Every finding on record at Marquardt Memorial Manor

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are thoroughly investigated for 2 of 3 residents reviewed for abuse (R1 & R3).R1 reported verbally and in writing an allegation of neglect. The facility did not complete a thorough investigation of the allegation.CNA F (Certified Nursing Assistant) and CNA E heard R3 screaming from behind a closed door. When they entered they saw CNA H transferring R3 using a hoyer lift alone, without a second staff member. The facility did not complete a thorough investigation that included an interview by R3, interview with other residents, and skin assessments of non-interviewable residents.Evidenced by:Facility policy, titled Abuse, Neglect, Misappropriation of Resident Property, reviewed 2/11/26, includes: It is the policy of the facility that each resident will be free from abuse. Abuse is the willful infliction of injury, . intimidation, or punishment. includes verbal abuse, .mental abuse. Abuse also includes the deprivation by. caregiver or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Verbal abuse involves the use of speech, sound, writing, or gestures when communicating with a resident. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The investigation is the process used to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered will be given to the administrator. Investigation of abuse: When an incident or suspected incident of abuse is reported, the Executive or designee will investigate the incident with the assistance will investigate the incident with the assistance of appropriate personnel. The investigation will include: who was involved, residents' statements, for nonverbal residents, cognitively impaired residents or residents who refuse to be interviewed. Attempt to interview resident first. If unable, observe the resident, complete an evaluation of resident behavior, affect, and response to interaction, and document findings. Involved staff and witness statements of events. Injuries present including a resident assessment. A summary of the investigation will be submitted to the State agency within five working days of the initial report. It is the policy of the facility that the resident will be protected from the alleged offenders. Immediately upon receiving a report of abuse. Ensuring safety and well-being for the vulnerable resident is of utmost priority. Safety, security, and support or the resident. and other residents with the potential to be affected will be provided. The alleged perpetrator will immediately be removed and resident protected. If the alleged perpetrator is a facility staff resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator and wait for further instructions from administration. Examine, assess, and interview the resident and other residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary.Example 1R1 admitted to the facility on [DATE] with the following diagnoses: complex regional pain syndrome 1, Mononeuropathy, muscle wasting and atrophy, pruritus, and a need for assistance with personal care.R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/19/26 indicates R1's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15.R1's Comprehensive Care Plan, initiated 9/27/24, includes: Focus- R1 has an ADL (Activities of Daily Living) self-care performance deficit related to weakness, . right mandibular osteomyelitis with teeth extraction, . alcohol hepatitis. Interventions- toilet use: 2 staff assist. bed mobility- 2 staff assist. transfer- 2 staff assist with hoyer.R1's Grievance Form, dated 4/4/26, includes: Individual or Individual Representative initiating the grievance: Individual. Concern received in what form: writing. Does the Individual identify this event as abuse, neglect, or misappropriation: Yes. Describe concern using factual terms: CNA H. 1.25 hours for a bed pan change. Questioned me on re-wearing a clearly soiled brief. Spilled bed pan. Brought wrong color sling. Did not check for all strapped into sling before lifting hoyer. Attempted to lift me out of bed without pants despite me wearing them in the morning. Pants around my ankles. I had asked her why everything was wet at least 4 times before she said the bed pan spilled. Then did not re-clean the skin after laying on wet pad for 10 minutes while she got a new pad and sling. Overall careless. Additionally her hygiene is poor. She has bad body odor. I could smell it after she left my room. Typically, toileting takes 20 minutes from start to finish and supplies are gotten while I am using the bedpan. She used an hour more than necessary. Previously she offered me BioFreeze roll-on as deodorant and argued with me about it's purpose. NHA A statement: Writer received voicemail at 1:10 PM on Saturday, April 4, 2026, from R1's representative stating, Received disturbing phone call from R1. Um she was blatantly neglected by your caregiver. who my mother described left her on the bed pan with urine and feces for over an hour and a half and then would not let her get dressed before getting her up in the hoyer. Please I expect a call back no later than 24 hours, by Monday at the latest. This is unacceptable. Writer returned phone call at 1:15 PM. Writer thanked resident representative for calling and advocating for R1 and describing details of the incident resulting in allegations of neglect. Explained. next steps that writer will be taking in pursuit of allegation of neglecting R1, investigation including to first suspend CNA H from caregiving pending investigation to ensure safety and security of residents.Facility Self Report, submitted 4/5/26, includes: Brief Summary of Incident- In R1's words on receipt of Grievance, Saturday, 4/4/26: Took 1.25 hours for a bed pan change. Questioned me on re-wearing a clearly soiled brief. Spilled bed pan. Brought wrong color sling for lift. Did not check for all strapped into sling before lifting hoyer. Attempted to lift me out of bed without pants despite me wearing them in morning. Pants around my ankles. I had asked her why everything was wet at least 4 times before she said the bed pan spilled. Then did not re-clean the skin after laying on wet pad for 10 minutes while she got a new pad and sling. Overall careless. Additionally her hygiene is poor. She has bad body odor. I could smell it after she left my room. Typically, toileting takes 20 minutes from start to finish and supplies are gotten while I am using the bedpan. She used an hour more than necessary. Previously she offered me BioFreeze roll-on as deodorant and argued with me about it's purpose. R1 identified this event, and checked the box on the written Grievance form as Abuse, Neglect, Misappropriation. Writer also received a phone call on Saturday 4/4/26 from the daughter of R1, at 1:10 PM describing that she had received a very disturbing phone call from my mother. in your facility. Um she was blatantly neglected by your caregiver. who my mother described left her on the bed pan with urine and feces for over an hour and a half and then would not let her get dressed before getting her up in the hoyer. Law Enforcement was not contacted. Writer immediately left home and reported to the facility by 1:45 PM on 4/4/26. Writer met with staff and suspended the accused immediately pending further investigation to protect both R1 as well as other residents under the accused staff's care in the future if investigation substantiates accusations of neglectful caregiver conduct. Briefly explain the incident- On Saturday, April 4, 2026, R1 received cares and services from CNA H. Alleged by R1 and supported by witness statements of other CNAs working the shift, that appear to have met the State of Wisconsin Office of Caregiver Quality definition of Neglect. Describe the effect that the incident had on the affected person: The incident caused much anger and frustration and humiliation to R1 per her description, which manifested through many tears and sadness. Explain the steps the entity took upon learning of the incident to protect the affected person or persons and others from potential misconduct: Immediately upon learning of incident, writer left home. It was a Saturday. and went to the facility to speak with CNA H in the presence of RN D (Registered Nurse). Informed CNA H of the receipt of grievance and phone call from R1's Representative. Informed CNA H of writer's obligation to suspend CNA H pending further investigation to ensure the safety and security of the resident alleging neglect by her, as well as to ensure that all other residents in the facility are safe and secure. Before gathering her personal belongings, RN D handed writer the letter that CNA H handed her earlier which stated that she was resigning effective immediately. RN D's Witness Statement, dated 4/5/26, includes: While I was providing cares to a resident, CNA F instructed me to go to R1's room. Upon arrival, I observed R1 is on the phone talking with her family member; visibly upset and crying. CNA E was also present in the room. After ending the call, R1 explained the situation regarding an incident involving CNA H. R1 reported that CNA H used a hoyer lift with an incorrect sling size and applied the sling improperly. She also stated that during care CNA H accidentally tipped over a bed pan containing urine and feces onto the bed. Although CNA H cleaned the bed afterwards, R1 reported that her back was not cleaned following the incident, which caused her to be significantly upset, distressed, and