting on bed alone, in robe and gown, gripper socks on, drinking coffee. R32 had a duffle bag in hand and a Wanderguard on ankle. Surveyor found the 1:1 aide (CNA-L) in the hallway who entered R32's room at 8:21 AM. On 12/20/22 at 8:23 AM and 11:15 AM Surveyor interviewed CNA-L. Surveyor asked how much of the shift she is the 1:1 for R32. CNA-L stated the whole time. NA-L stated R32 kicks her out which happens every 2-3 minutes. Surveyor asked if CNA-L had other residents that you care for? CNA-L stated she is my only assignment but I answer call lights sometimes to help out. Surveyor asked if she is the only 1:1 aide. CNA-L stated no, there is a 1:1 aide on all 3 shifts. Surveyor asked how long this 1:1 has been in place. CNA-L stated it had been about a month to a month and a half. Surveyor asked how she knows how to take care of R32. CNA-L showed Surveyor a piece of paper with a note that documented 1:1 supervision AT ALL TIMES. On 12/20/22 at 11:22 AM Surveyor interviewed Unit Manager (UM)-M Surveyor asked on what shifts R32 has a 1:1. UM-M stated R32 always had a 1:1 and Scheduler-O schedules them and the Nurses will cover if needed. Surveyor asked when the 1:1 was put in place, UM-M stated it started when she fell outside referring to the 11/5/22 incident. Surveyor asked what the 1:1 would do throughout a shift. UM-M stated just keeping an eye on her. UM-M stated she was not sure what specifically and she I would have to look in her chart. CNA care card binder - no [NAME] card. On 12/21/22 at 8:51 AM Surveyor interviewed Registered Nurse (RN)-N. Surveyor asked when R32 usually wanders or tries to leave the unit. RN-N stated really early in the morning, more on Night shift. RN-N stated she is usually fine on First shift and that is the only shift she works. Surveyor asked if she has had any training or In-services on elopement at the facility. RN-N stated no, she did in prior jobs at other facilities that had locked units. RN-N stated this is not a locked unit but has Wanderguard alarms on the side dining room, the front door and the elevators. On 12/21/22 at 9:15 AM Surveyor interviewed Scheduler-O. Surveyor asked when she schedules 1:1 aides for R32. Scheduler-O stated for the AM and PM shifts. Surveyor asked about Night shift. Scheduler-O stated she does not schedule Night shift 1:1. Scheduler-O stated the RN Supervisor assigns a 1:1 from the staff that is scheduled. Surveyor asked if there are ever AM or PM shifts that are not covered. Scheduler-O stated sometimes. Surveyor asked what happens if you do not have anyone assigned. Scheduler-O stated the Nurse or Activities covers. Surveyor asked when she started scheduling the 1:1 aides. Scheduler-O stated 11/6/22. On 12/21/22 at 10:46 AM Surveyor interviewed NHA-A, DON-B and Clinical Quality Support RN (RN)-J. Surveyor asked what does 1:1 mean. DON-B stated I would have to look at the policy. Surveyor asked what was done after [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 (R11) of 7 Residents reviewed for pressure injuries. R11 had a right buttock pressure injury that increased in size and slough percentage. The wound doctor assessed the pressure injury and wrote orders for a new treatment. The facility failed to transcribe the order, R11 continued to receive the previous treatment for two weeks and the pressure injury continued to increase in size and slough percentage. Findings include: R11 was admitted to the facility on [DATE] with diagnoses that include, multiple sclerosis; diabetes mellitus 2 with long term insulin use; quadriplegia; chronic respiratory failure with dependency on ventilator; and pressure wound of the sacral region. R11's most recent Minimum Data Set Assessment with an Assessment Reference Date of 11/29/2022 documented R11 was at risk for developing a pressure injury, had one unstageable pressure injury, and needed total staff assistance for activities of daily living. R11's most recent Braden scale assessment dated [DATE] documented a score of 12 which indicated R11 was at a high risk to develop a pressure injury. R11's skin care plan, dated 12/02/2022 documented, Altered Skin Integrity, as evidenced by Unstageable Pressure Injury to Right Buttock. Risk Factors for Skin Breakdown include: Hx (history) of Stage 4 pressure injury to sacrum, hx of MASD (Moisture Associated Skin Damage), quadriplegia, Cdiff (Clostridium difficile), incontinence, MS (Multiple Sclerosis), decreased mobility. Interventions included: Monitor skin daily with cares, during baths, and weekly. MD (Medical Doctor) update if indicated . Assess for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible . Wound treatment to be performed by nursing, as ordered by MD/NP (Medical Doctor/Nurse Practitioner). Nursing to monitor integrity of dressing, with each encounter, and replace dressing if soiled, loose, or missing. Wound assessment / measurement performed weekly by wound care team. If resident unavailable, assessment to be completed at earliest availability. Referral to Wound MD for management / debridement of Unstageable pressure ulcer. Place pillow between knees, legs, & feet, when lying on her side. On 12/19/22 at 11:13 AM, Surveyor observed R11 lying on back on an air mattress. R11 was covered with a blanket. R11's daughter came into the room and informed Surveyor she was concerned because R11's pressure injury to the buttocks had worsened. Surveyor reviewed R11's medical record and noted the pressure injury to the right buttock was first documented by the wound doctor on 02/17/2022. At this time the right buttock pressure injury measured 3.5 cm (centimeters) x 3 cm x 0.1 cm and was documented as unstageable due to the presence of slough. R11 continued to be followed by the wound doctor weekly. R11 was sent out to the hospital on 08/17/2022 and returned to the facility on [DATE]. Upon return to the facility, R11 continued to be seen by the wound care team. On 08/26/2022, the facility documented an assessment of the right buttock pressure injury: 3.5 cm x 3 cm x 0.5 cm; 10% slough/ 90% granulation; treatment ordered - Dakin's 1/2 strength cleanse f/b (followed by) Santyl, f/b Mesalt, f/b bordered foam, every day. Surveyor noted this order in R11's discontinued physician's orders. According to facility documentation, from 08/26/2022 until 09/16/2022, the pressure injury/wound assessment and treatment remained the same On 09/16/2022, the right buttock pressure injury assessment was the same as on 08/26/2022, however the wound doctor changed the order to Dakin's 1/2 strength, f/b Mesalt, f/b bordered foam dressing, every day. Surveyor noted this order in R11's discontinued physician's orders. According to facility documentation, from 09/16/2022 until 10/28/2022, the same treatment remained in place and pressure injury measurements decreased in width by 0.5 cm; length and depth measurements remained the same and percentages of tissue types remained the same. On 10/28/2022, the facility documented the pressure injury as 3.5 cm x 2.5cm x 0.5 cm with 70% necrosis / 30% granulation. The wound doctor changed the treatment to Dakin's 1/2 strength cleanse, f/b Silver Alginate, f/b bordered foam dressing, every day. Surveyor noted this order in R11's discontinued physician's orders. On 11/04/2022, the facility documented the pressure injury as 3.5 cm x 2 cm x 0.1 cm with 20% slough / 80% granulation. The treatment from 10/28/2022 remained in place. From 11/04/2022 until 12/02/2022, according to facility documentation, the pressure injury measurements remained the same and the treatment remained the same. On 12/02/2022, the facility documented the pressure injury as 4.5 cm x 3.5 cm x 0.1 cm with 40% slough / 60% granulation. This assessment showed a decline in the pressure injury's length by 1 cm and a decline in the tissue type by 20%. The wound doctor changed the treatment order to Dakin's 1/2 strength cleanse, f/b Mesalt, f/b bordered foam, every day. Surveyor was unable to locate this order in R11's discontinued physician's orders. A wound progress note dated, 12/01/2022, documented, Seen by wound team for weekly wound rounds. Unstageable to right buttock has deteriorated (length, width and slough increased), wound bed is 40% slough .primary treatment changed to Mesalt . Surveyor noted a physician's order with a start date of 10/28/2022, Treatment to right buttocks: Cleanse with Dakin's 1/2 strength. Apply silver alginate to wound bed, then cover with bordered foam dressing, every day. This order was not discontinued until 12/15/2022. Surveyor could not locate a physician's order corresponding to the wound doctor assessment and treatment recommendations from 12/02/2022. On 12/09/2022, the facility documented the pressure injury as 4.5 cm x 3 cm x 0.1 cm with 20% slough / 80% granulation. Per facility wound documentation, the treatment remained the same as on 12/02/2022: Dakin's 1/2 strength cleanse, f/b Mesalt, f/b bordered foam, every day. However, since that order was not transcribed the treatment continued with Dakin's 1/2 strength, f/b silver alginate, f/b bordered foam, daily. On 12/16/2022, the facility documented the pressure injury as 5 cm x 5 cm x 0.1 cm with 50% slough / 50% granulation. The pressure injury had deteriorated in length, width, and tissue type. The treatment was changed to Dakin's 1/2 strength cleanse, f/b Santyl ointment, f/b Calcium Alginate, f/b bordered foam dressing, every day. This order was properly transcribed and had a start date of 12/16/2022. On 12/21/22 at 8:19 AM, R11 gave Surveyor permission to observe wound care to the right buttock unstageable pressure injury. CNA-H and Wound Care RN (Registered Nurse)-K donned appropriate PPE (Personal Protective Equipment), entered R11's room, and explained the procedure. RN-K performed wound care per professional standards and followed R11's treatment order. The pressure injury appeared clean with red granulated tissue with a scant amount of sanguineous drainage and no signs or symptoms of infection. Surveyor had no concerns with how RN-K provided treatment to the pressure injury. On 12/21/22 at 9:21 AM, Surveyor interviewed RN-Q. RN-Q informed Surveyor he rounds with the wound MD weekly on Thursdays, but the floor nurses do the daily dressing changes. Surveyor asked how the nurses know what the treatment is. RN-Q stated the nurses would follow the orders on the ETAR (Electronic Treatment Administration Record). Surveyor asked RN-Q who is responsible for transcribing the treatment order if the wound MD alters the treatment. RN-Q informed Surveyor he, RN-Q, transcribes the treatment orders. Surveyor asked RN-Q about the treatment order from 12/02/2022. At this time, RN-Q reviewed R11's ETAR and showed Surveyor the discontinued physician's order for Dakin's 1/2 strength cleanse followed by Silver Alginate, f/b bordered foam dressing. Surveyor questioned the wound assessment from 12/02/2022 that documented a change in the treatment from Silver Alginate to Mesalt. RN-Q continued reviewing R11's physician's orders and informed Surveyor he could not locate that order. Surveyor asked RN-Q if the order was not found in the discontinued orders would you assume it was not transcribed. RN-Q replied yes, I would assume the order was not transcribed. RN-Q then reviewed his wound care binder and informed Surveyor he was aware of the treatment change and the treatment change was documented in the wound care binder. RN-Q was not sure why the order was not transcribed and informed Surveyor the Mesalt order should have been in place from 12/02/2022 through 12/15/2022. Surveyor asked for any additional information. On 12/21/22 at 12:51 PM, RN-Q approached Surveyor in the conference room and informed Surveyor he still was not sure how that order was missed. RN-Q confirmed he was aware of the new order but that it did not get transcribed. Surveyor expressed concerns the pressure injury had deteriorated and the floor nurses would not have known the order had been changed. RN-Q acknowledged the pressure injury did deteriorate during the second week of using the incorrect treatment. On 12/21/22 at 3:04 PM, during the end of the day meeting with NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B and Director of Clinical Operations-C, Surveyor relayed concerns regarding R11's pressure injury deteriorating during the time when the facility failed to transcribe a new treatment order. Surveyor asked for any additional information. No additional information was provided.

Based on interview and record review the facility did not ensure 1 (R12) of 1 residents with a change in condition following a fall was thoroughly assessed, so appropriate treatment could be provided based off the assessment. * R12 was readmitted to the facility on [DATE] following hospitalization from [DATE] thru 3/25/22. Upon arrival to the facility R12 informed staff of the need to use the bathroom. R12 was assisted to the toilet, provided the call light, and instructed to call for assistance when finished. Staff left R12 unattended in the bathroom. R12 was then found on the floor with her head at base of toilet and wall. From 3/26/22 through 3/31/22, R12 was documented to be experiencing a change in condition with increased weakness, increased confusion, difficulty expressing needs, only able to answer yes/no questions and incontinent. On 3/31/22, R12 was transferred to the hospital with a concern for altered mental status and was diagnosed with bilateral subdural hematomas. R12 was admitted to the Neuro (Neurological) ICU (Intensive Care Unit). The facility did not complete a thorough assessment of R12 after the unwitnessed fall including routine neurological assessments given R12 was prescribed Eliquis, which could increase the likelihood of bleeding and bruising. Findings include: The facility policy, entitled Cran Checks (Neurological), dated 11/89 and revised 8/19, documents: Policy: Cran Checks are obtained to: a. Assist the nursing staff in a systematic approach to current neurological data documentation. b. Provide pertinent data for the physician which will assist in evaluating the resident's status. c. Create a baseline for all health team members in evaluating current and changing status of resident. General Information: 1. This procedure is done following an unwitnessed fall or a witnessed fall with resident hitting head. 2. Frequency of neurological checks based upon nurse evaluation or M.D. (Medical Doctor) orders, routinely done q (every) 30 min (minutes) x (for) 2, q hr (hour) x2, q 4 hrs (hours) + (and) PRN (as needed) at nursing direction. 3. Document findings on the Neurological Assessment in EMR (Electronic Medical Record). 4. Describe abnormal findings in nurse's progress notes. 5. Report significant findings to the physician and resident representative. R12 was admitted to the facility on [DATE] with diagnoses that include: Atrial fibrillation, diabetes mellitus, congestive heart failure, depression and anxiety. R12's Admission MDS (Minimum Data Set Assessment), with an ARD (Assessment Reference Date) of 1/19/22, documents, a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately impaired daily decision making; no behavior concerns; requires extensive 1 person assist for bed mobility, transfers, dressing, toileting and personal hygiene; not steady and only able to stabilize with human assistance when moving from a seated to standing position, walking with assistive devices, turning around to face the opposite direction while walking, moving on and off the toilet, and surface to surface transfers; occasionally incontinent of bladder and bowel and had a fall in the month prior to admission. R12's Care Plan, dated 3/14/22, documents: [R12] has potential for falls related to impaired mobility, impaired cognition. Interventions include: -Encourage use of assistive device, if applicable, describe: w/c (Wheel Chair) for mobility, start date: 3/14/22; -PT (Physical Therapy)/OT (Occupational Therapy) screen/evaluation and treat as ordered, start date: 3/14/22; -Floors free from spills or clutter, start date: 3/14/22, -Provide adequate, glare free lighting, start date: 3/14/22; -Keep call light, personal, and frequently used items within reach, start date: 3/14/22; -Assess for appropriate foot wear, start date: 3/14/22. On 1/12/22, R12's Fall Risk Assessment documents a score of 18, which indicates a high risk for falls. Surveyor notes R12's care plan does not address R12's high risk for falls until 3/14/22 even though R12 was assessed to be at high risk for falls upon admission to the facility on [DATE]. R12's March 2022 MAR (Medication Administration Record) documents a physician's order for: Eliquis 2.5 mg (milligrams) tablet, 1 tab by mouth every 12 hours for prevention, start date 1/12/22, end date 3/25/22. (Eliquis is used for the prevention of serious blood clots from forming due to certain irregular heartbeat (Atrial fibrillation). On 3/25/22, at 9:35 PM, R12's medical record documents, Resident readmit (readmission) the shift at 1750 (5:50 PM) from [name of] hospital via [name of] ambulance transport. Resident assisted by paramedic staff from gurney to wheelchair as resident stated she did not want to lay down in bed. Resident asking to use the bathroom, this LN (Licensed Nurse) asked resident to please wait a few minutes while this LN can see what her transfer status was. Resident stated okay, resident noted to be attempting to self transfer onto toilet a couple minutes after that, this LN assisted resident onto toilet as she was already standing at toilet. Resident sat on toilet safely, resident noted to be dry but not wearing any brief or undergarment. This LN handed resident call light string asking her to pull string when she is done. This LN had gone down hall and when coming back toward nursing station this LN heard resident call out in soft voice for help. This LN went into check on resident. Resident noted to be lying on right side with head at base of toilet and wall. Resident had no apparent injury noted and states she did not hit her head. Resident assist into bed via Hoyer lift.Supervisor did skin check at this point, noting two areas on buttock, one area on left heel, bruise to right thigh, right upper arm and scattered bruising throughout BUE (Bilateral Upper Extremities), also noted with midline scar. Resident with non slip socks and diabetic shoes on at the time of the fall, did have pants around ankles when found. MD (Medical Doctor) and family notified, No new orders given at this time. Resident continues with VSS (Vital Signs Stable) and no complaint of pain. [Name of responsible party] states she has concerns (R12) maybe sundowning. This LN did let [responsible party] know that was given in report from the hospital that (R12) does have signs of dementia. Resident now in bed resting. Bed in lowest position. On 3/25/22, at 10:15 PM, R12's medical record documents a Nursing Data Base/Comprehensive assessment which documents: . Neuro: Oriented to person; Hand Grasps: weak, equal; Right Pupil: 2 mm (millimeters) and reactive; Left Pupil: 2 mm and reactive; speech clear and understands . The assessment is signed as completed by Agency LPN (Licensed Practical Nurse)-D on 3/25/22 and RN (Registered Nurse)-E on 3/28/22. Surveyor notes an LPN completed the Nursing Data Base/Comprehensive assessment after R12's unwitnessed fall and it is not signed by an RN until 3 days later. Surveyor also notes there is no documentation to identify if R12's documented weak hand grasps are a new concern or baseline. Surveyor notes there are no further documented neurological assessments that include details of R12's orientation, hand grasps, pupil size and reaction, speech and ability to be understood and understand. On 3/26/22, at 11:42 AM, R12's medical record documents: Left a message for therapy office to see when they will see [Resident name]. Resident needs a reevaluation post fall from 3/25/22. Pt (patient) weaker since fall. On 3/26/22, at 2:14 PM, R12's medial record documents, Patient is confused and A&Ox1 (Alert and oriented to self). Denies any pain and has weakness. VSS (Vital Signs Stable) NP (Nurse Practitioner) [Name] made aware. On 3/26/22, R12's medical record documents, NP [name] notes res alert and oriented x1 neuro check unremarkable. On 3/27/22, at 1:30 PM, R12's medical record documents, Resident still confused and weak. Spoke with PT (physical therapy) and is a Hoyer lift until PT able to reassess her, as resident is tired and would not sit up to the edge of the bed today. On 3/27/22, at 6:31 PM, R12's medical record documents a SNF (Skilled Nursing Facility) Visit by NP-F which documents, .Psychiatric-alert and oriented x1 some confusion noted, appears a bit spacey. Muscle weakness (generalized): PT (Physical Therapy) for transfers, mobility, strengthening, balance and family training. Patient is high fall risk, already fell without injury in bathroom on arrival, monitor progress. Unspecified Atrial fibrillation: continue on Eliquis, on 2.5 mg although creatine is within normal limits patient is a very high fall risk, also on aspirin, monitor for bleeding. On 3/27/22, at 11:59 PM, R12's medical record documents: Alert to self only. Confusion and weakness still persist. Ate 100% dinner with good fluid intake. Has difficulty expressing her thoughts. Neurocheck negative. Hoyer lift is being used until PT reassessment. Surveyor notes there is no documentation of the neurological assessment being completed on 3/27/22. On 3/28/22, at 11:55 AM, R12's medical record documents, Pt (patient) is on board for new admit. Pt is appearing to be confused according to NP [name] (NP-G). No new orders. No concerns noted. Vitals WNL (within normal limits). On 3/28/22, at 3:53 PM, R12's medical record documents a SNF Progress Note completed by NP-G, which documents, High risk visit. Patient seen sitting in wheelchair. She is in no acute distress. Care discussed with therapy who is present in room. She denies chest pain shortness of breath nausea vomiting fever chills. Psychiatric-alert, normal affect.Unspecified Atrial fibrillation: continue on Eliquis. Surveyor notes NP-G's progress note dated 3/28/22 at 3:53 PM does not address R12's earlier noted confusion on 3/28/22 at 11:55 AM. On 3/28/22, at 9:19 PM, R12's medical record documents, Resident remains on 24 hour report from 3/25/22 related to readmit and unwitnessed fall. Resident noted to be having a hard time verbalizing her needs. Will call out for help at times and will point toward what she needs but noted to be struggling to state her needs. Manager aware of residents speech and weakness, states MD (Medical Doctor) will see her tomorrow 03/29/22. VSS. Resident assisted into bed via Hoyer transfer. Resident did refuse dinner eating only her jello, applesauce and some of her milk. Surveyor notes there is no documentation R12 was seen by the MD on 3/29/22. On 3/29/22 at 11:03 AM, R12's medical record documents, Alert to self only. Unable to express her needs verbally. Observed some frustration on her face by frowning. Need assistance with dinner. Needs total care for ADL's (Activities of Daily Living). On 3/29/22, at 12:07 PM, R12's medical record documents, Post fall investigation complete: Resident self transferred from toilet to chair and was lying on right side next to toilet. Intervention is for staff to stay in room if she is using bathroom. Therapy will eval and treat also. On 3/30/22, at 2:38 AM, R12's medical record documents, Resident alert and can only answer yes or no questions. Resident attempts to verbalize her needs but can't get any words besides yes/no. On 3/30/22, at 12:53 PM, R12's medical record documents, Resident A&O (Alert and Oriented) to person. Clear speech with poor ability to express all needs. Able to respond yes & no when inquiring with resident. VSS & blood sugars stable. Requires total assistance for positioning & ADL completion. Incontinent of bowel and bladder. Consumed 75% of breakfast & 25% of lunch with total assistance. Assessed by [NP-F's name]. Awaiting labs results. Will continue to monitor, and document changes as indicated. Surveyor notes there is no documentation by NP-F related to a visit with R12 on 3/30/22. On 3/30/22, at 8:59 PM, R12's medical record documents, Resident has trouble expressing her needs verbally. Updated on call NP [initials of NP] with lab results from today. NNO (No New Orders). On 3/31/22, at 11:45 AM, R12's medical record documents, Resident sent out to [name of] hospital for AMS (Altered Mental Status]. Resident is alert but unable to respond to questions in a timely manner. ROM (Range of Motion) is weaker than baseline. Resident appears sluggish. No c/o (complaint of) pain or discomfort. NP [name]-F requested resident to be sent to ER (emergency room ) for evaluation. On 3/31/22, at 7:40 PM, R12's medical record documents a Focused Note, documented by NP-F, which documents, Chief Complaint: altered mental status, change in condition. Assessment: Patient was seen in her room today, having worsening of symptoms expressive aphasia with increased weakness, labs were unremarkable except for elevated TSH (Thyroid-stimulating hormone) and free T4 (Thyroxine), due to mental status changes patient sent out to hospital for further evaluation, noted in [name of medical record] patient did have evidence on CT (computerized tomography) of SDH (Subdural Hematomas) acute on chronic with left thickness 2.5 cm (centimeters) and right 1.5 cm with midline shift left to right, plan to go into surgery tomorrow am. Surveyor notes there are no documented neurological checks for R12 except for the initial one completed after the unwitnessed fall on 3/25/22. Surveyor notes if the facility had completed comprehensive assessments, of R12 including neurological checks, a change in condition could possibly have been identified sooner. On 12/22/22, at 9:22 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated she would expect to see and RN assessment completed following a witnessed or unwitnessed fall. DON-B stated after the initial assessment by the RN after the fall DON-B would expect neuro checks, a fall evaluation, a fall assessment and then immediate interventions put into place to prevent future falls. DON-B stated the standard of practice the facility uses is for all unwitnessed falls to have neuro checks completed. DON-B stated that prior to R12's hospitalization and readmission to the facility on [DATE], R12 would transfer herself to the toilet. On 12/22/22, at 12:25 PM, DON-B informed Surveyor neuro checks are being done but we (the facility) needs to clean up our practice of documenting them as the nurse is just documenting neuro checks completed. Surveyor asked DON-B for documentation of the completed neuro checks for R12 after the unwitnessed fall on 3/25/22. DON-B stated it is the facility's policy to document completed neuro checks in the Neurological Assessment section of the EMR (Electronic Medical Record). On 12/22/22, at 12: 28 PM, DON-B informed Surveyor she is not seeing neuro checks completed for R12 after the unwitnessed fall on 3/25/22. DON-B stated there is documentation of the RN supervisor completing a skin body check after the fall and that would be considered documentation R12 was assessed by an RN after the fall and that would include a neuro check. DON-B stated the nurse completing the incident report, which includes the neuro check and the body check is the nurse that attended to the resident after the fall. DON-B stated if that nurse is an LPN they will then call the RN, the RN will complete the neuro and body check but the LPN will completed the incident report. DON-B stated she would expect to see neuro checks completed by staff after an unwitnessed fall. That is their policy and that is what they do. DON-B stated it would have been nice if the supervisor documented her own but the LPN put the information into her note instead. On 12/12/22 at 2:01 PM, Surveyor interviewed NP-G who stated, she believes she saw R12 on 3/28/22 but isn't certain. Surveyor informed NP-G of the progress note in R12's medical record documenting the visit on 3/28/22. NP-G stated she knows R12 and she did seem different but can not recall when (what date) she saw R12 even given the documentation in R12's medical record. NP-G stated she really could not recall if R12 seemed different enough when she saw her to recommend she be transferred to the hospital. On 12/12/22, at 2:09 PM, DON-B provided Surveyor with copies of the facility 24 hour report board for 3/26/22 and 3/27/22. R12's name appears on both days. On 3/26/22 the 24 hour report board documents R12 readmitted [DATE], had a fall. Day shift: confused and weakness; PM shift: confused, neuro check negative; NOC (night shift): slept well. On 3/27/22 the 24 hour report board documents R12: readmit and fall on 3/25/22. Day shift: confused and weak, A&Ox1 (alert and oriented to self); PM shift: Alert to self only, still confused and weak, at 100% of dinner; NOC: slept well. Surveyor notes R12 remained at the facility until 3/31/22. Staff documented changes of condition from 3/26/22 thru 3/31/22 but R12 did not remain on the 24 hour report board for observation/supervision. On 12/12/22, Surveyor informed Nursing Home Administrator (NHA)-A of the concern R12 had an unwitnessed fall on 3/25/22 and thorough assessments of R12, including neurological assessments, were not completed even though staff documented R12 was experiencing changes in condition from 3/26/22 until 3/31/22. The change of condition included requiring total assistance from the staff, declining cognition and inability to express needs. R12 is also prescribed the blood thinner Eliquis which increases the chance for bleeding. R12 was transferred to the hospital on 3/31/22 and admitted to the Neuro ICU with bilateral subdural hematomas requiring surgery.

Based record review and staff interviews, the facility did not always ensure that 1 of 2 (R215) residents reviewed for receiving enteral nutrition received the appropriate treatment and services to prevent complications of enteral feeding including aspiration pneumonia and vomiting. R215 was admitted to the facility with a history of aspiration pneumonia and had discharge orders from the hospital that the head of the bed is to be at 60 degrees or higher during the day and 45 minutes after the last tube feeding is administered. The facility did not follow these orders and placed the head of the bed at 30 degrees which is the standard used in the facility for residents while receiving tube feedings. R215 experienced 2 episodes of vomiting and was sent out to the hospital for aspiration pneumonia and acute hypoxemic [CONDITION(S)]. Findings include: R215 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor conducted a review of hospital discharge paperwork, dated 8/19/21, that was sent to the facility upon admission of R215. The paperwork contained information stating that the patient (R215) had vomiting a couple of days ago appears at risk for intermittent aspiration. His (R215) aspiration risk is high. Risk can be lessened with dietary modifications and feeding precautions. Tube feeding via PEG, rate recently decreased for emesis under guidance of Dietician. Emesis resolved: Discharge tube feeding order: [MEDICATION(S)] 1.5 feedings of 240 cc each over 90 minutes via pump daily at 6:00 a.m., 10:00 a.m. , 2:00 p.m., 6:00 p.m., 10:00 p.m. and midnight with 1 packet banana flakes daily at 6:00 a.m.,10:00 a.m., 2:00 p.m.,10:00 p.m. with water flushes of 100 cc pre and post feedings. Banana flakes added to help bulk up stool . The discharger order continues to state, Keep HOB (head of bed) at > 60 (greater than) during day and 45 minutes after last tube feeding free water flushes: dietician to adjust. Thick secretions: continue frequent suctioning (patient is able to use suction with set-up assist, needs reminders, continue [MEDICATION(S)] scheduled and prn. Did not tolerate [MEDICATION(S)] patch. Facility admission Note, dated 8/19/21; Pt (R215) arrived via family at approx. at 7:30 p.m. in W/C (wheelchair)with oxygen at 4liters. R215 is alert x3 daughter with patient assisted to bed with two assist and pivot. HOB (head of bed) up. Blood sugar was 114 [MEDICATION(S)] started R215 gets six feeding a day. Has Foley Cath due to urine retention per report. Incontinent of stool. Is diabetic, has peg tube, is full code. A review of the physician orders, dated 8/19/21 showed that the facility obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted that this order is not the same as the above discharge tube feeding order form the hospital. It was also noted that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted that the hospital discharge order to keep the head of bed at 60 degrees or greater during day and 45 minutes after last tube feeding was not transferred to the facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the initial individual plan of care, started on 8/19/21, stated R215 requires feeding tube for nutritional needs due to right cerebellar IPH (intraparenchymal hemorrhage). Interventions included to elevate head of bed 30- 45 degrees during feeding and 30 minutes after. On 08/30/21 at 11:01 a.m., Surveyor interviewed RN Unit Manager- J. RN Manager-J stated that R215 came in on a Thursday afternoon and the care plan was developed that day. RN Manager- J stated that some of the care plans have the same standard entries/ interventions including standard interventions for those resident who receive tube feedings. RN Manager -J stated that the intervention to keep the head of bed elevated to 30- 45 degrees during feeding and 30 minutes after is a standard intervention used by the facility. RN Manager-J stated that usually the nutrition and tube feeding care plan is filled in by Dietician if there are any specific interventions that need to be used. RN-Manager-J shared they just put in information for feeding tube that is standard and would expect the others to change it if needed. RN- Manager- J was asked if she was aware that R215 had a discharge order from the hospital that stated that the head of bed should be kept at 60 degrees or greater during the day and 45 minutes after the last tube feeding. RN Manager -J stated that when a new resident is admitted they usually come with a stack of papers from the hospital that she may not have access to. RN Manager- J stated that she did not review the discharge orders from the hospital prior to developing the plan of care on 8/19/21. RN Manager - J stated that any nurse can go in and change care plans if they noticed the orders said something different than what is listed on the care plan. RN Manager-J stated that the Nursing Supervisor can put information in the care plan once they obtain nursing admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Note 8/20/21: Post Admit day #1. Continuous TF / qt 6 hr flushes. IDDM (insulin dependent diabetes mellitus) - no hyper/[CONDITION(S)]. Pureed/Nectar with SLP (speech therapy) only. On 8/20/21 the facility obtained a new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Will provide 2016 Kcal, 93 grams of protein for nutrition. Water flushes- 200 cc tube four times a day for hydration. Banana flakes - 1 packet tube three times a day. 1 packet three times daily via PEG tube for nutritional deficiency. Further review of R215's medical record did not show evidence that the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor conducted a review of the Skilled Nursing Facility Initial Visit progress noted dated 8/20/21. The progress note stated that R215 has a rocky clinical course with pneumonia aspiration septic shock hypoxic [CONDITION(S)] and required intubation with pressors and ultimately tracheotomy with PEG tube placement. R215 was at (name of) hospital on 6/15/21 with a stroke and after being medically stabilized was transferred to West [NAME] (name of ) Hospital on 7/8/21 for further management and rehabilitation. R215 has been decannulated and weaned down to 2 liters' oxygen nasal cannula but failed video swallow and remains nothing by mouth on tube feeding with PEG tube. R215 was transferred in medically stable condition but continued weakness and debilitation on 8/19/21 and transferred to (name of facility) on 8/19/21. Dietary Note dated 8/23/21; Resident (R215) admitted NPO (nothing by mouth) status with PEG tube. In the hospital resident was receiving [MEDICATION(S)] 1.5 240cc 6x a day. Facility does not carry [MEDICATION(S)] 1.5. No cans of [MEDICATION(S)] 1.2 in stock. Wrote order for [MEDICATION(S)] 1.2 70cc/hr for 1680cc per day. Will provide 2016 Kcal, 93grams of protein. This should be tolerable per hour. Banana Flakes TID. Resident is working with SLP (speech therapy) for any possible oral intake. Nursing note dated 8/23/21; Writer received call from R215's family who is concerned about the timing of the resident's feeding and would like a status update from the provider. Writer spoke with Nurse Practitioner and she will examine the resident and update the family. Nursing Change of Condition note dated 8/23/21; I arrived in Pt's (R215) room this morning to give medications and assist CNA with cares for Pt at 0930. I took vital signs and CNA reported that Pt had a large emesis which looked like his Tube feeding, according to his CNA I did not see the emesis myself the first time. I did not hook up a new bottle of tube feeding at the time because of the emesis. After I assisted CNA with cares, I gave Pt some of his medications but shortly afterwards he had another moderate amount of emesis, which looked like particles of his medications. I checked his Vital signs and also assessed his lungs. Pt's lungs were coarse sounding bilaterally. Skin warm and dry. Skin color mildly pale. Pt denied discomfort and had no facial grimacing. Breathing was labored and 28 RR, PO2 was fluctuating from 74 to 81% on O2 4L/min via nasal cannula. Pt had a [MEDICATION(S)] suction on his lap in his hand at this time. I notified RT to come and assist with assessment for him. T 98.6. Pulse increased to 124 from 120 earlier. BP 130/80. RT applied NRB which brought PO2 up to 92. I notified NP, (name of) of status and received order to send Pt out to (name of hospital) for ER evaluation. I called 911 and (name of) ambulance arrived at approximately 1030AM to transport Pt to ER. Pt's daughter arrived on unit and I explained the need to send Pt to the ER. Therapy Change of Condition note dated 8/23/21; This writer called to resident's room to assess patient after emesis X 2. Resident awake and alert. POX (pulse oxygen) 74 HR 124 RR 40 on 2LNC. Increased O2 to 6lpm via NC (nasal cannula) POX 78, Placed resident on NRB (non-rebreather mask) POX increased to 92 HR 124 RR 36. Breath sounds coarse rhonci/rales t/o. Good congested cough with dark brown and yellow secretions coughed into continuous sx via yankhauer. BP taken by nurse 119/73 Resident remained awake and alert. Ambulance arrived at 1050 for transport to hospital. Skilled Nursing Facility Progress Note dated 8/23/21 and written by Nurse Practitioner (NP)-K stated (R215) was seen at the request of the nursing staff regarding vomiting. Notified that the patient (R215) vomited with subsequently coarse sounding lungs bilaterally and labored respirations with pulse ox fluctuating from 74 to 81% on oxygen per nasal cannula at 4 liters. Pulse 124. Respiratory Therapist applied nonrebreather mask which brought pulse ox up to 92%. Instructed staff to send (R215) to Emergency Department for urgent evaluation of [CONDITION(S)]. Later notified that the family would like to speak with writer, entered room and EMS present to transport (R215) to higher level of care. No chest pain, nausea, vomiting fever or chills noted. Care discussed with Respiratory Therapist and Unit Manager. On 08/30/21 at 11:13 a.m. Surveyor interviewed NP- K who stated that she went to talk with R215's daughter but EMS was in the room. I asked to have the resident sent out. They had a concern that we were doing continuous feeding. Family concerned that would cause aspiration pneumonia but bolus would actually be more of a risk. With bolus this could be higher risk of emesis. NP-K stated that she had not previously evaluated R215. On 08/30/21 11:33 a.m., Surveyor interviewed Registered Dietician (RD)-C regarding R215's tube feeding orders. RD- C stated that she did not have a chance to assess R215 when he was admitted on [DATE] as she was gone for the day. RD- C stated that R215 came on Thursday night and was not alerted a resident with a tube feeding was coming in as a new admission prior to her leaving for the day. RD- C stated that when she came in Friday morning she saw R215 received tube feeding. RD- C stated that she recognized that the order in computer was in- correct on 8/19/21 for the tube feeding formula a rate of administration RD- C stated that whoever put the order in did not clarify that it was [MEDICATION(S)] 1.2 vs 1.5. There was no name on the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RD- C stated that the admission order was not written like that, so it was confusing to follow. RD- C stated that upon her assessment of R215 , she noted that the facility does not have [MEDICATION(S)] 1.5 in stock and they do have [MEDICATION(S)] 1.2 but don't have it in cans for bolus feedings. RD- C stated that she was aware R215 was tolerating the bolus feedings, 6 times a day in the hospital. RD- C stated that with the product they had on hand, the only option would be to do continuous feeding. RD- C stated it would take a couple days to get product. RD- C stated that she didn't receive any messages that R215 was not tolerating a tube feeding at a continuous rate after it was started on 8/20/21. RD- C stated that in her opinion, the continuous tube feeding administration is a slower feeding so less risk for aspiration, as long as head of bed is up. RD- C stated that the standard nursing is to have head of bed at 30 -45 degrees. RD- C stated that she does not change anything on the plan of care that is nursing related. RD-C stated she will change formulas and water flushes and nursing would enter head of bed instructions from the hospital on the orders. RD- C stated that she wrote what happened on 8/23/21 that we didn't have the tube feeding formula into the nursing notes but had the actual order changed on 8/20/21. I received a call that the daughter wanted to talk to me. RD-C stated that she did talk to daughter and explained the facility did not have the formula and a slower administration of the tube feeding is generally tolerated. RD- C stated the family was upset with this and saw this way of feeding as a setback for R215. RD- C stated she is not certain what caused R215 to have the emesis and it could be related to the head of bed or to constipation. RD- C stated she was not aware of the order for the head of bed to be 60 degrees or greater during the day and 45 minutes after the last feeding. On 8/30/21 at 4:29 p.m., Surveyor interviewed Interview Licensed Practical Nurse (LPN)- L who stated that she does not recall R215. LPN- L stated that she usually isn't made aware of a new admission until they are in their room and wished she would have more information presented to her to review prior. LPN-L stated that the HOB is standard, usually between 30-45 degrees. The admission RN would have obtained the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/31/21 at 10:27 a.m., Surveyor interviewed Medical Director (MD)-M regarding R215 and the discharge orders he was presented with upon admission to the facility. MD- M stated that the standard head of bed is 30 -45 degrees and that a bed placed at 30 degrees versus 60 degrees would make a difference to the patient. If the bed was placed at 45 degrees versus 60 degrees this would not be as big of difference for the patient. MD- M stated that if R215 had issues with aspiration and is use to having the head of the bed at 60 degrees this could make a difference. MD-M stated most staff are putting the head of the bed at 30 -45 degrees but up to 60 degrees. MD- M stated that she would not have known where the head of the bed was placed for R215 as she had not seen him while at the facility. MD- M reviewed the hospital discharge orders and stated that the tube feeding order can be seen as a bolus feeding and it appears that the instructions were not followed. MD- D stated that R215 sounds like in general for being at risk for aspiration pneumonia. MD- D stated that bolus feeding would be more of a risk than continuous tube feeding for aspiration and also putting him flatter in the bed can cause an increased risk. On 8/31/21 at 11:15 a.m., Surveyor continued interview with MD- M who stated she recalled seeing R215 at (name of) Hospital. R215 had a lot of secretions and tried [MEDICATION(S)] and [MEDICATION(S)] patch but they were not helpful with the amount of secretions. MD- M stated that R215 would be a risk for aspiration from the secretions. MD- M stated she wouldn't be surprised if head of bed was up high due to the amount of secretions. R215 couldn't manage secretions due to his poor cough reflux. On 08/31/21 at 01:01p.m, Surveyor interviewed Certified Nursing Assistant (CNA)- N who cared for R215 on 8/23/21. CNA- N stated that she went in to do cares for R215 and R215 seemed fine. CNA- N stated that she went to assist R215 put pants on and that is when he threw up. CNA-N stated his head was up at the time and she cleaned R215 up and went and got the nurse. CNA- N stated it appeared to be tube feeding that R215 threw up. CNA- N stated that the nurse gave R215 his meds and he threw up again. CNA-N stated at lot of vomit came up. CNA- N stated that she told the nurse not to hook up the tube feeding again because family was concerned with continuous feeding. The Nurse didn't hook back up the tube feeding. CNA- N stated that she cleaned R215 up and made sure he was comfortable. CNA- N stated R215 was real pale and tired after this and then all of a sudden he was going in and out. CNA- A stated that R215's head of the bed was placed little higher than 30 degrees. CNA- N stated that R215 has a thick cough and he uses a [MEDICATION(S)] for his secretions. When R215 was coughing he would have a lot of secretions then he threw up. CNA- N stated that R215's family talked to her about keeping bed up higher to keep R215 safe so she would put pillows behind him to prop him up because of his size he would slouch a bit. CNA- N stated she has worked on the unit for many years and the standard is to keep the head of the bed at 30 degrees or higher. CNA-N was not aware of the order to keep the head of the bed at 60 degrees but did state the family placed a note above the bed requesting the bed be placed at 60 degrees. On 09/01/21 at 09:21 a.m., Surveyor interviewed RN Supervisor- OO who worked on the unit and cared for R215 on 8/23/21. RN- OO stated she was made aware R215 had and emesis and didn't hook up tube feeding right away. RN- OO stated she assessed R215 and noted his respirations were increased. RN- OO stated that she wasn't real familiar with R215 as he was a newer patient. R215's lungs sounds were coarse so RN- OO stated she made the judgment call to notify doctor. RN- OO stated that she gave R215 a few of his meds and he was still having issues. RN- OO called for the Respiratory Therapist to come in as his respirations were between 74- 81 and this is when the Respiratory Therapist put rebreather on him. RN- OO stated she gave report to the EMS staff when they arrived. RN- OO stated that R215's head of the bed was a little bit over 30 degrees. RN- OO stated she was not aware that the head of the bed was to be 60 degrees and never saw that order. RN- OO stated that there were no concerns with tube feeding pump not working correctly. RN- OO stated that tube feeding had emptied and she went to restart the new tube feeding when R215 had the emesis. Surveyor conducted a review of the (name of hospital) Inpatient Encounter Consult Note dated 8/23/21 when R215 was transferred to the emergency room via EMS. The consult note stated that the chief complaint was Aspiration Pneumonia. The assessment stated that this was a [AGE] year-old male with a history of regurgitation of tube feeding material, vomited twice. Tube feed rates were 70/ ml an hour and now without tube feeds since then. Acute hypoxemic [CONDITION(S)] secondary to aspiration pneumonia requiring 4 liters of oxygen via nasal cannula. R215 was subsequently admitted to the hospital for further evaluation and treatment. On 9/1/21, Surveyor interviewed Administrator-A and Director of Nursing-B in regards to the facility staff not following the physician discharge orders from the hospital requiring R215's head of the bed to be placed at 60 degrees or greater during the day and 45 minutes after the last tube feeding. Surveyor asked if they were aware that R215 was at high risk for aspiration pneumonia and had a recent history of this prior to being admitted to the facility. Surveyor asked why R215's head of the bed was not placed at 60 degrees or higher on 8/23/21 when R215 had two episodes of emesis resulting in him being sent to the emergency room for aspiration pneumonia. Administrator- A and DON- B were not able to provide any additional information.