frustrated.CNA E's Witness Statement, dated 4/5/26, includes: Upon entering the dining room on 4/4/26 I saw R1 crying. I gave her a side hug and asked what was going on. She proceeded to tell me that she had a bad experience with CNA H. I asked her what happened and it was quite a long list. For starters she said she was on the bedpan for over an hour and a half and it typically takes about 20 minutes. She had then stated CNA H held her dirty brief up to her and asked if it was still good to wear. R1 obviously declined to wear it. CNA H then tried putting R1 into sling with her pants still down by her ankles. While getting her up she was trying to convince R1 to use BioFreeze roll on for deodorant. By the time R1 was able to get down to the dining room she was in full tears and almost missed lunch. Also when getting ready to transfer R1, CNA H did not put the straps on to the lift and R1 had to tell CNA H to do it. When taking out the bedpan she spilled it into the bed and refused to tell R1 what happened until like the fourth time she asked. I did not actually see any of this happen but was told.Med Tech G's Witness Statement, dated 4/5/26, includes: Yesterday on 4/4/26 when I was in the dining room for lunch, I was informed about CNA H that she transferred R3 by herself and R3 was screaming and crying about it. I told the other aides they needed to report it. I was also informed about her transferring R1 by herself and R1 was very upset and did not feel safe with CNA H. I didn't actually see any of it happen, but was told by R1, R3, and staff.CNA E's Witness Statement, dated 4/5/26, includes: I saw CNA H self-transfer R3 and R1 in and out of bed. When we saw this CNA F and I went to Nurse Supervisor I to let her know that CNA H was self-transferring. Before she started to transfer R3, CNA F asked her if she needed help with her and she said No, I got it. And closed the door. I was working with another resident when all of a sudden I heard R3 screaming Help me, and Oww. So I ran over to see her in bed and CNA H was unhooking her from the hoyer.CNA F's Witness Statement, dated 4/4/26, includes: I heard R1 crying. I asked her what was wrong and gave her a hug. She said she never was treated so badly in her life. That CNA H left her on the bed pan for an hour, used BioFreeze as deodorant. She didn't know how to use the lift. Put a dirty pad in her face. Spilled the bedpan in bed and wasn't going to clean her. I didn't actually see any of this happen.(It is important to note CNA H is accused of putting a dirty pad in R1's face, treating her badly, using BioFreeze for deodorant, not cleaning R1, and leaving her on a bed pan for an hour.)CNA E's Witness Statement, dated 4/4/26, includes: On Saturday, April 4, I heard R3 screaming at the time CNA H was putting her to bed by herself. I asked if she needed help and CNA H responded, No. She also transferred R1 by herself. I did report it to Nurse Supervisor I.Nurse Supervisor I's Witness Statement, dated 4/9/26, includes: On Saturday April 4th, I had been working. when 2 staff members had approached me about some issues that happened with CNA H. The first incident happened when one of the staff heard R3 scream/yell loudly from her room. She had gone into her room to find R3 was in the lift and sling and was sitting on bed leaning to the left side. CNA H was asked if she needed any help and CNA H had stated no that she was ok now. I had gone to talk to CNA H after hearing the report of the one person transfer. I had reminded CNA H to stick to her assignment, to follow resident care plans, and to use proper procedure for transfers. Later staff noted R1 in the lunchroom sobbing and had asked her what was wrong. She too had been very roughly handled by CNA H. Her cares had been done poorly and she too had also been transferred alone with a hoyer.(It is important to note this investigation does not include interviews of R1, R3, other residents who were cared for by CNA H this shift, and it does not include assessments of non-interviewable residents who also may have been affected by CNA H's conduct.)On 7/1/26 at 12:30 PM NHA A (Nursing Home Acting Administrator) indicated she is not a licensed NHA, rather she is an Interim Acting Administrator while she waits for INHA C (Interim Nursing Home Administrator) to take her last test. NHA A indicated this was an allegation of neglect that she thought affected one resident. NHA A indicated she did not get interviews by other residents that CNA H cared for that night and she did not have the nursing staff perform skin checks on the non-interviewable residents. NHA A indicated she did not get a statement by or conduct an interview with R3. NHA A indicated she did not get a statement by R1 about how this incident made her feel. NHA A indicated a thorough investigation was not completed and should have been. NHA A indicated she talked with the IDT (Interdisciplinary Team) about this situation and the team thought since CNA H resigned the residents were not in any more danger and there were no lingering concerns so nothing more needed to be done.On 7/1/26 at 1:39 PM INHA C (Interim Nursing Home Administrator) and DON B (Director of Nursing) indicated the investigation was not thorough and should have included interviews by other residents, including R3, and skin checks of the non-interviewable residents. Example 2(A second incident involving R3 was reported through written statements during the facility's self report investigation for R1.)R3 admitted to the facility on [DATE] with the following diagnoses: Rheumatoid arthritis, polyneuropathy, Non-[NAME] Lymphoma, Osteoarthritis, and dependence on other enabling machines and devices.R3's most recent MDS with ARD of 5/27/26 indicates R3's cognition is intact with a BIMS score of 13 out of 15.R3's Comprehensive Care Plan, initiated 5/13/24, includes: Focus- R3 has an ADL (Activities of Daily Living) self-care performance deficit related to weakness. Interventions- bed mobility: 2 staff assist. toileting- 2 staff assist. transfer- 2 staff assist with hoyer.CNA F's Witness Statement, dated 4/4/26, includes: On Saturday, April 4, I heard R3 screaming at the time CNA H was putting her to bed by herself. I asked if she needed help and CNA H responded, No. She also transferred R1 by herself. I did report it to Nurse Supervisor I.CNA E's Witness Statement, dated 4/5/26, includes: I saw CNA H self-transfer R3 and R1 in and out of bed. When we saw this CNA F and I went to Nurse Supervisor I to let her know that CNA H was self transferring. Before she started to transfer R3, CNA F asked her if she needed help with her and she said No, I got it. And closed the door. I was working with another resident when all of a sudden I heard R3 screaming Help me, and Oww. So I ran over to see her in bed and CNA H was unhooking her from the hoyer.Nurse Supervisor I's Witness Statement, dated 4/9/26, includes: On Saturday April 4th, I had been working. when 2 staff members had approached me about some issues that happened with CNA FAI. The first incident happened when one of the staff heard R3 scream/yell loudly from her room. She had gone into her room to find R3 was in the lift and sling and was sitting on bed leaning to the left side. CNA H was asked if she needed any help and CNA H had stated no that she was ok now. I had gone to talk to CNA H after hearing the report of the one person transfer. I had reminded CNA H to stick to her assignment, to follow resident care plans, and to use proper procedure for transfers. Later staff noted R1 in the lunchroom sobbing and had asked her what was wrong. She too had been very roughly handled by CNA H. Her cares had been done poorly and she too had also been transferred alone with a hoyer.(It is important to note R3 is heard screaming, Help me, and Oww. behind her closed bedroom door. The facility failed to investigate this incident thoroughly by interviewing R3 and other residents who CNA H cared for during this shift and by completing skin assessments on non-interviewable residents.)On 7/1/26 at 12:30 PM NHA A (Nursing Home Acting Administrator) indicates she did not include R3 in this report as an affected person and she should have. NHA A indicated hearing a resident screaming behind a closed door and/or yelling, Help Me, and Oww, would make her suspicious of abuse. NHA A indicated she should have interviewed R3 as part of the investigation. NHA A indicated she is unsure how many residents were affected because she did not interview other residents and did not complete skin assessments on non-interviewable residents. NHA A indicated staff get annual abuse training, but there was no house wide abuse training offered after this incident. NHA A indicated she did not follow the facility's abuse policy and procedure but should have. NHA A indicated she has not had the proper training to be an Administrator and was put in the role to act as Administrator until INHA C (Interim Nursing Home Administrator) takes her last test.On 7/1/26 at 1:39 PM INHA C and DON B (Director of Nursing) indicated if staff hear a resident screaming, Help me, and Oww, they should intervene immediately and stay with the resident until they know the resident is safe. DON B indicated staff should have removed CNA H from the room and took over cares with R3. INHA C and DON B indicated this is a second allegation of abuse against CNA H and the facility should have conducted a thorough investigation and educated staff on the abuse policy and procedure after this incident.

Based on observation, interview, and record review the facility did not ensure the resident environment remains as free of accidents/hazards as is possible for 2 of 3 sampled residents (R1, R3) reviewed for accidents/hazards.CNA H (Certified Nursing Assistant) transferred R1 and R3 alone using a hoyer lift, while the facility policy is to have 2 staff when using the hoyer lift.Evidenced by:Facility policy titled Full Body Lift, undated, includes: . At all times full body lifts are two staff transfers.CNA D's Witness Statement, dated 4/5/26, includes:. Upon arrival I observed R1 is on the phone talking with her daughter; visibly upset and crying. CNA E was also present in the room. After ending the call, R1 explained the situation regarding an incident involving CNA H, R1 reported that CNA H used a hoyer lift with an incorrect sling size and applied the sling improperly. She also stated that during care, CNA H accidentally tipped over a bedpan containing urine and feces onto the bed. Although CNA H cleaned the bed afterward, R1 reported that her back was not cleaned following the incident, which caused her significant upset, distress, and frustrated.CNA E's Witness Statement, dated 4/5/26, includes: . when getting ready to transfer R1, CNA H did not put the straps on to the lift and R1 had to tell CNA H to do it.Med Tech G's Witness Statement, dated 4/5/26, includes: Yesterday on 4/4/26 when I was in the dining room for lunch, I was informed about CNA H that she transferred R3 by herself and R3 was screaming and crying about it. I told the other aides they needed to report it. I was also informed about her transferring R1 by herself and R1 was very upset and did not feel safe with CNA H. I didn't actually see any of it happen, but was told by R1, R3, and staff.CNA E's Witness Statement, dated 4/5/26, includes: I saw CNA H self-transfer R3 and R1 in and out of bed. When we saw this CNA F and I went to Nurse Supervisor I to let her know that CNA H was self-transferring. Before she started to transfer R3, CNA F asked her if she needed help with her and she said No, I got it. And closed the door. I was working with another resident when all of a sudden I heard R3 screaming Help me, and Oww. So I ran over to see her in bed and CNA H was unhooking her from the hoyer.CNA F's Witness Statement, dated 4/4/26, includes: On Saturday, April 4, I heard R3 screaming at the time CNA FAI was putting her to bed by herself. I asked if she needed help and CNA H responded, No. She also transferred R1 by herself. I did report it to Nurse Supervisor I.Nurse Supervisor I's Witness Statement, dated 4/9/26, includes: On Saturday April 4th, I had been working. when 2 staff members had approached me about some issues that happened with CNA H. The first incident happened when one of the staff heard R3 scream/yell loudly from her room. She had gone into her room to find R3 was in the lift and sling and was sitting on bed leaning to the left side. CNA H was asked if she needed any help and CNA H had stated no that she was ok now. I had gone to talk to CNA H after hearing the report of the one person transfer. I had reminded CNA H to stick to her assignment, to follow resident care plans, and to use proper procedure for transfers. Later staff noted R1 in the lunchroom sobbing and had asked her what was wrong. She too had been very roughly handled by CNA H. Her cares had been done poorly and she too had also been transferred alone with a hoyer.On 7/1/26 at 1:39 PM INHA C (Interim Nursing Home Administrator) and DON B (Director of Nursing) indicated all hoyer lift transfers are to be done with 2 staff assisting. INHA C and DON B indicated they should have educated all staff who use the lifts after CNA H (Certified Nursing Assistant) was found to be hoyer transferring R1 and R3 alone. DON B indicated staff should intervene if they observe another staff member using a hoyer lift alone.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to 72 of 73 residents residing in the facility (1 resident was fed via tube). The microwave in the main kitchen was not in a clean condition. Staff did not test the water temperature of the sanitizing solution in the sanitizer buckets or test the sanitization level in the three-compartment sink per manufacturer's recommendations. Staff did not complete appropriate hand hygiene and safe food handling practices while serving food. Findings include: On 2/23/26 at 10:21 AM, Surveyor completed an initial tour of the kitchen with Food Services Director (FSD)-L and Dietary Manager (DM)-M who stated the facility follows the Wisconsin Food Code. Microwave Cleanliness: The Wisconsin Food Code documents at 4-602.12 Cooking and Baking Equipment: (A) The food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours .(B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. During an initial tour of the kitchen that began at 10:21 AM on 2/23/26, Surveyor and DM-M observed the microwave in the main kitchen and noted dried food debris on the interior ceiling of the microwave. DM-M stated the microwave should be cleaned daily. Sanitizing Solution: The Wisconsin Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure .(K) Employees are properly sanitizing cleaned multi-use equipment and utensils before they are reused through routine monitoring of solution temperature and exposure time for hot water sanitizing and chemical concentration, pH, temperature, and exposure time for chemical sanitizing. The Wisconsin Food Code documents at 4-501.116, Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Hydrion QT-40 test strips: Product directions state the test solution should be between 65 and 75 degreess Fahrenheit (F). On 2/25/26 at 7:45 AM, Surveyor toured the facility's off-site kitchen. Surveyor reviewed logs that contained parts per million (PPM) for the sanitizing solution in the sanitizing buckets and three-compartment sinks. The logs did not include temperature monitoring. On 2/25/26 at 7:45 AM, Surveyor interviewed FSD-L who verified the facility uses Hydrion QT-40 strips to test the sanitizing solution. FSD-L stated staff test the water temperature by placing a hand in the water to ensure it appears to be room temperature. FSD-L stated staff do not use a thermometer to ensure the water temperature meets the manufacturer's recommendations. Hand Hygiene: The Wisconsin Food Code documents at Chapter 2 Personal Cleanliness 2-301.14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11 (B); (D) Except as specified in 2-401.11 (B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before putting on gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. The facility's undated Hand Washing policy states hand washing should occur .After touching bare human body parts other than clean hands and clean, exposed portions of arms .After handling soiled equipment or utensils .During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; When switching between working with raw food and working with ready-to-eat food; Before donning gloves for working with food; After engaging in other activities that contaminate the hands. On 2/24/26 at 11:00 AM, Surveyor observed lunch and tray line service. During tray line service, Surveyor observed Dietary Aide (DA)-N change gloves five times without completing hand hygiene. DA-N touched toasted garlic bread and noodles with gloved hands, and touched utensils, countertops, and meal slips without completing hand hygiene. Surveyor also observed DA-O open cooler doors with gloved hands and grab ready-to-eat food, including cheese, lettuce, and bacon, and put the ready-to-eat food on residents' plates. DA-O did not change gloves or complete hand hygiene. Surveyor observed DA-O repeat the process two more times. On 2/24/26 at 11:31 AM, Surveyor interviewed FSD-L and DM-M who stated it is ideal for staff to use tongs when working with ready-to-eat food; however, staff can touch ready-to-eat food with gloved hands provided they complete appropriate hand hygiene. FSD-L stated staff should complete hand hygiene prior to donning gloves and between glove changes. FSD-L stated glove should be changed if they are contaminated, visibly soiled, or between tasks.

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. Three of 6 medication carts were observed unlocked and unattended. In addition, 2 of 6 medication carts and 1 of 2 medication storage rooms contained expired medication and medical supplies. This practice had the potential to affect more than 4 of the 73 residents residing in the facility. Medication carts on the 400 and 200 wings were unlocked and unattended. Medication carts and the medication storage room on the 200 and 400 wings contained expired medication and medical supplies. Findings include: The facility's Medication Storage policy, dated 5/2018, indicates: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication (such as medication aides) are permitted to access medication. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access .H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory .Expiration Dating (beyond-use dating): .C. Certain medication or package types, such as intravenous (IV) solutions, multiple dose injectable vials .once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency . Medication Carts: On 2/24/24 at 8:32 AM, Surveyor observed a medication cart that was unlocked and unattended on the 400 wing. The front of the medication cart faced the hallway while Nurse Extern (NE)-I was in a resident's room. On 2/24/26 at 8:36 AM, Surveyor interviewed NE-I who verified medication carts should be locked when unattended. On 2/24/26 at 9:14 AM, Surveyor noted the 400 and 500 wing medication cart was unlocked and licensed staff were not in the area. A Certified Nursing Assistant and Housekeeping staff were in the nurses' station. On 2/24/26 at 10:37 AM, Surveyor noted the 100, 200, and 300 wing medication cart was unlocked in the nursing station and licensed staff were not present. Surveyor observed a resident roaming the area in a wheelchair. On 2/24/26 at 9:20 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who stated the medication cart was only left open when LPN-D was in the area. LPN-D verified LPN-D left the desk for a brief period to attend to a resident. LPN-D verified medication carts should be locked when unattended. On 2/25/26 at 1:16 PM, Surveyor interviewed Director of Nursing (DON)-B who stated medication carts should be locked at all times when not in sight of licensed staff. Expired and Unlabeled Medication and Supplies: On 2/24/26 at 2:11 PM, Surveyor observed 1 of 2 medication treatment carts and 1 of 2 medication storage rooms and noted the following: 400 Wing Registered Nurse (RN) Medication/Treatment Cart: ~ An open vial of insulin for R3 without an open or use-by date ~ A tube of Desenex for R52 with an expiration date of 12/2025 ~ Three DermaView adhesive dressings with expiration dates of 10/2019 On 2/24/26 at 2:16 PM, Surveyor interviewed RN-J who verified the undated and expired medications/dressings in the medication/treatment cart. RN-J indicated staff should label insulin vials with an open/use-by date when the vial is opened. 400 Wing Medication Technician (MT) Medication Cart: ~ Albuterol inhalers for R70 with expiration dates of 2/2025 and 12/2025~ Nine Aspercreme lidocaine patches for R56 with expiration dates of 12/2025 400/500 Wing Medication Storage Room: ~ Two oxygen tubings dated 11/2025~ One container of Clorox wipes with an expiration date of 8/2021~ One box of adhesive remover with an expiration date of 2/2025~ Four bottles of lubricant with expiration dates of 9/2024~ One bottle of Hibiclens antiseptic skin cleanser with an expiration date of 1/2026~ One 14 French catheter with an expiration date of 2/1/26~ Thirteen COVID-19 tests with expiration dates of 10/2025~ Twenty COVID-19 tests with expiration dates of 1/2023 On 2/24/26 at 2:26 PM, Surveyor interviewed MT-K who verified the above findings and indicated inhalers are good for 30 days post opening. On 2/25/26 at 1:16 PM, Surveyor interviewed DON-B who stated staff should monitor medication carts and storage rooms to ensure expired medications and supplies are removed timely. DON-B verified staff should label an insulin vial with an open and use-by date when the vial is opened.