Based on observation, record review, and interview, the facility did not thoroughly assess and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 3 (R6, R8, and R7) of 3 residents reviewed for pressure injuries. * R6 was admitted into the facility with 2 pressure injuries and by the time R6 discharged to another facility three months later, R6 had 5 unstagable pressure injuries. R6 was admitted with a pressure injury to the sacrum that did not have a treatment order for seven days and a pressure injury to the left clavicle that did not have a treatment order for eleven days. R6 developed an unstageable pressure injury to the right ischium, the left ischium, and the left hip while a resident at the facility. The sacrum, the left clavicle, the right ischium, and the left ischium pressure injuries were not monitored or assessed weekly. Treatment orders were not initialed in the Treatment Administration Record (TAR) as being administered as ordered for all pressure injuries. R6's air mattress malfunctioned and the facility did not know how long the air mattress was not working. * R8 developed a pressure injury to the sacrum that deteriorated to an unstagable wound with 90% slough and 10% granulation. The nurse practitioner surgically debrided the sacral wound and after debridement, the wound was determined to be a Stage 4. A change in treatment was obtained at that time and broad spectrum antibiotics were started prophylactically to treat possible [CONDITION(S)]. In addition, R8 developed a Stage 3 pressure injury to the right heel. Treatment orders were not initialed in the TAR as being administered as ordered for the pressure injuries. * R7 developed two unstageable pressure injuries to the spine and mid-spine while a resident at the facility. Treatment orders were not initialed in the TAR as being administered as ordered for the pressure injuries. The facility did not assess the skin the skin condition timely after admission, did not always get treatment orders or changes in orders timely, did not stage wounds correctly, did not do treatments as frequently as ordered, did not turn residents as frequently as they needed to be turned and did not identify that the air mattress for R6 had malfunctioned. This created a finding of immediate jeopardy (IJ) that began on 5/19/20. Surveyor notified the Nursing Home Administrator (NHA)-A, the Chief of Clinical Operations-H and Registered Nursing (RN) -G on 10/8/20 at 3:34 pm. The IJ was removed on 8/25/20, however, the deficient practice is not yet corrected and continues a scope and severity level of E (potential for harm/pattern) for all residents who are at risk for the development of pressure injuries. Findings: The facility policy and procedure entitled Wound Management Program dated 2/2018 states: The purpose of our Wound Management Program is to ensure our residents have access to the appropriate assessment and management in the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Risk and Skin Assessment: . II. All residents will have a visual inspection of their skin. A. A complete head-to-toe skin check is completed by the licensed nurse upon admission. B. Skin checks are completed by the Director of Nursing or designee weekly. C. Skin check is completed on each shower day by nursing assistant staff. Pressure Ulcer Prevention: . III. Unavoidability - At times a pressure ulcer may develop despite implementing all the appropriate interventions. In such cases, the pressure ulcer is identified as unavoidable. A. An assessment of the resident is completed to determine whether all appropriate interventions were in place. 1. Comorbid conditions that may contribute to pressure ulcer development. 2. Interventions in place for pressure ulcer prevention. 3. Compliance with the implemented interventions. B. The physician is the person who determines whether the pressure ulcer is identified as unavoidable. C. The determination of unavoidability is documented in the medical record by the physician. Wound Assessment: . Procedure: I. The presence of any wounds, ulcers, and/or other skin abnormalities will be identified upon admission and documented on the Nursing Admission Assessment. A. The complete skin and wound assessment is documented by the Wound Team in the EMR (Electronic Medical Record). 1. Any wounds present will include sites and measurements of each wound. 2. Additional skin conditions will be identified. B. Any wound identified during the resident's stay will be documented in the same manner as when identified upon admission. II. Wounds are measured weekly by the Wound Care Team or designee. A. The status of the wound is documented in the EMR. B. Wound status is also monitored with each dressing change. C. Any changes in the wound are documented at the time identified and the physician is notified. III. Type of wound/etiology will be identified. A. Per physician notes. B. Based upon the location, clinical features, and appearance of the wound. III[sic]. Stage or tissue depth. A. For pressure ulcers, the wound is staged according to the NPUAP (National Pressure Ulcer Advisory Panel) Pressure Ulcer Staging and the Centers for Medicare and Medicaid Services (CMS) in the Minimum Data Set guidelines: 1. Stage I - Intact skin with non-blanchable redness of a localized area usually over a boney prominence. 2. Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough or bruising. May present as intact or open/ruptured serum filled blister. 3. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. a. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. c. Bone or tendon is not visible or directly palpable. 4. Stage IV - Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. a. Often includes undermining and/or tunneling. c. Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon, or joint capsule) making [CONDITION(S)] possible. Exposed bone or tendon is visible or directly palpable. 5. Unstageable - Eschar or Slough - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. a. The true stage cannot be determined until enough slough and/or eschar is removed to expose the base of the wound. 6. Suspected Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure and/or shear. a. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. C. Stage or tissue depth is recorded weekly. IV. Dimensions/Measurements . D. Measurements are recorded weekly. VII. Documentation. A. Initial wound assessment by the wound team is completed using in the EMR. B. Wounds are documented in the EMR. C. Any additional documentation may be completed in the EMR. Wound Cleansing and Dressings: . V. Documentation: A. Documentation of the dressing change is completed on the Treatment Administration Record (TAR). B. Additional documentation may be completed in the EMR or on the Wound Documentation Form. 1. R6 was admitted to the facility 5/11/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 was in a vegetative state on a ventilator and receiving all nutrition through a gastrostomy tube. R6 was completely dependent for all activities of daily living and mobility. R6's hospital discharge summary (prior to admission) dated 5/11/2020 did not indicate or address any pressure injuries. No wound treatments were ordered upon discharge from the hospital. On 5/11/2020 at 8:30 PM in the progress notes, nursing charted R6 arrived via ambulance at 2:45 PM and the admissions nurse came to assess R6. No pressure injury care plan was initiated on admission with pressure injuries present. The Nursing Data Base/Comprehensive assessment dated [DATE] at 1:00 AM was completed by the admissions nurse. The Skin/Wound section of the assessment indicated R6 had a pressure ulcer to the coccyx with an Allevyn dressing in place, the right and left heels were dry and boggy, the right and left buttocks were red due to pressure, and the right shoulder had a possible old pressure area including the bilateral elbows which had scabs. No measurements or staging of the pressure wounds were documented and no descriptions of the wound bases were documented. In an interview on 10/1/2020 at 10:00 AM with Nursing Home Administrator (NHA)-A, NHA-A stated the admissions nurse no longer is employed at the facility and unavailable for interview. A pressure injury care plan was initiated on 6/23/2020 with interventions of: monitor skin daily with cares, during baths, and weekly; apply lotion to arms and legs twice daily and as needed; assess for presence of risk factors and treat, reduce, eliminate risk factors to the extent possible; encourage range of motion to maximum potential; wound care to be completed as ordered; provide bowel incontinence care after each episode; pressure reduction mattress when in bed and wheelchair cushion when up in chair; avoid friction and shearing forces during transfers or position changes; wound team evaluate/follow weekly until pressure ulcer resolved; treat existing pressure ulcer per current doctor orders/wound team recommendations-see TAR (Treatment Administration Records) for details; and Foley catheter to assist with keeping wound clean/dry. The pressure injury care plan was revised on 7/21/2020 with interventions of: reposition resident every 1-2 hours and as needed; peri-care every 1-2 hours and as needed. LEFT CLAVICLE R6 wore a cervical collar due to the fractured cervical vertebrae, and this caused pressure to the left clavicle. The risk for pressure injury was not addressed on the care plan. On 5/12/2020 on the Skin Evaluation Form, nursing documented R6 had a deep tissue injury to the left clavicle that was present on admission on 5/11/2020. No admission documentation had been made of this wound being present. On 5/12/20 on the Skin Evaluation Form, the wound measured 2.0 cm x 2.5 cm with depth unable to determine. The wound base was 50% slough and 50% pink tissue. By definition, this wound would be either Stage 3 or Unstageable, not a deep tissue injury, due to slough in the wound bed. No assessment was completed for nine days. No treatment was ordered for the left clavicle wound. On 5/22/2020 on the Skin Evaluation Form, nursing documented R6 had a deep tissue injury to the left clavicle that measured 3.5 cm x 2.0 cm with depth unable to determine due to 100% slough in the wound base. The physician was notified and a treatment order was received. The wound was assessed and documented on weekly. Treatment to the left clavicle wound was not initialed in the Treatment Administration Record (TAR) as being completed on the following dates: 5/22/2020, 5/26/2020, 5/27/2020, 5/28/2020, 5/29/2020, 6/1/2020, and 6/4/2020. On 6/5/2020 on the Skin Evaluation form, nursing documented the pressure injury was Unstageable measuring 1.3 cm x 3.5 cm with depth unable to determine with 100% slough in the wound base. The treatment was changed at that time. No further assessment was completed for eleven days from 6/5/20 to 6/16/20. Treatment to the left clavicle wound was not initialed in the TAR as being completed on the following dates: 6/5/2020, 6/6/2020, 6/7/2020, 6/8/2020, 6/9/2020, 6/10/2020, and 6/11/2020. On 6/16/2020 on the Skin Evaluation form, nursing documented the pressure injury was Unstageable measuring 1.3 cm x 3.5 cm with depth unable to determine with 100% slough in the wound base. The treatment was changed at that time. The wound was assessed and documented on weekly. Treatment to the left clavicle wound was not initialed in the TAR as being completed on the following dates: 6/16/2020, 6/17/2020, 6/19/2020, 6/23/2020, and 6/25/2020. On 7/21/2020 on the Skin Evaluation Form, nursing documented the pressure injury was a Stage 3 measuring 1.3 cm x 2.8 cm x 0.1 cm with 100% granulation tissue. Treatment to the left clavicle wound was not initialed in the TAR as being completed on the following dates: 7/24/2020, 8/15/2020, and 8/16/2020. The wound was assessed and documented on weekly until R6 discharged from the facility on 8/18/2020. The left clavicle pressure injury was present on admission, but was not staged appropriately in that the facility staged it as a deep tissue injury. Surveyor noted the pressure injury as described on 5/12/20 was either a stage 3 or unstagable. Surveyor noted no treatment was ordered for eleven days from 5/11/20 until 5/22/20. The wound was not assessed from 5/12/2020 to 5/22/2020 and from 6/5/2020 to 6/16/2020. The treatment ordered to the wound was not initialed as completed on multiple days. The final staging of the wound was Stage 3 with 100% granulation tissue in the wound base. SACRUM The sacral wound was not evaluated or assessed on admission on 5/11/2020. No treatment was ordered on admission for the sacral wound. The sacral wound was not assessed for 3 days from 5/11/20 until 5/14/20. On 5/14/2020 on the Skin Evaluation Form, nursing documented R6's sacral wound as a deep tissue injury measuring 6.0 cm x 8.3 cm with depth unable to determine. The wound base was 90% slough, 5% deep tissue injury to the peri wound, and 5% granulation tissue. Surveyor noted by definition, this wound would be unstageable due to slough in the wound bed, not a deep tissue injury. On 5/17/2020 (6 days later), a treatment was ordered for R6's sacral pressure injury. Treatment to the sacral wound was not initialed in the Treatment Administration Record (TAR) as being completed on the following date: 5/21/2020. On 5/22/2020 on the Skin Evaluation Form, nursing documented the pressure injury as a deep tissue injury measuring 7.5 cm x 10.5 cm with depth unable to determine due to 90% slough and 10% granulation tissue. The treatment was changed at that time. Treatment to the sacral wound was not initialed in the TAR as being completed on the following dates: 5/22/2020, 5/26/2020, 5/27/2020, 5/28/2020, 5/29/2020, 6/1/2020, and 6/4/2020. On 6/5/2020 on the Skin Evaluation Form, nursing documented the pressure injury as Unstageable measuring 9.0 cm x 9.5 cm with depth unable to determine due to 90% slough and 10% granulation tissue. The treatment was changed at that time. No assessment was completed for eleven days from 6/5/20 until 6/16/20. Treatment to the sacral wound was not initialed in the TAR as being completed on the following dates: 6/5/2020, 6/6/2020, 6/7/2020, 6/8/2020, 6/9/2020, 6/10/2020, and 6/11/2020. On 6/16/2020 on the Skin Evaluation Form, nursing documented the pressure injury as unstageable measuring 8.0 cm x 10.5 cm with depth unable to determine due to 75% slough and 25% granulation tissue. The treatment was changed at that time. The wound was assessed and documented on weekly. Treatment to the sacral wound was not initialed in the TAR as being completed on the following dates: 6/16/2020, 6/17/2020, 6/19/2020, 6/23/2020, 6/25/2020, 7/24/2020, 8/15/2020 and 8/16/2020. The wound was assessed and documented on weekly until R6 discharged from the facility on 8/18/2020. The sacral pressure injury was present on admission but was not assessed for three days (5/11-5/14/20) and did not have a treatment in place for six days (5/11-5/17/20). The facility identified the wound as a deep tissue injury however based on the description of the assessment on 5/14/20, the wound would have been unstagable. The wound was not assessed weekly from 6/5/2020 to 6/16/2020 (for 11 days). The treatment ordered to the wound was not initialed as completed on multiple days. The final staging of the wound was unstageable with 75% slough and 25% granulation tissue in the wound base with undermining of 2.0 cm. RIGHT ISCHIUM On 5/22/2020 at 8:07 PM in the progress notes, nursing charted the right ischium had a Stage 2 pressure injury measuring 0.8 cm x 0.8 cm x 0.1 cm. A treatment was obtained to the area. The wound was assessed and documented on weekly. Treatment to the right ischium was not initialed in the TAR as being completed on the following dates: 5/22/2020, 5/26/2020, 5/27/2020, 5/28/2020, 5/29/2020, 6/1/2020, and 6/4/2020. On 6/5/2020 on the Skin Evaluation Form, nursing documented the pressure injury as Unstageable measuring 4.6 cm x 4.0 cm with depth unable to determine due to 100% slough in the wound base. The treatment was changed at that time. No assessment was completed for eleven days from 6/5/20 until 6/16/20. Treatment to the right ischium was not initialed in the TAR as being completed on the following dates: 6/5/2020, 6/6/2020, 6/7/2020, 6/8/2020, 6/9/2020, 6/10/2020, 6/11/2020, and 6/12/2020. On 6/16/2020 on the Skin Evaluation Form, nursing documented the pressure injury as Unstageable measuring 4.0 cm x 6.0 cm with depth unable to determine due to 100% slough in the wound base. The treatment was changed at that time. The wound was assessed and documented on weekly. Treatment to the right ischium was not initialed in the TAR as being completed on the following dates: 6/16/2020, 6/17/2020, 6/19/2020, 6/23/2020, 6/25/2020, 7/24/2020, and 7/27/2020. On 7/28/2020, the treatment was changed to twice daily and was not signed out for one of the treatments on the following dates: 7/29/2020 (both treatments), 8/2/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/10/2020, 8/15/2020 and 8/16/2020. The wound was assessed and documented on weekly until R6 discharged from the facility on 8/18/2020. The right ischium pressure injury was discovered on 5/22/2020 as a stage 2 pressure injury, acquired in the facility. On 6/5/20, this pressure injury deteriorated from a stage 2 to unstagable. The wound was not assessed from 6/5/2020 to 6/16/2020 (11 days). The treatment ordered to the wound was not initialed as completed on multiple days. The final staging of the wound was Unstageable with 50% slough and 50% granulation tissue in the wound base with undermining of 2.0 cm showing deterioration of the wound. LEFT ISCHIUM On 5/29/2020 at 5:38 PM in the progress notes, nursing charted the left ischium had two stage 2 pressure injuries, one proximal and one distal. The left ischium proximal measured 2.0 cm x 2.5 cm x 0.1 cm with 100% red base and the left ischium distal measured 3.5 cm x 5.0 cm x 0.1 cm with 50% deep tissue injury and 50% red tissue. A treatment was obtained at that time. Treatment to the left ischium was not initialed in the TAR as being completed on the following dates: 5/29/2020, 6/1/2020, 6/4/2020, 6/5/2020, and 6/7/2020. The proximal and distal left ischial wounds were documented on 5/30/2020, 5/31/2020, 6/2/2020, and 6/3/2020. No documentation was found indicating one of the wounds healed or the two wounds joined to become one wound. On 6/5/2020 on the Skin Evaluation Form, nursing documented the left ischium had one Unstageable pressure injury measuring 4.5 cm x 5.5 cm with depth unable to determine due to 100% slough in the wound base. On 6/8/2020, treatment to the left ischial wound was changed. No wound documentation was found addressing the need for a treatment change or deterioration of the wound. Treatment to the left ischium was not initialed in the TAR as being completed on the following dates: 6/8/2020, 6/9/2020, 6/10/2020, 6/11/2020, and 6/12/2020. On 6/16/2020 on the Skin Evaluation Form, nursing documented the pressure injury as Unstageable measuring 4.5 cm x 5.5 cm with depth unable to determine due to 100% slough in the wound base. The treatment was changed at that time. The wound was assessed and documented on weekly. Treatment to the left ischium was not initialed in the TAR as being completed on the following dates: 6/16/2020, 6/17/2020, 6/19/2020, 6/23/2020, 6/25/2020, and 7/24/2020. On 7/28/2020, the treatment was changed to twice daily and was not signed out for one of the treatments on the following dates: 7/29/2020 (both treatments), 8/2/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/10/2020, 8/15/2020 and 8/16/2020. The wound was assessed and documented on weekly until R6 discharged from the facility on 8/18/2020. The left ischium pressure injury was discovered on 5/29/2020 as two stage 2 pressure injuries, acquired in the facility. The charting on 6/5/2020 did not show healing of one of the wounds or merging of the two wounds into one but documented measurements and description of one wound to the area. On 6/5/20 the one wound was staged as unstagable. The wound was not assessed from 6/5/2020 to 6/16/2020 (11 days). The treatment ordered to the wound was not initialed as completed on multiple days. The final staging of the wound was unstageable with 40% slough and 60% granulation tissue in the wound base with undermining of 1.2 cm showing deterioration of the wound. LEFT HIP On 7/14/2020 on the Skin Evaluation Form, nursing documented the left hip had a stage 2 pressure injury measuring 3.5 cm x 2.6 cm x 0.1 cm with 100% smooth red wound base. A treatment was obtained at that time. Treatment to the left hip was not initialed in the TAR as being completed on the following dates: 7/17/2020, 7/19/2020, and 7/20/2020. On 7/21/2020 on the Skin Evaluation Form, nursing documented the pressure injury as Unstageable measuring 3.7 cm x 3.5 cm with depth unable to determine due to 100% slough in the wound base. There was no change in treatment. Treatment to the left hip was not initialed in the TAR as being completed on the following dates: 7/21/2020, 7/22/2020, 7/23/2020, and 7/24/2020. On 7/28/2020 on the Skin Evaluation Form, nursing documented the pressure injury as Unstageable measuring 3.0 cm x 2.0 cm with depth unable to determine due to 100% slough in the wound base. A change in treatment was obtained at that time. On 7/28/2020, the treatment was changed to twice daily and was not signed out for one of the treatments on the following dates: 7/29/2020 (both treatments), 8/2/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/10/2020, 8/15/2020 and 8/16/2020. The wound was assessed and documented on weekly until R6 discharged from the facility on 8/18/2020. The left hip pressure injury was discovered on 7/14/2020 as a stage 2 pressure injury, acquired in the facility. On 7/21/20, the stage 2 pressure injury was now unstagable. The treatment ordered to the wound was not initialed as completed on multiple days. The final staging of the wound was Unstageable with 100% slough in the wound base showing deterioration of the wound. On 10/1/2020 at 10:38 AM in a phone interview with Nurse Practitioner (NP)-C, NP-C stated R6 did not have a lot of extra tissue, weighing only about 100 pounds putting R6 at risk for developing pressure injuries. NP-C stated the air mattress bed R6 was using malfunctioned at least once which could have contributed to the rapid decline of the pressure injuries. Due to R6's bed malfunctioning, NP-C stated the facility implemented a lot of interventions to check on bed functioning for all beds in the facility. NP-C stated R6's bed was not functioning at least once, but couldn't say if it was broken for an hour or a week before the bed was replaced. NP-C stated it was replaced once it was discovered, but didn't know how long it had been broken before discovery. NP-C stated R6 came in with a neck brace that caused difficulty turning and repositioning R6. NP-C stated NP-C rounded weekly and R6 was always seen in the supine position and during a care meeting on 5/29/2020, it was discussed that R6 needed to be turned even when on an air mattress. When asked why R6 wasn't assessed between 6/6/2020 and 6/16/2020, NP-C stated NP-C must not have been available at that time to see R6. NP-C couldn't find any notes to indicate why R6 wasn't seen or assessed at that time. NP-C stated with COVID-19 in the building, staff were hesitant to go into resident rooms to reposition residents and skin injuries increased throughout the building at that time. On 10/1/2020 at 12:00 Noon, Surveyor requested information from Nursing Home Administrator (NHA)-A about R6's air mattress: when was it broken, how quickly was it fixed or replaced. NHA-A stated that information would be provided. NHA-A provided specifications for the mattress that was in use. NHA-A did not provide any information on when R6's air mattress was found to be malfunctioning or when the mattress was replaced. 2. R8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 was on a ventilator and was receiving all nutrition through a gastrostomy tube. R8 was completely dependent for all activities of daily living and mobility. A Pressure Injury Care Plan was initiated on admission to include the following interventions: repositioning/turning every 2-3 hours, offloading heels, incontinence care, alternating pressure mattress, routine wound assessments, routine risk assessments, passive range of motion, and a draw sheet for repositioning in bed. On 3/4/2020 at 4:58 PM in the progress notes, nursing charted R8 was seen that morning by the wound care team. R8 had a Stage 2 pressure injury to the right heel measuring 1.5 cm x 0.5 cm x 0.1 cm with 100% dermis to the wound base and a Stage 2 pressure injury to the left heel measuring 0.5 cm x 0.5 cm x 0.1 cm with 100% dermis to the wound base. On 3/11/2020 at 7:02 PM in the progress notes, nursing charted the Stage 2 pressure injuries to the right and left heels had healed. SACRUM On 3/22/2020 at 1:45 PM in the progress notes, nursing charted R8 had an open area to the sacrum measuring 2.5 cm x 2.0 cm x 0.1 cm with 100% dermis to the wound base caused by moisture. A treatment was obtained. On 3/31/2020 at 1:12 PM in the progress notes, nursing charted R8 was seen by the wound care team for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound was determined to be caused by moisture. On 4/7/2020 at 3:21 PM in the progress notes, nursing charted R8's sacral wound was now an Unstageable pressure injury measuring 1.9 cm x 1.0 cm with depth unable to determine with 90% slough and 10% granular tissue to the wound base. A change in treatment was obtained at that time. The sacral wound was assessed and documented on weekly with lessening of slough in the wound base to 50% and decline with undermining of wound edges measuring 1.5 cm. Treatment to the sacrum was not initialed in the Treatment Administration Record (TAR) as being completed on the following dates: 4/25/2020, 4/27/2020, 4/30/2020, and 5/4/2020. On 5/6/2020 at 1:23 PM in the progress notes, nursing charted the sacral pressure wound was unstageable measuring 6.0 cm x 3.0 cm with 100% slough in the wound base and undermining of 2.0 cm from 6 o'clock to 1 o'clock and with new unstageable area distal to the wound with undermining of 1.5 cm to the circumference. The wound deteriorated due to increase in size and more slough. A change in treatment was obtained at that time. Treatment to the sacrum was not initialed in the TAR as being completed on the following date: 5/6/2020 On 5/19/2020 in the Wound Care Assessment note, Nurse Practitioner (NP)-C charted R8 was seen that day for wound care and evaluation of the breakdown to the buttocks. R8 was unresponsive but alert. R8 was unable to turn side to side due to the back brace and the wound team had begun using wedges to offload sacrum which appeared to be helping. NP-C surgically debrided the sacral wound. After debridement, the sacral wound was determined to be a Stage 4 pressure injury measuring 7.0 cm x 4.5 cm x 2.4 cm with 50% slough, 50% granular tissue, and palpable bone. Undermining was present at 4.4 cm from 11 o'clock to 12 o'clock. A change in treatment was obtained at that time and broad spectrum antibiotics were started. Treatment to the sacrum was not initialed in the TAR as being completed on the following date: 5/23/2020. The sacral wound was assessed and documented on weekly with lessening of size of wound and improvement of wound base. Treatments to the wound base were modified as the wound appearance changed including the use of a wound VAC (Vacuum-Assisted Closure) from 5/27/2020 to 6/19/2020. On 6/23/2020 in the Wound Care Assessment note, Nurse Practitioner (NP)-C charted R8 was seen that date for wound care follow up evaluation of the Stage 4 pressure injury to the sacrum. R8 was alert and moved arms at times in response to questioning. R8 continued to independently push onto R8's back. The Stage 4 sacral pressure injury measured 6.5 cm x 4.0 cm x 3.5 cm with 25% bone and 75% granular tissue with 4.0 cm undermining from 9 o'clock to 3 o'clock. The treatment was changed at that time to discontinue the wound VAC and place a treatment to the wound bed every other day. Treatment to the sacrum was not initialed in the TAR as being completed on the following date: 6/23/2020. In an interview on 10/1/2020 at 10:38 AM with NP-C, NP-C stated NP-C put the new dressing on R8 on 6/23/2020 and didn't sign it out in the TAR as completed since NP-C doesn't have access to the TAR. On 6/26/2020 at 4:46 PM in the progress notes, nursing charted the sacral wound had copious amounts of drainage. NP-C was updated on the wound and the treatment was changed to a twice daily dressing change. Treatment to the sacrum was not initialed in the TAR as being completed on the following dates for one of the two shifts: 6/27/2020, 7/8/2020, 7/17/2020, 7/19/2020, 7/20/2020, 7/21/2020, 7/22/2020 (both shifts), 7/23/2020, 7/24/2020 (both shifts), 7/30/2020, 7/31/2020, 8/2/2020, 8/4/2020 (both shifts), and 8/11/2020. R8 was admitted to the hospital from 8/12/2020 to 8/18/2020 for ventilator-associated pneumonia. On 8/19/2020 at 7:23 AM in the progress notes, nursing charted the Stage 4 sacral pressure ulcer measured 6.0 cm x 3.5 cm x 2 cm with 10% bone and 90% granular tissue with circumferential undermining with the greatest depth of 4.2 cm at 11 o'clock. The treatment was continued from before hospitalization . Treatment to the sacrum was not initialed in the TAR as being completed on the following dates for one of the two shifts: 8/19/2020, 8/21/2020 (both shifts), 8/22/2020, 8/24/2020, 8/25/2020 (both shifts), 8/26/2020 (both shifts), and 9/1/2020 (both shifts). On 9/4/2020 at 9:42 PM in the progress notes, nursing charted the Stage 4 sacral pressure ulcer measured 6.0 cm x 4.0 cm x 2.5 cm with 20% bone and 80% granular tissue with undermining from 8 o'clock to 3 o'clock with 4.7 cm at 10 o'clock. The wound was beginning to fill in distally and treatment was changed to the wound VAC. The most recent wound assessment on 9/22/2020 on the Skin Evaluation Form documented the Stage 4 sacral pressure injury to measure 5.3 cm x 4.0 cm x 2.0 cm with 30% exposed bone and 70% granulation to the wound base. U [TRUNCATED]