Based on staff, resident, and resident representative interview and record review, the facility did not ensure 5 residents (R) (R11, R36, R13, R39, and R80) of 6 sampled residents received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, name and address (mailing and email) with telephone number of the office of the state long-term care Ombudsman plus notification of discharge/transfer to the Ombudsman. In addition, the facility did not ensure residents received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility.R11 was transferred to the hospital on 1/24/26. R11 was not provided with a written bed hold or transfer notice. R36 was transferred to the hospital on 1/27/26. R36 was not provided with a written bed hold or transfer notice. R13 was transferred to the hospital on 1/16/26. R13's representative was not provided with a written bed hold or transfer notice.R39 was transferred to the hospital on [DATE]. R39 was not provided with a written bed hold or transfer notice.R80 was transferred to the hospital on [DATE] and 12/1/25. R80 was not provided with written bed hold or transfer notices.Findings include: The facility's undated Individual Bed Hold policy and procedure indicates: The individual, Guardian, and/or individual representative will be informed upon admission and/or hospital/therapeutic leave of their bed hold options at the facility .B. Upon transfer to the hospital and/or therapeutic leave: 1. The individual will be informed and receive a copy of the bed hold procedure and letter. 2. Options will be given for a decision to be made regarding bed hold status. 3. If the individual is unable to make their preference known, the designee will contact the Guardian and/or individual representative to determine preference. 4. The response will be documented. 5. A Life Coach or designee will contact the individual representative on the next working day to ensure the representative understands the bed hold and return to facility information. The facility's undated Individual Transfer and Discharge policy and procedure indicates: .A. Acceptable conditions for transfer or discharge from the facility: 1. Upon the request or with the informed consent of the individual or Guardian .3. If the individual requires care other than that which the facility is licensed to provide or does not provide. 4. For medical reasons as ordered by a physician. 5. In case of a medical emergency .B. Notice: 1. The individual, the individual's physician, Guardian, relative, or other individual representative will receive a written notice including the reason for the transfer .2. The notice shall contain the name, address, and telephone number of the Board on Aging and Long-Term Care . 1. From 2/23/26 to 2/25/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had a diagnosis of congestive heart failure. R11's Minimum Data Set (MDS) assessment, dated 12/6/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 had intact cognition. R11 was responsible for R11's healthcare decisions. R11's medical record indicated R11 was transferred to the hospital on 1/24/26 due to vomiting. R11's medical record did not contain a written bed hold or transfer notice. On 2/23/26 at 1:12 PM, Surveyor interviewed R11 who indicated R11 did not feel well and vomited. R11 went to the hospital and was not sure if R11 received a written bed hold or transfer notice. (See interview under example 2.) 2. From 2/23/26 to 2/25/26, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had a diagnosis of congestive heart failure. R36's MDS assessment, dated 2/19/26, had a BIMS score of 15 out of 15 which indicated R36 had intact cognition. R36 was responsible for R36's healthcare decisions. R36's medical record indicated R36 was transferred to the hospital on 1/27/26 due to a urinary tract infection (UTI) and pneumonia. R36's medical record did not contain a written bed hold or transfer notice. On 2/24/26 at 4:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Regional Nurse Consultant (RNC)-C regarding the facility's bed hold policy and transfer notices. NHA-A and RNC-C indicated the facility did not have bed hold or transfer notices for R11 and R36. NHA-A and RNC-C indicated it was an area the facility needed to work on and confirmed written bed hold and transfer notices should have been provided. 3. From 2/23/26 to 2/25/26, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, diabetes, and chronic kidney disease. R13's most recent MDS assessment, dated 1/6/26, had a BIMS score of 0 out of 10 which indicated R13 had severe cognitive impairment. R13 had a Power of Attorney ((POA)-H) who was responsible for R13's healthcare decisions. R13's medical record indicated R13 was transferred to the hospital on 1/16/26 after a fall. R13's medical record did not contain a written bed hold or transfer notice. On 2/23/26 at 11:03 AM, Surveyor interviewed POA-H who did not recall if POA-H was given a written bed hold or transfer notice for R13's hospital transfer. (See interview under example 4.) 4. From 2/23/26 to 2/25/26, Surveyor reviewed R39's medical record. R39 was admitted to the facility on [DATE] and had diagnoses including pneumonia, depression, and anxiety. R39's most recent MDS assessment, dated 1/13/26, had a BIMS score of 8 out of 10 which indicated R39 had moderate cognitive impairment. R39 was responsible for R39's healthcare decisions. R39 was transferred to the hospital on [DATE] for a gastrointestinal (GI) bleed. R39's medical record did not contain a written bed hold or transfer notice. On 2/24/26 at 8:04 AM, Surveyor interviewed R39 who did not recall if R39 received a written bed hold or transfer notice. On 2/24/26 at 4:20 PM, Surveyor interviewed NHA-A and RNC-C regarding the facility's bed hold policy and transfer notices. NHA-A and RNC-C indicated it was an area the facility needed to work on and confirmed written bed hold and transfer notices should have been provided. 5. From 2/23/26 to 2/25/26, Surveyor reviewed R80's medical record. R80 was admitted to the facility on [DATE] and had diagnoses including pleural effusion and pulmonary embolism. R80's MDS assessment, dated 10/7/25, had a BIMS score of 6 out of 15 which indicated R80 had severely impaired cognition. R80 had a Power of Attorney for Healthcare (POAHC) who assisted R80 with healthcare decisions. R80's medical record indicated R80 was hospitalized twice while in the facility. The first hospitalization was from 10/22/25 to 11/2/25 and the second hospitalization started on 12/1/25. R80 did not return to the facility. R80's medical record did not include written bed hold or transfer notices. On 2/25/26 at 12:17 PM, Surveyor interviewed NHA-A who confirmed the facility did not have a written bed hold or transfer notice for either of R80's hospitalizations. NHA-A acknowledged the facility's previous process for bed hold and transfer notices was insufficient and did not follow regulations.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R68) of 6 sampled residents.During the provision of incontinence care for R68, Certified Nursing Assistant (CNA)-F did not complete hand hygiene after removing soiled gloves.During the provision of incontinence care for R68, CNA-G did not wear a gown, appropriately change gloves, or complete hand hygiene after removing soiled gloves. Findings include: The facility's Hand Hygiene policy, revised 12/5/24, indicates: Hand hygiene should be completed before moving from work on a soiled body site to a clean body site on the same resident, after contact with bodily fluids, and immediately after glove removal. The facility's Enhanced Barrier Precautions (EBP) policy, revised 2/6/25, indicates: For residents for whom EBP is indicated, a gown and gloves should be worn when completing high-contact resident cares such as dressing, bathing, providing hygiene, changing linens, and changing briefs. On 2/24/26, Surveyor reviewed R68's medical record. R68 was admitted to the facility on [DATE] and had diagnoses including spastic quadraplegic cerebral palsy, epilepsy, severe intellectual disability, cachexia, and weakness. R68's most recent Minimum Data Set (MDS) assessment, dated 2/13/26, indicated R68 had severe cognitive impairment, had a feeding tube, and was always incontinent of bowel and bladder. A care plan, revised 2/14/26, indicated R68 had a history of urinary tract infections (UTIs) and was on EBP related to a feeding tube. On 2/24/26 at 1:34 PM, Surveyor observed CNA-F provide incontinence care for R68 who was incontinent of urine. CNA-F provided care, removed gloves, and donned clean gloves before putting a clean brief on R68 and changing R68's linens. CNA-F did not complete hand hygiene after removing soiled gloves. On 2/24/26 at 2:02 PM, Surveyor interviewed CNA-F who verified CNA-F should have completed hand hygiene after removing soiled gloves and prior to donning clean gloves. On 2/25/26 at 8:47 AM, Surveyor observed CNA-G provide incontinence care for R68 who was incontinent of bowel. CNA-G did not wear a gown during cares. CNA-G provided care, changed R68's linens, touched items in R68's closet, and touched soiled linen carts outside R68's room before removing gloves. CNA-G did not complete hand hygiene prior to touching another resident's wheelchair and wheeling the resident to the nurses' station. CNA-G completed hand hygiene at the nurses' station. On 2/25/26 at 9:14 AM, Surveyor interviewed CNA-G who verified CNA-G should have worn a gown during incontinence care and should have changed gloves and washed hands when moving from dirty to clean areas. On 2/25/26 at 11:20 AM, Surveyor interviewed Director of Nursing (DON)-B and Registered Nurse Consultant (RNC)-C regarding proper infection control practices during cares. DON-B verified staff should complete hand hygiene after removing soiled gloves and should change gloves after completing perineal care for an incontinent resident before doing anything else. RNC-C verified staff should wear gloves and a gown during high-contact cares for residents on EBP.

Based on observation, staff interview, and record review, the facility did not incorporate recommendations from a Pre-admission Screening and Resident Review (PASRR) Level II and PASRR evaluation report into the plan of care for 1 resident (R) (R68) of 5 sampled residents . R68's PASRR Level II Screen indicated R68 required specialized services. A PASRR evaluation stated staff should focus on sensory stimulation activities, socialization, and recreational opportunities to benefit R68's social development. An activities note for R68 indicated R68 should be provided with fidget objects and sensory items. On 2/23/26, 2/24/26, and 2/25/26, R68 was observed in R68's room with the lights down and blinds closed. R68 did not have any sensory stimulation objects and was not invited to any activities during that time period.Findings include:From 2/23/26 to 2/25/26, Surveyor reviewed R68's medical record. R68 was admitted to the facility on [DATE] and had diagnoses including spastic quadriplegia cerebral palsy, epilepsy, severe intellectual disability, cachexia, and weakness. R68's most recent Minimum Data Set (MDS) assessment, dated 2/13/26, indicated R68 had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs), including transfers, bed mobility, and hygiene.A care plan, revised 2/14/26, indicated R68 had the potential for decreased socialization due to health status and needed specialized services. The goal was to fill leisure time with watching TV, listening to music, people watching, participating in games as able, enjoying objects such as crinkly books, and being around animals as able. The care plan contained the following interventions: Sensory 1:1 visits as able; Assist with obtaining in-room leisure items such as music and safe sensory objects; Invite to music/social events, sensory programs, games (especially tossing games), and religious programs as able; Offer in-room entertainment, music activities, spiritual activities, and pet visits as able.R68's most recent PASRR Level II assessment, dated 7/17/25, indicated R68 required specialized services for a developmental disorder of speech and language and severe intellectual disabilities. The focus of specialized services was to maintain or improve R68's current level of functioning and indicated opportunities for sensory stimulation, socialization, and leisure should be continued. The Qualified Intellectual Disability Professional (QIDP) indicated staff should focus on sensory stimulation activities, socialization, and recreational opportunities to aide in R68's social development and vocational skills.A behavior note, dated 12/18/25, indicated R68 was alert and enjoyed independently manipulating leisure objects, passively participated in and observed activities around R68, and was at times playful and interactive and threw things. The note indicated R68 enjoyed observing the environment by the nurses' station.A care conference note, dated 1/12/26, indicated R68 enjoyed manipulating smaller toys while in a wheelchair. R68 was non-verbal, seemed to be up and out of bed less, and participated passively in activities. The note indicated staff would continue to bring R68 to activities.A life enrichment quarterly note, dated 1/14/26, indicated R68 spent most of the day in bed with stimulation fidgets and the TV on and had 1:1 visits from staff as able. When up, R68 spent time sitting among peers with fidget objects and sensory items. R86 participated in live music and entertainment when able. The note indicated R68 participates in music and church when up.On 2/23/26 at 10:34 AM, 11:44 AM, 1:02 PM, and 2:55 PM, Surveyor observed R68 in bed with the door half closed, the lights turned down, and the blinds closed. Surveyor observed sensory objects on a shelf in R68's room but none in R68's hands. R68's TV was on the facility's informational channel with no sound.Surveyor reviewed the facility's Activity Calendar for 2/23/26 and noted the following scheduled activities: 9:30 AM Exercise; 10:00 AM Sit and be fit; 10:15 AM Card club, coffee, and social group; 11:15 AM Activity talk; 1:15 PM Music videos; 1:30 PM Banana bread and coffee; 2:00 PM Dice; 3:30 PM Mail pass; 4:45 PM Old time radio show; 7:00 PM Antique roadshow. Surveyor did not observe R68 go to any activities. R68's medical record did not indicate R68 was invited to any activities.On 2/24/26 at 9:20 AM, Surveyor observed R68 in bed with the door open, the curtain drawn, the lights turned down, and the blinds closed. R68 did not have any sensory objects. R68's TV was on the facility's informational channel.On 2/24/26 from 10:03 AM to 1:24 PM (a continuous observation for 3 hours and 21 minutes), Surveyor observed R68 in bed with the lights turned down and the blinds closed. R68 did not have any sensory objects. R68's TV was on the facility's informational channel. Surveyor noted several staff walked past R68's room during that time but did not enter R68's room.On 2/24/26 at 1:44 PM, Surveyor observed Certified Nursing Assistant (CNA)-F provide incontinence care for R68. CNA-F did not interact with R68 aside from providing care. CNA-F left R68's room without providing R68 with any sensory items.On 2/24/26 at 2:10 PM, Surveyor observed R68 in bed with the lights turned down and the blinds closed. R68 did not have any sensory objects. R68's TV was on the facility's informational channel.On 2/24/26 at 1:44 PM, Surveyor interviewed CNA-F who stated staff get R68 up depending on the day. CNA-F indicated R68 had not been getting out of bed recently due to having loose stools.On 2/24/26, Surveyor reviewed the facility's activity calendar for 2/24/26 and noted the following scheduled activities: 9:15 AM Daily chronicles and current events; 9:45 AM Greet your neighbor; 10:00 AM Chips and salsa; 10:30 AM Dice; 1:15 PM Music videos; 1:30 PM Happy hour/birthday party; 3:00 PM Cards; 3:30 PM Mail pass; 7:00 PM Bucks basketball.Surveyor did not observe R68 participate in any activities. R68's medical record did not indicate R68 was invited to any activities.On 2/25/26 at 8:47 AM, Surveyor observed R68 in bed fidgeting with the bed sheet and pulling it over R68's face. R68 did not have any sensory items. R68's TV was on the facility's informational channel.On 2/25/26 at 9:02 AM, Surveyor interviewed CNA-Q who stated staff use a lift to get R68 out of bed. CNA-Q was not sure when R68 had last gotten out of bed.On 2/25/26 at 10:02 AM, Surveyor observed R68 in bed. A fidget toy was on the floor next to the bed. The lights were turned down and the blinds were closed. R68 did not have any other sensory items. R68's TV was on the facility's informational channel.On 2/25/26, Surveyor reviewed the facility's activity calendar and noted the following scheduled activities: 9:45 AM Music videos; 10:00 AM [NAME] basketball/monopoly exercises; 10:30 AM Bocce ball; 11:15 AM Activity talk; 1:15 PM Trivia; and 1:30 PM Beanbag fishing. Surveyor did not observe R68 go to any activities. R68's medical record did not indicate R68 was invited to any activities. On 2/25/26 at 12:04 PM, Surveyor interviewed Life Enrichment Assistant (LEA)-P who stated staff typically invite/bring R68 to activities, even to passively participate, when R68 is in R68's wheelchair. LEA-P stated nursing staff are responsible for getting R68 into the wheelchair. LEA-P reviewed R68's activity attendance for the last 6 months and indicated R68 had attended only 12 activities. LEA-P verified R68 did not attend any activities from 2/23/26 to 2/25/26.On 2/25/26 at 11:20 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding R68's specialized services. NHA-A verified staff should get R68 out of bed to provide opportunities for socialization and confirmed staff should be provide R68 with sensory items throughout the day when R68 is in bed.