Based on interview and record review the facility did not ensure that 2 (R1, R4) of 2 residents reviewed had an environment that was free from accident hazards and received adequate supervision and assistive devices to prevent accidents. *R1 had 2 falls that were not thoroughly investigated and the interventions put into place post falls did not address the reason for the falls to prevent future falls. One fall resulted in major injury of an intraparenchymal hemorrhage (brain bleed) and right patellar fracture. *R4 had a fall that was not thoroughly investigated and interventions were not put into place to prevent future falls. Findings include: The facility policy, entitled Falls-Prevention/Falling Star, dated 11/01 and revised 11/19, states: (Facility) maintains the responsibility to assess each residents as to the risk of injury from falling, implement an individualized interdisciplinary care plan addressing those risks in a proactive manner and evaluates the effectiveness on a routine basis. In addition to addressing the issue of individual fall incidents, (the facility) takes seriously its responsibility to be at the forefront in fall prevention efforts by tracking and trending of fall incidents to identify extrinsic as well as [MEDICATION NAME] causes and implementing fall prevention interventions. Proactive: To prevent the first fall: 1. All residents are assumed to have some risk of falls and staff is aware of the potential for a fall of any resident at any time and takes precautions when transferring/ambulating all residents. 3. Care Plan will be updated to reflect changed in interventions that are necessary to maintain Resident's safety. Residents that have a score of 18 or higher on Fall Risk Assessment, or residents that experience a fall incident, will have one or more interventions implemented immediately following each fall incident. Assessing Risk Potential: . 2. Assessment and care planning and monitoring of residents related to fall issues will be initiated by the primary nursing staff along with input from Team Meetings, observation and/or staff report. V. Documentation: 1. All fall interventions will be care planned and recorded on Care Plan and on CNA (certified Nursing Assistant) care card as appropriate. 3. Interdisciplinary review of fall incident will be completed in EHR (Electronic Health Record). VI. Post Fall Incident: 4. Determine and implement an immediate intervention to prevent another fall with guidance from fall program coordinator or designee. VII. Nurse Manager to review fall incident within 24 hours of fall (next business day). 2. The fall intervention recommendations from the meeting will be added to the Resident Care Plan . 3. The Care Plan will be reviewed and modified as needed. 1. R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1's Change in status Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/24/19, documents: A Brief Interview of Mental Status (BIMS) score of 14, indicating R1 is cognitively intact for decision making; requires extensive assistance of 2 staff for toilet use and transfers, extensive assist of 1 staff for bed mobility, dressing and personal hygiene and walking in the corridors did not occur; unsteady and only able to stabilize with staff assistance for moving from a seated to standing position, walking, turning around, moving on and off the toilet and transferring between surfaces, frequently incontinent of urine and always continent of bowel. Care Area Assessment (CAA)'s documented for Falls indicates: Proceed to care plan to decrease fall risk; (R1) triggered for falls because she has impaired balance, a history of falls and is on an antidepressant, (R1) was readmitted to the facility after hospitalization for a right gluteal abscess. (R1) attends therapy per MD (Medical Doctor) order to promote resident to return to top of her baseline level of function. R1's Care Plan, dated 7/5/19, documents: (R1) has the potential for falls related to generalized weakness, [MEDICAL CONDITION], orthostatic [MEDICAL CONDITION]. Interventions include: Encourage to use assistive devices, if applicable Describe: w/c (wheelchair), (start: 7/5/19); PT (physical therapy)/OT (occupational therapy) scree/evaluation and treat as ordered, (start: 7/5/19); Floors free from spills or clutter, (start: 7/5/19); Provide adequate, glare free lighting, (start: 7/5/19); Keep call light, personal, and frequently used items within reach, (start: 7/5/19); Assist to wear non-skid footwear, (start: 7/5/19); Mat to floor when in bed, (start: 7/5/19); Bed at safe transfer height and soft touch call light, (start: 7/5/19). (R1) has had multiple falls related to [MEDICAL CONDITION], orthostatic [MEDICAL CONDITION] and weakness. Interventions include: Have resident stand up slowly from a sitting position for a few minutes before attempting to ambulate or stand. Monitor Orthostatic BPs (blood pressures) prn (as needed), (started: 7/5/19); Instruct to stand and gain balance before beginning ambulation, (started: 7/5/19); Will wear proper fitting shoes that are supportive with non-skid soles for ambulation, (started: 7/5/19); Falling Star, (started 10/7/19). (R1) has impaired mobility related to orthostatic [MEDICAL CONDITION], generalized weakness, [MEDICAL CONDITION], history of C7 (Cervical spine) fracture as evidenced by required assistance with ADL's (Activities of Daily Living). Interventions include: . Transfers with sit to stand lift prior to 11 AM, After 11 AM assist with 1 and 2 ww (wheeled walker), bed mobility extensive A (assist) of 1, (start: 8/13/19). (R1) will not display alerted self-esteem, UTIs (urinary tract infections), will remain clean, dry and free from breakdown related to incontinence, (start: 10/3/19), interventions include: . Offer toileting Q (every) 1 H (hour) and prn (as needed), (start: 10/7/19). On 10/4/19, at 10:15 AM, R1's Medical Record documents a Fall/Incident Report: Resident found on the floor in shower room in her bedroom laying on her right side with head against the wall. Resident states she was going to the shower to get something and the walker tipped on the raised tile and she fell and hit her head. Resident was assessed by RN (Registered Nurse) on floor, assisted up by two CNAs (Certified Nursing Assistances) with Hoyer lift and laid into bed. Writer assessed resident and noted hematoma to top of head and forehead, ice pack applied, NP (Nurse Practitioner) and POA (Power of Attorney) updated. New orders received to send resident to ER (emergency room ) for CT (Computed Tomography) scan. Pre-incident ambulation status: Limited Assistance; Continent at the time of the fall; . Investigation/Follow Up: Dated 10/7/19: Investigation/IDT (Interdisciplinary Team) met to discuss fall. Toileting schedule, medication review, labs to be requested. R1's Fall Evaluation, dated 10/4/19 at 10:15 AM, documents: . Resident was ambulating with the proper device; call light was in reach, call light was not sounding; performing the specific activity: getting something out of the shower; the resident was agitated; prior to the fall the resident was incontinent; New interventions put into place following the fall: fall review with IDT, toileting program was implemented/revised, UA (Urinary Analysis) OT/ PT/ ST (speech therapy) referral; care plan updated to include new interventions added: offer toilet Q 1 H (every 1 hour) and PRN (as needed). The resident's Fall Risk Assessment: prior to the fall was: 20 and after the fall was 23; a score of 18 or higher is considered high risk for falls. The new interventions added to the care plan does not address the reason for R1's fall. R1 did not fall ambulating to the bathroom for use of the bathroom. R1 fell on the way to the bathroom to get something from the shower room that was located in the bathroom. Facility documentation states the shower caddy was moved to a more assessable position and the tile on the bathroom floor was checked for any concern that would have caused R1 to fall. On 2/23/20, at 2:20 PM, R1's Medical Record documents a Fall/Incident Report: (R1) found lying on right side on bathroom entrance floor; R1 stated: I'm clumsy when asked for a description of what occurred; Several staff respond to lg (large) thud across from nurse's station to Pt's (patient's) room. Found lying on right side @ (at) bathroom entrance floor. Lg bleeding observed from O/A (open area) on crown of head. Lg hematoma right forehead: Pt. A/O (alert/oriented) x3 (person, place, time), forgetful per baseline. Pt ind (independently) moved all extremities when instr. (instructed). Pt rpt (reported) pain to O/A rated @ 3/10 on pain scale. LOC (Loss of Conscience) intact throughout incident; VSS (vital signs stable), pressure applied to bleeding f/b (followed by) kerlix. Cold compress applied to hematoma sit until EMT (Emergency Medical Team) arrived. 14:42 (2:42 PM) Pt transported via Bell ambulance to SLMC (St. Luke's Medical Center). Staff in nursing station and heard someone fall and went across to resident's room and located resident on the floor in front of bathroom. Resident stated she didn't know why she didn't use call light for help. Staff CNA went in room at beginning of shift and resident declined the need to be toileted. Resident bleeding from head, supervisor administered first aid and writer called 911, and daughter. Supervisor updated MD (Medical Doctor) and DON (Director of Nursing). Contributing environmental factors: lost balance; footwear: non-skid footwear; pre-incident ambulation status: Extensive Assistance; continent at the time and toileting schedule in place. On 2/24/20, Investigation/Follow-Up: IDT met to discuss fall. Resident at high risk for falls. Upon readmission, res will be added to falling star program, a new B&B (Bowel and Bladder) will in initiated and placed on 15 minute checks x (times) 3 days to assess activity patterns. Surveyor noted adding R1 to the falling star program was an intervention that was supposed to be in place following the October 2019 fall. On 2/23/20, at 2:20 PM, R1's Medical Record documents, Fall Evaluation: . Prior to the fall R1 was sitting in recliner chair; . attempting to transfer from recliner chair to the bathroom; . R1 was offered and declined toileting when staff CNA went in resident's room at the beginning of the shift; . new interventions put into place following the fall: pt education/staff education/family educations, falling star, add to list. New Interventions added to the care plan: date and time, this area was left blank and not completed; Fall Risk Assessment worksheet updated after the fall. Fall Risk score prior to the fall was: 18, and Fall Risk score after the fall was 30. A score of 18 or higher is considered High Risk for falls. R1 was hospitalized from [DATE]-3/2/20, following the fall, and was diagnosed with [REDACTED]. R1's Fall Evaluation does not document when R1 was actually last assisted to use the toilet prior to the staff offering and R1 declining at the beginning of the shift. R1's Care Plan documents: R1 should be offered toileting Q 1 Hour and PRN. R1's Care Plan, dated 3/2/20, documents new interventions of: Offer toileting 1-2 hours and prn; mat to floor when resident is in bed; close supervision when resident in bathroom, 15 minute checks x 72 hours upon readmission; Falling Star program; new B&B assessment to be initiated upon readmission and encourage to be in common areas (i.e. dining room during meals, activities per schedule) as appropriate for closer supervision. R1's Care Plan from 10/7/19 already documented the interventions of: offer toileting assistance Q 1 hour; Falling Star program. The new interventions documented do not address the reason for the fall as R1 self-transferred and self-ambulated to the bathroom. On 3/11/20, at 11:36 AM, Surveyor interviewed Registered Nurse (RN) Unit Manager-C, who stated: R1 has [MEDICAL CONDITION] and has very specific times medications are dispensed. This causes R1 to have different level of care needs. In the morning, before 11:00 AM, before the [MEDICAL CONDITION] medications kicks in, R1 requires as sit to stand for transfers, after 11:00 AM, R1 requires assist of 1 for transfers and ambulation. RN Unit Manager-C stated: R1 is very stubborn and tries to do things for herself. R1 was not cleared to ambulate independently at the time of the fall on 2/23/20. RN Unit Manager-C stated, the shift changes occurs at 2:00PM, and at that time staff offered R1 assist with toileting. R1 declined staff assistance and did not use the call light and self-transferred and self-ambulated to the bathroom. RN Unit Manager-C, stated she does not know when R1 was actually last assisted to the toilet as the CNA's will document toileting at the end of the each shift so accurate times of toileting are not documented. RN unit Manager-C, stated R1 does not always use her call light to alert staff for assistance. R1 typically will stand up, walk then fall vs standing and falling right away. RN Unit Manager-C stated: the IDT will review all falls that occurred that week on Friday. The IDT will come up with new interventions to prevent falls and the Director of Nursing or Unit Manager will add the new interventions to the care plan. RN Unit Manager-C stated: the new fall interventions that were initiated after R1's fall on 2/23/20, were to complete 15 minute checks for 72 hours and add R1 to the Falling Star program. RN Unit Manager-C was not aware R1's care plan, prior to the fall, documented a toileting schedule of offering toileting assistance Q1 hour and prn and the Falling Star program. RN Unit Manager-C stated she wasn't aware of any other new fall interventions for R1. On 3/11/20, at 1:14 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D, who stated: R1 would get up and walk and was very spontaneous in her behavior. R1's use of the call light was hit and miss and was day by day. Some days R1 would call for staff assistance and other days R1 would not. R1's fall that occurred on 10/4/19, occurred on the unit that LPN Unit Manager-D was assigned to. LPN Unit Manager-D, stated: on the day of the fall, R1 got up to get something that was in the bathroom/shower room that was located in her room. The family brought in a cabinet/basket [MEDICATION NAME] for R1's belongings. R1 was reaching for the item in the [MEDICATION NAME], located in the shower, when she fell . LPN Unit Manager-D, stated: R1's walker got stuck on the raised tile of the shower stall. Per LPN Unit Manager-D, the tile is raised in that area to keep the water in the shower and off the bathroom floor. LPN Unit Manager-D stated she moved the [MEDICATION NAME] so it allowed for easier access for R1 and maintenance staff checked the tile to make sure there was nothing defective, and no defects were found. LPN Unit Manager-D stated: the new interventions put into place to prevent future falls was to relocate the [MEDICATION NAME] for easy access for R1 and for maintenance to check the floor tile. LPN Unit Manager-D, stated the IDT did not put any intervention into place for R1 self-ambulating and self-transferring as they facility only uses motion sensors when someone attempts to get out of bed unassisted but not from a chair. The interventions of moving the [MEDICATION NAME] for easier access and maintenance to check the shower tile were not documented in R1's Care Plan. On 3/11/20, at 3:25 PM, Surveyor informed: Director of Nursing-B, Assistant Administrator-E, and Administrator-A, via speaker phone of the above concerns. 2. R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R4's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/26/20, documents: A Brief Interview of Mental Status (BIMS) score of 14, indicating R4 is cognitively intact for daily decision making; requires extensive assistance of 2 staff for bed mobility and transfers, requires extensive assist of 1 staff for locomotion on and off the unit, dressing, toilet use and personal hygiene; is unsteady and only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving off the toilet and surface to surface transfers; has an indwelling catheter and is frequently incontinent of bowel. R4's Care Plan, dated 2/19/20, documents: (R4) has potential for falls related to weakness, AMS (Altered Mental Status), DM2 (Diabetes Mellitus 2), [MEDICAL CONDITION] with A Fib ([MEDICAL CONDITION] Fibrillation). Interventions include: Encourage use of assistive devices, if applicable Describe: per therapy, (start: 2/19/20); PT (Physical Therapy)/OT (Occupational Therapy) screen/evaluation and treat as ordered, (start: 2/19/20; Floors free from spills or clutter, (start: 2/19/20); Provide adequate, glare free lighting, (start: 2/19/20); Keep light, personal, and frequently used items within reach, (start2/19/20); Assist to wear non-skid footwear, (start 2/19/20); Bed at safe transfer height, (start 22/19/20). On 2/25/20, at 7:20 PM, R4's Medical Record documents: Res (resident) found lying flat on the floor, on his stomach, Res appeared angry, yet calm. Asked if anyone hurt him, res stated no. Supervisor notified and came to assess. Vitals signs taken and neuro-checks started. Pre-Incident ambulation status: Extensive Assistance. R1 was documented to be barefoot and incontinent. On 2/26/20, the IDT (Interdisciplinary Team) met to discuss the fall. Placed immediately on 15 minute checks. Transferred to the hospital with increasing lethargy and AMS (Altered Mental Status). No injuries were documented related to the fall. On 2/25/20, at 7:20 PM, R4's Medical Record, documents a Fall Evaluation stating: (R4) is alert and oriented x (times) 3 (person, place, and time), alert with some confusion and forgetfulness, cognitive impairment but no change from baseline; R4 is angry, stating I want to go home; . Prior to the fall the resident was: sitting in w/c (wheelchair) in bedroom; Environmental Conditions contributing to the fall: resident was attempting to self-transfer from w/c to toilet; the call light was within reach but not sounding; the resident was anxious and agitated; the last time the resident was toileted: before dinner; and the resident was incontinent at the time of the fall; new interventions put into place following the fall: this area is left blank. R4's Care Plan, dated 3/2/20, upon return to the facility after the fall, documents new fall intervention of: low bed with fall mat in place when resident is in bed. The intervention added to the care plan does not addressed the reason for R4's fall from the wheelchair. R4's Fall Evaluation does not document the last time R4 was actually assisted with toileting needs. On 3/11/20, at 11:47 AM, Surveyor interviewed Registered Nurse (RN) Unit Manager-C, who stated: R4 was not cleared by therapy to be transferring or ambulating without staff assistance. RN Unit Manager-C stated: R4 fell from the wheelchair trying to toilet himself when he has a Foley catheter. RN Unit Manager-C stated she is unable to determine when R4 was last assisted with toileting needs as the CNA's will enter in toileting documentation at the end of each shift. RN Unit Manager-C stated: the IDT will review all falls that occurred that week on Friday. The IDT will come up with new interventions to prevent falls and the Director of Nursing or Unit Manager will add the new interventions to the care plan. RN Unit Manager-C stated she was unable to identify new interventions that were put into place to prevent future falls. On 3/11/20, at 3:25 PM, Surveyor informed: Director of Nursing-B, Assistant Administrator-E, and Administrator-A, via speaker phone of the above concerns.

Based on interview and record review the facility did not ensure 1 (R2) of 3 residents reviewed had an environment that remained as free from accident hazards as possible and received adequate supervision and assistive devices to prevent accidents. *R2 was transferred from bed to a Broda chair. The Broda chair was not placed in the reclined position and R2 fell from the Broda chair hitting her head on the floor. R2 had a fall in the hallway attempting to self-transfer and R2 was found in a back TV lounge on the floor. R2 fell from a wheelchair and sustained a [CONDITION(S)] when R2's care plan stated she should be in a supervised area. Findings include: The facility policy,entitled Falls -Prevention/Falling Star, dated 11/01, reviewed and revised 11/19. States: . the facility maintains the responsibility to assess each resident as to the risk of injury from falling, implement an individualized interdisciplinary care plan that addresses those risks in a proactive manner and evaluates the effectiveness on a routine basis. 1. Identifying specific fall risk factors for each resident; 2. Increasing the team's awareness of these residents and their risk factors; 3. Discussing and documenting strategies initialized for each resident and eliciting the team's cooperation in attempting to minimize the risk factors identified, without compromising mobility and functional independence, whenever possible; 4. Reporting and recording falls and near falls so the new risk factors or residents that are high risk can be identified; 5. Ultimately, decreasing risk and preventing falls to the degree possible; 6. Trending and tracking of extrinsic as well as [MEDICATION(S)] causes of fall occurrences. V. Documentation 1. All fall interventions will be care planned and recorded on Care Plan and CNA (Certified Nursing Assistant) Care Card as appropriate; . 3. Interdisciplinary review of fall incident will be completed in EHR (Electronic Health Record). Review of Broda's operating manual indicates: Before the chair is put into service, this manual must be read thoroughly by the caregiver(s) directly responsible for the resident's care. After the chair is put into service, this manual must be read thoroughly by any new caregivers prior to operating or moving the chair. For the purpose of this manual, a resident's family member who shares responsibility for their care is considered a caregiver and is subject to the same competency before being permitted by the resident's primary caregiver to operate of move the chair. Prior to first use, the customer must arrange for an in-service on the operation and safety requirements in this manual, must be given to the resident's caregivers by the local BRODA representative who supplied the chair. The primary caregiver must maintain a list of caregivers who have read this manual and who they have authorized to operate and move the chair. The resident's primary caregiver is responsible for ensuring that anyone who is unfamiliar with, unwilling, or unable to adhere to the safety and operating instructions, is not permitted to operate or move the chair. The operations of the chair must be performed by the resident's primary caregiver who is responsible for seating. All The operations and adjustments performed should be done in a manner to ensure the overall safety, comfort and well-being of the resident, caregiver and third party. All operations and adjustments required for the resident should be determined by the resident's primary caregiver who is responsible for seating. The Broda Operating Manual also states: Position of chair - 'Danger of Falling': After a resident is transferred into a chair, assess the amount of tilt required. We recommend that the chair's seat be tilted sufficiently to prevent the resident from sliding or falling forward off the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. We recommend that the resident's feet be correctly positioned on the footrests and slightly too fully elevated to prevent the resident from sliding or falling forward off the chair. The amount of elevation used should be determined by the resident's caregiver who is responsible for seating. Improper Use: As outlined, the improper use of the chair is dangerous to the resident, caregivers, or third parties, and can consist of, but is not limited to the following: . 3) Inappropriate use of the chair for a resident who has not been assessed by a qualified caregiver responsible for their seating. 7) Leaving the resident unattended in the chair near other objects. 8) Leaving an agitated resident in the chair in an unsupervised area. 9) Leaving a resident unattended. R2 was admitted to the facility on [DATE] with diagnoses that include: History of CVA (Cerebrovascular Accident), hemorrhagic strokes, chronic hypoxic [CONDITION(S)], and dysphagia/[CONDITION(S)] from stroke, hypertension, [CONDITION(S)] and non-Alzheimer's dementia. R2's Admission MDS (Minimum Data Set) assessment, with and ARD (Assessment Reference Date) of 8/13/19, documents: R2 rarely/never understands other or is understood by other; long and short term memory loss; severely impaired decision making; totally dependent on one staff for eating, requires extensive assistance of two staff for bed mobility and toilet use, and assist of 2 staff for transfers and one staff for dressing and personal hygiene; range of motion impairment of the upper and lower extremities on one side. R2's Care Plan, dated 8/6/19, documents: R2 has the potential for falls related to recent [CONDITION(S)]. Interventions include: Encourage use of assistive devices if applicable, Describe: full body lift and geri chair; (start: 8/6/19); PT (physical therapy)/OT (occupational therapy) screen/evaluation and treat as ordered, (start: 8/9/19); Floors free from spills and clutter, (start: 8/6/19); Provide adequate, glare free lighting, (start: 8/6/19); Keep call light, personal and frequently used items within reach, (start: 8/6/19); Assist to wear non-skid footwear, (start: 8/6/19); Bed at safe transfer height, (start 8/6/19). On 10/9/19, at 1:15 PM, R2's medical record documents: A fall incident report. (R2) was found in front of her Broda chair. Roommate's husband stated she (R2) was moving around in chair and before he could get help or alert someone, she fell forward out of the chair. Contusion and laceration above the left eye. 911 called and (R2) was sent to the hospital. The investigation follow up documents: IDT (Interdisciplinary Team) discussed fall. Resident sent out to the hospital for eval (evaluation)/tx (treatment). When resident returns PT/OT to eval due to resident now moving. On 2/12/20, at 12:15 PM, Surveyor interviewed Director of Nursing (DON)-B, who stated: she responded to R2's fall from the Broda chair on 10/9/19 and it was noted the Broda chair was not in the tilted back position at the time of the fall. DON-B stated, R2 was recently transferred from bed to the Broda chair and was attempting to converse with her roommate and roommate's husband when the fall occurred. R2's hospital paperwork, dated 10/18/19, documents: R2 was hospitalized [DATE] to 10/18/19 for a fall off a wheelchair w/(with) head trauma and SAH (Subarachnoid Hemorrhage) while on ASA (medication that contains aspirin). R2 had a [CONDITION(S)] (tracheostomy)/peg (Percutaneous endoscopic gastrostomy, feeding tube) from prior stroke. Repeat HCT (Head Computerized Tomography) with stable SAH. Pt's (patient's) hospital course prolonged due to Pt. taking her [CONDITION(S)] out multiple times. On 10/9/19, R2's Care Plan was updated to include interventions of: tilt Broda chair back and 30 minute checks x (for) 48 hours. Upon return from the hospital, on 10/18/19, R2's Care Plan was updated to include the intervention of: encourage to stay in common area for closer supervision, and use of wheelchair. On 10/27/19, R2's Medical Record indicates: R2 had a fall at 5:30 PM. R2 fell from her wheelchair while eating at a table in hallway. No injury was noted. Investigation follow up documented on 11/1/19, documents: After viewing the camera on 10/28/19, it was seen that staff was in and out of rooms on unit where resident was sitting with over bed table eating supper. Resident used hand rail and stood up and then sat down in w/c (wheelchair). A little while later she attempted the same transfer but w/c turned and she fell to the floor. No staff were in the hall to view fall. Footwear was changed from slippers to shoes after fall. Resident continues in therapy. There is no documentation R2 was assessed by therapy and was found safe to stand in the hallway using the handrail for support or that R2 was safe to transfer independently. R2's fall investigation does not address why R2 was eating dinner in the hallway and not in a dining room with increased supervision. Surveyor noted R2 already had a care plan intervention with a start date of 8/6/19 to wear non skid footwear. On 11/8/19, at 9:00 AM, R2's Medical Record documents: R2 was found on the floor next to table in the back lounge area on unit. R2 had requested to go back there to watch TV. R2 has been working in therapy and has improved mobility status. R2's description of the fall was: she tried to walk and will never do that again. R2 remained on the floor and comfortable until the paramedics arrived. R2 was transported to the hospital for evaluation. R2 sustained a [CONDITION(S)] and did not return to the facility. Review of R2's Care Plan indicates intervention of: (R2) to be encouraged to stay in common area for closer supervision and had impaired mobility related to [CONDITION(S)] as evidenced by need for assistance with ADLs (Activities of Daily Living), total assist of 1 with all self-cares and full body lift for transfers. On 2/13/20, at 1:33 PM, Surveyor interviewed Director of Nursing (DON)-B about all 3 of R2's falls. DON-B stated R2 was becoming more awake after her hospitalization (prior to admission) and the staff had just assisted R2 from bed to the Broda chair and did not put the Broda chair in the tilt back position as they should have resulting in R2's fall on 10/9/19. DON-B stated she did not believe R2 sustained a new SAH from this fall indicating she thought the hospital paperwork is inconclusive but the Broda chair should have been placed in the tilt back position. DON-B stated the fall that occurred on 10/27/19 was viewed on the facility video and R2 was observed pushing herself up to a stand using the hand railing and since she had slippers on her feet she slid causing the wheelchair to move and when R2 went to sit the wheelchair it was no longer behind her. The facility added the intervention of having R2 wear shoes instead of slippers. DON-B cannot state why the resident wasn't eating in a dining room setting when it is documented R2 should be in a supervised area. DON-B stated the third fall that occurred on 11/8/19 was because R2 propelled herself to the back TV lounge area. DON-B stated this was watched on the facility video monitor. Surveyor asked how R2 propelled herself to the back TV lounge area when R2's MDS documents a requirement of one staff assistance for mobility on the unit and R2's care plan states she should be encouraged to stay in a common area for closer supervision. DON-B stated that since R2 did not require continuous supervision that is why staff did not notice R2 propel herself to the TV lounge and/or redirect R2 to a common area that provided closer supervision. Surveyor noted the documentation in the medical record regarding the fall indicates R2 requested to go to that lounge but is not clear if staff assisted or redirected to ensure supervision/safety. On 2/13/20 at 1:33 PM, Surveyor informed DON-B of concern related to R2's risk for falls, assessment of all falls and needed interventions and assessment of R2's need for increased supervision when R2 became more mobile increasing R2's fall risk. During the survey both NHA-A and DON-B referenced to Surveyor they did not believe R2 sustained a subarachnoid hemorrhage following the 10/9/19 fall. During the survey, the facility could not provide any investigation or documentation from 10/2019 indicating that potential discrepancy was reviewed or investigated until Surveyor expressed concerns related to R2's falls. On 2/17/20 following exit from the survey, the facility provided information documenting on 10/25/19, R2 required assist of one staff for locomotion. During 10/25/19-11/8/19 R2 was receiving therapy services. The facility indicates per therapy documentation, not provided to Surveyor, R2 was noted to show improvement in a therapy setting and it was starting to be seen inconsistently on the unit. The facility indicated a significant change assessment was not completed prior to R2's fall and hospital discharge as R2 was being assessed for a significant change. However, R2's medical record does not document the facility was assessing R2 for a possible change in condition. On 2/17/20, at 8:08 AM, Surveyor interviewed Medical Doctor (MD)-D (who is a covering physician for R2's attending physician as they were not available for interview), who stated since Surveyor was in the facility, she reviewed R2's medical record on 2/14/20 (following exit from the facility and sharing of concerns). MD-D indicated she reviewed R2's medical records from the hospital stay prior to admission to the facility. MD-D stated, upon review of R2's medical information from the hospitalization prior to admission to the facility and the hospital paperwork from R2's hospitalization from [DATE]-[DATE], following the fall from the Broda chair, MD-D stated, it appears inconclusive if R2 suffered a new SAH (subarachnoid hemorrhage) with the fall on 10/9/19. MD-D indicated because the area of the head that was hit on 10/9/19 was also the area of the head where a prior brain bleed occurred. Surveyor noted the fall occurred because R2's Broda chair was not positioned in the proper position for safety per the manufacturer's recommendations and required R2 to go to the hospital and be admitted following hitting her head. The facility also provided to the Surveyor a written review of R2's discharge summaries by MD-D dated 2/14/20, which documents: (R2) fell on [DATE] and CT showed focal area of increased attenuation which could represent focal SAH. Repeat CT was recommended and done on 10/10/19, and showed, Stable encephalomacia in right front parietal region, bilateral occipital and temporal lobes. MD-D also documents: upon (R2's) return from the hospital (R2) was evaluated by therapy and care plan was updated to use wheelchair and to stay in common area for closer supervision. (R2's) Care Plan also documents, R2 to continue with the transfer with the assist of a full body lift.

Based on observation, interview, and record review, the facility did not ensure supervision was provided to prevent falls for 1 (R76) of 7 residents reviewed. R76 was to be supervised in the bathroom at all times per the care plan. R76 was observed in the bathroom by a Certified Nursing Assistant (CNA) after self-transferring to the toilet; the CNA left R76 unsupervised to alert another CNA who was assigned to the resident that R76 was in the bathroom. During the time R76 was not supervised, after discovery, R76 fell from the toilet and fractured a hip. Findings include: R76 was admitted to the facility 6/11/2018 after a fall at home resulting in a [MEDICAL CONDITION]. R76 has the following Diagnoses: [REDACTED]. A fall care plan was initiated 6/11/2018 on admission which includes: Problem: R76 has potential for falls related to history of falls and left [MEDICAL CONDITION]. Interventions: -Encourage use of assistive device, if applicable (wheelchair and wheeled walker) 6/11/2018 -PT/OT Screen/evaluation and treat as ordered. 6/11/2018 -Floors free from spills or clutter 6/11/2018 -Provide adequate, glare free lighting 6/11/2018 -Keep call light, personal, and frequently used items within reach 6/11/2018 -Assist to wear non-skid footwear 6/11/2018 On 8/11/2018, R76 was unsupervised in the bathroom and fell off of the toilet with no injuries. R76's care plan was updated with the intervention: staff not to leave resident unattended in bathroom. R76's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R76 as needing extensive assistance of two people with toileting and extensive assistance of one person with transfers. R76's Brief Interview for Mental Status (BIMS) score was 04 indicating severe cognitive impairment. The Certified Nursing Assistant (CNA) Care Card dated 3/19/2019 states: Staff not to leave resident unattended in the bathroom. On 3/20/2019 at 6:34 PM in the progress notes, nursing charted R76 was observed on the floor in the bathroom at 4:00 PM. R76 attempted to self-transfer from the toilet to the wheelchair. R76 did not pull the call light for assistance. R76 complained of soreness to legs which was baseline for R76. On 3/21/2019 at 8:00 AM in the progress notes, the Nurse Practitioner charted R76 had been having increased pain to the right leg since the fall. An x-ray was ordered and showed a fracture to the right femur. R76 was sent to the hospital for evaluation and treatment. The facility self-report regarding R76's fall filed with the State Office was reviewed. The report states: Staff were interviewed regarding the fall. Staff C.N.[NAME] (CNA-U) reported that she told assigned C.N.[NAME] (CNA-Q) that (R76) was on the toilet. (CNA-Q) was attending to another resident in another room at that time. When (CNA-Q) arrived to (R76's) room, (R76) was on the floor yelling, 'help.' The nurse (Licensed Practical Nurse (LPN-R)) and night supervisor (RN-G) were called to assess. The two aides and the nurse got (R76) off the floor using a full body lift. They placed (R76) into the wheelchair. Upon further investigation, it was noted that (R76's) care card said not to leave resident unattended in the bathroom at any time. It is not unusual for (R76) to get herself on the toilet, per staff interviews, but (R76) usually does use her call light when she needs to get off. The staff were educated on the importance of reading care cards and following them. Review of R76's plan of care for falls dated 3/26/19 includes the same interventions as the 6/11/18 care plan including the revision from 8/11/18 of staff not to leave resident unattended in bathroom. The care plan indicates 3/26/19: Problem: R76 has potential for falls related to history of falls and left [MEDICAL CONDITION]. Interventions: -Encourage use of assistive device, if applicable (wheelchair and wheeled walker); -PT/OT Screen/evaluation and treat as ordered; -Floors free from spills or clutter; -Provide adequate, glare free lighting; -Keep call light, personal, and frequently used items within reach; -Assist to wear non-skid footwear; -Staff not to leave resident unattended in bathroom. On 8/14/2019 at 2:12 PM, Surveyor observed R76 self-propelling the wheelchair down the hallway. When asked if R76 had any falls, R76 stated she fell and broke her leg twice now. On 8/20/2019 at 10:58 AM, Surveyor interviewed Registered Nurse (RN)-G regarding R76's fall on 3/20/2019. RN-G stated R76 fell in the bathroom. R76 did not immediately complain of pain, but knew R76 later was taken to the hospital for a broken hip. RN-G asked R76 why the call light was not used, and R76 said she knew she should have asked for help. RN-G educated R76 to use the call light. On 8/20/2019 at 3:58 PM, Surveyor interviewed CNA-Q regarding the events of 3/20/2019. CNA-Q stated CNA-U told CNA-Q R76 was in the bathroom. When CNA-Q got to the room, R76 was on the floor in the bathroom. R76 had taken herself to the bathroom and didn't call for help when she was done. CNA-Q stated it was normal for R76 to go into the bathroom by herself and had reminded R76 a lot that R76 needs to ask for help. On 8/20/2019 at 4:02 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-R regarding the events of 3/20/2019. LPN-R stated everyone was very busy that day and was surprised R76 had a fall because R76 was cognitively aware. LPN-R couldn't recall the circumstances before the fall, such as if R76 was in the bathroom by herself or not. On 8/21/2019 at 8:19 AM, Surveyor interviewed CNA-S regarding R76. CNA-S was caring for R76 that day. CNA-S stated all general information regarding a resident's care is on the CNA Care Card. It should be in each CNA's pocket. When asked what would you do if you saw a resident trying to get up out of a chair or toilet, CNA-S stated she would intervene and keep the resident safe. When asked if CNA-S was familiar with other residents on the unit that were not part of the assignment, CNA-S stated yes. CNA-S stated for new CNAs assigned to the unit, CNA-S would educate them on who needs to be watched more closely to prevent falls. CNA-S stated for R76, she keeps an eye on R76 because R76 can move independently in the wheelchair around the room and facility. R76 has a tendency to take herself to the bathroom. R76 is much better now and uses the light, but CNA-S still needs to keep an eye on R76 just in case. On 8/21/2019 at 8:31 AM, Surveyor interviewed LPN-T regarding general care of the residents on the unit. LPN-T stated that unit was not her normal unit to work on. When asked how LPN-T was aware of who needed assistance with transfers or who couldn't be left in the bathroom alone, LPN-T stated nurses have papers with the care status of each resident on it. LPN-T stated even if the paper said the resident could be alone in the bathroom, LPN-T would use personal judgement to determine if the resident should be left alone or stand by, even if that's not on the care card. LPN-T stated she is more apt to stand by for safety even if the care card says the resident can be left alone. On 8/21/2019 at 9:32 AM, Surveyor interviewed Unit Manager (UM)-O regarding CNA expectations. UM-O stated the CNA taking care of R76 would have a Care Card in their pocket and would know R76 shouldn't be left alone in the bathroom. Other CNAs on the unit should also be aware even though they aren't responsible for R76's care. UM-O would expect any CNA to go into the bathroom and stay with R76 to make sure she's safe. On 8/21/2019 at 9:44 AM, Surveyor interviewed CNA-U over the phone. CNA-U could not remember the events surrounding R76's fall on 3/20/2019. CNA-U stated she thought R76 had put herself on the toilet. On 8/21/2019 at 12:55 PM, Surveyor interviewed CNA-V and CNA-W regarding the process of assignments for CNAs on each shift and how it's determined who takes what grouping of residents. CNA-V stated assignments are done on a first come, first serve basis. All the CNAs get to know all the residents. CNA-V stated CNA-U was a full time CNA on the unit and was familiar with all the residents and their cares on the unit. On 8/21/2019 at 1:03 PM, Surveyor interviewed Director of Nursing (DON)-B regarding CNA-U's work schedule history. DON-B looked up the scheduling for CNA-U for (MONTH) through March, 2019. CNA-U worked four to five days a week on R76's unit. On 8/21/2019 at 1:34 PM, Surveyor met with Nursing Home Administrator (NHA)-A to review the above findings. On 3/20/2019, CNA-U observed R76 in the bathroom on the toilet unsupervised. CNA-U, instead of staying with R76 per care plan intervention, left R76 alone in the bathroom to inform CNA-Q R76 was in the bathroom. CNA-Q was assisting another resident and could not leave that resident alone. When CNA-Q was able to go to R76's room, R76 had fallen and sustained a [MEDICAL CONDITION]. CNA-U was a full-time CNA on that unit and was expected to be aware of R76's care plan stating R76 was not to be left alone in the bathroom. This fall was avoidable and harm had occurred. No further information was provided at that time. On 8/22/2019, the facility provided Archived Daily Charting Details for March, 2019, a Physical Therapy Discharge Summary dated 11/8/2018, Comprehensive Therapy Screens dated 11/20/2018 and 2/7/2019, and Occupational Therapy Discharge Summary dated 11/9/2018 alleging upon further review at the time of the survey, R76 should not have required supervision while toileting at the time of the fall. Review of the Archived Daily Charting Details for (MONTH) 2019 and specifically 3/20/19 indicate R76 required limited assistance for toilet use for self-performance and support provided. Surveyor noted while this detail may document how R76 used the toilet including transferring, cleaning self, adjusting clothes etc, this does not speak to overall assessed need for supervision while toileting to prevent a fall. Surveyor noted there were multiple opportunities for the facility to modify R76's plan of care to reflect no longer needing supervision including, at the time of the fall investigation, submission of the self-report and upon return from the hospital following the [MEDICAL CONDITION]; however, the most recent plan of care (at the time of the survey dated -3/26/19) includes the intervention for staff to not leave resident unattended in bathroom with an initiation date of 8/11/2018.