Based on staff interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented for 2 residents (R) (R63 and R12) of 20 sampled residents. R63 had orders for gastrostomy (G)-tube management for seizure rescue medication administration. R63's care plan did not include G-tube care. R12 had an order for the use of continuous oxygen to maintain optimal oxygen saturation rates. R12's care plan did not indicate R12 used continuous oxygen. Findings include: The facility's policy and procedure for Individual Care Plan Conferences, dated 2/21/24, indicates: A written care plan is developed and maintained directing a course of comprehensive care specific to the individual's needs from all appropriate disciplines and the individual's primary care provider . 1. On 2/24/26, Surveyor reviewed R63's medical record. R63 was admitted to the facility on [DATE] and had diagnoses including hemiplegia, Arnold Chiari Syndrome, epilepsy, dysphagia, and depression. R63's Minimum Data Set (MDS) assessment, dated 1/15/26, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R63 had significant cognitive impairment. R63 had a Guardian for healthcare decisions. R63's medical record indicated R63 had a G-tube to provide rescue medication for seizures and contained the following orders: ~ Exchange Mic-Key button G-tube every 3 months. Size 16 French, 3.5 centimeter (cm) length with 5 milliliter (ml) balloon. Every day shift every 3 months starting on the 14th for 1 day for G-tube (dated 1/14/26) ~ G-tube care: Cleanse skin with gentle soap and water. Pat dry. Apply a thin strip of Silvercel antimicrobial alginate around insertion site. Apply drain sponge over Silvercel in evening, every day (dated 4/11/25) ~ Flush G-tube with 30 cubic centimeters (ccs) free water flush twice daily (dated 4/11/25) R63's care plan did not contain goals or interventions to address maintenance of the G-tube or the potential for impaired skin integrity. On 2/25/26 at 12:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated LPN-D followed the Medication Administration Record (MAR) for R63's G-tube orders. LPN-D verified R63's care plan should address G-tube maintenance. On 2/25/26 at 1:06 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff are expected to develop a care plan intervention for skin integrity to address R63's G-tube placement and maintenance. 2. On 2/24/26, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, dysarthria, hypoxemia, dependence on supplemental oxygen, and epilepsy. R12's MDS assessment, dated 1/28/26, had a BIMS score of 10 out of 15 which indicated R12 had moderate cognitive impairment. R12 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. R12's medical record contained the following oxygen orders: ~ Change humified air canister as needed (dated 2/11/25) ~ Change oxygen tubing - Date tubing every night shift every 7 days (dated 2/11/25) ~ Cleanse top of left ear/crease behind ear with soap and water. Pat dry. Apply non-sting skin prep to area. Ensure foam is intact to nasal cannula to prevent further skin injury two times daily (dated 10/20/25) ~ Oxygen at 1-5 liters per nasal cannula to keep oxygen saturation greater or equal to 90% every shift (dated 5/12/25) R12's care plan did not contain goals or interventions to address R12's dependence on oxygen and potential for airway disturbance. On 2/25/26 at 12:24 PM, Surveyor interviewed Medication Technician (MT)-E who indicated MT-E would ask the nurse or refer to R12's care plan for information regarding oxygen use. On 2/25/26 at 1:04 PM, Surveyor interviewed DON-B who indicated staff should refer to a resident's MAR and Treatment Administration Record (TAR) for oxygen orders and confirmed residents who use oxygen should have a care plan to address airway needs.

Based on observation, staff interview, and record review, the facility did not ensure timely incontinence care was provided for 1 resident (R) (R68) of 4 sampled residents.R68's care plan indicated R68 should be checked and changed every 2 to 3 hours or as needed. On 2/24/26, staff did not check and change R68 for 3 hours and 21 minutes. R68 was in a brief that had soaked through to a Chux pad underneath R68 and R68's room smelled of urine. Findings include: The facility's undated Activities of Daily Living (ADL) Protocol indicates: Toileting should be offered every 2 to 3 hours and incontinence care should be provided as needed. On 2/24/26, Surveyor reviewed R68's medical record. R68 was admitted to the facility on [DATE] and had diagnoses including spastic quadriplegia cerebral palsy, epilepsy, severe intellectual disability, cachexia, and weakness. R68's most recent Minimum Data Set (MDS) assessment, dated 2/13/26, indicated R68 had severe cognitive impairment, was always incontinent of bladder and bowel, and required staff assistance for incontinence cares. A care plan, revised 2/14/26, indicated R68 had a history of urinary tract infections (UTIs) and should be checked and changed every 2 to 3 hours and as needed. On 2/24/26 at 10:03 AM, Surveyor observed R68 in bed. Surveyor noted a strong urine odor in the room. Surveyor continuously observed R68 from 10:03 AM to 1:24 PM (3 hours and 21 minutes) and noted several staff walked past R68's room but did not enter to see if R68 was incontinent and needed to be changed. On 2/24/26 at 1:24 PM, Surveyor observed Certified Nursing Assistant (CNA)-F enter R68's room and provide incontinence care. CNA-F verified R68 was incontinent of urine and stated urine had soaked into a washable Chux pad beneath R68. CNA-F provided R68 with a clean brief and Chux pad. On 2/24/26 at 1:38 PM, Surveyor interviewed CNA-F who stated CNA-F tries to check and change R68 every two hours, however, it does not happen at times. CNA-F stated CNA-F last checked R68 at approximately 10:00 AM and R68 was dry. CNA-F stated R68 did not routinely use the call light to make R68's needs known. On 2/24/26, Surveyor reviewed R68's CNA charting and noted R68 was provided incontinence care at 8:49 AM. On 2/25/26 at 11:08 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R68 should be checked and changed every two to three hours and should not have been left in a wet brief for over three hours.

Based on observation, staff interview, and record review, the facility did not ensure a gastrostomy (G)-tube was flushed as ordered for 1 resident (R) (R63) of sampled 2 residents. R63 had a G-tube to provide rescue medication for seizures. R63 had an order to flush the G-tube for patency. R63's G-tube was not flushed in accordance with the order. Findings include: The facility's General Guidelines for Administering Medication via Enteral Tube policy, dated 5/2018, indicates: The facility assures the safe and effective administration of enteral formula and medication via enteral tubes .D. Enteral tubes are flushed with at least 15 milliliters (ml) of purified or sterile water before administering medication, between each medication, and after all medications have been administered . On 2/24/26, Surveyor reviewed R63's medical record. R63 was admitted to the facility on [DATE] and had diagnoses including hemiplegia, Arnold Chiari Syndrome, epilepsy, dysphagia, and depression. R63's Minimum Data Set (MDS) assessment, dated 1/15/26, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R63 had severe cognitive impairment. R63 had a Guardian for healthcare decisionsR63's medical record indicated R63 had a G-tube to provide rescue medication for seizures. R63 had the following orders: ~ Exchange Mic-Key button G-tube every 3 months. Size 16 French, 3.5 centimeters (cm) length with 5 milliliter (ml) balloon. Every day shift every 3 months starting on the 14th for 1 day for G-tube (dated 1/14/26) ~ G-tube care: Cleanse skin with gentle soap and water. Pat dry. Apply a thin strip of Silvercel antimicrobial alginate around the insertion site. Apply drain sponge over Silvercel in evening, every day (dated 4/11/25) ~ Flush G-tube with 30 cubic centimeters (ccs) of free water twice daily (dated 4/11/25) R68's Medication Administration Record (MAR) indicated R68's G-tube was not flushed on the 1/25/26, 2/22/26, 2/23/26, and 2/24/26 AM shifts. On 2/25/26 at 1:06 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should provide flushes as ordered.

Based on staff interview and record review, the facility did not ensure monitoring interventions for high-risk medications were in place for 1 resident (R) (R7) of 9 sampled residents.R7 was prescribed morphine sulfate (an opioid medication) for pain and gabapentin (an anticonvulsant medication) for nerve pain. Staff did not monitor R7 for adverse reactions or side effects of the high-risk medications.Findings include: The facility's Miscellaneous Special Situations policy, dated May 2018, indicates: Box warning medications - Many medications used by residents in the nursing home may carry a Food and Drug Administration (FDA)-issued box warning. The box warning is a serious type of warning the FDA can require on medication labeling and is important to the health and safety of prescription drug consumers. Nursing facility staff, prescribers, and pharmacists should be familiar with box warnings for any medication used for a nursing home resident and assure the medications are used and monitored appropriately .C. The attending physician should assure and document .2. Ongoing monitoring for any adverse events. 3. Evaluation and management of any experienced adverse events .E. Nursing staff must be informed by the attending physician or via in-service or clinical protocol of symptoms, side effects, and special monitoring to monitor and report associated with medications with box warnings.From 2/23/26 to 2/25/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dementia, fibromyalgia, and osteoarthritis. R7's Minimum Data Set (MDS) assessment, dated 1/24/26, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R7 had severe cognitive impairment. R7 received Hospice services and had an activated Power of Attorney (POA).R7's medical record contained the following orders: ~ Morphine sulfate solution 20 milligrams (mg)/milliliter (ml), give 0.5 ml by mouth every hour as needed for moderate pain/dyspnea.~ Gabapentin capsule 100 mg, give 3 capsules by mouth every morning and at bedtime for pain.R7's plan of care did not contain monitoring interventions for the use of opioid or anticonvulsant medication, including side effects for opioid use of sedation, dizziness, nausea, vomiting, constipation, and respiratory depression or side effects for anticonvulsant use of fatigue, tremors, rash, blurred vision, and weight gain.On 2/24/26 at 1:34 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who reviewed R7's medical record and confirmed R7 did not have monitoring interventions for opioid or anticonvulsant use. LPN-D stated LPN-D updates the provider if there is anything unusual with a resident. LPN-D indicated the facility does not schedule daily monitoring for adverse reactions or side effects.On 2/25/26 at 12:20 PM, Surveyor interviewed Regional Nurse Consultant (RNC)-C who verified R7's plan of care did not contain adverse reaction/side effect monitoring for opioid or anticonvulsant use.