Based on interview and record review, the facility did not ensure that 1 of 6 sampled residents (R4) received an RN (Registered Nurse) assessment and appropriate medical care when R4 had a significant change in her medical condition. On [DATE] at 3:30 PM, R4 had a significant change in her condition when her oxygen saturation level dropped to 80% on room air and she complained of being Short of Breath (SOB). LPN (Licensed Practical Nurse) - D contacted RN (Registered Nurse) Supervisor - E. RN Supervisor - E did not complete an RN assessment of R4. As a result of the RN assessment not being completed, the facility did not identify R4 was having a significant change in her medical condition. There was no ongoing documented monitoring or assessment of R4 and R4 had to wait over 4 hours for medical care after having had a significant change in her condition. R4's change in condition began at 3:30 PM. The facility did not call for ambulance transport to the hospital until 7:50 PM. R4 was admitted to the Intensive Care Unit at the hospital on [DATE] and died 6 days later on [DATE]. The facility's failure to complete an RN assessment, including the monitoring of vital signs for R4 and to provide her with appropriate medical care during a significant change in condition, created a finding of Immediate Jeopardy beginning on [DATE]. Administrator - A, Consultant - B, and DON (Director of Nursing) - C were informed of the Immediate Jeopardy on [DATE] at 10:30 a.m. The Immediate Jeopardy was removed on [DATE] when the facility implemented an action plan related to assessment of a resident when there is a change in condition. This deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: R4's medical record was reviewed ,[DATE] - [DATE]. R4 was admitted to the facility on [DATE] for rehabilitation, after having a fall at home and fracturing her hip and pelvis. R4 was [AGE] years old and had [DIAGNOSES REDACTED]. R4's medical condition improved while she was at the facility and it was thought that she could discharge to the facility's independent apartment complex. The [DATE] inter-disciplinary note indicated a care conference was held with the inter-disciplinary team, R4, and R4's family. Therapy anticipated R4's last covered day of service to be [DATE]. The family was most interested in discharge to the facility's independent living complex. Therapy was in agreement with this level of care. After the inter-disciplinary note on [DATE], there was no documentation in R4's medical record until [DATE] when she experienced a significant change in her medical condition. LPN-D, who was an agency nurse, documented the following on [DATE] at 10:17 PM. 3:30 PM: R4 verbalized not feeling well and being short of breath. R4's oxygen saturation level was 80% on room air. R4 was administered oxygen at 4 liters/minute via a nasal cannula (device used to deliver supplemental oxygen). R4's oxygen level rose to 92% after 3 minutes of supplemental oxygen. Audible wheezing was noted to R4's upper and lower lungs and she had a non-productive cough at this time. R4 was administered [MEDICATION NAME] and a Proair inhaler, which are used by R4 as needed. R4 vomited shortly after due to coughing. No swelling was observed at this time. RN (Registered Nurse) Supervisor - E was called, updated, and came to assess R4. MD - F, the on-call physician was paged at 3:40 PM and 3:45 PM for an update and possible emergency room evaluation. (Surveyor noted that R4's record did not contain a documented Registered Nurse Assessment, as noted above. RN Supervisor - E confirmed that he did not assess R4 on [DATE].) 3:45 PM: LPN - D called R4's daughter to update her on R4's status. 4:30 PM: LPN - D paged MD - F again for an update. Awaiting call back. 7:15 PM: R4's family called the facility for an update and was upset that the facility had not received a return call from MD - F. LPN - D paged MD - F at this time and returned a call to R4's daughter. The daughter wanted R4 sent to the hospital. The following information was obtained from R4's hospital record: R4 arrived at the ED (Emergency Department) at 8:43 PM. The EMS (Emergency Medical Services), who transported R4 from the facility to the hospital reported that when they arrived at the facility, R4's oxygen saturation level was 88% with supplemental oxygen supplied at 4 liters/minute via a nasal cannula. EMS put a NRB (Non Re-Breather) oxygen mask on R4 and her oxygen saturation level increased into the 90's. (According to https://www.nursingtimes.net, The non-rebreathing oxygen mask enables the delivery of high concentrations of oxygen and is recommended for use in patients who are critically ill.) On [DATE] at 8:45 PM, the ED documented R4's vitals as follows: Temperature 101.3 F, Pulse 140, Respiration 49, Blood Pressure ,[DATE], and oxygen level 88%. The physical exam at this time noted that R4 was in respiratory distress (moderate). The ED noted her [DIAGNOSES REDACTED]. It was determined that R4 would be admitted to the ICU (Intensive Care Unit) at the hospital. R4 was noted to be in critical condition. R4's hospital course was described as follows: R4 was admitted into the intensive care unit, treated as per the critical care and other consultants recommendations, despite all measures not show any significant improvement, after multiple discussion with the family, they all agreed for comfort measures. R4 was admitted to hospice services at the hospital on [DATE] and died the following day, [DATE]. R4's discharge [DIAGNOSES REDACTED]. Interview with RN Supervisor -E On [DATE] at 2:20 PM, RN Supervisor - E was interviewed. He confirmed that he was the nursing supervisor on duty on [DATE] and that he had responded to LPN - D. RN Supervisor - E said that on [DATE] he had looked at LPN - D's assessment and agreed with her findings. He was aware that R4's oxygen level was at 80%. He said he would have reviewed R4's documented vital signs, but he did not know if R4's vital signs had been taken. RN Supervisor - E said that he did not listen to R4's lungs. RN Supervisor - E said that he did not complete an RN assessment because R4 had a history of [REDACTED]. RN Supervisor -E said that he did not consider R4 to be having a change in condition. The surveyor reported that she had reviewed R4's medical record and saw no previous documentation of R4's oxygen levels decreasing and then increasing. The surveyor said that she reviewed R4's oxygen levels that were recorded in the Vitals Section of the chart. The surveyor said that R4's oxygen level never was below 90%. RN Supervisor - E had no response. RN Supervisor - E was asked about the documentation made by LPN - D, indicating that R4 may need an emergency room evaluation. RN Supervisor - E said that he never suggested to LPN - D that R4 might need to be sent to the hospital. RN Supervisor - E said that R4's oxygen level rose to 92% after she was supplied with supplemental oxygen and it did not seem that there was an alarming situation. R4's Oxygen Saturation Levels R4's oxygen saturation levels were reviewed from ,[DATE] - [DATE]. (There were no documented oxygen levels from ,[DATE] - [DATE].) R4's oxygen levels ranged between 90% and 98% on 10 occasions. According to https://www.mayoclinic.org, Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. There was no evidence, as RN Supervisor - E had stated, that R4's oxygen levels routinely dropped and then rose again. Additionally, R4 had a [DATE] physician's orders [REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with LPN-D On [DATE] at 1:35 PM, LPN - D was interviewed. LPN - D could not recall who the nursing supervisor was on [DATE], but she did know that she had consulted with the nursing supervisor on [DATE]. LPN - D said that she had informed the nursing supervisor regarding R4's condition. LPN - D did not recall if the nursing supervisor saw R4 or completed an assessment. LPN - D said that she had wanted to update the physician regarding R4's condition but that the nursing supervisor had also asked her to request a possible emergency room evaluation from the physician. LPN - D was asked about the delay in sending R4 to the hospital. LPN - D said that R4's condition changed after being supplied with the supplemental oxygen. Her oxygen level rose to 92%. LPN - D said that after having received some [MEDICATION NAME], R4's coughing subsided. LPN - D said that she knew R4's condition had changed, but because she was an agency nurse she was relying on the expertise of the nursing staff at the facility who were more familiar with R4 to direct her regarding R4's care needs. Continued monitoring of R4 during a significant change in condition There was no documentation in the medical record, indicating that R4 was being monitored from 3:30 PM, when her condition changed, until 7:50 PM, when she was transported to the hospital. When interviewed on [DATE], RN Supervisor - E was unable to provide additional information related to on-going monitoring of R4. When interviewed on [DATE], LPN - D was unable to provide additional information related to on-going monitoring of R4. On [DATE] at 3:45 PM, the preceding information was shared with Administrator - A, Consultant - B, and DON - B. On [DATE] the facility provided the surveyor with the emergency room Transfer Form for R4. It was dated [DATE], but there was no time. R4's condition was described, as noted above on [DATE] at 3:30 PM. The vital signs were noted as follows. Temperature 100.3 F, Pulse 102, Respiration 20, Blood Pressure ,[DATE], Oxygen 91 - 92% after 4 liters of oxygen via nasal cannula. The time these vital signs were taken was not noted. It is not known if R4's oxygen level temporarily rose to 92 % and continued at that level or if her oxygen level dropped again and she was having other signs and symptoms that had not been assessed. Facility Policy The facility's Paging Procedures and Response Standards For Licensed Medical Practitioners, dated (MONTH) 2012, was reviewed. The policy defined an emergency situation as an oxygen level of less than 90% with shortness of breath. According to this definition, R4 was having an emergency situation. Although R4 was having an emergency situation, RN Supervisor - E did not assess R4 and determine that she was having a significant change in her condition. Without an RN assessment and identification of R4's significant condition change and without ongoing monitoring and assessment, the facility was unable to provide appropriate medical care to R4. On [DATE] the preceding information was shared with Administrator - A, Consultant - B, and DON - C. No additional information was provided to the survey team. The facility's failure to ensure an RN assessment which includes the monitoring of a resident's vital signs with a change in condition created a situation of Immediate Jeopardy which was removed on [DATE] when the facility implemented the following action plan: 1. Facility identified R-4 is no longer in the facility. R-4 was discharged on [DATE]. According to the facility, R-4 was the only resident who was affected. 2. The policy and procedure on change of condition and MD notification were updated based on clinical standards of practice, and have been reviewed and approved by Medical Director, Director of Nursing (DON), and Administrator during a special Quality Assurance (QA) meeting on [DATE]. 3. In person in-services have been conducted and will continue until all clinical staff has been in-serviced on the identification of a change of condition RN assessment and MD notification. 4. Shift supervisor's evaluate competency of clinical staff on the timely identification of a change of condition, RN assessment and documentation of the change of condition, process of MD notification and notifying the Medical Director if the MD is unresponsive. 5. On [DATE], a QA committee was held including the Medical Director, DON, Administrator to review the change of condition process and MD notification. The QA committee reviewed and updated the policies including Change of Condition and MD Notification policy and procedure. All IDT Team members and clinical staff were inserviced on Change of Condition identification and RN assessment of the change of condition, MD notification policy/procedure policy. Additional focused education provided to staff in person. The RN or RN nursing supervisor's will monitor each unit during rounds each shift and determine if there are any potential changes of condition. Post assessment, if there is a change of condition the RN will document the findings, initiate immediate notification of physician for further direction. MD notification will be initiated immediately for any potential change of condition. If the MD does not respond according to Policy and Procedure, the Medical Director will be notified immediately. At any time the licensed staff member determines that in their best clinical judgement a resident needs immediate transfer due to a potentially life threatening change of condition 911 is to be notified. 6. Nursing Management will continue to meet with units at least daily to review 24 hour reports, potential change of conditions and new admissions documentation to determine level of staff compliance with understanding of change of condition and MD notification. Nursing Management will provide data to the QA Committee monthly. New staff will receive orientation to include Change of Condition, assessment and MD notification. Staff will receive annual competency to review change of condition, RN assessment/ documentation of findings and MD notification. The Administrator and/or designee will monitor overall compliance through general supervision and reports from Department Heads on staff compliance.

Based on interview and record review, the facility did not consult with the resident's physician when 1 of 1 resident (R4) had a significant change in her medical condition. On [DATE] at 3:30 PM, R4 had a significant change in her condition when her oxygen saturation level dropped to 80% on room air and she complained of being Short of Breath (SOB). Although facility staff attempted to page the on-call physician, the physician did not return the facility's calls. When the physician does not respond to the facility's calls within 45 minutes, the facility's policy directs the Nursing Supervisor to call the Medical Director in an emergency situation. Facility staff did not call the Medical Director after 45 minutes but instead continued to page the on-call physician who did not respond to calls from the facility. On [DATE] at 7:15 PM, facility staff called R4's family and asked them if they wanted R4 sent to the hospital. R4's family directed facility staff to send R4 to the hospital. As a result of the physician not being contacted for direction, R4 had to wait over 4 hours for medical care when she had a significant change in her condition. On [DATE], R4's change in condition began at 3:30 PM. The facility did not call for ambulance transport to the hospital until 7:50 PM. R4 was admitted to the Intensive Care Unit at the hospital on [DATE] and died 6 days later on [DATE]. The facility's failure to timely contact R4's physician when she had a significant change in her condition created a finding of Immediate Jeopardy beginning on [DATE]. Administrator - A, Consultant - B, and DON (Director of Nursing) - C were informed of the Immediate Jeopardy on [DATE] at 10:30 a.m. The Immediate Jeopardy was removed on [DATE] when the facility implemented an action plan related to physician notification for changes in condition. The deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's Paging Procedures and Response Standards For Licensed Medical Practitioners, dated (MONTH) 2012, was reviewed. The policy defined an emergency situation as an oxygen level of less than 90% with shortness of breath. The policy further stated that it was expected that physicians return their pages or phone calls within 15 minutes in an emergency situation. If the call is not returned in 15 minutes, the physician is to be re-paged. If a return call for an emergency situation is not returned in 30 minutes a repeat call is to be made. After 45 minutes of elapsed time in an emergency situation, the nurse will contact the Nursing Supervisor to advise of the situation. The Nursing Supervisor is to notify the Medical Director. R4's medical record was reviewed ,[DATE] - [DATE]. R4 was admitted to the facility on [DATE] for rehabilitation, after having a fall at home and fracturing her hip and pelvis. R4 was [AGE] years old and had [DIAGNOSES REDACTED]. R4's medical condition improved while she was at the facility and it was thought that she could discharge to the facility's independent apartment complex. The [DATE] inter-disciplinary note contained the following information: A care conference was held with the inter-disciplinary team, R4, and R4's family. Therapy anticipated R4's last covered day of service to be [DATE]. The family was most interested in discharge to the facility's independent living complex. Therapy was in agreement with this level of care. After the inter-disciplinary note on [DATE], there was no documentation in R4's medical record until [DATE] when she experienced a significant change in her medical condition. LPN (Licensed Practical Nurse) - D, who was an agency nurse, documented the following on [DATE] at 10:17 PM; 3:30 PM: R4 verbalized not feeling well and being short of breath. R4's oxygen saturation level was 80% on room air. R4 was administered oxygen at 4 liters/minute via a nasal cannula (device used to deliver supplemental oxygen). R4's oxygen level rose to 92% after 3 minutes of supplemental oxygen. Audible wheezing was noted to R4's upper and lower lungs and she had a non-productive cough at this time. R4 was administered [MEDICATION NAME] and a Proair inhaler, which are used by R4 as needed. R4 vomited shortly after due to coughing. No swelling was observed at this time. RN (Registered Nurse) Supervisor - E was called, updated, and came to assess R4. MD - F, the on-call physician was paged at 3:40 PM and 3:45 PM for an update and possible emergency room evaluation. Surveyor noted that R4's record did not contain a documented Registered Nurse assessment, as noted above. RN Supervisor - E confirmed that he did not assess R4 on [DATE]. (See F684 for additional information.) 3:45 PM: LPN - D called R4's daughter to update her on R4's status. 4:30 PM: LPN - D paged MD - F again for an update. Awaiting call back. (Note: The facility did not follow their written policy. The facility paged MD - F at 3:40 PM and 3:45 PM, with no return call. After 45 minutes of elapsed time, the Nursing Supervisor did not notify the Medical Director.) 7:15 PM: R4's family called the facility for an update and was upset that the facility had not received a return call from MD - F. LPN - D paged MD - F at this time and returned a call to R4's daughter. The daughter wanted R4 sent to the hospital. The following information was obtained from R4's hospital record. R4 arrived at the ED (Emergency Department) at 8:43 PM. The EMS (Emergency Medical Services), who transported R4 from the facility to the hospital, reported that when they arrived at the facility R4's oxygen saturation level was 88% with supplemental oxygen supplied at 4 liters/minute via a nasal cannula. EMS put a NRB (Non Re-Breather) oxygen mask on R4 and her oxygen saturation level increased into the 90's. (According to https://www.nursingtimes.net, The non-rebreathing oxygen mask enables the delivery of high concentrations of oxygen and is recommended for use in patients who are critically ill.) On [DATE] at 8:45 PM, the ED documented R4's vitals as follows: Temperature 101.3 F, Pulse 140, Respiration 49, Blood Pressure ,[DATE], and oxygen level 88%. The physical exam at this time noted that R4 was in respiratory distress (moderate). The ED noted her [DIAGNOSES REDACTED]. It was determined that R4 would be admitted to the ICU (Intensive Care Unit) at the hospital. R4 was noted to be in critical condition. R4's hospital course was described as follows: R4 was admitted into intensive care unit, treated as per the critical care and other consultants recommendations, despite all measures not show any significant improvement, after multiple discussion with the family, they all agreed for comfort measures. R4 was admitted to hospice services at the hospital on [DATE] and died the following day, [DATE]. R4's discharge [DIAGNOSES REDACTED]. Interview with RN Supervisor - E: On [DATE] at 2:20 PM, RN Supervisor - E was interviewed. He confirmed that he was the nursing supervisor on duty on [DATE] and that he had responded to LPN - D. RN Supervisor - E said that on [DATE] he looked at LPN - D's assessment and agreed with her findings. He was aware that R4's oxygen level was at 80%. RN Supervisor - E said that he did not think that these findings constituted a significant change in R4's condition because R4's oxygen level increased to 92% when R4 received supplemental oxygen via the nasal cannula. RN Supervisor - E said that he had had directed LPN - D to call the physician; but that he had not directed LPN - D to request a possible emergency room evaluation from MD - F per LPN- D's [DATE] 10:17 pm note. In response to contacting the physician, RN Supervisor - E said that LPN - D told him that she had not heard from MD - F (no time was specified). RN Supervisor - E told LPN - D to call MD - F again. RN Supervisor - E said that he had no further discussion regarding LPN - D's inability to contact MD -F; until LPN - D said that R4's family wanted R4 sent to the hospital. (This was at 7:15 PM.) RN Supervisor - E was asked about the delay in sending R4 to the hospital; noting her change at 3:30 PM and not being sent to the hospital until 7:50 PM. RN Supervisor - E said that The time frame is a little long, although she did go back up to 92% so it would not be as common to monitor. Interview with LPN - D: On [DATE] at 1:35 PM, LPN - D was interviewed. LPN - D could not recall who the nursing supervisor was on [DATE] but she did know that she had consulted with the nursing supervisor on [DATE]. LPN - D said that she had informed the nursing supervisor regarding R4's condition. LPN - D said that she had wanted to update the physician regarding R4's condition but that the nursing supervisor had also asked her to request a possible emergency room evaluation from the physician. LPN - D was asked about the delay in sending R4 to the hospital. LPN - D said that R4's condition changed after being supplied with the supplemental oxygen. Her oxygen level rose to 92%. LPN - D said that after having received some [MEDICATION NAME], R4's coughing subsided. LPN - D said that she knew R4's condition had changed but because she was an agency nurse she was relying on the expertise of the nursing staff at the facility who were more familiar with R4 to direct her regarding R4's care needs. No MD order for continuous oxygen at 4 Liters/Minute: R4's current physician orders [REDACTED]. According to R4's medical record and noted above on [DATE] at 3:30 PM, R4 was provided with oxygen at 4 liters/minute via the nasal cannula. Although it is not documented, it appeared that the oxygen was supplied to R4 continuously on [DATE]. The EMS, per the hospital record, noted that R4 normally uses oxygen at 4 liters/minute continuously. The EMS, via the hospital record, also noted that R4 was receiving oxygen at 4 liters/minute when they arrived at the facility. On [DATE] at 1:35 PM, LPN - D was interviewed. LPN - D said that she would not have put someone on 4 liters of oxygen. That is high. I would not go outside of a physician's orders [REDACTED]. In addition to not contacting MD - F to inform him of R4's significant change in condition, the facility did not contact MD - F to get orders related to R4's use of oxygen. The facility provided 4 liters of continuous oxygen to R4 without a valid physician's orders [REDACTED].>The facility did not follow their written policy on [DATE] at 3:30 PM when R4 had a significant change in her condition that met the facility's definition of an emergency situation. The facility paged MD - F at 3:40 PM and 3:45 PM, with no return call. After 45 minutes of elapsed time, the Nursing Supervisor did not notify the Medical Director. The facility was unable to contact MD - F and because of this, R4 was not sent to the hospital until after 7:15 PM; when R4's family directed that she be sent to the hospital. R4 arrived at the ED at 8:43 pm On [DATE] the preceding information was shared with Administrator - A, Consultant - B, and DON - C. No additional information was provided to the survey team. The facility's failure to promptly consult with a physician during a significant change in condition created a situation of Immediate Jeopardy that was removed on [DATE] when the facility implemented the following action plan: 1. Facility identified R-4 is no longer in the facility and was discharged on [DATE]. According to the Facility, R-4 was the only resident who was affected. 2. The policy and procedure on change of condition and MD notification were updated based on clinical standards of practice, and have been reviewed and approved by Medical Director, Director of Nursing, and Administrator during a special Quality Assurance (QA) meeting on [DATE]. 3. In-services were conducted immediately in person and will continue until all clinical staff has been in-serviced on change of condition and MD notification. 4. Shift supervisor's to evaluate competency of clinical staff on the timely identification of a change of condition process, the process of MD notification and notifying the Medical Director if the MD is unresponsive. 5. On [DATE], a QA committee was held including the Medical Director to review the change of condition process and MD notification. The QA committee reviewed the policies including Change of Condition Notification which contains the MD notification. Interdisciplinary Team (IDT) Team members, clinical staff and ancillary departments were inserviced on identification of Change of Condition, MD notification policy/procedure. Additional focused in person education was provided on Change of condition, notification of MD, RN assessment and notification of the Medical Director. The RN or RN nursing supervisor's will monitor each unit during rounds each shift and determine if there are any potential changes of condition. Post assessment, if there is a change of condition the RN will document the findings, initiate notification of physician for further direction as indicated by policy. If the MD does not respond according to Policy and Procedure, the Medical Director will be notified immediately. At any time the licensed staff member determines that in their best clinical judgement a resident needs immediate transfer due to a potentially life threatening change of condition 911 is to be notified. 6. Nursing Management will continue to meet with units daily to review 24 hour reports, potential change of conditions and new admissions. Nursing Management will do spot checks at least once daily, for 30 days, and ongoing as determined in QA committee, to determine level of staff compliance with understanding of change of condition and MD notification. If there is a near miss or incident that has occurred an immediate investigation and a root cause analysis will be completed, issue corrected and staff educated. New staff will receive orientation to include Change of Condition and MD notification. Staff will receive annual competency to review change of condition, assessment/ documentation of findings and MD notification. The Administrator and/or designee will monitor overall compliance through general supervision and reports from Department Heads on staff compliance.

Based on observation, interview and record review, the facility did not ensure that 1 (R26) of 21 residents reviewed was free of verbal and emotional abuse from facility staff. Video evidence shows two CNAs (Certified Nursing Assistants) laughing at, taunting, pointing their fingers, attempting to provoke and kicking the wheel chair of R26 on 1/19/17. Statements from visitors document that on 1/19/17, R26 asked another's resident's family member (a former neighbor) to change her because she had been sitting in an incontinence product for hours but was afraid to ask the CNAs for help. Further investigation revealed that the previous DON (Director of Nursing) was aware of the mental and verbal abuse directed at R26 by the two CNAs and directed staff to not report the abuse to the facility's administration. As a result of the mental and verbal abuse directed at R26 by two CNAs, R26 slept poorly, became more paranoid and was afraid to go to bed. The Facility's failure to prevent facility staff from verbally and mentally abusing R26 created a findings of Immediate Jeopardy beginning on 1/4/17. Administrator-A, DON (Director of Nursing)-B and Assistant Administrator-P were informed of the Immediate Jeopardy on 3/20/17 at 11:30 a.m. The Immediate Jeopardy was removed on 2/14/17 when the Facility implemented an action plan related to the prevention and reporting of resident abuse. The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) as the facility continues to implement its action plan. Findings include: On 3/16/17 at 3:08 p.m., Surveyor reviewed a self-report involving CNA-W and R26 on 1/19/17. The self-report documents under Summary of Incident section, On 1/21/17, R26 reported that CNA-W was taunting and laughing towards resident. Under the Describe the Effect section it documents, Resident was in emotional distress and afraid of the two CNA's. The resident was emotionally and verbally abused by two aids witnessed on camera (video). On 3/16/17 at approximately 4:15 p.m., Surveyors and observed the video provided by Administrator-A involving the two CNA's described in the above incident (CNA-W & CNA-X). The video and a timeline of the witnessed events on the video camera show the time that CNA-W and CNA-X are observed taunting and emotionally abusing R26 on 1/19/17. The video and timeline document: Video Camera TV (Terrace View) 1 Hallway on 1/19/17: 1629 (4:29 p.m.): R26 comes out of her room. 1631 (4:31 p.m.): CNA-W kicks the wheelchair of R26 (with R26 sitting in it). Video Camera TV1 Nursing Station on 1/19/17: 1945 (7:45 p.m.): R26 enters the nurses station with a wooden board in her hand. 1946 (7:46 p.m.): CNA-X pushes wheelchairs backwards (with R26 sitting in it), R26 swings the board, CNA-W laughs. 1946 (7:46 p.m.): CNA-W points and laughs at R26. 1947 (7:47 p.m.): CNA-X starts talking to R26 and pointing/shaking her fingers at R26. 1947 (7:47 p.m.): Both CNA-X and CNA-X laugh and point their fingers at R26. Statement collected from Former Neighbor-GGG by Social Services Director-F on 1/21/17 documents: I arrived to the unit about 7:30 p.m. on Thursday (1/19/17) .As I was going down the hall I saw (R26) in the doorway of the nursing station. I saw (R26) had the block of wood (card holder) in her hand and she was shaking at (CNA-W) and (CNA-X). I (Former Neighbor-GGG) asked (R26) was she was doing with the card holder. (R26) stated those 2 girls (referring to CNA-W and CNA-X) are trying to hurt me. They are pushing me and pushing me . (R26) then asked me if I would do something for her. I asked her what and she said change my diaper. She has never asked me to do that before. I explained to (R26) that I am not sure I should be doing that. (R26) explained to me how to help her in the bathroom. She stated to me I don't want to girls to help me (referring to CNA-W and CNA-X), I don't want them to do it, they are evil. (R26) stated she has been in the diaper all day and did not want to get a rash. Last time she (R26) got a rash it took a long time to heal I (Former Neighbor-GGG) took her (R26) into the bathroom and she pulled herself up. She then told me to take her pants down and go behind her. Then she (R26) said to place the diaper in between her legs and she would grab it in the front. I (Former Neighbor-GGG) did that and removed the old diaper that was heavy. (R26) then asked me to get help her get into bed. I (Former Neighbor-GGG) stated I should not be transferring her. (R26) told me to put her by the chair and she will lean over and I just need to help her with her legs. I did that. When I came back the next night, (CNA-W) told me that I should not have put (R26) to bed. CNA-W said (R26) is telling everyone that you put her to bed. (CNA-W) told me that was not my job. On 3/20/17 at 9:30 a.m., Surveyor asked Administrator-A if the facility had investigated the statement by Former Neighbor-GGG regarding R26 not being toileted by CNA-W and CNA-X. Administrator-A informed Surveyor that the facility investigated the statement by Former Neighbor-GGG and confirmed that R26 had not being toileted by CNA-W and CNA-X. Statement collected from Former Neighbor-FFF by Administrator-A on 1/21/17 documents: On Saturday 1/21/17, I (Administrator-A), was approached by Former Neighbor-FFF who asked to speak with me privately. He (Former Neighbor-FFF) stated that he believed that CNA-W was intentionally agitating and taunting R26. I asked him why he believed that and he stated that he had heard CNA-W say things to intentionally agitated R26 such as, you know I am your aide tonight so you better behave. And you better be nice to me because otherwise I am not going to put you to bed. Former Neighbor-FFF then stated he had talked to Previous DON-Q about two weeks ago (from 1/21/17) and provided her (Previous DON-Q) with more examples at the time. He states that Previous DON-Q had told him CNA-W would not be assigned to that unit anymore. On 3/20/17 at 9:54 a.m., Surveyor interviewed Former Neighbor-FFF regarding the above incidents. Surveyor asked Former Neighbor-FFF is he had let Previous DON-Q know of any instances where R26 was taunted by facility staff. Former Neighbor-FFF informed Surveyor that in the first week of January, he had informed Previous DON-Q that he had witnessed CNA-W and CNA-X taunt R26. Former Neighbor-FFF informed Surveyor that he had informed Previous DON-Q that R26 had told him that CNA-W and CNA-X were trying to kill her and that Previous DON-Q told him (Former Neighbor-FFF) that she (Previous DON-Q) would take care of the situation. Former Neighbor-FFF informed Surveyor that he would always know when CNA-W and CNA-X were on the unit working with R26. Former Neighbor-FFF informed Surveyor that whenever CNA-W and CNA-X were on the unit working with R26, R26 would become increasingly paranoid, have difficulty sleeping and was afraid to go to bed. Former Neighbor-FFF informed Surveyor that whenever CNA-W and CNA-X were on the unit working with R26, R26 would make statements to him (Former Neighbor-FFF) that CNA-W and CNA-X were trying to kill her (R26) and that Former Neighbor-FFF should help her (R26) leave the facility. Former Neighbor-FFF informed Surveyor that he had informed Previous DON-Q that R26 had told him that CNA-W and CNA-X were trying to kill her and that Previous DON-Q told him (Former Neighbor-FFF) that she (Previous DON-Q) would take care of the situation. In (Previous DON-Q's) work binder, there was a note confirming that she had spoken to (Former Neighbor-FFF) on or around 1/4/17. Also found in her work binder was a small piece of paper with a note that appeared to be written by Previous (DON-Q) stating, (CNA-W) & friend work her up/trigger (R26). No further information was provided as to why the facility did not ensure that R26 was free of verbal and emotional abuse from facility staff. The facility's failure to prevent abuse to R26 created a situation of Immediate Jeopardy that was removed on 2/14/17 when the facility implemented the following action plan. By 2/14/17 the facility implemented the following: 1. The facility's policy and procedure for abuse was reviewed and revised as indicated. 2. All allegations of potential abuse were reviewed for appropriate investigation and reporting. 3. All facility staff were trained on reporting allegations of abuse, neglect, mistreatment, exploitation, misappropriation and injuries of unknown origin. 4. A schedule of ongoing training was established by the facility to work with staff hesitant to report allegations. 5. An audit process was established by the facility to review for allegations. 6. R26 was assessed to ensure all psychosocial needs are met. 7. A QA process was established related to abuse, neglect, mistreatment, exploitation, misappropriation and injuries of unknown origin. Cross reference F225 and F226: the facility staff failed to report abuse and the facility, subsequently, failed to prevent further abuse to R26.

Based on record review and staff interview, facility staff did not thoroughly investigate, immediately report to the State Agency, or prevent further potential abuse for one resident involving abuse (R26), one incident regarding misappropriation (R25) and one incident involving missing money (R21) for 3 out of 4 investigations reviewed involving residents R26, R25 and R21. Video evidence shows two CNAs (Certified Nursing Assistants) laughing at, taunting, pointing their fingers, attempting to provoke and kicking the wheel chair of R26 on 1/19/17. Statements from visitors document that on 1/19/17, R26 asked another resident's family member to change her because she had been sitting in an incontinence product for hours but was afraid to ask the CNAs for help. Further investigation revealed that the previous DON (Director of Nursing) was aware of the mental and verbal abuse directed at R26 by the two CNAs and directed staff to not report the abuse to the facility's administration. Additional interviews with facility nurse management staff indicates facility staff were aware of a long standing situation of potential abuse between CNA-W to R26 but was not appropriately acted upon to prevent recurring encounters of potential abuse. As a result of the mental and verbal abuse directed at R26 by two CNAs, R26 slept poorly, became more paranoid and was afraid to go to bed. The Facility's failure to ensure that all allegations of abuse were adequately investigated in order to prevent facility staff from verbally and mentally abusing R26 created a finding of Immediate Jeopardy beginning on 1/4/17. Administrator-A, DON (Director of Nursing)-B and Assistant Administrator-P were informed of the Immediate Jeopardy on 3/20/17 at 11:30 a.m. The Immediate Jeopardy was removed on 2/14/17 when the Facility implemented an action plan related to the prevention and reporting of resident abuse. The deficient practice continues at scope/severity of F (potential for harm/widespread) as the facility continues to implement its action plan and as evidenced by the examples related to R25 and R21. * R25 reported an allegation of misappropriation of money that was not thoroughly investigated or reported to the State Agency. The facility did not immediately report the missing money to the state agency. Immediately means as soon as possible but not exceed 24 hours after discovery of the incident. * R21 reported missing money that was not thoroughly investigated or reported to the State Agency. The facility did not immediately report the missing money to the state agency. Immediately means as soon as possible but not exceed 24 hours after discovery of the incident. In addition, the facility did not submit the results of either investigation (Misconduct Incident Report form DQA F ) to the State Agency within 5 working days of such incidents. Findings include: 1.) On 3/16/17 at 3:08 p.m., Surveyor reviewed a self-report submitted to the State Agency involving CNA-W and R26. The self-report documents under Summary of Incident section, On 1/21/17, R26 reported that CNA-W was taunting and laughing towards resident. Under the Describe the Effect section it documents, Resident was in emotional distress and afraid of the two CNA's. The resident was emotionally and verbally abused by two aids witnessed on camera (video). An addendum to the self-report submitted on 1/27/17 by Administrator-A documents, This is an addendum to the self-report regarding R26 and CNA-W and CNA-X. Through further investigation, we have become aware that Previous DON (Director of Nursing)-Q, may have had prior knowledge of (R26) and CNA-W's behavior towards her (R26). Further investigation and staff interviews were obtained. The addendum documents: On 1/21/17, (Former Neighbor-FFF) approached the administrator and stated he had talked to (Previous DON-Q) about two weeks ago (prior to 1/21/17) and provided examples that (CNA-W) was intentionally agitating and taunting R26. Additionally, (Former Neighbor-FFF) stated when he told (Previous DON-Q) this information, (DON-Q) was taking down notes and that (Previous DON-Q) stated to (Former Neighbor-FFF), (CNA-W) will not be on that unit anymore. In (Previous DON-Q's) work binder, there was a note confirming that she had spoken to (Former Neighbor-FFF) on or around 1/4/17. Also found in her work binder was a small piece of paper with a note that appeared to be written by Previous (DON-Q) stating, (CNA-W) & friend work her up/trigger (R26). Throughout the investigation, interviews, and outcome of our findings, we confirmed (Previous DON-Q) may have had prior knowledge of this resident's (R26) behavior towards CNA-W. Additionally, (Previous DON-Q) failed to act to prevent the employee (CNA-W) from experiencing repeated harassing behavior from the resident. By failing to move the CNA from the repeated derogatory statements of the resident, the resident and staff member were placed in a compromising situation that may have contributed to the actions that occurred on 1/19/17. Additionally, the information (Previous DON-Q) was aware of was never reported to the Administrator/designee or the state department (Agency) as state and federal regulations regulations as VMP (Village at Manor Park) policy and federal regulations require. (Previous DON-Q) failed to, 'report any incident of alleged abuse, neglect or misappropriation to the Administrator or designee as soon as the alleged abuse occurs, is discovered, or known to the employee.' Surveyor noted that attached to this addendum was a copy of the note found in Previous DON-Q's documents which notes previous knowledge by Previous DON-Q of R26's and CNA-W's interactions. The note documents, (CNA-W) & friend worker her/trigger (R26). On 3/16/17 at approximately 4:15 p.m., Surveyors and observed the video provided by Administrator-A involving the two CNA's described in the above incident (CNA-W & CNA-X). The video and a timeline of the witnessed events on the video camera show the time that CNA-W and CNA-X are observed taunting and emotionally abusing R26 on 1/19/17. The video and timeline document: Video Camera TV (Terrace View) 1 Hallway on 1/19/17: 1629 (4:29 p.m.): R26 comes out of her room. 1631 (4:31 p.m.): CNA-W kicks the wheelchair of R26 (with R26 sitting in it). Video Camera TV1 Nursing Station on 1/19/17: 1945 (7:45 p.m.): R26 enters the nurse's station with a wooden board in her hand. 1946 (7:46 p.m.): CNA-X pushes wheelchairs backwards (with R26 sitting in it), R26 swings the board, CNA-W laughs. 1946 (7:46 p.m.): CNA-W points and laughs at R26. 1947 (7:47 p.m.): CNA-X starts talking to R26 and pointing/shaking her fingers at R26. 1947 (7:47 p.m.): Both CNA-X and CNA-X laugh and point their fingers at R26. Statement collected from Former Neighbor-GGG by Social Services Director-F on 1/21/17 documents: I arrived to the unit about 7:30 p.m. on Thursday (1/19/17) .As I was going down the hall I saw (R26) in the doorway of the nursing station. I saw (R26) had the block of wood (card holder) in her hand and she was shaking at (CNA-W) and (CNA-X). I (Former Neighbor-GGG) asked (R26) was she was doing with the card holder. (R26) stated those 2 girls (referring to CNA-W and CNA-X) are trying to hurt me. They are pushing me and pushing me . (R26) then asked me if I would do something for her. I asked her what and she said change my diaper. She has never asked me to do that before. I explained to (R26) that I am not sure I should be doing that. (R26) explained to me how to help her in the bathroom. She stated to me I don't want to girls to help me (referring to CNA-W and CNA-X), I don't want them to do it, they are evil. (R26) stated she has been in the diaper all day and did not want to get a rash. Last time she (R26) got a rash it took a long time to heal I (Former Neighbor-GGG) took her (R26) into the bathroom and she pulled herself up. She then told me to take her pants down and go behind her. Then she (R26) said to place the diaper in between her legs and she would grab it in the front. I (Former Neighbor-GGG) did that and removed the old diaper that was heavy. (R26) then asked me to get help her get into bed. I (Former Neighbor-GGG) stated I should not be transferring her. (R26) told me to put her by the chair and she will lean over and I just need to help her with her legs. I did that. When I came back the next night, (CNA-W) told me that I should not have put (R26) to bed. CNA-W said (R26) is telling everyone that you put her to bed. (CNA-W) told me that was not my job. On 3/20/17 at 9:30 a.m., Surveyor asked Administrator-A if the facility had investigated the statement by Former Neighbor-GGG regarding R26 not being toileted by CNA-W and CNA-X. Administrator-A informed Surveyor that the facility investigated the statement by Former Neighbor-GGG and confirmed that R26 had not being toileted by CNA-W and CNA-X. Statement collected from Former Neighbor-FFF by Administrator-A on 1/21/17 documents: On Saturday 1/21/17, I (Administrator-A), was approached by Former Neighbor-FFF who asked to speak with me privately. He (Former Neighbor-FFF) stated that he believed that CNA-W was intentionally agitating and taunting R26. I asked him why he believed that and he stated that he had heard CNA-W say things to intentionally agitated R26 such as, you know I am your aide tonight so you better behave. And you better be nice to me because otherwise I am not going to put you to bed. Former Neighbor-FFF then stated he had talked to Previous DON-Q about two weeks ago (from 1/21/17) and provided her (Previous DON-Q) with more examples at the time. He states that Previous DON-Q had told him CNA-W would not be assigned to that unit anymore. On 3/20/17 at 9:54 a.m., Surveyor interviewed Former Neighbor-FFF regarding the above incidents. Surveyor asked Former Neighbor-FFF is he had let Previous DON-Q know of any instances where R26 was taunted by facility staff. Former Neighbor-FFF informed Surveyor that in the first week of January, he had informed Previous DON-Q that he had witnessed CNA-W and CNA-X taunt R26. Former Neighbor-FFF informed Surveyor that he had informed Previous DON-Q that R26 had told him that CNA-W and CNA-X were trying to kill her and that Previous DON-Q told him (Former Neighbor-FFF) that she (Previous DON-Q) would take care of the situation. Former Neighbor-FFF informed Surveyor that he would always know when CNA-W and CNA-X were on the unit working with R26. Former Neighbor-FFF informed Surveyor that whenever CNA-W and CNA-X were on the unit working with R26, R26 would become increasingly paranoid, have difficulty sleeping and was afraid to go to bed. Former Neighbor-FFF informed Surveyor that whenever CNA-W and CNA-X were on the unit working with R26, R26 would make statements to him (Former Neighbor-FFF) that CNA-W and CNA-X were trying to kill her (R26) and that Former Neighbor-FFF should help her (R26) leave the facility. Former Neighbor-FFF informed Surveyor that he had informed Previous DON-Q that R26 had told him that CNA-W and CNA-X were trying to kill her and that Previous DON-Q told him (Former Neighbor-FFF) that she (Previous DON-Q) would take care of the situation. The facility's self-report included statements from RN (Registered Nurse) Manager-C and RN Manager-D and RN Manager-N and documents that all three RN supervisors were aware of the behaviors between R26 and CNA-W. A statement collected from RN Manager-C on 1/31/17 documents: 1. I have been told on multiple times by (Previous DON-Q) . not to bring up issues and areas of concern to administration especially if they involve the nursing department. This was stated to me after morning/ IDT (interdisciplinary team) incident meetings when I brought up a resident or family concern during the concern portion of the morning meeting. 2. I am aware of conversations last year of (R26's) behaviors and how specific staff have triggered her behavior at times I had conversations with (Previous DON-Q) that putting (CNA-W) on the unit with (R26) was not a good idea as her presence alone agitated the resident. I asked to have regular CNAs that could be trained to address behavioral issues and develop a routine for the residents. I was told by (Previous DON-Q) that I need to work with what I had. I am not surprised that there was a situation with (CNA-W, CNA-X and R26) since I had requested they not work together and had requested that (CNA-W) not work on Terrace View 1 (unit where R26 resided). A statement collected from RN Manager-D on 1/27/17 documents: About a year ago, maybe a year and half ago, R26 had a very racial streak with behaviors. CNA-W was one of her (R26) targets .There was an occasion where I moved her (CNA-W) to the other side on Park View to help decrease R26's behaviors and protect both R26 and CNA-W. A statement collected from RN Manager-N on 1/27/17 documents: I recall an incident shortly after I (RN Manager-N) started working here where I was called to the unit by the nurse who stated R26 was harassing CNA-W. When I arrived, CNA-W was visibly upset, threatening to leave because R26 was harassing her (I believe she (R26) was using racial slurs towards CNA-W). I did notify either the group, or the social worker, I cannot recall who, and I believe I did turn in a concern form into Social Services Director-H. I recall that the response I received was with the general idea that this is not a new issue, but an ongoing one. I suggested to CNA-W that I switch her to a different unit to get away from R26. CNA-W refused stating she shouldn't have to leave her unit/assignment. I explained that this is R26's home, so in order to get away from R26, CNA-W must be the one to move. I offered CNA-W a new assignment repeatedly, yet she continued to refuse and continued to walk off the job. On 3/17/17 at 12:44 p.m., Surveyor interviewed RN Manager-C. Surveyor asked RN Manager-C if Previous DON-Q was aware of R26's behaviors and conflict between R26 and CNA-W prior to 1/19/17. RN Manager-C informed Surveyor that Previous DON-Q was aware of R26's behaviors and the conflict between R26 and CNA-W prior to 1/19/17. RN Manager-C informed Surveyor that she had spoken with Previous DON-Q about the R26's behaviors and the conflict between CNA-W and R26 at least three times throughout 2016. RN Manager-C informed Surveyor that whenever she brought up the conflict between R26 and CNA-W, Previous DON-Q would tell her I'm on it. RN Manager-C informed Surveyor that at times Previous DON-Q would reassign CNA-W to another unit to prevent her (CNA-W) from working with R26, but that due to scheduling issues CNA-W would return to the unit and work with R26. Surveyor asked RN-Manager-C if she had ever reported the conflict between R26 and CNA-W to administration. RN Manager-C informed Surveyor that Previous DON-Q would instruct her not to report any nursing issues, including the conflict between R26 and CNA-W, to administration. On 3/17/17 at 1:13 p.m., Surveyor informed Administrator-A of the above findings. Surveyor asked if she was aware prior to 1/21/17 that CNA-W and CNA-X were verbally and mentally abusing R26. Administrator-A informed Surveyor that she personally did not know prior to 1/21/17 that CNA-W and CNA-X were verbally and mentally abusing R26. On 3/20/17 at 9:30 a.m., Surveyor asked Administrator-A if Previous DON-Q should have reported to the State Agency and ensured the safety of R26 after she became first aware of incident regarding verbal and mental abuse of R26 by CNA-W and CNA-X, on or around 1/4/1/4/17. Administrator-A informed Surveyor that Previous DON-Q should have reported to the State Agency and ensured the safety of R26 after she became first aware of the incident regarding verbal and mental abuse of R26 by CNA-W and CNA-X, on or around 1/4/17. No further information was provided as to why the facility did not thoroughly investigate or report to the State Agency in accordance with regulatory requirements an incident involving verbal and mental abuse of R26 when Previous DON-Q became aware on or around 1/4/17. The facility's failure to prevent abuse to R26 created a situation of Immediate Jeopardy that was removed on 2/14/17 when the facility implemented the following action plan. The deficient practice continues at a scope and severity of an F (potential for harm/widespread). By 2/14/17 the facility implemented the following: 1. The facility's policy and procedure for abuse was reviewed and revised as indicated. 2. All allegations of potential abuse were reviewed for appropriate investigation and reporting. 3. All facility staff were trained on reporting allegations of abuse, neglect, mistreatment, exploitation, misappropriation and injuries of unknown origin. 4. A schedule of ongoing training was established by the facility to work with staff hesitant to report allegations. 5. An audit process was established by the facility to review for allegations. 6. R26 was assessed to ensure all psychosocial needs are met. 7. A QA process was established related to abuse, neglect, mistreatment, exploitation, misappropriation and injuries of unknown origin. 2.) On 3/16/17 at 10:15 a.m., during a routine Sub Task 5g (Abuse Prohibition Review) of incident and self-reports, Surveyor reviewed a self-report regarding misappropriation involving R25. The form titled Concern Review Form for Violation of Individual Rights and Responsibilities dated 1/27/17 documents, R25 states she gave $20 to CNA-W 2-3 weeks ago, so that CNA-W could get her candy. R25 said she asked CNA-W, last week, for her candy but was told it was in CNA-W's trunk (of car). R25 was never given the candy. Under the What was done to prevent further violation of rights while manner is under investigation section it documents, SW (social worker)-I spoke with R25 about not giving employees money for things. Encouraged R25 to let SW-I know when she is in need of candy. Under the Was concern referred to DQA (Division of Quality Assurance) section it documents, No. Under the Outcome of investigation section it documents, SW-I provided R25 with bags of gummy candy per her request. R25 to be reimbursed the $20 that was gives to CNA-W. Under the Corrective action taken by facility section it documents, Money reimbursed, R25 provided with candy. CNA-W no longer employed at facility. So cannot ask her if she received money. On 3/16/17 at 2:33 p.m., Surveyor informed SW-I of the above findings. Surveyor asked SW-I if the facility had self-reported this allegation of misappropriation to the State Agency. SW-I informed Surveyor that she had no further information and that Administrator-A made the determination to report allegations of misappropriation to the State Agency. On 3/16/17 at 3:01 p.m., Surveyor informed Administrator-A of the above findings. Surveyor asked Administrator-A if the facility had self-reported this allegation of misappropriation to the State Agency. Administrator-A informed Surveyor that the facility had not reported this allegation of misappropriation to the State Agency because R25 did not feel that CNA-W had willfully taken her money without getting R25 her candy. Administrator-A informed Surveyor that since CNA-W was no longer at the facility, the facility was unable to interview CNA-W but that the facility should have self-reported this allegation of misappropriation to the State Agency. On 3/20/17 at 3:20 p.m., during the daily exit conference, Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not investigate or report to the State Agency an allegation of misappropriation as reported by R25 on 1/27/17. 3.) On 3/16/17 at 10:15 a.m., Surveyor reviewed a self-report regarding misappropriation involving R21. The form titled Concern Review Form for Violation of Individual Rights and Responsibilities dated 2/20/17 documents, Missing $6 from his pouch in wheelchair bag. Under the Was concern referred to DQA (Division of Quality Assurance) section it documents, No. Under the Investigation Concern section it documents, Offered R21 a lock box. Under the Outcome of investigation section it documents, R21 now in agreement with having a lock box. SW-I contacted buildings and grounds to have lock box installed and SW-I will provide R21 with a keychain for they key. Under the Corrective action taken by facility section it documents, See above. Surveyor noted that there was no investigation into the missing $6 reported by R21 in the incident report provided to Surveyor . On 3/16/17 at 2:33 p.m., Surveyor informed SW-I of the above findings. Surveyor asked SW-I if she had performed an investigation on the missing $6 reported by R21. SW-I informed Surveyor that she did not perform an investigation into the missing $6 dollars reported by R21 as R21 had later informed her (SW-I) that he was not missing any money. Surveyor asked SW-I if the facility had self-reported this allegation of missing money to the State Agency. SW-I informed Surveyor that she had no further information and that Administrator-A made the determination to report missing money to the State Agency. On 3/16/17 at 3:01 p.m., Surveyor informed Administrator-A of the above findings. Surveyor asked Administrator-A if the facility had investigated the missing $6 reported by R21. Administrator-A informed Surveyor that investigation into the missing $6 dollars reported by R21 as R21 had later informed her (SW-I) that he was not missing any money. Surveyor asked Administrator-A if the facility had self-reported this allegation of missing money to the State Agency. Administrator-A informed Surveyor that the facility had not reported this allegation of missing money to the State Agency. Administrator-A informed Surveyor that the facility should have self-reported this allegation of missing money to the State Agency and at the time investigated the allegation of missing $6 reported by R21. On 3/20/17 at 3:20 p.m., during the daily exit conference, Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not investigate or report to the State Agency an allegation of missing money as reported by R21 on 2/20/17.

Based upon interview, observation and record review, the Facility did not operationalize its policy and procedure titledAbuse, Mistreatment, Neglect and Misappropriation of Resident/Client Property/Funds, Injury of Unknown Origin for 3 of 4 reviewed allegations involving R26, R25 and R21. The facility did not report to the State Agency and/or have evidence that they thoroughly investigated one incident involving abuse, one incident regarding misappropriation and one incident involving missing money. The facility did not prevent further potential abuse from occurring. Video evidence shows two CNAs (Certified Nursing Assistants) laughing at, taunting, pointing their fingers, attempting to provoke and kicking the wheel chair of R26 on 1/19/17. Statements from visitors document that on 1/19/17, R26 asked another's resident's family member to change her because she had been sitting in an incontinence product for hours but was afraid to ask the CNAs for help. Further investigation revealed that the previous DON (Director of Nursing) was aware, by at least 1/4/17, of the mental and verbal abuse directed at R26 by the two CNAs. She did not report the allegations of abuse and directed staff to not report the abuse to the facility's administration. As a result of the mental and verbal abuse directed at R26 by two CNAs, R26 slept poorly, became more paranoid and was afraid to go to bed. The Facility's failure to ensure that all allegations of abuse were adequately investigated in order to prevent facility staff from verbally and mentally abusing R26 created a findings of Immediate Jeopardy beginning on 1/4/17. Administrator-A, DON (Director of Nursing)-B and Assistant Administrator-P were informed of the Immediate Jeopardy on 3/20/17 at 11:30 a.m. The Immediate Jeopardy was removed on 2/14/17 when the Facility implemented an action plan related to the prevention and reporting of resident abuse. The deficient practice continues at scope/severity of F (potential for harm/widespread) for the examples related to R25 and R21. Additionally, the deficient practice has the potential to affect all residents living in the facility as the facility continues to implement its action plan. * R25 reported an allegation of misappropriation of money that was not thoroughly investigated or reported to the State Agency. The facility did not immediately report the missing money to the state agency. Immediately means as soon as possible but not exceed 24 hours after discovery of the incident. * R21 reported missing money that was not thoroughly investigated or reported to the State Agency. The facility did not immediately report the missing money to the state agency. Immediately means as soon as possible but not exceed 24 hours after discovery of the incident. In addition, the facility did not submit the results of either investigation (Misconduct Incident Report form DQA F ) to the State Agency within 5 working days of such incidents. Findings include: The facility's abuse policy titled Abuse, Mistreatment, Neglect and Misappropriation of Resident/Client Property/Funds, Injury of Unknown Origin with an reviewed date of March 2017 documents under the Policy section: In keeping with our mission of of caring for residents with respect and dignity, all residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. 1. Residents will not be subject to abuse by anyone including, but not limited to, facility staff. 3. All employees must report any incident of alleged abuse, neglect, or misappropriation to their Administrator or designee as soon as the alleged abuse occurs, is discovered or known to the employee. 5. All alleged violation involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of property will be reported by Administration to the Division of Quality Assurance (DQA) as soon as required by law. In a SNF (skilled nursing facility), the initial report will be sent to DQA no later than two (2) hours after the allegation is made if the event(s) that cause the allegation involve abuse or result in serious bodily harm; or no later than 24 hours if the event(s) that cause the allegation do not involve abuse and do not result in serious bodily harm. 1.) On 3/16/17 at 3:08 p.m., Surveyor reviewed a self-report submitted to the State Agency involving CNA-W and R26. Residents will not be subject to abuse by anyone including, but not limited to, facility staff. The facility failed to operationalize its policy to prevent R26 from being abused. The self-report documents under Summary of Incident section, On 1/21/17, R26 reported that CNA-W was taunting and laughing towards resident. Under the Describe the Effect section it documents, Resident was in emotional distress and afraid of the two CNA's. The resident was emotionally and verbally abused by two aids witnessed on camera (video). On 3/16/17 at approximately 4:15 p.m., Surveyors and observed the video provided by Administrator-A involving the two CNA's described in the above incident (CNA-W & CNA-X). The video and a timeline of the witnessed events on the video camera show the time that CNA-W and CNA-X are observed taunting and emotionally abusing R26 on 1/19/17. The video and timeline document: Video Camera TV (Terrace View) 1 Hallway on 1/19/17: 1629 (4:29 p.m.): R26 comes out of her room. 1631 (4:31 p.m.): CNA-W kicks the wheelchair of R26 (with R26 sitting in it). Video Camera TV1 Nursing Station on 1/19/17: 1945 (7:45 p.m.): R26 enters the nurse's station with a wooden board in her hand. 1946 (7:46 p.m.): CNA-X pushes wheelchairs backwards (with R26 sitting in it), R26 swings the board, CNA-W laughs. 1946 (7:46 p.m.): CNA-W points and laughs at R26. 1947 (7:47 p.m.): CNA-X starts talking to R26 and pointing/shaking her fingers at R26. 1947 (7:47 p.m.): Both CNA-X and CNA-W laugh and point their fingers at R26. Statement collected from Former Neighbor-GGG by Social Services Director-F on 1/21/17 documents: I arrived to the unit about 7:30 p.m. on Thursday (1/19/17) .As I was going down the hall I saw (R26) in the doorway of the nursing station. I saw (R26) had the block of wood (card holder) in her hand and she was shaking at (CNA-W) and (CNA-X). I (Former Neighbor-GGG) asked (R26) was she was doing with the card holder. (R26) stated those 2 girls (referring to CNA-W and CNA-X) are trying to hurt me. They are pushing me and pushing me . (R26) then asked me if I would do something for her. I asked her what and she said change my diaper. She has never asked me to do that before. I explained to (R26) that I am not sure I should be doing that. (R26) explained to me how to help her in the bathroom. She stated to me I don't want to girls to help me (referring to CNA-W and CNA-X), I don't want them to do it, they are evil. (R26) stated she has been in the diaper all day and did not want to get a rash. Last time she (R26) got a rash it took a long time to heal I (Former Neighbor-GGG) took her (R26) into the bathroom and she pulled herself up. She then told me to take her pants down and go behind her. Then she (R26) said to place the diaper in between her legs and she would grab it in the front. I (Former Neighbor-GGG) did that and removed the old diaper that was heavy. (R26) then asked me to get help her get into bed. I (Former Neighbor-GGG) stated I should not be transferring her. (R26) told me to put her by the chair and she will lean over and I just need to help her with her legs. I did that. When I came back the next night, (CNA-W) told me that I should not have put (R26) to bed. CNA-W said (R26) is telling everyone that you put her to bed. (CNA-W) told me that was not my job. On 3/20/17 at 9:30 a.m., Surveyor asked Administrator-A if the facility had investigated the statement by Former Neighbor-GGG regarding R26 not being toileted by CNA-W and CNA-X. Administrator-A informed Surveyor that the facility investigated the statement by Former Neighbor-GGG and confirmed that R26 had not being toileted by CNA-W and CNA-X. On 3/20/17 at 9:54 a.m., Surveyor interviewed Former Neighbor-FFF. Former Neighbor-FFF informed Surveyor that in the first week of January, he had witnessed CNA-W and CNA-X taunt R26. Former Neighbor-FFF informed Surveyor that he would always know when CNA-W and CNA-X were on the unit working with R26. Former Neighbor-FFF informed Surveyor that whenever CNA-W and CNA-X were on the unit working with R26, R26 would become increasingly paranoid, have difficulty sleeping and was afraid to go to bed. Former Neighbor-FFF informed Surveyor that whenever CNA-W and CNA-X were on the unit working with R26, R26 would make statements to him (Former Neighbor-FFF) that CNA-W and CNA-X were trying to kill her (R26) and that Former Neighbor-FFF should help her (R26) leave the facility. A statement from Neighbor-FFF collected by Administrator-A on 1/21/17 states, On Saturday 1/21/17, I (Administrator-A), was approached by Former Neighbor-FFF who asked to speak with me privately. He (Former Neighbor-FFF) stated that he believed that CNA-W was intentionally agitating and taunting R26. I asked him why he believed that and he stated that he had heard CNA-W say things to intentionally agitated R26 such as, you know I am your aide tonight so you better behave. And you better be nice to me because otherwise I am not going to put you to bed. All employees must report any incident of alleged abuse, neglect, or misappropriation to their Administrator or designee as soon as the alleged abuse occurs, is discovered or known to the employee. The facility failed to operationalize its policies and procedures to ensure immediate reporting of allegations of abuse to the administrator. An addendum to the self-report submitted on 1/27/17 by Administrator-A documents, This is an addendum to the self-report regarding R26 and CNA-W and CNA-X. Through further investigation, we have become aware that Previous DON (Director of Nursing)-Q, may have had prior knowledge of (R26) and CNA-W's behavior towards her (R26). Further investigation and staff interviews were obtained. The addendum documents: On 1/21/17, (Former Neighbor-FFF) approached the administrator and stated he had talked to (Previous DON-Q) about two weeks ago (prior to 1/21/17) and provided examples that (CNA-W) was intentionally agitating and taunting R26. Additionally, (Former Neighbor-FFF) stated when he told (Previous DON-Q) this information, (DON-Q) was taking down notes and that (Previous DON-Q) stated to (Former Neighbor-FFF), (CNA-W) will not be on that unit anymore. In (Previous DON-Q's) work binder, there was a note confirming that she had spoken to (Former Neighbor-FFF) on or around 1/4/17. Also found in her work binder was a small piece of paper with a note that appeared to be written by Previous (DON-Q) stating, (CNA-W) & friend work her up/trigger (R26). Throughout the investigation, interviews, and outcome of our findings, we confirmed (Previous DON-Q) may have had prior knowledge of this resident's (R26) behavior towards CNA-W. Additionally, (Previous DON-Q) failed to act to prevent the employee (CNA-W) from experiencing repeated harassing behavior from the resident. By failing to move the CNA from the repeated derogatory statements of the resident, the resident and staff member were placed in a compromising situation that may have contributed to the actions that occurred on 1/19/17. Additionally, the information (Previous DON-Q) was aware of was never reported to the Administrator/designee or the state department (Agency) as state and federal regulations regulations as VMP (Village at Manor Park) policy and federal regulations require. (Previous DON-Q) failed to, 'report any incident of alleged abuse, neglect or misappropriation to the Administrator or designee as soon as the alleged abuse occurs, is discovered, or known to the employee.' Statement collected from Former Neighbor-FFF by Administrator-A on 1/21/17 documents: On Saturday 1/21/17, I (Administrator-A), was approached by Former Neighbor-FFF who asked to speak with me privately. He (Former Neighbor-FFF) stated that he believed that CNA-W was intentionally agitating and taunting R26. I asked him why he believed that and he stated that he had heard CNA-W say things to intentionally agitated R26 such as, you know I am your aide tonight so you better behave. And you better be nice to me because otherwise I am not going to put you to bed. Former Neighbor-FFF then stated he had talked to Previous DON-Q about two weeks ago (from 1/21/17) and provided her (Previous DON-Q) with more examples at the time. He states that Previous DON-Q had told him CNA-W would not be assigned to that unit anymore. On 3/20/17 at 9:54 a.m., Surveyor interviewed Former Neighbor-FFF regarding the above incidents. Surveyor asked Former Neighbor-FFF is he had let Previous DON-Q know of any instances where R26 was taunted by facility staff. Former Neighbor-FFF informed Surveyor that in the first week of January, he had informed Previous DON-Q that he had witnessed CNA-W and CNA-X taunt R26. Former Neighbor-FFF informed Surveyor that he had informed Previous DON-Q that R26 had told him that CNA-W and CNA-X were trying to kill her and that Previous DON-Q told him (Former Neighbor-FFF) that she (Previous DON-Q) would take care of the situation. A copy of the note found by the facility in Previous DON-Q's documents notes previous knowledge by Previous DON-Q of R26's and CNA-W's interactions. The note documents, (CNA-W) & friend worker her/trigger (R26). The facility's self-report included statements from RN (Registered Nurse) Manager-C and RN Manager-D and RN Manager-N and documents that all three RN supervisors were aware of the behaviors between R26 and CNA-W. Statement collected from RN Manager-C on 1/31/17 documents: 1. I have been told on multiple times by (Previous DON-Q) . not to bring up issues and areas of concern to administration especially if they involve the nursing department. This was stated to me after morning/ IDT (interdisciplinary team) incident meetings when I brought up a resident or family concern during the concern portion of the morning meeting. 2. I am aware of conversations last year of (R26's) behaviors and how specific staff have triggered her behavior at times I had conversations with (Previous DON-Q) that putting (CNA-W) on the unit with (R26) was not a good idea as her presence alone agitated the resident. I asked to have regular CNAs that could be trained to address behavioral issues and develop a routine for the residents. I was told by (Previous DON-Q) that I need to work with what I had. I am not surprised that there was a situation with (CNA-W, CNA-X and R26) since I had requested they not work together and had requested that (CNA-W) not work on Terrace View 1 (unit where R26 resided). A statement collected from RN Manager-D on 1/27/17 documents: About a year ago, maybe a year and half ago, R26 had a very racial streak with behaviors. CNA-W was one of her (R26) targets .There was an occasion where I moved her (CNA-W) to the other side on Park View to help decrease R26's behaviors and protect both R26 and CNA-W. A statement collected from RN Manager-N on 1/27/17 documents: I recall an incident shortly after I (RN Manager-N) started working here where I was called to the unit by the nurse who stated R26 was harassing CNA-W. When I arrived, CNA-W was visibly upset, threatening to leave because R26 was harassing her (I believe she (R26) was using racial slurs towards CNA-W). I did notify either the group, or the social worker, I cannot recall who, and I believe I did turn in a concern form into Social Services Director-H. I recall that the response I received was with the general idea that this is not a new issue, but an ongoing one. I suggested to CNA-W that I switch her to a different unit to get away from R26. CNA-W refused stating she shouldn't have to leave her unit/assignment. I explained that this is R26's home, so in order to get away from R26, CNA-W must be the one to move. I offered CNA-W a new assignment repeatedly, yet she continued to refuse and continued to walk off the job. On 3/17/17 at 12:44 p.m., Surveyor interviewed RN Manager-C. Surveyor asked RN Manager-C if Previous DON-Q was aware of R26's behaviors and conflict between R26 and CNA-W prior to 1/19/17. RN Manager-C informed Surveyor that Previous DON-Q was aware of R26's behaviors and the conflict between R26 and CNA-W prior to 1/19/17. RN Manager-C informed Surveyor that she had spoken with Previous DON-Q about the R26's behaviors and the conflict between CNA-W and R26 at least three times throughout 2016. RN Manager-C informed Surveyor that whenever she brought up the conflict between R26 and CNA-W, Previous DON-Q would tell her I'm on it. RN Manager-C informed Surveyor that at times Previous DON-Q would reassign CNA-W to another unit to prevent her (CNA-W) from working with R26, but that due to scheduling issues CNA-W would return to the unit and work with R26. Surveyor asked RN-Manager-C if she had ever reported the conflict between R26 and CNA-W to administration. RN Manager-C informed Surveyor that Previous DON-Q would instruct her not to report any nursing issues, including the conflict between R26 and CNA-W, to administration. On 3/17/17 at 1:13 p.m., Surveyor informed Administrator-A of the above findings. Surveyor asked if she was aware prior to 1/21/17 that CNA-W and CNA-X were verbally and mentally abusing R26. Administrator-A informed Surveyor that she personally did not know prior to 1/21/17 that CNA-W and CNA-X were verbally and mentally abusing R26. On 3/20/17 at 9:30 a.m., Surveyor asked Administrator-A if Previous DON-Q should have reported to the State Agency and ensured the safety of R26 after she became first aware of incident regarding verbal and mental abuse of R26 by CNA-W and CNA-X, on or around 1/4/1/4/17. Administrator-A informed Surveyor that Previous DON-Q should have reported to the State Agency and ensured the safety of R26 after she became first aware of the incident regarding verbal and mental abuse of R26 by CNA-W and CNA-X, on or around 1/4/17. The facility's failure to prevent repeated abuse to R26 by failing to operationalize its policies and procedures created a situation of Immediate Jeopardy. The jeopardy was removed on 2/14/17 when the facility implemented the following action plan. 1. The facility's policy and procedure for abuse was reviewed and revised as indicated. 2. All allegations of potential abuse were reviewed for appropriate investigation and reporting. 3. All facility staff were trained on reporting allegations of abuse, neglect, mistreatment, exploitation, misappropriation and injuries of unknown origin. 4. A schedule of ongoing training was established by the facility to work with staff hesitant to report allegations. 5. An audit process was established by the facility to review for allegations. 6. R26 was assessed to ensure all psychosocial needs are met. 7. A QA process was established related to abuse, neglect, mistreatment, exploitation, misappropriation and injuries of unknown origin. The deficient practice continues at severity level 2 as evidenced by the following: 2.) On 3/16/17 at 10:15 a.m., during a routine Sub Task 5g (Abuse Prohibition Review) of incident and self-reports, Surveyor reviewed a self-report regarding misappropriation involving R25. The form titled Concern Review Form for Violation of Individual Rights and Responsibilities dated 1/27/17 documents, R25 states she gave $20 to CNA-W 2-3 weeks ago, so that CNA-W could get her candy. R25 said she asked CNA-W, last week, for her candy but was told it was in CNA-W's trunk (of car). R25 was never given the candy. Under the What was done to prevent further violation of rights while manner is under investigation section it documents, SW (social worker)-I spoke with R25 about not giving employees money for things. Encouraged R25 to let SW-I know when she is in need of candy. Under the Was concern referred to DQA (Division of Quality Assurance) section it documents, No. Under the Outcome of investigation section it documents, SW-I provided R25 with bags of gummy candy per her request. R25 to be reimbursed the $20 that was gives to CNA-W. Under the Corrective action taken by facility section it documents, Money reimbursed, R25 provided with candy. CNA-W no longer employed at facility. So cannot ask her if she received money. On 3/16/17 at 2:33 p.m., Surveyor informed SW-I of the above findings. Surveyor asked SW-I if the facility had self-reported this allegation of misappropriation to the State Agency. SW-I informed Surveyor that she had no further information and that Administrator-A made the determination to report allegations of misappropriation to the State Agency. On 3/16/17 at 3:01 p.m., Surveyor informed Administrator-A of the above findings. Surveyor asked Administrator-A if the facility had self-reported this allegation of misappropriation to the State Agency. Administrator-A informed Surveyor that the facility had not reported this allegation of misappropriation to the State Agency because R25 did not feel that CNA-W had willfully taken her money without getting R25 her candy. Administrator-A informed Surveyor that since CNA-W was no longer at the facility, the facility was unable to interview CNA-W but that the facility should have self-reported this allegation of misappropriation to the State Agency. On 3/20/17 at 3:20 p.m., during the daily exit conference, Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not investigate or report to the State Agency an allegation of misappropriation as reported by R25 on 1/27/17. 3.) On 3/16/17 at 10:15 a.m., Surveyor reviewed a self-report regarding misappropriation involving R21. The form titled Concern Review Form for Violation of Individual Rights and Responsibilities dated 2/20/17 documents, Missing $6 from his pouch in wheelchair bag. Under the Was concern referred to DQA (Division of Quality Assurance) section it documents, No. Under the Investigation Concern section it documents, Offered R21 a lock box. Under the Outcome of investigation section it documents, R21 now in agreement with having a lock box. SW-I contacted buildings and grounds to have lock box installed and SW-I will provide R21 with a keychain for they key. Under the Corrective action taken by facility section it documents, See above. Surveyor noted that there was no investigation into the missing $6 reported by R21 in the incident report provided to Surveyor . On 3/16/17 at 2:33 p.m., Surveyor informed SW-I of the above findings. Surveyor asked SW-I if she had performed an investigation on the missing $6 reported by R21. SW-I informed Surveyor that she did not perform an investigation into the missing $6 dollars reported by R21 as R21 had later informed her (SW-I) that he was not missing any money. Surveyor asked SW-I if the facility had self-reported this allegation of missing money to the State Agency. SW-I informed Surveyor that she had no further information and that Administrator-A made the determination to report missing money to the State Agency. On 3/16/17 at 3:01 p.m., Surveyor informed Administrator-A of the above findings. Surveyor asked Administrator-A if the facility had investigated the missing $6 reported by R21. Administrator-A informed Surveyor that investigation into the missing $6 dollars reported by R21 as R21 had later informed her (SW-I) that he was not missing any money. Surveyor asked Administrator-A if the facility had self-reported this allegation of missing money to the State Agency. Administrator-A informed Surveyor that the facility had not reported this allegation of missing money to the State Agency. Administrator-A informed Surveyor that the facility should have self-reported this allegation of missing money to the State Agency and at the time investigated the allegation of missing $6 reported by R21. On 3/20/17 at 3:20 p.m., during the daily exit conference, Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not investigate or report to the State Agency an allegation of missing money as reported by R21 on 2/20/17.