Based on staff interview and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R1) of 3 sampled residents.R1 had an unstageable deep tissue injury that was treated without a physician order. In addition, R1 had a stage 2 pressure injury that was not identified in the facility and was discovered while R1 was at a medical appointment. Findings include: The facility's Pressure Injury Prevention and Managing Skin Integrity policy and procedure, dated 5/8/25, indicates: Prevention measures are put in place to reduce the occurrence of pressure injuries .1. Risk Assessment: a. Upon admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. b. Re-evaluation: Braden Scale will be completed upon change of condition and quarterly. c. Based on the individual's Braden Scale score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record. 2. Identify Interventions and Care Plan: a. Identify Interventions: i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the Interdisciplinary Team (IDT) regarding the presence of breakdown and the intervention plan. 2. When indicated, a referral to additional resources (.ie., Wound Care Specialist, Registered Dietitian, Physical Therapist, Occupational Therapist) may occur. 3. Identification of risk factors present or acquired that compromise skin integrity will be considered .b. Care Plan: i. In developing a plan of care, the following will be considered: 1. Individual pressure injury history; 2. Cognitive changes or impairment of the individual; 3. Current state of skin integrity and personal hygiene practices of the individual that impact skin health; 4. Any cultural practices that impact the health or integrity of the skin; 5. Risk for pressure ulcer development (Braden Scale) .3. Skin Checks: a. Skin check will be done upon admission, readmission, or as clinically indicated. skinb. While providing routine care, a licensed nurse is to monitor the skin condition of each individual weekly and document the skin check in the medical record. 4. Weekly Wound Rounds: a. Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds; b. Registered Nurse (RN) or designee will: i. Conduct weekly skin evaluation; ii. Update the provider with any decline in wound appearance, or as necessary; iii. Update the care plan with any new interventions as applicable; iv. Update individual representative as indicated.5. Administrative Review: a. IDT reviews pressure ulcer/abnormal skin findings through Quality Assurance Committee .From 2/2/26 to 2/3/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including complete paraplegia (total loss of motor and sensory function in the lower half of the body), diabetes mellitus type 2, anxiety, obesity class 3, neuromuscular dysfunction of bladder, and neurogenic bowel. R1's most recent Minimum Data Set (MDS) assessment, dated 12/24/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. A care plan, initiated 12/19/25, indicated R1 had a pressure injury on the coccyx and had the potential for skin breakdown/pressure ulcer development related to a need for assistance with mobility, anxiety/depression, catheter tubing, morbid obesity, and bowel incontinence. The care plan contained a goal for R1 to have intact skin, free of redness, blisters, or discoloration. The care plan contained interventions to administer treatments as ordered, monitor for effectiveness, and follow facility policies/protocols for the prevention/treatment of skin breakdown. The care plan also indicated R1 had bowel incontinence related to neurogenic bowel, a need for assistance with toileting, and laxative use. The care plan contained a goal to reduce skin breakdown, decrease episodes of incontinence as able, and maintain regular bowel pattern. The care plan contained interventions to apply barrier cream as ordered, clean peri-area with each incontinence episode, laxatives as ordered, and monitor skin for signs of breakdown related to incontinence. R1's admission information contained a hospital Discharge summary, dated [DATE], that did not contain wound information or orders. On 12/17/25, Registered Nurse (RN)-M completed R1's Admit/Readmit Screener for pressure injuries and documented one stage 2 coccyx pressure injury (partial-thickness loss of skin with exposed dermis). R1's skin assessments titled SW-Skin Issues indicated the following: ~ An assessment, dated 12/17/25, indicated R1 had coccyx bruising present upon admission that measured 14.79 centimeters (cm) (length) x 19.81 cm (width).~ An assessment, dated 12/21/25, indicated R1 had a new moisture-associated skin damage (MASD) left gluteal wound that measured 7.46 cm x 3.53 cm.~ An assessment, dated 12/22/25, indicated R1's coccyx bruising was improving and measured 16.15 cm x 10.1 cm. ~ On 12/24/25, R1's left gluteal MASD resolved. R1 had a new unstageable coccyx pressure injury that presented as a deep tissue injury (DTI) upon admission with an unknown onset. The wound measured 15.43 cm x 16.48 cm.~ On 12/30/25, R1's coccyx pressure injury was unstageable and deteriorating. The surrounding tissue was denuded (loss of top layer of skin) and there was a loss of epidermis (top layer of skin) caused by exposure to urine, feces, body fluid, wound exudate, or friction. There was no swelling or edema. The wound measured 13.65 cm x 9.96 cm and did not contain a dressing.~ On 12/31/25, R1's coccyx pressure injury was unstageable, stable, and measured 15.95 cm x 16.66 cm.~ A first wound evaluation progress note by Advanced Practice Nurse Practitioner (APNP)-N, dated 12/24/25, indicated R1 was non-ambulatory due to paraplegia and had ongoing issues with sacral pressure injuries for the last several months. The note indicated to clean the wound, apply chamosyn (skin barrier) cream twice daily (BID) (second application should be after bowel program), and aggressively offload for pressure-induced deep tissue damage of the sacral region with scattered open areas. The wound measured 15.43 cm x 16.48 cm and was deep purple with scattered granulated areas, scant bleeding to open areas, and no odor or sign of infection. ~ A wound note by APNP-N, dated 12/31/25, indicated R1 had a stable DTI of the sacrum with scattered open areas that measured 15.95 cm x 16.66 cm. The wound was deep purple with scattered granulated areas, scant bleeding to open areas, and no odor or sign of infection.On 2/2/26, Surveyor requested R1's medical records from the hospital where R1 was discharged on 1/5/26. Surveyor received the records on 2/3/26. (Of note: The hospital R1 was at prior to admission to the facility on [DATE] was not the hospital where R1 discharged to on 1/5/26.) R1's hospital record contained burn and wound surgical service consult follow-up note, dated 1/29/26, that indicated R1 had a suprapubic cather placed on 1/5/26 at 11:51 AM. The records indicated R1 had a pressure injury on the left calf proximal (dated 1/17/26); A penis/scrotum wound (dated 11/2/25); and Buttocks bilateral friction/shear (dated 10/27/25). (Of note: R1's penis/scrotum wound (dated 11/2/25) was identified during that hospitalization and also noted upon admission to the same hospital on 1/5/26.) The facility received hospital notes for R1, dated 1/5/26 through 1/7/26, which were scanned into R1's medical record. The notes included a consult note, dated 1/6/26, that stated R1 and Family Member (FM)-I were not aware of the scrotal (also referred to in documentation as penile area, scrotum, and penis) wound until R1's admission to the hospital on 1/5/26. Two wounds were documented which included an unstageable pressure injury on the buttocks and left posterior thigh and one wound on the scrotum. The note indicated R1 would likely require continued bedside debridement as the eschar continued to soften but did not require surgical debridement or antibiotics at that time. The provider could not determine the depth or if the wound was a full-thickness wound and would continue to monitor. The note also indicated R1's scrotal wound may have been due to pressure from an object or clothing in the skin fold. An assessment, dated 1/6/26, indicated R1 would benefit from wound care and development of an appropriate outpatient wound plan for the sacral wound. While extensive, there was no sign of infection. Imaging did not indicate an abscess or osteomyelitis and antibiotics were not prescribed. The assessment indicated R1 also had a penile wound that was noted during suprapubic catheter placement (not related to the placement).A progress note, dated 1/7/26, indicated R1 had an unstageable sacral pressure wound with eschar per documentation from 1/6/26. Burn consultants recommended a daily Silvadene (cream used for burn care) wound care plan and aggressive pressure offloading. The note included photos of the sacral and penile wounds. R1's Order Summary Report from the facility (printed 2/2/26) included the following orders: ~ Coccyx wound: Clean with soap and water followed by chamosyn cream BID and as needed (PRN). As needed for wound care (Start date: 12/24/25)~ Coccyx wound: Clean with soap and water followed by chamosyn cream BID and PRN two times daily for wound care (Start date: 12/24/25)~ Coccyx wound: Clean with soap and water followed by chamosyn cream BID and PRN. DO NOT COVER WITH ANY DRESSING. As needed for wound care (Start date: 12/31/25)~ Coccyx wound: Clean with soap and water followed by chamosyn cream BID and PRN. DO NOT COVER WITH ANY DRESSING. Two times daily for wound care (Start date: 12/31/25) ~ Complete weekly skin check and bath (according to shower schedule) once daily every Thursday. If any new skin abnormalities upon assessment, complete Skin Only Evaluation. Document bath refusals (Start date: 12/18/25)~ Offer repositioning every 2 hours due to skin break down. Every 2 hours for wound care (Start date: 12/24/25)On 2/3/26 at 9:29 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who charted on R1's wound on 12/21/25 as if R1's wound was new because LPN-E was unsure if