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 8 of 21 sampled Residents (Residents R8, R3, R5, R6, R17, R19, R12, and R13) R8 was admitted to the facility on [DATE] with unstageable pressure injuries on his left and right heels, a bruise on his left lateral ankle, multiple scabs on the top of his right and left feet, and excoriation on his coccyx measuring 5.5 cm (centimeters) by 5 cm. On 11/10/16 the Facility developed a pressure ulcer care plan with interventions to monitor skin daily, apply lotion to arms and legs, assess for presence of risk factors and treat, reduce, eliminate risk factors as possible and encourage physical activity, mobility and range of motion. This care plan was updated on 11/11/16 to include air mattress on the bed, reposition resident frequently with cares and rounds, pressure relieving boots at all times and elevate heels off bed. There was no change in R8's plan of care until 2/15/17 when interventions were added to assess and measure wounds weekly with wound rounds and apply wound vac to coccyx as ordered by the wound doctor. Although R8 spent almost all of this time in bed, the Facility did not look at repositioning R8 more frequently nor did they look at checking and changing R8 more frequently as he was incontinent of bowel and frequently stooled. The Facility did not revise the plan of care when R8's pressure injury deteriorated. R8 coccyx pressure injury deteriorated to an avoidable Stage 4 that became infected. The Facility's failure to provide the necessary care and services to R8 created a finding of Immediate Jeopardy beginning on 1/10/17. Administrator-A, DON (Director of Nursing)-B and Assistant Administrator-P were informed of the Immediate Jeopardy on 3/21/17 at 10:38 a.m. The Immediate Jeopardy was removed on 3/24/17 when the Facility implemented an action plan related to proper pressure injury care. The deficient practice continues at scope/severity of G (harm/isolated) for the example related to R3. R3 was admitted to the facility on [DATE] with unstageable pressure injuries on the right upper coccyx and coccyx. On 1/19/17 R3 was noted to have a dark discoloration to her right heel which was documented as a bruise not a suspected deep tissue injury. R3's physician was not consulted with until 1/25/17 when the Facility received a treatment of [REDACTED]. The Facility did not stage R3's pressure injury until 3/7/17. On this date the Facility staged the right heel incorrectly as a suspected deep tissue injury when the pressure injury presented with 100% slough. Also on 3/7/17 R3's coccyx pressure injury was incorrectly staged as a Stage 1 when the pressure injury presented with 50% slough. Additional examples of deficient practice identified, but at severity level 2 (potential for harm that is not immediate jeopardy) include: * R5 was observed without the Allevyn dressing on and there is an incorrect treatment order dated 2/13/17. * R6 was observed for multiple days without pressure relieving boots. * R17 did not have barrier cream applied after an incontinence episode according to the plan of care. * R19 is at high risk for pressure injury development. Interventions were not implemented to prevent pressure injuries and R19's heels were not offloaded. Barrier cream was not applied after an incontinence episode according to the plan of care. * R12's heels were not offloaded. * R13's heels were not offloaded. Findings include: The facility's Pressure Sore Prevention and Treatment policy and procedure revised 5/13 under General Information documents Preventative care is the main goal of the Wound Care Team. However, even with the best of care, wound develops or residents are admitted with wounds. Upon discovery of a pressure ulcer, the online staff must: 1. Assess the wound 2. Measure the wood 3. Complete a weekly wound observation report and document in Resident Record 4. MD (medical doctor) must be notified and treatment order must be obtained. (See Skin Care Protocol) 5. Care plan must be updated 6. Resident/POA (power of attorney) must be notified and informed of plan of care. 7. Contact Wound Team 8. Contact Dietician. Under prevention of skin breakdown and pressure sore development documents The resident's refusal of treatment or non-compliance with preventative measures must be documented in the resident's medical record. The resident and legal representative will be notified and educated to the risks associated with not complying with preventative measures. The care plan will also be updated to reflect non-compliance and alternatives will be considered for resident with positioning needs caused by contractures that promote pressure areas. 1.) Surveyor reviewed R8's medical record on 3/13/17 to 3/20/17. R8 was admitted to the facility on [DATE]. R8 is on a ventilator, has a Foley catheter, and receives continuous tube feeding of [MEDICATION NAME] 1.5 at 75 cc (cubic centimeters)/ hour. The nursing data base comprehensive dated 11/10/16 under the skin/wound section for coccyx documents describe: excoriated pinkish open. For right heel documents describe: non and left heel documents describe: see skin sheets. Under describe skin concerns documents non stageable. The Braden assessment dated [DATE] has a score of 14. A score of 12 or less is considered high risk. The skin evaluation form dated 11/10/16 for the coccyx documents for size Length: 5.5 cm (centimeter) Width 5.0 cm. Under description documents area excoriated pinkish red open bleeding slightly scattered. For treatment documents Allevyn life to coccyx change q (every) 7 days x (times) 14 days. For turning repositioning programs documents Inapplicable. For nurses notes documents Excoriated area was noted upon admission body check. R8 was also admitted with scabs on his left and right foot which healed on 12/13/16, and unstageable pressure injuries on his right and left heel. R8's left heel pressure injury has healed. Deficient practice was not identified in regards to the right heel pressure injury. The pressure ulcer care plan dated 11/10/16 under (P) (problem) documents R8 has impaired skin integrity r/t (related to) admitted with SDTI (suspected deep tissue injury) to Right heel heels and open area to coccyx. Interventions dated 11/10/16 are: Monitor skin daily with cares, during baths, and weekly. Md (medical doctor) update if indicated. Apply lotion to arms and legs every am (morning) and hs (hour sleep). Assess for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible and Encourage physical activity, mobility and Range of Motion to maximum potential. Interventions dated 11/11/16 are Air mattress to bed, reposition resident frequently with cares and rounds. Resident to wear pressure relieving boots at all times and Elevate heels off bed. Interventions dated 2/15/17 are Nurse will apply and change NWPT (negative pressure wound therapy) to coccyx as order by wound doctor 3 x (three times)/week. and Nurse will assess and measure wounds weekly with wound rounds. Surveyor noted R8's care plan was only updated on 11/10/16, 11/11/16 and 2/15/17. There were no changes to the care plan even as the coccyx pressure injury deteriorated and became a stage 4 injury. The physician progress notes [REDACTED]. Under A/P (assessment/plan) documents Multisystem degeneration of autonomic nervous system, [MEDICAL CONDITION], Hypertension, Dysphasia, [MEDICAL CONDITION]. The acute problem care plan dated 11/14/16 under (P) (problem) documents WOUND: R8 has pressure area on heels and redness noted upon admission body check. Intervention dated 11/14/16 documents Wound treatment as ordered. Assess wound status for evidence of healing and report concerns to physician. The skin evaluation form dated 11/15/16 for the coccyx documents for size Length: 2.5 cm Width 1.5 cm. Under description documents Center coccyx area is dark red 2.5 x 15, closed, no odor, surrounding reddened discoloration is 12.0 x 7.5. For treatment documents Allevyn life to coccyx change q (every) 7 days x (times) 14 days.For stage documents Suspected Deep Tissue Injury and for turning repositioning programs documents Inapplicable. For nurses notes documents Wound team evaluated, area is closed, red center surrounded by red discoloration, no odor, no drainage. Resident is vent dependent, receives tube feeding for nutrition and fluids, staff provide ADLs (activities daily living) including positioning toward sizes to keep pressure off coccyx. Air mattress. The Braden assessment dated [DATE], 11/25/16, and 12/1/16 all have a score of 13. A score of 12 or less is considered high risk. The admission MDS (minimum data set) with an assessment reference date of 11/17/16 and signed as complete on 11/22/16 has a BIMS (brief interview mental status) score of 14 which is cognitively intact. R8 is totally dependent with two plus person physical assist for bed mobility, transfers and toilet use, does not ambulate, is checked for an indwelling catheter and is always incontinent of bowel. Height is documented as 72 inches and weight 179 pounds. R8 is at risk for pressure injury development has has one or more unhealed pressure injuries at stage 1 or higher. R8 is coded as having 2 unstageable - slough and/or eschar and 1 unstageable Deep Tissue Injury. Under skin and ulcer treatments pressure reducing device for chair, pressure reducing device for bed, pressure ulcer care and applications of dressings to feet (with or without topical medications) are checked. The pressure ulcer CAA (care area assessment) dated 11/22/16 under description of problem documents R8 triggered the pressure ulcer CAA because he needs assist with bed mobility and is incontinent of BM (bowel movement). R8 admitted with bilateral heel unstageable pressure ulcers and a deep tissue injury to his coccyx. Surveyor noted R8 was admitted with excoriation not a deep tissue injury. The skin evaluation form dated 11/22/16 for the coccyx documents for size Length: 2.5 cm Width 3.0 cm. Under description documents Open area is 70% slough, no s/s (signs symptoms) infection. For treatment documents NSW (normal saline wash) f/b (followed by) santyl, f/b dry dressing. For stage documents Suspected Deep Tissue Injury and for turning repositioning programs documents Inapplicable. For nurses notes documents Wound team evaluated, treatment change recommended for Santyl. Area has 70% slough, no s/s infection. Surveyor noted the pressure injury has increased in width and the wound bed has changed to slough. There is no change to R8's care plan and the pressure injury has been staged incorrectly as the pressure injury presents as a Stage 3 not a deep tissue injury. The telephone order for the Santyl is not dated until 11/23/16 and the November TAR (treatment administration record) reveals that the Santyl treatment was not started until 11/24/16, two days after there was a change in treatment. The skin evaluation form dated 11/29/16 for the coccyx documents for size Length: 3.5 cm Width 7.5 cm. Under description documents Two open areas are measured as one with island in between. Open area has 95% slough, no s/s infection. For treatment documents NSW f/b santyl, f/b dry dressing. For stage documents Suspected Deep Tissue Injury and for turning repositioning programs documents Inapplicable. For nurses notes documents Wound team evaluated, 95% slough noted, no s/s infection, no treatment change recommended. There is no change to R8's care plan, the stage continues to be documented as deep tissue injury and there is no evidence that R8's physician was consulted with. The skin evaluation form dated 12/6/16 for the coccyx documents for size Length: 3.5 cm Width 5.0 cm. Under description documents Open area is 3.5 x 5.0 with surrounding area red discoloration 15.0 x 18. Wound has no drainage, 50% slough, no odor, no pain, no s/s infection. For treatment documents NSW f/b santyl, f/b dry dressing. For stage documents Suspected Deep Tissue Injury and for turning repositioning programs documents Inapplicable. For nurses notes documents Coccyx area is reduced in size, wound team evaluated, open area is 3.5 x 5.0 with surrounding area red discoloration 15.0 x 18. Wound has no drainage, 50% slough, no odor, no pain, no s/s infection. Continue treatment There is no change to R8's care plan and the stage continues to be documented as deep tissue injury when it should be staged as a Stage 3. The skin evaluation form dated 12/13/16 for the coccyx documents for size Length: 2.9 cm Width 5.5 cm. Depth utd (unable to determine). Under description documents 95% slough, no drainage, no s/s infection no odor. For treatment documents NSW f/b santyl, f/b dry dressing. For stage documents Suspected Deep Tissue Injury and for turning repositioning programs documents Inapplicable. For nurses notes documents Wound team evaluated, no drainage no s/s infection, cooperative with re-positioning, denies pain. Continue plan of care. There is no change to R8's care plan and the stage continues to be documented as deep tissue injury when it should be staged as a Stage 3. The skin evaluation form dated 12/19/16 for the coccyx documents for size Length: 2.5 cm Width 6.0 cm. Depth .1. Under description documents 20% slough, 5 % granular, 75% necrotic, breakthrough drainage noted on dressing, serosanguineous, no s/s infection, moderate odor. For treatment documents Changed to iodosorb with dressing, ROHO cushion, offloading when possible, pressure reduction mattress. For stage documents 3 and for turning repositioning programs documents Inapplicable. For nurses notes documents Wound physician-XX and Wound NP (Nurse Practitioner)-YY from AZH wound care here for evaluation and debridement. There is no change to R8's care plan. The physician order [REDACTED]. Wound Physician-XX progress note dated 12/19/16 for wound #3 documents Location: coccyx Wound/Ulcer Type: Pressure Comments: Stage III (3) pressure ulcer with some acute pressure changes. Length: 2.5 Width 6 Depth .1 Volume: 1.50 Area: 15 Exudate/Drainage: Moderate Odor Serosanguineous % granulation: 5 [MEDICATION NAME]/slough: 20 Necrotic: 75 Hypergranular? No Dressing Appearance: Breakthrough Drainage Saturated. Under Problem #3 Pressure ulcer Stage III documents Assessed as: New Coccyx with stage III (3) pressure ulceration. Mild acute pressure changes noted. Wound with adherent [MEDICATION NAME]/necrotic tissue with slight odor. Post debridement, tissue healthier and no acute infection noted. No tunnels, no palpable or visible bone. Periwound with blanchable [DIAGNOSES REDACTED]. Patient has santyl and will use remaining tube. Once completed, will switch to iodosorb with occlusive dressing to be changed daily patient incontinent of stool. Patient will need aggressive offloading schedule. Patient will need head of bed upright with tube feedings thus side to side turning schedule with use of a pillow educated to patient. Continue with pressure reduction mattress. Patient stated would like to be up in wheelchair. Patient has 4 inch ROHO. Staff report patient has been in bed since admission. Stated patient to try up for two hour intervals twice daily. Will re-assess within a week to determine if pressure reduction efforts enough or if further orders needed. Patient in agreement. As patient does not eat oral foods patient to select time up per personal preference. Continue with all nutritional supplements, pressure reduction efforts. Any negative wound change, staff encouraged to call AZH for future orders. The physician progress notes [REDACTED]. skin. The skin evaluation form dated 12/26/16 for the coccyx documents for size Length: 2.5 cm Width 6.0 cm. Depth .1. Under description documents 10% slough, granulation noted, scant breakthrough drainage noted on dressing, serosanguineous, no s/s infection, no odor For treatment documents Changed to iodosorb with dressing, ROHO cushion, offloading when possible, pressure reduction mattress. For stage documents 3 and for turning repositioning programs documents Inapplicable. For nurses notes documents Wound team continues to follow with AZH Wound care as consultants. Coccyx area improving, no s/s infection. Review of the December 2016 and January 2017 TAR (treatment administration record) reveals Santyl was continued until 1/3/17 and the treatment of [REDACTED]. The skin evaluation form dated 1/3/17 for the coccyx documents for size Length: 2.5 cm Width 6.0 cm. Depth .1. Under description documents Wound improved, 100% granulation For treatment documents NSW (normal saline wash) f/b (followed by) Iodosorb cover with gauze dressing f/b [MEDICATION NAME] change QOD (every other day). For stage documents 3 and for turning repositioning programs documents Yes. There is no documentation under nurses notes. Wound NP-YY note dated 1/3/17 under impression and recommendations documents for Problem # 3 Pressure Ulcer Stage III Coccyx with stage III pressure ulceration. No acute pressure changes noted. wound with 100% granulation tissue, no odor. No acute infection noted. No tunnels no palpable or visible bone. Periwound intact. Patient to continue with iodosorb with occlusive dressing to be changed daily patient incontinent of stool. Would like staff to use [MEDICATION NAME] like dressing over gauze. May use stomadhesive paste on distal aspect to assist with maintaining dressing integrity. Patient will need continued aggressive offloading schedule. Patient will need head of bed upright with tube feedings, thus side to side turning schedule with use of a a pillow educated to patient. Continue with pressure reduction mattress. Patient stated he has not been up in wheelchair. Patient has 4 inch ROHO. Staff report patient has been in bed since admission. Stated patient may be up for two hour intervals twice daily. Will re-assess once patient up in wheelchair to determine if pressure reduction efforts enough or if further orders needed. Patient in agreement. Patient has not been up at this time. As patient does not eat oral foods, patient to select time up per personal preference. The skin evaluation form dated 1/10/17 for the coccyx documents for size Length: 5.0 cm Width 3.8 cm. Depth utd. Under description documents Wound base has slough and is tunneling at 1200 1.5 cm . No s/s of infection, no pain. New orders received for new tx. (treatment). For treatment documents Wash with Purecin (sic). Purecin dampened gauze packed in wound cover with dressing change q (every) day and prn (as needed) For stage documents Suspected Deep Tissue Injury and for turning repositioning programs documents Yes. There is no documentation under nurses notes. Surveyor noted this pressure injury is not staged correctly as this does not present as a suspected deep tissue injury and there has been no change to R8's plan of care. The skin evaluation form dated 1/17/17 for the coccyx documents for size Length: 6.0 cm Width 3.8 cm. Depth utd. Under description documents Wound in size remains the about the same but is now undermining between 9-2 with the deepest being 2.5 cm. area appears clean and not s/s of infection noted. Resident tolerated tx (treatment) well. For treatment documents Wash with Purecin. Purecin dampened gauze packed in wound cover with dressing change q (every) day and prn (as needed) For stage documents Suspected Deep Tissue Injury and for turning repositioning programs documents Yes. There is no documentation under nurses notes. Surveyor noted this pressure injury is not staged correctly as this does not present as a suspected deep tissue injury and there has been no change to R8's plan of care. Wound NP-YY note dated 1/19/17 documents for wound #3 Location: coccyx Wound/Ulcer Type: Pressure Comments: Stage III pressure ulcer with significant wound decline. Increase in wound depth and undermining. No palpable bone or periosteum but close. Wound with odor, heavily colonized but not acutely infected. Length: 3.5 cm Width 3.5 cm Depth 2.5 cm Volume: 30.63 Area: 12.25 sq (square) cm (centimeters) Exudate/Drainage: Moderate, Serosanguineous % granular: 20 [MEDICATION NAME]/slough: 80 Necrotic: 0 Eschar: 0 Hypergranular? No Sinus Tract: Depth: 3.4 Desc: Other:0 Wound Marin: Undermining: Dist: 3.4 Desc: Clock Position: 10-4 Dressing Appearance: Loose. Under impression and recommendations documents Problem #3 Pressure Ulcer Stage III Assessed as Deteriorated Coccyx ulceration with increased depth and undermining. Wound heavily colonized with bacteria but not acutely infected. No palpable bone or periosteum palpable. Wound with some viable and non-viable tissue. Will continue with puracyn wound cleansing to all wound then [MEDICATION NAME] flex to be placed to wound base daily. Cover with dressing per facility choice. If wound continues with odor or deteriorates, nursing staff to AZH Centers and new orders will be provided. Patient on therapeutic alternating air mattress and aggressive turning schedule. Patient has 4 inch ROHO wheelchair cushion in wheelchair. Patient has had very limited time up and patient prefers cushioned recliner in room. Patient may continue to be placed in recliner for quality of life concerns. Patient was up twice last week for wife to cut hair and to spend a few hours (less than 5 total) for personal preference. Will encourage use of wheelchair cushion in recliner when patient would like to be up for two hours or less at a time and with staff re-positioning after one hour. Patient should be assessed for safety with use of cushion in chair for falling concerns. If ROHO cannot be in recliner, then apply ROHO to wheelchair for patient use. The skin evaluation form dated 1/24/17 for the coccyx documents for size Length: 5.0 cm Width 4.0 cm. Depth 2.2 cm. Under description documents Slough removed and now has 2.2 depth. Area is undermining at 12-1 and depth of tunnel is 3.5 cm. No s/s of infection. Tolerated tx well. Wound clean and smaller in size with increase in undermining noted. For treatment documents Wash with Purecin. Purecin dampened gauze packed in wound cover with dressing change q (every) day and prn (as needed) For stage documents 3 and for turning repositioning programs documents Yes. There is no documentation under nurses notes. Surveyor noted there has been no change to R8's plan of care. Wound NP-YY note dated 1/26/17 documents under history of present illness Coccyx wound with [MEDICATION NAME] flex changed daily for previous week the wound was larger and with odor Patient's nutritional intake is fair. Patient is peg tube feedings only. Pre-[MEDICATION NAME] on 1-23-17 [MEDICATION NAME] was 14.6, total protein 6.8. Patient has started on prostat daily. Wound #3 documents Location: coccyx Wound/Ulcer Type: Pressure Comments: Stage IV (4) pressure ulcer with palpable bone or periosteum, smooth to palpation. Wound without odor, not acutely infected. Granulation tissue increased. Of visible wound bed, 40% granulation tissue Length: 3.4 cm Width 3 cm Depth 2.0 cm Volume: 20.40 Area: 10.20 sq (square) cm (centimeters) Exudate/Drainage: Copious, Serosanguineous % granular: 40 [MEDICATION NAME]/slough: 60 Necrotic: 0 Eschar: 0 Hypergranular? No Sinus Tract: Depth: 3.5 Desc: Other:12 Peri-Wound: [DIAGNOSES REDACTED], Macerated Wound Margin: Undermining: Dist: 3.4 Desc: Clock Position: 10-4 Dressing Appearance: Loose, Saturated Under impression and recommendations documents Problem #3 Pressure Ulcer Stage IV Assessed as Deteriorated Coccyx ulceration now with palpable bone or periosteum. Not able to visualize structure Wound exudate without odor but remains heavy. Periwound macerated. Not acutely infected but as underlying structures now palpable, will stop [MEDICATION NAME] flex dressing to start NWPT with sponge to assist in granulation of periosteum or bone. Will continue with puracyn wound cleansing. Education provided to remain on aggressive turning schedule. Will bring endoform matrix and apply to wound base on next visit. Patient is incontinent of stool and NWPT may be problematic in maintaining a seal. Nurses encouraged to use skin prep [MEDICATION NAME] of [MEDICATION NAME], or stomadhesive paste to assist in seal. The skin evaluation form dated 1/31/17 for the coccyx documents for size Length: 2.5 cm Width 2.5 cm. Depth 2.2 cm. Under description documents Slough removed and now has 2.2 depth. Area is undermining at 12-2 and depth of tunnel is 3.8 cm. No s/s of infection. Tolerated tx well. Wound clean and smaller in size with increase in undermining noted. For treatment documents Wash with Purecin. Purecin dampened gauze packed in wound cover with dressing change q (every) day and prn (as needed) For stage documents 3 and for turning repositioning programs documents Yes. There is no documentation under nurses notes. Surveyor noted there has been no change to R8's plan of care and Wound NP-YY documents the pressure injury as a Stage 4 while the Facility continues to document Stage 3. Wound NP-YY note dated 2/2/17 under impression and recommendations documents for Problem #2 Pressure Ulcer Stage IIV (sic) Assessed as Improved. Patient with Stage IIV pressure ulcer to coccyx. The visible wound is contracted and healthier with increase in granulation tissue. NWPT sponge needs to be placed into all wound regions, especially to undermined regions. This will assist with the wound closure. Today, NWPT held and endoform collagen matrix applied to wound base. Tucked saline damp gauze over the collagen to ensure endoform placed over bony regions. Placed alginate to outer wound region and occlusive dressing. Requested NWPT to be resumed 2-3 16 sic (should be 2-3-17). The skin evaluation form dated 2/7/17 for the coccyx documents for size Length: 2.5 cm Width 2.5 cm. Depth 2.2 cm. Under description documents Slough removed and now has 2.2 depth. Area is undermining at 12-2 and depth of tunnel is 3.8 cm. No s/s of infection. Tolerated tx well. Wound clean and smaller in size with increase in undermining noted. For treatment documents Wash with Purecin. Purecin dampened gauze packed in wound cover with dressing change q (every) day and prn (as needed) For stage documents 3 and for turning repositioning programs documents Yes. There is no documentation under nurses notes. Surveyor noted the Facility continues to stage R8's coccyx pressure injury as a Stage 3 while Wound NP-YY stages the pressure injury as a Stage 4. The skin evaluation form dated 2/14/17 for the coccyx documents for size Length: 2.0 cm Width 1.2 cm. Depth 2.5 cm. Under description documents Area is smaller in diameter slightly deeper in depth. Undermining 12-4 with deepest at 2 at 3.5 cm. Wound base clean no s/s infection. To be seen by wound nurse this week. For treatment documents Wash with Purecin. Purecin dampened gauze packed in wound cover with dressing change q (every) day and prn (as needed) For stage documents 3 and for turning repositioning programs documents Yes. There is no documentation under nurses notes. Surveyor noted there has been no change to R8's plan of care. Wound NP-YY note dated 2/16/17 documents under impression and recommendations Problem #2 Pressure ulcer Stage IIV Coccyx ulceration with increased in granulation tissue, bone now covered. As undermining remains stable, wound is improved. No acute pressure changes today. I applied NWPT with bridge to left hip. Continue with puracyn wound wash. One sponge placed in wound. The pressure ulcer care plan dated 11/10/16 was updated on 2/15/17 with the following interventions Nurse will apply and change NWPT (negative pressure wound therapy) to coccyx as order by wound doctor 3 x (three times)/week. and Nurse will assess and measure wounds weekly with wound rounds. The skin evaluation form dated 2/21/17 for the coccyx documents for size Length: 2.0 cm Width 1.2 cm. Depth 2.5 cm. Under description documents Area is smaller in diameter slightly deeper in depth. Undermining 12-4 with deepest at 2 at 3.5 cm. Wound base clean no s/s infection. To be seen by wound nurse this week. For treatment documents Wash with Purecin. Purecin dampened gauze packed in wound cover with dressing change q (every) day and prn (as needed) For stage documents 3 and for turning repositioning programs documents Yes. There is no documentation under nurses notes. The skin evaluation form dated 2/28/17 for the coccyx documents for size Length: 2.0 cm Width 2.5 cm. Depth 1.2 cm. Under description documents Area is cleaner 100% granulation noted. Undermining 12-4 with deepest at 2 at 3 cm. no s/s infection. To be seen by wound nurse this week. For treatment documents Wash with Purecin. Purecin dampened gauze packed in wound cover with dressing change q (every) day and prn (as needed) For stage documents 3 and for turning repositioning programs documents Yes. There is no documentation under nurses notes. Wound NP-YY note dated 3/2/17 for wound #3 documents Location: coccyx, Wound/Ulcer Type: Pressure Comments Stage IV (4) pressure ulcer with new palpable bone or periosteum along distal aspect. Wound with odor, not acutely infected. Granulation tissue decreased. Of visible wound bed, 80% granulation tissue. Acute pressure change along distal aspect. I re-applied NWPT post assessment with bridge to left hip. Measurements depend on patient positioning. Under impressions and recommendations for Problem #2 Pressure ulcer Stage IIV documents Patient with some new bone to distal aspect of coccyx visible and palpable wit wound assessment. Periwound improved, no new blister formation since [MEDICATION NAME] has been used. Continue with puracyn wash and NWPT application. New region at 5 o'clock region separate from other undermining. Nurse shown and requested to pack all wound regions The skin evaluation form dated 3/7/17 for the coccyx documents for size Length: 2.5 cm Width 2.6 cm. Depth 2.2 cm. Under description documents Undermining 12-4 with deepest at 1 at 3.5 cm. no s/s infection. To be seen by wound nurse this week. For treatment documents Wash with Purecin. Purecin dampened gauze packed in wound cover with dressing change q (every) day and prn (as needed) For stage documents 3 and for turning repositioning programs documents Yes. There is no documentation under nurses notes. Wound NP-YY note dated 3/9/17 documents for wound #3 Location coccyx, Wound/Ulcer Type: Pressure Comments: Stage IIV pressure ulcer with new palpable bone or periosteum along distal aspect. Jagged bone to proximal region. Wound with slight odor, not acutely infected. Granulation tissue decreased. Of visible wound bed, 80% granulation tissue. Acute pressure change along distal aspect. Measurements depend on patient positioning. Under impression and recommendations for Problem #3 Pressure Ulcer Stage IV documents Assessed as: Deteriorated Coccyx wound with increase in undermining and exposed bone. Of concern is the new presence of jagged bone at proximal undermining. Used endoform with moist gauze today and occlusive dressing. Once KCI can assist with educating SNF (skilled nursing facility) in packing sponge to wound base and use of Y connector, would like NWPT to be changed three times weekly and as needed. Continue with cont (continuous) 125 mmhg settin

Based on record review, interviews and observations, the facility has failed to ensure 9 of 24 residents (R11, R5, R8, R18, R4, R12, R13, R14, R21) received adequate supervision and assistance devices to prevent accidents. Additionally, the facility failed to identify hazards and risks and did not ensure the implementation of new interventions and monitoring of current interventions on the care plans. *R11-had two incidents in which she sustained burns to her skin with no evidence of how it occurred, no update of safety interventions to the care plan and no monitoring after each accident. * R5 was not transferred according to the care plan. * R8 use of siderails assessment does not contain risk/benefits, no assessment for entrapment. * R18 No effective fall interventions to prevent future falls and no root cause of current falls. * R12 observed in bed that was not in a low position and no evidence of a fall mat next to the bed per plan of care. * R4 use of siderails assessment does not contain risk/benefits, no assessment for entrapment. * R13 not transferred by plan of care. * R14 observed in bed that was not in a low position and no evidence of a fall mat next to the bed per plan of care. * R21 no investigation and inadequate supervision of resident who eloped from the facility. Example 1 pertaining to R11 rises to a scope and severity level of G (harm/isolated.) Findings include; 1.) R11 had been residing in the facility since 04/2016 after a hospitalization post stroke that left the resident with left sided weakness. Clinical record documentation noted that even on admission and noted in the admission notes, R11 required constant supervision with meals. The resident also experienced cognitive deficits, seizures, and a history of falls. The most recent MDS (minimum data set) of 11/17/16 noted that R11 had a Brief Interview of Mental Status (BIMS) score of 5 indicating a severe cognitive deficit. A review of the IDT notes (interdisciplinary team) noted that on 12/02/16 the following is documented at 12:40 p.m., Res. has redness noted to bilateral inner thighs no pain or discomfort noted when area touched .no signs or symptoms infection noted. Res. afebrile 97.0, staff ST-DD (speech therapist) stated resident was in cafeteria drinking coffee and spilled the drink on her hand and lap. On 03/15/17 Surveyor interviewed the DON at 9:20 a.m. and asked whether there was a facility investigation and if there was any additional information, the DON stated I don't know, I could have. The DON never provided any investigation or additional information. On 03/15/17 at 3:20 p.m. an interview with RN-C (registered nurse manager) revealed that RN-C was unaware of this incident and acknowledged that this incident was just brought to her attention today. Per interview RN-C stated that she was unaware of this incident but began an investigation and noted and provided a half completed incident report that was allegedly completed by Licensed Practical Nurse (LPN)-J. Per RN-C, this report was just found and it was never reported to her. RN-C stated that ST-DD also had no knowledge of the incident even though she was mentioned in the IDT note. Interview with ST-DD on 03/15/17 revealed that ST-DD had no information on this incident. ST-DD stated an unidentified nurse aide asked her her to complete and incident report regarding the spilled coffee to which ST-DD stated she would not as she had note witnessed the incident. Per interview with LPN-J on 03/16/17 at 8:25 a.m., LPN-J stated that the girls came up to me and the activity lady (unable to identify by name) and said she spilled her coffee. LPN-C indicated that she took R11 to the bathroom, pulled pants down, she had redness on her thighs. When questioned if the RN supervisor was notified, LPN-J stated I honestly don't remember. Asked if R11's daughter was informed, stated, I don't believe so, I didn't call. There is no evidence of such in the clinical record. A review of the skin evaluation form date 12/02/17 documents as what is documented in the IDT notes. In addition, there is no evidence that any first aide having been provided to the resident. Per interview with RN-C on 03/016/17 at 3:40 p.m., RN-C acknowledged that there was no RN assessment conducted and there should have been and that no physician was contacted nor was the residents daughter notified at the time of the incident and they should have. RN-C also indicated that R11 at that time was extensive assistance for adl's (activities of daily living) and was receiving a mechanical soft diet and thin liquids (regular liquids). It was never determined how and or who provided R11 with the hot coffee as there was no evidence of supervision of this resident who required extensive assistance. In addition, there was no evidence that new interventions were added to the R11 care plan to provide safety and supervision so that an incident like this would not occur. On 03/16/17 NHA did indicate to Surveyors that video recordings were being made of dining room activity at that time but footage is only kept for a week at a time then is re-recorded over and if the facility had been made aware of the incident involving R11, the video would have been viewed. From 12/06/16 forward, R11 declined in her eating skills with the mechanical soft diet and experienced some weight loss and issues with her upper dentures. The resident was seen and followed by the facility dietitian and speech therapist. Per documentation on the care plan with a start date of 01/13/17, under nutritional status it is noted for R11, EXTENSIVE FEEDING ASSISTANCE. The care plan also states that If she says she's done, give her some time and encouragement and she will usually continue eating. Temp. downgrade to pureed related to no denture. Thin liquids .she may have jello. Assist to cut up food into small pieces. Frequent verbal cueing to take small bites and sips (this means she does not need 1:1 supervision anymore but she does need a staff member at her table.) One bite per swallow, check mouth for pocketing, give resident reminders to clear her mouth before taking more food. Close observation with oral intake. Pt. is a high choking risk. Nursing staff to complete oral cares after meals. Per clinical record documentation it is noted on 02/26/17 at 7:17 p.m. res. has burn mark and blister to left upper thigh area. Per res. assigned CNA, she sat beside res. in dining room to assist her with meal and saw a napkin and the contents of the res. soup bowl sitting on her left thigh. CNA cleaned the area off and began to feed res. Then when when later putting res. in bed saw the red burn area with the intact blister and informed writer of blister and the incident in the dining room. Area was cleansed with warm water and soap, left open to air. Residents daughter updated on incident. On call MD also on incident and said to monitor and update primary MD in a.m. on 02/27/17 resident placed on 24 hour board for monitoring, vital signs no signs symptoms of pain noted. Surveyor requested and received on 03/15/17 the facility incident report and follow up and noted that there was not an adequate investigation conducted to determine if this accident was avoidable or unavoidable. There was no evidence that staff provided the supervision needed per care plan and no evidence immediate first aide was given after observing injury to the resident. Per the incident report dated 02/26/17, LPN-O was the licensed staff on duty. On 03/16/17 at 12:37 p.m. per telephone, LPN-O stated to Surveyor that CNA-L (certified nurse assistance) went to feed her and saw the soup bowl on residents lap. The nurse aide then took the R11 to her room, per LPN-O somewhere between 6:30-7:00 p.m. and came and got me. When questioned why the CNA waited until after feeding the resident to notify her, LPN-O stated, not sure why. Per LPN-O, the CNA washed the area off with soap and water as she was providing night time cares on the resident. When asked if RN-N (RN supervisor) was notified of the incident, LPN-O stated yes. Asked if the RN assessed the resident, not sure was her response. Surveyor review of the food temperature log for 02/26/17 documents the temperature of the soup that was served for supper on the unit in which the resident resided to be at 200 degrees. Per interview with RN-N on 03/16/17 at 3:15 p.m., RN-N acknowledged recall of the situation. RN-N indicated that she recalled LPN-(O) called me between 8-9 p.m. and said she found redness to the residents thigh and had already cleaned the resident up. RN-N verbalized that she remembered the soup being hot, it was tomato soup, I remember, because it spilled a little on my thumb as I was stirring it for another resident. RN-N stated that she told staff around her to be careful as the soup was hot. Questioned if she completed an assessment on the resident after being notified. RN-N stated no. RN-N also acknowledged that she did not make an observation of R11 either. Per RN-N it was a busy night, the staff was not sure how hot it got spilled. Per RN-N, I was told the area was red, intact, no opening, nothing about a blister . I would have checked on resident if I had known . not told of blistering. There is no documented measurements of the blistered site. Per interview with CNA-L on 03/16/17 at 3:55 p.m., CNA-L acknowledged that she was the staff member responsible for the provision of cares for R11 on the 02/26/17 tour of duty. CNA-L stated that she went over to feed her, saw her napkin on her lap with empty soup bowl and soup on her. Per the CNA, R11 was at a table for residents who needed help and that it was known that this resident would pick and grab at things. When questioned who put the meal tray on the table, CNA-L indicated that it was already on the table when she sat down to feed her. CNA-L also stated that, usually those with assist are not to get their meal until staff can sit with them. CNA-L acknowledged that she took R11 down to her room, so that she could look at her thigh, and saw a blister on it, I told LPN-(O) and she looked at it right away. Surveyor questioned CNA-L as to what CNA-M and CNA-K had to do with this incident as they were identified on the facility incident report. Per CNA-O, she told CNA-M and CNA-K what had happened. However there was only a statement by CNA-L and not CNA-K. Per University of Rochester Medical Center Kessler Burn and Trauma Center, 1st degree burn classified as redness and pain. 2nd degree burn classified as redness, pain and blistering and 3rd degree burn is classified as charred skin, pain and loss of tissue. The injury sustained by R11 presented as a 2nd degree burn. A hospital record review was conducted on the resident as she was sent out for an evaluation and a change in condition on 03/01/17 and that record did make reference to the resident's wound thigh-left upper blister. Noting that three days later the blistering remained. The facility did not ensure the safety of R11 by making sure that the residents environment was free of accident hazards and by failing to provide supervision to prevent another accidents that resulted in actual harm to the resident. After the first accident of spilling hot coffee, there was no investigation to determine what happened and what staff was involved and there was no notification to the legal representative or any physician. There was also no additional immediate safety interventions instituted on the care plan at that time. The resident finally had an update to the care plan 01/13/17 that required staff to be at the meal table. This was not done and on 02/26/17 when R11 experienced another avoidable accident involving hot liquids in which the resident sustained [REDACTED]. A review of the facility policy regarding incident reporting and investigation effective 06/01, revised 10/16 states Any resident that is noted to have an injury or verbalizes that they have had an injury or perceive that they have been injured is taken seriously. A thorough investigation to determine the source/cause and rule out potential abuse will be conducted in a timely manner. This investigation is to be done in addition to a thorough assessment of the resident's condition and treatment of [REDACTED]. The above incidents were shared with NHA-A and on DON-B on 03/16/17. The NHA acknowledged that she was not aware of any of these incidents. No additional information was forth coming. 2.) Surveyor reviewed R5's medical record on 3/13/17 to 3/16/17. R5 is on a ventilator, receives his nutrition via a feeding tube, and has a Foley catheter. The CNA (Certified Nursing Assistant) care card dated 3/10/17 documents Transfer with extensive A (assistance) of 2 to the chair. On 3/13/17 at 11:09 a.m. Surveyor observed CNA (Certified Nursing Assistant)-II enter R5's room. CNA-II washed her hands, placed gloves on, filled a wash basin and removed R5's pressure relieving boots. CNA-II placed socks and slippers on R5, informed R5 she was going to get the nurse to disconnect his tube feeding, removed her gloves and left R5's room. CNA-II returned a moment later washed her hands, placed gloves on and informed R5 that the nurse was coming. At 11:15 a.m. LPN (Licensed Practical Nurse)-HH entered R5's room placed gloves on, placed a soaker pad on the recliner, disconnected R5's tube feeding, removed her gloves and left R5's room. CNA-II sat R5 on the edge of the bed. At 11:17 a.m. CNA-UU entered R5's room stating she was going to do range of motion with R5 but could do it later. CNA-II washed R5's back and asked R5 if has to use the bathroom, does he want to use the commode. CNA-II & CNA-UU removed their gloves, washed their hands, and placed gloves on. CNA-II placed the collection bag through the pull up incontinence product while CNA-UU placed a gown on R5. CNA-II placed a wheeled walker in front of R5 and moved the commode near the bed. CNA-UU placed a gait belt around R5, CNA-II told R5 to scoot towards the edge of the bed and then CNA-II & CNA-UU assisted R5 to stand. CNA-II wiped R5's rectal area with a soaker pad and then CNA-II & CNA-UU assisted R5 with sitting on the commode. CNA-II placed the call pad in reach and then CNA-II & CNA-UU removed their gloves, washed their hands, and left R5's room. On 3/13/17 at 11:35 a.m. CNA-II informed Surveyor that she was going to check R5. Surveyor entered R5 room with CNA-II who washed her hands and placed gloves on. While R5 was sitting on commode CNA-II washed R5's inner thighs and the tubing of the catheter. CNA-II asked R5 if he was ready to stand and then assisted R5 to stand. While R5 was holding onto the wheeled walker, CNA-II washed R5's rectal area and buttocks. CNA-II pulled up R5's incontinence product, telling R5 that she was hurrying. CNA-II held onto the gait belt while R5 took a couple steps, turned and sat in the recliner chair. CNA-II removed her gloves and washed her hands. Surveyor noted that CNA-II did not follow R5's care plan as she transferred R5 by herself. On 3/21/17 at 8:06 a.m. Surveyor informed DON (Director of Nursing)-B of the observation of R5 being transferred with one CNA when the care plan documents extensive assistance with two. Surveyor inquired if R5 should be transferred with two. DON-B looked at the computer and informed Surveyor that R5 should be transferred with two staff. 3.) Surveyor reviewed R8's medical record on 3/13/17 to 3/20/17. On 3/14/17 at 8:16 a.m. Surveyor entered R8's room with CNA (Certified Nursing Assistant)-AA and CNA-VV to observe morning cares. Surveyor observed R8 in bed and there are two half rails up on R8's bed. During this observation, Surveyor observed that after staff positioned R8 on his side R8 would hold onto the side rail. During R8's record review Surveyor was unable to locate a side rail assessment. On 3/16/17 at 10:20 a.m. Surveyor informed RN (Registered Nurse) Manager-C that during morning care observations Surveyor observed R8 holding onto the side rail after he was positioned on his side but was unable to locate a side rail assessment in R8's medical record. RN Manager-C informed Surveyor that she would look into this. On 3/20/17 at 3:15 p.m. Surveyor informed Administrator-A and DON-B that Surveyor hasn't been provided with side rail assessment and asked if there was an assessment. On 3/21/17 at 8:15 a.m. Surveyor asked DON-B if there was a side rail assessment for R8. DON-B informed Surveyor they just did an assessment. Surveyor requested a copy of R8's side rail assessment. On 3/21/17 at 8:39 a.m. Surveyor was provided with a therapy screen dated 3/17/17 under results of screening documents Pt. (patient) uses bilateral rail to help maintain side lying for cares. Pt uses rails safely and appropriately. Under recommendations documents continue use of bilateral rails. On 3/21/17 at 11:40 a.m. Surveyor met with TD (Therapy Director)-U and PT (Physical Therapist)-KK to discuss the therapy screen regarding R8's side rails that was completed on 3/17/17. Surveyor asked if this screen assessed for the risk of entrapment and if the risk and benefits were discussed with R8 and whether a consent was obtained. PT-KK informed Surveyor that she assessed R8 in how he rolled, that he can use the side rails safely and they did help him maintain side lying for ease of care. PT-KK indicated that she did not assess R8 for entrapment and did not discuss the risk and benefits nor did she obtain a consent obtained. Surveyor discussed the new regulations effective 11/28/16 relating to the side rails with TD-U and PT-KK. On 3/21/17 at 11:51 a.m. Surveyor asked LPN (Licensed Practical Nurse)-WW if nursing is involved with side rail assessments, if they discuss the risk and benefits with the resident and or their legal representative, and if nursing obtains consent for use of the side rail. LPN-WW informed Surveyor that she's not involved as far as she is aware and that therapy assesses the side rail and they do what therapy says. On 3/21/17 at 11:55 a.m. Surveyor asked DON-B if nursing is involved with the side rail assessment. DON-B replied no and explained they would let therapy know if a Resident wants side rails or needs them. Surveyor asked who would assess for the risk of entrapment. DON-B replied therapy. Surveyor informed DON-B that TD-U & PT-KK informed Surveyor that they don't assess for risk of entrapment. Also neither therapy or nursing discusses the risk & benefits and a consent is not obtained. DON-B replied nursing can get a consent. The side rails policy and procedure reviewed 03/03 documents under policy Side rails/bed rails can be used for accident prevention and/or to assist in positioning and/or bed mobility. Side rails can also pose significant risk for the resident. Before side rails (any size/type/number) are instituted, a safety risk assessment must be completed. Under general information documents Side rails are to be down on all patients/resident unless all of the following criteria are met: 3.1 Valid physician's order for side rails used as a restraint. 3.2 If a bed as a split railing or only 1/2 rail is engaged, a physician's order is not required. However all other criteria must be satisfied. 3.3 Interdisciplinary assessment that resident has a medical [DIAGNOSES REDACTED]. A determination must be made as to how the use of the siderail would: A. Treat the medical symptom B. Protect the resident, and C. Assist in his/her highest practicable well being. 3.4 Therapy Department safety assessment completed and both the resident and bed rail(s) are deemed safe to have rail(s) up when in bed. 4. A siderail release and/or a physician order is not needed to have siderails down. 5. A thorough explanation of potential risk and benefits of siderail use must be communicated prior to use and quarterly thereafter. 6. Risk of using siderails include (but are not limited to): 6.1 Possibility of falls from bed despite rails. 6.2 Possibility of bowel/bladder incontinence. 6.3 Possibility of damage to skin, muscle or bone from being wedged between siderail and mattress. 6.4 Possibility of social isolation. 6.5 Possibility of strangulation or other serious injury from becoming caught in rail openings. 7. Benefits of using siderails include (but are not limited to): 7.1 Enables individual to change position independently. 7.2 Increases feeling of safety and security which may lead to better quality sleep. 7.3 May reduce potential for falls, which could result in injury. 7.4 May service as a reminder for individual to call and wait for assistance with transfer if they are unable to transfer independently. 4.) R18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] indicated that R18 is occasionally incontinent of bladder and continent of bowel and R18 is on a bladder toileting program. The Care Area Assessment (CAA) indicates to proceed to care plan. The MDS also indicated that R18 is at risk for falls, causes/contributing factors documented poor balance and history of falls. The CAA for falls indicates to proceed to care plan. Review of current care plan dated 9/24/15 documents R18 has potential for falls related to generalized weakness and deconditioning, decreased mobility. Approaches dated 9/24/15 include: Encourage use of assistive device if applicable, PT/OT screen/evaluation and treat as ordered, floors free from spills and clutter, provide adequate glare free lighting, keep call light, personal and frequently used items within reach, assist to wear non-skid footwear, mat on floor next to bed at all times when in bed. Revisions to approaches include: on 9/28/15 monitor resident on rounds on nights, if awake offer to take to toilet. On 10/26/15 frequent reminder for resident not to self-transfer or stand up independently and call and wait for assist. On 11/12/15 auto lock brakes on wheelchair (w/c) to prevent chair from rolling away. On 12/14/15 gripper socks on at night and when in bed. When in bed place w/c and walker next to bed on floor mat. On 1/19/17 every 30 minute safety checks. On 1/24/17 offer to place resident in w/c if appears anxious during the night. On 2/3/17 multiple falls in the last 30 days. On every 30 minute checks now. Review of current care plan dated 9/24/15 documents R18 is at risk for incontinence related to decreased mobility. Approaches dated 9/24/15 include: Provide toileting assist based on 7 day diary per schedule: Incontinent of bladder. Toilet upon rising; before lunch; before/after supper; at HS (hour of sleep) and PRN (as needed). Toilet if awake during night. Check and change PRN. Offer to assist to the bathroom whenever observed to be awake at night. Surveyor noted no documentation of 7 day diary completed. Review of R18 nurses notes reveal 10 falls/incidents that have occurred since January 2017. Surveyor requested and reviewed the facility's post fall investigations for R18. The investigation provided to surveyor indicates date of incident 1/19/17 at 5:30: found lying on floor between foot pedals of w/c in the middle of his room. Tip ups on w/c noted not to be working properly. R18 description section documents: Asked resident what happened. I don't know, I just fell . Fall investigation dated 1/19/17 at 9:55 am documents resident was not incontinent. Interdisciplinary team (IDT) agrees to have B&G/therapy check anti-tippers and auto brakes for proper functioning. Review of incident form dated 1/19/17 at 9:45 am found sitting on the floor in the bathroom. R18 description section documents: Writer asked him what happened and he said I don't know but upon questioning him further found out he had used the bathroom and was getting off the toilet and fell . Fall investigation dated 1/19/17 at 10:23 am documents IDT team agrees to have therapy screen, UA and every 30 min checks ordered by MD. Surveyor noted no documentation on check sheets that 30 minute checks were completed after 1/19/17 fall occurred for dates covering 1/19/17 through 1/31/17. Check sheet provided to surveyor has earliest documented date of checks starting 2/1/17. Review of incident form dated 1/23/17 at 2:00 pm resident was attempting to get out of bed without any assistance from staff and scratched his left hand on the top of it. R18 description section documents: I bumped it on my wheelchair when I was getting in it, that's all, just put a Band-aid on it, it's no big deal Fall investigation dated 1/24/17 at 3:38 pm documents IDT team agrees to pad brake handle. Resident's original w/c is being repaired and was given an alternate chair. Review of incident form dated 1/24/17 at 1:45 am resident was seen sitting on mat leaning against bed. R18 description section documents: I was just trying to get out. Fall investigation dated 1/24/17 at 3:48 pm documents resident was noted with increased anxiety due to wife not visiting due to resident being in isolation for signs/symptoms of acute respiratory infection. Resident was seen approximately 30 minutes prior and provided with urinal. IDT team agrees to have staff offer for resident to get up in w/c when appears anxious. Surveyor noted care plan approach dated 9/28/15 already in place to monitor resident on rounds on nights, if awake offer to take to toilet. Review of Fall Risk assessment dated [DATE] reveals score of 18 which is considered high risk. Review of toileting assessment daily charting sheets dated 1/25/17 through 1/31/17 (which surveyor was informed is a 7 day bladder tracking tool) reveals no documentation of voiding on 1/25/17 during the hours of 2:00 pm through 8:00 pm. No documentation of voiding on 1/27/17 during the hours of 2:00 pm through 8:00 pm. No documentation of voiding on 1/29/17 during the hours of 4:00 pm through 8:00 pm. No documentation of voiding on 1/31/17 during the hours of 4:00 am through 8:00 pm. Surveyor noted due to incomplete data collection, a comprehensive assessment could not have been completed to help establish a toileting schedule based upon R18's individual voiding patterns. Review of incident form dated 1/27/17 at 7:45 pm resident found laying on floor, supine next to bed. Clothes on, shoes on, call light not on. R18 description section documents: Resident unable to state what happened, just keeps repeating help me up while attempting to sit up. Fall investigation dated 1/30/17 at 2:49 pm documents continent at time of fall, staff asked if need to use bathroom and he said no. IDT team agrees to trial of having resident's w/c away from the bed. Surveyor noted revision to care plan approach dated 12/15/15 documenting when in bed place w/c and walker next to bed on floor mat had not been removed from care plan. Certified Nursing Assistant (CNA) care card dated 3/15/17 which surveyor was informed is the tool used for the CNA to provide care to the resident, documents when in bed place w/c and walker next to bed on floor mat. Review of incident form dated 2/1/17 at 9:25 am resident found on left side lying position bracing himself with forearm. Call light not activated, bed in lowest position, room lights off, shoes on. R18 description section documents: I tried to get up. Fall investigation dated 2/2/17 at 10:00 am documents resident was continent at the time. Resident was trying to get up from a nap. It was noted that the unit has been closed for flu and residents routine has been disrupted which may have contributed to his restlessness. IDT team agrees to hourly checks for 7 days. Surveyor noted care plan approach dated 1/19/17 already in place for every 30 minute checks. Review of Bowel and Bladder assessment dated [DATE] indicated R18 has history of incontinence, weak or intermittent stream (dribbles) can identify urinary urge sensation. In addition, section C of assessment indicates scheduled voiding: resident is toileted at regular intervals to match the resident's voiding habits. Surveyor noted no individualized toileting plan in place on care plan for R18. Review of incident form dated 2/2/17 at 6:30 pm resident found laying on floor of room with head against wall next to his nightstand. Resident obtained a large skin tear to his right upper arm near elbow 7 centimeters (cm) by 3.5 cm, Resident not incontinent at time of fall. No shoes on, just slippery socks. Call light was not sounding. R18's description section documents: Writer asked resident what happened and he replied it was a false alarm. I was getting up to go to the bathroom but it was a false alarm. Fall investigation dated 2/3/17 at 10:46 am documents resident does have a history of unsafe self-transfers with falls. Resident had only socks on during transfer. IDT team agrees to have medication review done and call MD for lab orders. Therapy to screen transfer status. 30 minute checks initiated. Encourage resident to be in common area when up. Surveyor noted care plan approach dated 1/19/17 already in place for every 30 minute checks. Review of R18's check sheets dated 2/1/17 through 2/14/17 reveal inconsistency with staff documentation. Some staff documented 30 minute checks, while other staff documented 60 minute checks. Review of incident form dated 2/13/17 at 2:45 am residents' roommate came to common area to report resident had fallen. Resident lying on floor on left side next to mat. R18 description section documents: I was trying to go to the bathroom, I fell . Fall investigation dated 2/13/17 at 9:46 am documents IDT team agrees to place resident on every 30 minute checks x 2 weeks. Continues in PT. Surveyor noted care plan approach dated 1/19/17 already in place for every 30 min checks. Review of check sheets dated 2/1/17 through 2/14/17 reveal R18 was already on checks, though inconsistent documentation by staff. Some staff documented 30 minute checks while other staff documented 60 minute checks. Surveyor notes no check sheets for dates 2/15/17 through 2/18/17. Review of incident form dated 2/25/17 at 8:45 pm residents roommate alerted staff that resident on ground. Resident found sitting on ground next to bed with back propped against nightstand, w/c in front of him facing him. R18 description section documents: Resident said he was trying to get into his wheelchair to go to the bathroom to take a pee. Resident had been in bed prior to incident. Fall investigation dated 2/27/17 at 10:04 am documents IDT team agrees to start a 3 day toileting assessment and continue 30 minute checks. Surveyor noted no documentation of a 3 day toileting assessment had been completed. Review of check sheets reveal documentation of R18 being on 30 minute checks 2/18/17 through 3/13/17. Review of incident form dated 3/20/17 at 5:40 am resident calling out for help, found lying on floor on left side facing w/c next to mat. States bumped the back of his head on end table. Two 1 cm raised areas to right side back of head, areas intact. Resident incontinent of urine. R18 description section documents: I fell on the way to the bathroom. Fall investigation dated 3/20/17 at 9:53 am documents IDT team agrees to set up possible appointment with urology due to [DIAGNOSES REDACTED]. On 3/20/17 at 12:45 pm Surveyor interviewed RN Supervisor-Z. Surveyor asked why R18's care plan had not been updated

Based on record reviews, review of facility policies, and interviews, the facility did not follow its policy regarding offering of influenza vaccines as soon as they are available for the 14 residents residing on Park View living unit. Nine of the fourteen residents on Park View 2 tested positive for Influenza A between ,[DATE] - [DATE]. Seven of the nine residents (#6, #5, #4, #7, #8, #9 & #10), desired to receive the influenza vaccine, which was not made available until [DATE], or after. Influenza vaccines were available in the facility by [DATE]. The facility started contacting families and Healthcare Power of Attorneys- (HPOAs), in late September for consents to administer the influenza vaccines. Influenza vaccines had been administered in 6 of 7 living units by [DATE]. An influenza outbreak occurred on the living unit which had not been immunized. The outbreak began on [DATE]. Residents on that unit did not receive the influenza vaccine until [DATE], despite several of the residents/families giving consent for the vaccine as early as [DATE]. The delay in administering the vaccines to residents on Parkview 2 denied those residents an opportunity to develop any level of immunity to the [MEDICAL CONDITION]. *Resident #6 became ill with an Influenza Like Illness (ILA) on [DATE]. Resident #6 was later diagnosed with [REDACTED].#6 to receive the influenza vaccine on [DATE]. Resident #6 did not receive the influenza vaccine until [DATE]. Resident #6's family did not wish aggressive treatment (hospital or [MEDICAL CONDITION]). Resident #6 expired on [DATE]. *Resident #5 became ill with an ILA on the morning of [DATE]. Resident #5 was hospitalized the morning of [DATE]. The hospital discharge report indicates the resident tested positive for Influenza A. Resident #5 was discharged from the hospital to a hospice care facility. Resident #5's wife had given consent for the influenza vaccine on [DATE]. Resident #5 did not receive the influenza vaccine until [DATE]. *Resident #4 became ill with an ILA on the morning of [DATE]. Resident #4 was hospitalized from ,[DATE] - [DATE]. Resident #4 tested positive for Influenza A. Resident #4 had a consent form for the administration of the influenza vaccine dated [DATE]. According to Registered Nurse (RN)-B, a previously signed consent form had been lost. Resident #4 received the influenza vaccine on [DATE]. *Resident #7 became ill with an ILA on [DATE]. Resident #7 tested positive for Influenza A. Resident #7 had a signed consent form dated [DATE]. Resident #7 did not receive the influenza vaccine until [DATE]. *Resident #8 became ill with an ILA on [DATE]. Resident #8 tested positive for Influenza A. Resident #8 had a signed consent form dated [DATE]. Resident #8 did not receive the influenza vaccine until [DATE]. *Resident #9 became ill with an ILA on [DATE]. Resident #9 tested positive for Influenza A. Resident #9 had a signed consent form dated [DATE]. Resident #9 did not receive the influenza vaccine until [DATE]. *Resident #10 became ill with an ILA on [DATE]. Resident #10 tested positive for Influenza A. Resident #10 had a signed consent form dated [DATE]. Resident #10 did not receive the influenza vaccine until [DATE]. Findings include: On ,[DATE] - [DATE], Surveyor # reviewed facility documentation of an influenza outbreak which occurred in early [DATE], on 1 of 6 living units within the facility. Four residents on the Parkview 2 living unit presented with respiratory symptoms and an elevated temperature on the morning of [DATE]. The facility took immediate action to isolate both the infected residents and the living unit. Four residents were ill with the same symptoms on [DATE], and 1 additional resident became ill on [DATE]. A review of the facility policy, "Influenza -Prevention and Control in Long Term Care Facilities," with an effective date of ,[DATE], and a revision date of ,[DATE], revealed that "flu vaccines should be offered as soon as they become available." According to the Vaccine Information Statement, attached to the facility policy, "it takes up to 2 weeks for protection to develop after the shot." On [DATE] at 9:00 a.m., Surveyor # asked the Director of Nursing (DON) when the residents on Parkview 2 had been immunized. The DON stated the residents had not been immunized until the day the outbreak began. The DON suggested Surveyor # speak with the Registered Nurse/Nurse Manager (RN/NM), of the Parkview 2 living unit regarding the timing of the vaccine administration. On [DATE] at 9:40 a.m., Surveyor # spoke with RN/NM-B regarding the administration of influenza vaccine for Parkview 2 residents. RN/NM-B told Surveyor # that she was the nurse manager for three living units, and that residents on the other 2 living units had been vaccinated on [DATE]. RN/NM-B was planning on giving the vaccines to the residents on Parkview 2 on [DATE], but could not locate the vaccine consent forms which had been in a manila folder at the nurses' station. RN/NM-B stated since she could not find the consent forms she needed to contact the families/HCPOA's for the residents, and made those contacts during the week of ,[DATE] - [DATE]. RN/NM-B was planning on administering the vaccines on [DATE]. RN/NM-B stated that the facility administers vaccines to staff before starting to vaccinate the residents. RN-NM-B stated she thought the staff vaccinations had been completed by late [DATE], so nurses were instructed to start obtaining consents and giving vaccines to the residents. RN/NM-B stated the vaccine was in the building by late September, and her plan was to administer the vaccines when all the consents were obtained. On [DATE] at 10:40 a.m., Surveyor # spoke with the DON about vaccine administration in the facility. The DON stated vaccines were received in the facility in September, 2012. By the end of September all staff who wanted the vaccine had been vaccinated. Nurse Managers were instructed in late September to begin obtaining consent to administer the vaccines to residents. Nurses were supposed to start immunizing residents the first week of [DATE]. The Nurse Managers assist in obtaining the consents, and the vaccine should be given when the consents are received. Nurse Managers are to give the DON a list of all residents who have received the vaccine, when the vaccines for the living unit are all administered. The DON stated she was not aware that the residents on Parkview 2 had not received their influenza vaccines until [DATE], the day the outbreak began. During a review of resident records on Parkview 2, Surveyor # noted most of the consents in the records had been received between ,[DATE] - [DATE]. On [DATE] at 2:00 p.m., Surveyor # asked RN/NM-B about the dates on the consents in the records, since RN/NM-B had told the surveyor the consents had been lost. RN/NM-B stated maybe someone found the old consents and put them in the records. RN/NM-B again stated that she could not find the consents on [DATE], so she began obtaining the consents again. None of the vaccine consent forms, located in the reviewed resident charts on Parkview 2, were dated during the week of ,[DATE] - [DATE]. On [DATE] at 2:45 p.m., Surveyor # received from Corporate Nurse-C, a copy of when the facility received the influenza vaccine and when the vaccines were given to staff and residents. Vaccines were delivered to the facility on [DATE] and [DATE]. Administration of vaccines to residents began on [DATE], and were completed on [DATE], on all units except Parkview 2. Parkview 2 vaccines were administered on [DATE]. 1. Surveyor # reviewed Resident #6's record on [DATE], which included nurses notes and physician notification forms. Resident #6 had [DIAGNOSES REDACTED]. On [DATE] at 9:45 a.m., Resident #6 was noted with crackles (abnormal lung sounds) and wheezing. The family did not want the resident to have a chest x-ray, [MEDICATION NAME] or antibiotics. The family wished the resident to receive comfort measures only. The facility provided comfort measures, and the resident expired on [DATE]. According to the Daily Unit Infection Log, Resident #6 had a nasal swab for the [MEDICAL CONDITION] on [DATE]. The results on [DATE], were positive for Influenza A. Resident #6 has an Influenza Vaccine ,[DATE] Consent Form in the record that was signed by the HCPOA on [DATE]. Resident #6 received the influenza vaccine on [DATE]. 2. Surveyor # reviewed Resident #5's record on [DATE],which included nurses notes and physician notification forms. Resident #5 had [DIAGNOSES REDACTED]. On [DATE] at 9:00 a.m., Resident #5 was lethargic, had bilateral lower lobe crackles and an elevated temperature. A chest x-ray was ordered and completed, revealing slight bilateral lobe atelectasis (collapse of the lung). The resident had increased lethargy and confusion during the evening of [DATE]. The resident's wife did not want the resident hospitalized . By the morning of [DATE], the resident had increasing lethargy and continued elevated temperature. The resident's wife consented to hospitalization and the resident was transferred to the hospital on [DATE] at 8:40 a.m. While hospitalized , Resident #5 was diagnosed with [REDACTED]. The hospital discharge summary was reviewed, and revealed the resident was discharged to an in-patient hospice unit on [DATE]. Resident #5 has an Influenza Vaccine ,[DATE] Consent Form in the record that was signed by his wife [DATE]. Resident #5 received the influenza vaccine on [DATE]. 3. Surveyor # reviewed Resident #4's record on [DATE], which included nurses notes and physician notification forms. Resident #4 had [DIAGNOSES REDACTED]. On [DATE] at 9:15 a.m., Resident #4 was noted with a productive cough and crackles in the right lower lobe. A chest -x-ray revealed right lower lobe pneumonia. The resident was started on [MEDICATION NAME]. By the morning of [DATE], Resident #4 was experiencing expiratory wheezes, with a respiration rate of 24 and slightly labored. Her temperature was 100.8. Resident #4's antibiotic was changed and she was sent to the hospital early on the morning of [DATE]. Resident #4 was hospitalized ,[DATE] - [DATE]. According to the facility line list for the influenza outbreak, Resident #4 tested positive for Influenza A. Resident #4 has an Influenza Vaccine ,[DATE] Consent Form in the record that was signed by the HCPOA on [DATE]. Resident #4 received the influenza vaccine on [DATE]. 4. Surveyor # reviewed Resident #7's record on [DATE] which included nurses notes and physician notification forms. Resident #7 had [DIAGNOSES REDACTED]. On [DATE] at 10:00 a.m., Resident #7 was noted with a productive cough and crackles in the right lower lobe. A chest x-ray revealed cardiomegaly (enlarged heart) with lungs clear. According to the Daily Unit Infection Log, Resident #7 had a nasal swab for the [MEDICAL CONDITION] on [DATE]. The results on [DATE], were positive for Influenza A. Resident #7 has an Influenza Vaccine ,[DATE] Consent Form in the record that was signed by the HCPOA on [DATE]. Resident #7 received the influenza vaccine on [DATE]. 5. Surveyor # reviewed Resident #8's record on [DATE] which included nurses notes and physician notification forms. Resident #8 had [DIAGNOSES REDACTED]. On [DATE], Resident #8 was noted with a non-productive cough and nasal congestion. A chest x-ray revealed a slight right lower lobe pneumonia. According to the Daily Unit Infection Log, Resident #8 had a nasal swab for the [MEDICAL CONDITION] on [DATE]. The results on [DATE], were positive for Influenza A. Resident #8 has an Influenza Vaccine ,[DATE] Consent Form in the record that was signed by the HCPOA on [DATE]. Resident #8 received the influenza vaccine on [DATE]. 6. Surveyor # reviewed Resident #9's record on [DATE] which included nurses notes and physician notification forms. Resident #9 had [DIAGNOSES REDACTED]. On [DATE], Resident #9 was noted with a non-productive cough and low grade temperature. A chest x-ray was negative. According to the Daily Unit Infection Log, Resident #9 had a nasal swab for the [MEDICAL CONDITION] on [DATE]. The results on [DATE], were positive for Influenza A. Resident #9 has an Influenza Vaccine ,[DATE] Consent Form in the record that was signed by the HCPOA on [DATE]. Resident #9 received the influenza vaccine on [DATE]. 7. Surveyor # reviewed Resident #10's record on [DATE] which included nurses notes and physician notification forms. Resident #10 had [DIAGNOSES REDACTED]. On [DATE], Resident #10 was noted with an elevated temperature and crackles on the right lower lobe. A chest x-ray revealed cardiomegaly with [MEDICAL CONDITION]. According to the Daily Unit Infection Log, Resident #10 had a nasal swab for the [MEDICAL CONDITION] on [DATE]. The results on [DATE], were positive for Influenza A. Resident #10 has an Influenza Vaccine ,[DATE] Consent Form in the record that was signed by the HCPOA on [DATE]. Resident #10 received the influenza vaccine on [DATE].

Based on observation, interview, and record review, the facility did not ensure that 1 (Resident #1) out of 3 sampled residents reviewed for falls received adequate supervision to prevent falls. On 10/16/12 Resident #1 was assisted to the toilet by a Certified Nursing Assistant (CNA). Resident #1 was left alone in the bathroom by the CNA despite having a care plan that indicates that Resident #1 can not be left alone during activities of daily living (ADLs). While alone, Resident #1 fell off the toilet and fractured her right femur which required surgical intervention to repair. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/25/12 Surveyor # reviewed Resident #1's admission Minimum Data Set ((MDS) dated [DATE] which indicates Resident #1 has long and short term memory problems and moderately impaired decision making skills. The MDS also indicates Resident #1 requires extensive assistance of one person for transfers. The Care Area Assessment (CAA) for falls was triggered for this assessment and read: Resident #1 was admitted to the hospital after a fall that resulted in a 5th metatarsal fracture. Resident #1 has had a decline in activities of daily living (ADL) function, which may put her at risk for falls. Staff used a fall risk data collection tool to help determine her risk for falls. Resident #1 scored a 32, making her at risk. Resident #1's situation is complicated by her communication and visual impairment. On 10/25/12 Surveyor # reviewed the facility's self report investigation regarding Resident #1's fall from the toilet on 10/16/12 completed by Administrator-A which read: Certified Nursing Assistant (CNA)-B placed Resident #1 on the toilet and left the room to answer another call light. Resident #1 was found on the floor with the call light sounding. Resident #1 was assessed by the Registered Nurse and sent to the emergency room for x-rays which proved negative and a suture was placed in 'resident #1's inner ear. The next day following exam by the physician another x-ray was obtained of the right femur and it was positive at that time. Resident #1 was then sent back to the emergency room . The conclusion read: The CNA failed to follow the care plan which stated to not leave Resident #1 alone during ADL's. "Although the act was a negligent act, not following the care plan, making it an avoidable fall. I cannot substantiate that it was a 'willful act of neglect.'" On 10/25/12 Surveyor # reviewed Resident #1's hospital report dated 10/20/12 which read: A CT (computed tomography) scan of Resident #1's right hip showed a minimally displaced right hip intertrochanteric fracture. A surgical open reduction and internal fixation of the right intertrochanteric hip fracture was done on 10/19/12. Resident #1 was transferred back to the facility on [DATE]. On 10/25/12 Surveyor # reviewed the CNA care sheet in place for Resident #1 at the time of her fall on 10/16/12 the section labeled ADL'S read: do not leave alone. On 10/25/12 Surveyor # reviewed Resident #1's care plan for falls that was in place at the time of the fall on 10/16/12 which read: Resident #1 at risk for falling due to daily antidepressant use. Approach's included give resident #1 verbal reminders not to ambulate/transfer without assistance, keep personal items within reach. On 10/25/12 at 12:55 p.m. Surveyor # observed two CNA's transfer Resident #1 from the wheelchair to the toilet. A gait belt was used and Resident #1 transferred back and forth to the wheelchair with 2 assist without difficulty. Resident #1 was supervised while using the toilet. On 10/25/12 at 1:10 p.m. Surveyor # attempted to interview CNA-B via telephone. As of 10/29/12 CNA-B had not returned the phone call. On 10/25/12 at 1:25 p.m. Surveyor # interviewed Administrator-A who stated that CNA-B told her that the CNA instruction sheet said not the leave Resident #1 alone with ADL's, not specifically toileting. Administrator-A told CNA-B that toileting was an ADL. The above findings were shared with the Administrator on 10/25/12 at 4:00 p.m. additional information was requested if available and none was provided.

Based on observation, interviews and record reviews the facility did not ensure that the residents' environment remained as free of accident hazards as is possible and and that residents received the necessary supervision and assistance to prevent accidents for 5 of 24 residents reviewed. * Resident #13's care plan dated 2/18/11 indicated the need to have two staff assist with a Sit to Stand. On 4/6/11, Resident #13 was transferred by one staff assist with the Sit to Stand, which resulted in Resident #13 sustaining a dislocation of left humerus and shoulder. Since Resident #13 sustained the dislocated shoulder, Resident #13 is now transferred with a Hoyer Lift for all transfers and in regards to continence, Resident #13 is now checked and changed. Prior to the dislocated shoulder, Resident #13 utilized the Sit to Stand lift and utilized the toilet for continence needs. * On 2/10/11, Certified Nursing Assistant (CNA)-Q utilized a Sit to Stand lift to initiate a transfer with Resident #7. CNA-Q did not initiate this transfer with the assistance of 2 staff members as per physician's orders [REDACTED]. CNA-Q left Resident #7 in a standing position on the Sit to Stand lift for about 45 minutes. * Resident #3 has a history of falls, is at high risk for falls and has a care plan dated 4/20/11 with an intervention to have a mat on the floor while in bed. On 5/2, 5/3, and 5/4/11, Resident #3 was observed on multiple times to be in bed without the mat on the floor. * Resident #11 has a history of falls and a care plan dated 9/22/10 to have a bed alarm while in bed. On 5/2 and 5/3/11, Resident #11 was observed in bed however; the bed alarm was not fully activated. * Resident #10 has a care plan dated 3/29/11 which states, to be transferred with two staff and gait belt. On 5/4/11, Resident #10 was observed to be transferred with one staff and a gait belt. Findings include: 1. On 5/2/11 through 5/5/11, Surveyor # reviewed Resident #13's medical record along with a facility self report involving Resident #13 dated 4/8/11. The facility self report, indicates that on 4/6/11 at 8:00 p.m., Certified Nursing Assistant (CNA) X was transferring Resident #13 from her wheelchair into bed using the Sit to Stand lift. The facility's self report included copies of various components of Resident #13's medical record, such as physician's orders [REDACTED]. The facility's self report included a nursing and physician's orders [REDACTED].) to be transferred with sit to stand lift and assist X2 nursing staff." On 1/6/10, the facility developed a care plan for Resident #13 indicating Resident #13 was at "Risk for falls related to history of falls and dementia with decreased safety awareness." On 2/18/11, this care plan was updated to include the use of the "sit/stand lift and A-2 (assistance of 2). Resident #13's care plan for "Self Care Deficit," has documented that on 2/18/11, Resident #13 needed the use of a Sit to Stand lift with the assist of 2 staff members for transferring. The fall assessment dated [DATE] indicates that CNA X was able to transfer resident to the edge of the bed before resident let go of the hand rail and the sling slipped up her left arm. CNA X had the resident on the bed and removed the sling from around the resident. When CNA X was moving the Sit to Stand lift away from the resident, the resident started to slide off the bed. CNA X was able to ease Resident #13 to the floor. It also indicates that Resident #13 was complaining of left upper arm pain and bruising to the back of the arm was noted. The Physician Notification form indicates RN Supervisor W notified the physician on 4/6/11 at 8:30 p.m. and received an order for [REDACTED]. On 4/7/11 at 12:43 a.m., the facility staff received the X ray results which revealed a shoulder dislocation. The Physician Notification form indicates that the physician was notified immediately and received an order to send the resident to the emergency room . Resident #13 went to the emergency roiagnom on [DATE]. Resident #13 did not require surgical intervention however; upon return from the emergency room to present, Resident #13 continues to wear a sling. The Investigation Summary dated 4/8/11 indicates, (CNA X) did not follow the facility's policy in regards to use of all mechanical lifts states, that there must be 2 staff members at all times when using all mechanical lifts. On 5/4/11 at 7:16 a.m., Surveyor # observed Resident #13 dressed in bed laying on Hoyer sling. Certified Nursing Assistant (CNA)-U and CNA-V placed the Hoyer lift sling straps onto the Hoyer lift and raised resident up, then placed Resident #13 into the wheelchair. Surveyor # noted through record review that since Resident #13 sustained the dislocated shoulder, Resident #13 is now transferred with a Hoyer lift for all transfers. In regards to continence care, Resident #13 is checked and changed. Prior to Resident #13 sustaining the dislocated shoulder, Resident transferred with a Sit to Stand and was place on the toilet for continent needs. On 5/5/11 during the meeting with the facility administrative staff, the self report was discussed, no other information was provided. 2. On 5/3/11 at 7:40 a.m. Surveyor # observed Certified Nursing Assistant (CNA)-G and CNA-F transfer Resident #7 from her bed to her wheelchair with a Hoyer lift, which was a safe and smooth transfer. On 5/3/11, Surveyor # reviewed Resident #7's medical record along with a facility self report received on 2/16/11 involving Resident #7. The facility's self report included copies of various components of Resident #7's medical record, such as physician's orders [REDACTED]. The facility's self report indicates that on 2/10/11, Resident #7 was left unattended in a standing position, in a sit to stand lift for approximately 45 minutes to an hour without any staff present to assist her. Another Certified Nursing Assistant(CNA)-M entered Resident #7's room to see if she needed anything and found Resident #7 in a standing position in the lift. The CNA who found Resident #7 in a standing position in the sit to stand lift unattended, lowered Resident #7 into her chair. Resident #7's medical record indicates Resident #7 is a [AGE] year old female who was originally admitted into the facility on [DATE] and was readmitted to the facility on [DATE]. Resident #7's medical record indicates Resident #7 has a [DIAGNOSES REDACTED]. Surveyor # reviewed the most recent MDS (Minimum Data Set) dated 3/16/11, which states that Resident #7 needs total assist with transfers, and that Resident #7 does not ambulate and is scored with an 8 that ambulation did not occur. The physician's orders [REDACTED]." According to the physician's orders [REDACTED]. Surveyor # reviewed the weekly nursing summary dated 2/7/11 and under ambulation it notes, chair bound and wheel chair. Under transfers it notes extensive assist. Surveyor # reviewed the previous nurses' Care Plan dated (run date) 2/14/11, which states, "(Resident #7) experiences anxiety at times during transfers." Under approach it states: Offer cueing before transfers using the lift. Offer patient with emotional support during transfers and prn (as needed). An additional Resident Care Plan submitted with the facility's self report, states, "(Resident #7's) ability to perform ADLs has deteriorated related to CVA" and includes an approach of "transfer with mech. standing lift and assist of 2." This ADL Care Plan has a start date of 10/18/09 and a (run date) 2/14/11. The updated nurses' care plan dated (run date) 5/5/11 states, Patient experiences anxiety at times during transfers. Under "approach" it states: Offer cuing before transfers using the lift. Offer patient with emotional support during transfers. Reassure resident staff will remain with her during transfer when stand lift is used. Surveyor # reviewed the previous CNA care card (no date on it) which states: Resident #7 transfers with a mechanical standing lift and wheelchair for mobility. Stand lift to toilet and to wheel chair. Reviewed the updated CNA care card (no date on it) which states: Resident transfers with Hoyer lift with 2 assist, reassure pt (patient) you will remain during transfer. According to the facility's self report, on 2/10/11 at approximately 7:00 p.m., (Resident #7) was being assisted to the bathroom with a sit to stand lift by CNA-Q. CNA-Q left the room to assist another CNA. CNA-Q forgot about (Resident #7) and never went back to assist (Resident #7.) (Resident #7) was left in a standing position in the sit to stand lift for approximately 45 minutes to an hour unattended. The facility's investigation includes a statement made by CNA-M who indicated she went into (Resident #7's) room to see if (Resident #7) or her roommate needed anything and found Resident #7 in a standing position in the sit to stand lift. CNA-M asked what was going on and Resident stated to her "help me." CNA-M lowered Resident #7 down to her chair. Resident #7 stated to CNA-M that she has been like this for 45 minutes. The facility's self report indicates Resident #7 was interviewed on 2/11/11 during an investigation and stated that the aide put her on the lift and then forgot about her. Resident stated she didn't come back and no one came for 45 minutes maybe an hour. Resident #7 asked, " what's that about, you ask to go to the bathroom then she forgets about you." Resident #7 stated, "she didn't want that CNA to take care of her anymore." Resident #7 stated, the girl put her on the lift then went to find someone but she didn't come back and her arms were up and they hurt. Resident #7 demonstrated how her arms were which was up in the air like they would be when the sling is in place. Resident #7 was reassured that there was an investigation going on and the facility won't let this happen to her again. Resident #7 said, "what good does that do, then stated she was already sore." Surveyor # reviewed the facility's policy/procedure for Lifts, Mechanical: SARA standing and repositioning aid. The facility's policies were reviewed with an approval date of 03/06. The policy state: POLICY Provisions will be made to lift and reposition patients/residents in a safe and effortless manner. GENERAL INFORMATION 1. A physician's orders [REDACTED]. 2. Requires two staff members for safe transfer. On 2/10/11, CNA-Q did not follow Resident #7's physician's orders [REDACTED]. CNA-Q did not follow Resident #7's care plan initiated on 10/18/09 which directed CNA's to "transfer with mech. standing lift and assist of 2" and did not follow the facility's policy of ensuring Resident #7 was transferred with 2 staff members for a safe transfer. On 5/4/11 at the daily exit meeting, the above information was shared with the facility. 3. Surveyor # initiated a medical record review on 5/2/11 for Resident #3. Resident #3 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the nursing notes 4/19/11, Resident #3 had an unwitnessed fall from his bed, resulting in transfer to the emergency room to suture a laceration suffered above the left eye. The facility conducted a " Fall Risk Data Collection Tool," dated 4/19/11 which states that Resident #3 is at high risk for falls. The individual plan of care, last updated 4/20/11, states that Resident #3 is at risk for falling due to weakness, debility and recent falls. Listed interventions included mat next to bed, which was newly added to the care plan on 4/20/11. On 5/2/11 at 11:50 a.m., Surveyor # made observations of Resident # 3 lying in bed. It was noted that there was no mat on the floor next to the bed. On 5/3/11 at 10:20 a.m., Surveyor # made observations of Resident #3 lying in bed. At this time it was noted there was no mat on the floor next to the bed. On 5/4/11 at 10:55 a.m., Surveyor # made observations of Resident #3 lying in bed. At this time it was noted that there was no mat on the floor next to the bed. On 5/3/11 at the daily exit meeting, Surveyor # shared the above observations with the Administrator and Director of Nursing. As of the time of exit on 5/4/11, no additional information was provided as to why Resident #3 was lying in bed without the mat on the floor, as per the plan of care. 4. On 5/2/11 & 5/3/11, Surveyor # reviewed Resident #11's medical record which indicated Resident #11 is a [AGE] year old female admitted to the facility on [DATE]. Resident #11's medical record indicates Resident has a [DIAGNOSES REDACTED]. The CNA (Certified Nursing Assistant) Assignment 3 sheet not dated provided to Surveyor # on 5/2/11 after the initial tour documents for Resident #11 under the section: Alarms Wanderguard, "BA (bed alarm) CA (chair alarm)." The falls care plan with a start date of 9/22/10 has an approach that includes, "Equip Resident #11 with an alarm that monitors rising from bed and chair." The approach start date is 9/22/2010. The quarterly MDS (minimum data set) with an assessment reference date of 3/7/11 answers "yes" for has had falls since admission or the prior assessment. The fall risk data collection tool dated 4/23/11 has a total score of "42." A score of 18 or higher is considered "at high risk." On 5/2/11 at 2:19 p.m., Surveyor # observed Resident #11 in bed asleep. The bed was in the low position with a mat on the floor on the right side. Surveyor # observed the care sense bed monitoring system box was attached to the dresser to the right of the bed. The yellow stand by light was lit. The green light was not on. On 5/2/11 at 3:10 p.m., Surveyor # asked CNA (Certified Nursing Assistant)-M how she knows that a bed alarm is on. CNA-M explained to Surveyor # that when a Resident is not in bed the stand by light is on. When a Resident is in bed the green light is lit and the stand by light will be off. On 5/2/11 at 3:11 p.m., Surveyor # observed Resident #11 continues to be in bed. Surveyor # observed the green light is on and the yellow stand by light continues to be on. On 5/3/11 at 7:18 a.m., Surveyor # observed Resident #11 asleep in bed on her back. The bed is in the low position with a mat on the right side of the bed. Surveyor # observed the yellow stand by light is lit on the bed alarm. The green on light is not lit. On 5/3/11 at 7:58 a.m., Surveyor # observed Resident #11 is on her right side in bed. The yellow stand by light continues to be lit. The green on light is not lit. On 5/3/11 at 8:20 a.m., Surveyor # observed CNA (Certified Nursing Assistant)-G enter Resident #11's room, wash her hands and place gloves on. At 8:21 a.m., CNA-F entered the room and placed gloves on. CNA-F raised the bed and removed the body pillow. CNA-F and CNA-G assisted Resident #11 with sitting on the edge of the bed, CNA-F placed a gait belt on Resident #11 and staff transferred Resident #11 from the bed into the wheelchair. Surveyor # noted that the bed alarm did not sound. On 5/3/11 at 8:39 a.m., Surveyor # asked CNA-F to accompany Surveyor # to Resident #11's room and inquired why the bed alarm did not go off when she along with CNA-G transferred Resident #11 out of the bed into the wheelchair. CNA-F didn't know why. CNA-F checked the alarm and Surveyor # noted the cord was not plugged into where the alarm pad was. CNA-F stated, "I wonder if nights knew." Surveyor # informed CNA-F that when Surveyor was in a little after 7:00 a.m. the stand by light was lit. On 5/4/11 at 12:00 p.m., Surveyor # met with CC (Clinical Coordinator)-L to informed her that Surveyor # noted the care plan and CNA assignment sheet indicates that Resident #11 is to have a bed alarm and Surveyor # observed the bed alarm being on stand by when Resident #11 was in bed. On 5/4/11 at 3:15 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. 5. On 5/4/11 & 5/5/11, Surveyor # reviewed Resident #10's medical record which indicated Resident #10 is a [AGE] year old female readmitted to the facility on [DATE]. Resident #10's medical record indicates Resident #10 has a [DIAGNOSES REDACTED]. The care plan for "Resident #10's ability to perform ADLs (activities of daily living) has deteriorated r/t (related to) weakness secondary to generalized weakness, dementia and is easily fatigued" has a start date of 3/29/11. Approach include, "Staff will provide assistance per guidelines of PT(physical therapy)/OT (occupational therapy)/ST (speech therapy): refer to CNA (Certified Nursing Assistant) assignment sheet" has a start date of 3/29/11. Written next to the approach is a handwritten notation "2A (two assist)." The CNA (Certified Nursing Assistant) Assignment 3 sheet not dated provided to Surveyor # on 5/2/11 after the initial tour documents for Resident #10 under the section: Transfer/Mobility Device, "2A(assist) bed to w/c (wheelchair)." On 5/4/11 at 7:38 a.m., Surveyor # observed CNA-K position Resident #10 on the edge of the bed and place a gait belt on. CNA-K then asked Resident #10 if she was ready and told Resident #10 to give her a hug. CNA-K then stood Resident #10 up by holding onto the gait belt and transferred Resident #10 into the wheelchair from the bed. After Resident #10 was sitting in the wheelchair, CNA-K stated to Resident #10, "that wasn't too bad was it" and then asked Resident #10 to "scooch her bottom back a little." CNA-K placed a sweater on Resident #10 and attached the alarm to the back of the sweater. CNA-K transferred Resident #10 by herself and did not follow Resident #10's plan of care which was for two assist. On 5/4/11 at 11:14 a.m., Surveyor # observed CNA-K wheel Resident #10 into her room. CNA-K unhooked the chair alarm, lowered the bed, and asked Resident #10 if she wanted to get up for lunch. CNA-K removed the foot rest from the wheelchair, placed a gait belt on Resident #10 and transferred Resident #10 from the wheelchair into bed. After Resident #10 was in bed, CNA-K "that wasn't so good this time." Resident #10 responded "I know my feet slip and my legs hurt." CNA-K informed Resident #10, "you should have told me I would have gotten help." CNA-K transferred Resident #10 by herself and did not follow Resident #10's plan of care which was for two assist. On 5/5/11 at 9:17 a.m. Surveyor # asked CC (Clinical Coordinator)-L how staff should transfer Resident #10. CC-L replied, "Two assist bed to wheelchair and use a gait belt." Surveyor # informed CC-L of CNA-K transferring Resident #10 by herself. On 5/5/11 at 2:40 p.m. the Administrator and Director of Nursing were informed of the above.

Based on observation, record review, and staff interview the Facility did not ensure that 1(Resident #10) of 1 Residents who were hospitalized for [REDACTED]. Resident #10 was readmitted on [DATE] with a [DIAGNOSES REDACTED]. The nutrition assessment was incomplete in that the amount of fluids Resident #10 would require was not calculated. The 48 hour I & O (input and output) was not completed. The hydration/nutrition summary dated 3/19/11 did not address risk factors, intervention and monitoring criteria. From 3/15 through 3/24/11, the staff did not monitor Resident #10's fluid intake to ensure Resident #10's hydration. On 3/24/11, Resident was reamitted into the hospital for "Altered mental sustus. Suspected that this is due to dehydration, possibly due to poor intake. Findings include: On 5/5/11 Surveyor # reviewed the Facility's policy and procedure "Hydration/Nutrition" revised 12/10. Under standard documents, "Every individual admitted to the facility will be assessed with [REDACTED]. All residents at high risk will have interventions in place to prevent dehydration and/or inadequate nutrition." Under procedure the hydration risk assessment documents, "Hydration/Nutrition Screen (see attached copy) will be initiated within 24 hours of admission and every ARD period a. Hydration/Nutrition Screen will have a section completed by nursing and a second section to be completed by dietetic services b. A summary will be written by dietetic service to include a summary of risk factors, pertinent food and fluid needs, interventions, and monitoring criteria c. The assessment will be filed in the medical record under the flow sheet tab d. A hydration/nutrition care plan will be completed for all high risk residents e. Information from the Hydration/Nutrition Screen may be used to complete any corresponding CAA." Under Monitoring of Hydration Status: documents "Nursing will monitor food and fluid by: a. Recording food and fluid intake at meals on the ADL (activity daily living) flow sheet. These amounts will be listed on tray tickets to aid staff to correctly record intake at meals b. The ADL flow sheet is a permanent part of the medical record c. If staff, i.e. nurse, CNA, dietary, etc., notes a resident having a significant change in amount of food/fluids and/or poor fluid intake at meals over 48 hour period, the nurse will be notified. d. Once notified, the nursing staff will determine if the intake is due to: temporary condition which will require only additional monitoring over next 24 hours, condition requires immediate intervention such as, but not limited to, physical assessment for nutrition and/or hydration status, MD notification, labs, notification of nurse manager, dietetic services, and/or POA (power of attorney)/family 3. Dietetic services will monitor all residents by: a. Reviewing the ADL flow sheet and/or the meal percentage sheets on a weekly basis b. any pertinent change in the food and/or fluid intake will trigger further investigation on possible causes c. Chart notes will be completed if needed for updating hydration status or nutrition status d. Any change in interventions will be communicated to the interdisciplinary team. e. If hydration and/or nutrition status is deemed to have changed to high risk, MDS coordinator will be notified for possible COC (change of condition)." On 5/4/11 & 5/5/11, Surveyor # reviewed Resident #10's medical record & thinned medical record and noted the following: Resident #10 is a [AGE] year old female who was hosptalized on [DATE] to 3/15/11 and 3/24/11 to 3/29/11 with [DIAGNOSES REDACTED]. Comfort care measures were implemented on 3/31/11 for Resident #10. The CNA (Certified Nursing Assistant) Assignment 3 sheet not dated provided to Surveyor # on 5/2/11 after the initial tour documents for Resident #10 under the section Diet "general texture, thin liquid, assist with feeding." Resident #10's medical record and thinned medical record included the following: A hospital discharge summary dated 3/15/11 documents under final discharge diagnosis "Urinary tract infection with right hydro[DIAGNOSES REDACTED], [MEDICAL CONDITION], and dehydration with [MEDICAL CONDITION]." Under hospital course documents, "Dehydration, [MEDICAL CONDITION]. The patient was euvolemic throughout her hospital course. Upon admission she had clinical signs of dehydration. She was given gentle fluids upon admission." The readmission physician orders [REDACTED]. The nutrition/hydration plan of care dated 3/15/11 has goals of "Resident will consume 75% of each meal daily" and "Weight will remain stable" due to "Consumes less than 75%." Interventions checked and dated 3/15/11 are "Provide diet as ordered", "Monitor percentage of meals consumed, offer substitute if less than 75%" and "Monitor weights." Surveyor # noted the interventions of "Monitor for signs of dehydration" and "Provide fluids between meals and/or at bedside" are not checked as interventions implemented. The nutrition assessment for readmitted [DATE] is incomplete. The assessment does not have anything written for total calories, total protein, or total fluids that are required for Resident #10. Under the section risk factor the oral/nutrition intake: food and oral/nutrition intake: fluids has not been completed. The second page of the assessment has not been completed. The assessment does not have a signature or date. The nurses note dated 3/15/11 documents, "admitted from WAMH (West Allis Memorial Hospital) after being hospitalized for [REDACTED]." Surveyor # noted the only nurses notes that address fluids from 3/15/11 to 3/24/11 are nurses note dated 3/19/11 which documents "xtra (extra) fluids encouraged and tolerated well" and 3/23/11 which documents "drinking fluids ok." The treatment administration record documents I & O (intake and output) x 48 hours. This is signed as completed on 3/16/11 and 3/17/11. On 3/16/11, the intake and output record under the section oral intake is not filled out for nights and days. Evenings documents, "100 cc (cubic centimeters)." On 3/17/11, the oral intake is not filled out for nights, days documents "570 cc" and evenings "120 cc." Surveyor # reviewed the Facility's 24 hour nursing/supervisor report for Resident #10 on 5/5/11 and noted the following documentation: 3/15/11 Evening shift documents, "admitted from WAMH (West Allis Memorial Hospital) after being hospitalized for [REDACTED]. The night shift documents, "Alert & O (orientated ) x (times) 1. Picc line ok without c/o (complaints of) (except wants to go upstairs) inc. (incontinent) of urine." 3/16/11 Day shift documents "without problems", evening shift "without problems, alert & friendly" and night shift "sleeping well. Picc line ok. without c/o, pleasant & cooperative." There is no documentation regarding fluids. 3/17/11 Day shift documents "without problems", evening shift "without c/o pain, without issues reported" and night shift "ulcer coccyx healing, c/o cough, dimin (diminished) (L) (left), non prod. (productive) 94% RA (room air), x 1 BM (bowel movement) soft/green abd. (abdomen) dist. (distended) soft." There is no documentation regarding fluids. 3/18/11 There is no documentation for day or evening shift and night shift documents "Has slept well without c/o without cough, picc line ok." There is no documentation regarding fluids. 3/19/11 Day shift documents "cont. (continue) abt (antibiotic) for uti temp (temperature) wnl (within normal limits) (R) (right) Picc site CDI (clean dry intact) flushed per policy", evening shift "forgetful per usual, cont. abt. no s/s (signs/symptoms) adverse effects noted, denies pain, picc flushed per policy" and night shift "alert & o (oriented) to self & place. picc line ok without c/o dyspenia." There is no documentation regarding fluids. 3/20/11 Day shift documents "T97.6 picc (R) arm CDI without s/s inf. (infection) IV infused without problem" and there is no documentation for evening or night shift. There is no documentation regarding fluids. The hydration/nutrition screen summary of findings dated 3/19/11 documents, "97 y.o. (year old) resident hospitalized (3/8/11) r/t (related to) UTI, dehydration, weakness. Mild rehydration in hospital. Resident tolerates NAS (no added salt) diet with regular consistency. Encourage intake of food and fluid. Request rx to start [MEDICATION NAME] extra BID (twice a day) with med pass. Monitor tolerance for supplements." The summary does not address risk factors, interventions, and monitoring criteria. The nurses note dated 3/24/11 documents, "MD (Medical Doctor)-Y wants to send resident to hospital due to increased WBC (white blood cells) = 10.4, increased sodium = 148 and increased [DIAGNOSES REDACTED]s = 78, MD is concerned about her increased confusion, MD is sending her out for possible dehydration and infection. IV antibiotics were finished today for UTI. Picc was also d/c'd (discontinued old picc site dressing C/D/I. Supervisor will send resident out and notify family." The hospital history and physical exam for admitted [DATE] documents under assessment and plan "Altered mental status. Suspect that this is due to dehydration, possibly due to poor p.o. (by mouth) intake. Will hydrate patient with 0.9 Normal Saline, however, will have to be cautious as patient does have poor systolic function. Acute [MEDICAL CONDITION]. Suspect that this is due to dehydration as discussed above, will start on gentle hydration. [MEDICAL CONDITION] this goes along with patient's suspected dehydration as evidenced by dry mucous membranes on clinical exam. Will hydrate as discussed above. Dehydration. This is most likely due to poor p.o. intake at the nursing home. The patient will be started on 0.9 normal saline." Resident #10 was readmitted back to the facility on [DATE]. A nutritional assessment was completed for the readmission date of [DATE], assessing Resident #10's total daily fluid intake needs as 1775 cubic centerimeters (cc's). This nutritional assessment was not signed or dated. The nutrition care plan with a start date of 3/30/11 has a problem of "Resident #10 leaves 25% or more of food uneaten at meals." Approaches are "Diet General" with a start date of 3/30/11, "Provide supplement between meals (4oz [MEDICATION NAME] Extra)" with a start date of 4/5/11, "Monitor/record weight weekly. Notify MD and family of significant weight change" with a start date of 3/30/11, "Monitor and record intake of food" with a start date of 3/30/11 and "Provide nutrient dense foods and/or supplements with meals per dietary recommendations" with a start date of 4/7/11. The Facility did not implement a hydration care plan until 4/11/11. The problem, "At risk for fluid volume deficit r/t (related to) hx (history) of dehydration, decreased appetite and intake." Approaches which are not dated are "Evaluate factors that may impede ability to maintain fluid balance (e.g. [MEDICAL CONDITION], impaired decision making ability, comprehension/communication, body control, hand dexterity, constipation/impaction, swallowing, etc.)" and "Evaluate factors for dehydration (e.g. purposeful restriction of fluid intake, diarrhea, infection, fever, nausea, vomiting, excessive sweating, frequent laxative/enema/diuretic use, excessive urine output, etc.)" On 5/3/11 at 1:20 p.m., Surveyor # observed Resident #10 sitting in the dining room with her hand on her forehead. Resident #10 has not eaten or drank any of her lunch. At 1:45 p.m. CNA (Certified Nursing Assistant)-F approached Resident #10 and asked her if she was going to eat. CNA-F then stated, "you didn't eat your breakfast." Resident #10 then started to drink her coffee. On 5/5/11 at 9:46 a.m., Surveyor # interviewed CNM (Clinical Nutrition Manager)-T regarding Resident #10. CNM-T informed Surveyor # that they were just reviewing her chart yesterday because of weight loss. Surveyor # inquired if a Resident is on comfort care are their weights still obtained. CNM-T informed Surveyor # that weights have been taken on all Residents because there was a flu outbreak. CNM-T informed Surveyor # that if a Resident is on comfort care and is routinely getting up then weights are obtained on a monthly basis. Surveyor # informed CNM-T that Resident #10 had been readmitted with a [DIAGNOSES REDACTED]. Surveyor # asked how fluids were monitored for Resident #10 to ensure that she wouldn't become dehydrated. CNM-T informed Surveyor # that they look at the ADL (activities of daily living) flow sheet to see what Residents are consuming at their meals, they look at the person and see if anything is going on. Surveyor # inquired how often the ADL sheets are reviewed. CNM-T informed Surveyor # weekly. CNM-T informed Surveyor # that when Resident #10 returned from the hospital she wasn't herself, she wasn't eating or drinking even though she received different fluids at meals and preferred coffee. CNM-T explained that they also have a fluid pass program for Residents who are at risk. CNM-T explained that a list is sent to nursing and staff are to provide four to six ounces of fluids four times a day between meals. Surveyor # asked if staff are supposed to document how much a Resident consumes during the fluid pass. CNM-T informed Surveyor that staff just initial that they are giving the fluids. On 5/5/11 at 10:48 a.m., Surveyor # asked CC (Clinical Coordinator)-L if there is a list of Residents on the unit who are at high risk for dehydration and are on the fluid pass program. CC-L informed Surveyor # that she will have to ask dietary. On 5/5/11 at 10:50 a.m., Surveyor # interviewed DON (Director of Nursing)-B and RN (Registered Nurse)/DON (Director of Nursing)Vent-Z to inquire when would a Resident be considered at high risk for dehydration. Surveyor # was informed that Residents who come in with a current or history of dehydration, failure to thrive, [MEDICAL CONDITION], deconditioning would be examples. Surveyor # inquired how they monitor to ensure a Resident is not getting dehydrated. DON-B replied that they look at skin turgor, labs, meal intake, and if a Resident is on a diuretic they make sure they are hydrated. Surveyor # inquired if Resident #10 would have been considered for high risk when she returned from the hospital with a [DIAGNOSES REDACTED]. Surveyor # inquired who is responsible for monitoring the fluid intake for twenty four hours to ensure the fluids needs are being met. DON-B responded that dietary and nursing are. Surveyor # inquired who in nursing. DON-B informed Surveyor # that each shift should look at what the Resident has consumed the previous shift/shifts. On 5/5/11 at 11:02 a.m., Surveyor # met with CNM-T and DT (Dietetic Technician)-S regarding Resident #10. CNM-T informed Surveyor # that DT-S followed Resident #10. DT-S indicated that when Resident #10 came back from the hospital she was very confused, not eating, seeing people in her room, and needed help with eating. DT-S informed Surveyor # that she tried to feed her a couple times but she was bent over and didn't eat. DT-S stated on 3/20/11 they started [MEDICATION NAME] Extra and that the Resident was asking for a brandy old fashion but the doctor said no. DT-S stated that when Resident #10's brother would come in on the evening he would bring her hamburger and french fries but she would barely touch it. Surveyor # asked DT-S how she was monitoring Resident #10's fluid intake. DT-S informed Surveyor # that she would check on Resident #10, speak to nursing and review the CNA books. Surveyor # asked DT-S when Resident #10 returned on 3/15/11 with a [DIAGNOSES REDACTED]. DT-S did not respond. On 5/5/11 at 11:50 a.m., CNM-T and DT-S met with Surveyor # . CNM-T informed Surveyor # that Resident #10 was not eating or drinking, was very confused and that the Facility spoke with the family and the family decided no IV, tube feeding, or hospitalization . Surveyor # informed CNM-T that the Surveyor had noted this during record review but this was on 3/31/11 after the two hospitalization s. CNM-T stated that Resident #10 was on fluid pass but then this was switched to [MEDICATION NAME] extra. Surveyor # inquired when Resident #10 came back from the hospital on [DATE] was she on fluid pass. CNM-T informed Surveyor # that she wasn't sure if she was. Surveyor # informed CNM-T and DT-S that Surveyor # reviewed the ADL sheet and fluids given during med pass and noted: on 3/16/11 the fluid total was 790 cc, on 3/17/11 the fluid total was 930 cc, on 3/18/11 the fluid total was 660 cc, on 3/19/11 the fluid total was 620 cc, on 3/20/11 the fluid total was 830 cc, on 3/21/11 the fluid total was 680 cc, on 3/22/11 the fluid total was 550 cc on 3/23/11 the fluid total was 800 cc. Surveyor # informed CNM-T and DT-S that Surveyor # wasn't sure if this was what Resident #10 required as the required fluid intake was never calculated. CNM-T informed Surveyor # that "guess we need to relook at who's looking at it" and indicated that it needs to be better. Surveyor # informed CNM-T that it's the Surveyor's understanding that Dietary is looking at the ADL sheets weekly and nursing is documenting in the MAR (medication administration record) the amount of fluids they are giving during medication pass but who is looking at the amount the Resident is consuming each day. CNM-T responded "that's the missing link." Surveyor # noted Resident #10 was readmitted on [DATE] with a [DIAGNOSES REDACTED]. The nutrition assessment was incomplete in that the amount of fluids Resident #10 would require was not calculated. The 48 hour I & O (input and output) was not completed. The hydration/nutrition summary dated 3/19/11 did not address risk factors, intervention and monitoring criteria. From 3/15 through 3/24/11, the staff did not monitor Resident #10's fluid intake to ensure Resident #10's hydration. On 5/5/11 at 2:40 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above.