the buttocks wound was new or not. LPN-E stated LPN-E placed a 4 x 4 foam border adhesive bandage on R1's buttocks where the wound appeared to be open. LPN-E indicated R1 had a history of loose stools which made it difficult to keep bandages on. LPN-E stated when LPN-E returned from time off, the facility determined the adhesive from the foam border dressing did more damage than good and changed treatment to just cream. LPN-E could not find an order in R1's medical record for a 4 x 4 foam border adhesive dressing during the dates LPN-E applied the dressings. LPN-E stated LPN-E sent a message to the provider when LPN-E noticed an open spot on R1's buttocks which was also when LPN-E started applying bandages and barrier cream. LPN-E stated due to R1's diarrhea, LPN-E kept applying new bandages after incontinence care because the bandages came off. LPN-E stated LPN-E worked on the weekend which is when the bandages were applied. LPN-E reviewed R1's medical record and noted the wound team saw R1 on 12/24/25 and changed the order to include not to apply bandages. On 2/3/26 at 2:35 PM, Surveyor interviewed RN-M. When Surveyor asked if R1 had another pressure injury besides the coccyx/buttocks wound at the time of admission, RN-M stated RN-M conducted a head-to-toe skin check for R1 on 12/17/25 and did not observe any other pressure injuries besides the coccyx pressure injury. RN-M stated one to three Certified Nursing Assistants (CNAs) assisted RN-M with repositioning R1 so RN-M could complete R1's bowel management program and skin check. RN-M stated R1 had what appeared to be a stage 2 pressure injury on R1's backside/buttocks. RN-M took a photo of the wound and documented in the facility's wound application. RN-M stated there was not a dressing on the wound and instructed the CNAs to apply barrier cream until the wound team saw R1. RN-M stated there were no wound orders on R1's discharge summary from the hospital. RN-M stated if RN-M had seen a penile pressure injury, RN-M would have documented the wound during the admission process.On 2/3/26 at 2:15 PM, Surveyor interviewed Director of Nursing (DON)-B who stated a skin assessment should be done upon admission and should include viewing all of a resident's skin. DON-B stated (LPN-E) should have informed the provider as soon as R1's wound was identified. DON-B indicated there is a provider on-call at all times and staff should not apply a foam border dressing without an order.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 1 sampled resident received timely placement of a suprapubic catheter (a tube inserted through a small incision in the lower abdomen directly into the bladder to drain urine). R1 did not have transportation from the facility to a medical appointment on 12/31/25 that was scheduled to remove R1's indwelling urinary catheter (a flexible tube inserted through the urethra into the bladder to continuously drain urine into an external bag) and replace it with a suprapubic catheter. R1 scheduled a new appointment for 1/5/26 for placement of the suprapubic catheter. Findings include: On 2/2/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including complete paraplegia, diabetes mellitus type 2, anxiety, obesity class 3, neuromuscular dysfunction of bladder (loss of normal bladder control due to nerve damage), and neurogenic bowel. R1's most recent Minimum Data Set (MDS) assessment, dated 12/24/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. R1's medical record indicated R1 was admitted to the facility with an indwelling urinary catheter that was scheduled to be replaced with a suprapubic catheter on 12/31/25. According to a grievance, dated 1/7/26, R1 was scheduled to have a suprapubic catheter surgically inserted on 12/31/25. The facility did not ensure stretcher transportation was scheduled upon Family Member (FM)-I's request. As a result, R1's appointment had to be rescheduled for 1/5/26. On 2/2/26, Surveyor requested the facility's policy and procedure for appointments and transportation. The facility did not have a policy and procedure for appointments and transportation. On 2/3/26 at 1:05 PM, Surveyor interviewed Scheduling Coordinator (SC)-G who stated staff request transportation for appointments through the facility's electronic medical record system in the resident's medical record. After staff fill out a request, the request is sent to SC-G. If SC-G is on vacation, another staff processes the request. SC-G stated sometimes staff do not fill out a request properly and SC-G is not aware of the request. SC-G stated staff know how to submit a request and it is not often that requests do not go through. SC-G stated at times staff check the calendar in the resident's medical record and do not see the requested appointment or transportation scheduled. Staff then call SC-G. SC-G reviewed requests submitted for R1 and did not see an appointment or transportation request for 12/31/25. On 2/3/26 at 1:37 PM, SC-G informed Surveyor that SC-G looked further into R1's transportation request on 12/31/25 and found a last minute call from staff to SC-G's coworker. The staff requested stretcher transport for R1's appointment on 12/31/25; however, the faciity was unable to secure stretcher transport which is difficult to schedule at the last minute.

Based on staff, resident, and resident representative interview and record review, the facility did not ensure scheduled showers/baths were provided for 3 residents (R) (R4, R1, and R3) of 13 sampled residents.R4 was scheduled for a weekly shower on Tuesday evening. R4 did not receive showers as scheduled.R1 did not receive a shower while at the facility because the facility did not have a functioning bariatric shower chair.R3 did not receive weekly showers as scheduled. In addition, R3's preference to receive a shower instead of a bed bath was not consistently honored. The facility's undated Standard Activities of Daily Living (ADL) Protocol indicates: ADLS: .bathing .Individual will perform ADLs .with or without staff assist. Certified Nursing Assistant (CNA): Offer individual choices with care routines .Offer weekly bath or shower per individual preference . 1. On 2/4/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side. R4's Minimum Data Set (MDS) assessment, dated 12/11/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 had intact cognition. The MDS assessment also indicated R4 was dependent on staff for showers. R4 made R4's own healthcare decisions. On 2/4/26, Surveyor reviewed the facility's bath schedule and noted R4 was scheduled for a weekly bath on Tuesdays. The facility was unable to provide a November (2025) bath schedule or a December (2025) bath schedule for 12/1/25 to 12/21/25. The January (2026) bath log indicated R4 was ill on 1/27/26 with no follow-up shower or noted refusal. R4's Medication Administration Record (MAR) indicated the following: ~ Complete weekly skin check and bath (according to shower schedule) one time a day every Tuesday .Document bath refusals (Start date: 3/18/25; Discontinue date: 1/27/26). R4's MAR was blank for the following Tuesdays: 11/4/25, 11/18/25, 11/25/25, 12/2/25, 12/9/25, 12/16/25, 12/23/25, 12/30/25, 1/20/26, and 1/27/26. On 2/4/26 at 10:29 AM, Surveyor interviewed R4 who stated R4 wanted a shower but did not receive a shower yesterday (2/3/26) or the Tuesday before (1/27/26). R4 stated R4 was told by an (unknown) staff that R4 would receive a shower in the last few weeks; however, R4 did not receive one. R4 stated R4 did not refuse showers. On 2/4/26 at 4:10 PM, Surveyor interviewed FM-L who stated R4 did not receive showers and complained to staff. FM-L stated R4's showers were back on track and then R4 did not receive showers again in November and December (2025). (See interviews under example 3.) 2. On 2/2/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including complete paraplegia, diabetes mellitus type 2, anxiety, obesity class 3, neuromuscular dysfunction of bladder, and neurogenic bowel. R1's most recent MDS assssment, dated 12/24/25, had a BIMS score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. R1's TAR contained the following order: ~ Complete weekly skin check and bath (according to shower schedule) one time a day every Thursday. If any new skin abnormalities upon assessment, complete Skin Only Evaluation. Document bath refusals (Start date: 12/18/25; Discontinue date: 1/9/26). The order was documented as completed on 12/18/25, 12/25/25, and 1/1/26. (Of note: The facility did not have a working bariatric shower chair until after R1 discharged .) On 2/3/26 at 12:54 PM, Surveyor interviewed Scheduler and Central Supply (SCS)-H who stated a new bariatric shower chair was ordered specifically for R1 on 12/16/25 which was the day before R1 was admitted . SCS-H was made aware of the need to order the bariatric shower chair by Referral Specialist (RS)-J. SCS-H stated the facility had a bariatric shower chair; however, maintenance staff discovered the chair did not work. SCS-H e-mailed the company on 12/22/25 to check the delivery date for the new shower chair which was estimated to be 1/14/26. SCS-H stated maintenance staff were unable to fix the facility's bariatric shower chair and the new bariatric shower chair did not arrive until after R1 discharged . On 2/3/26 at 3:22 PM, Surveyor interviewed Registered Nurse (RN)-M who stated R1's scheduled shower would have been a bed bath because the facility did not have a bariatric shower chair. 3. On 2/4/26, Surveyor reviewed R3's medical record. R3's MDS assessment, dated 1/28/26, had a BIMS score of 10 out of 15 which indicated R3 had moderate cognitive impairment. The MDS assessment also indicated R3 was dependent on staff for bathing. R3 had an activated Power of Attorney (POA) since 1/22/12. On 2/4/26 at 11:55 AM and 1:17 PM, Surveyor interviewed R3 who stated R3 prefers showers over baths. R3 stated staff do not ask if R3's preference and give R3 bed baths. R3 stated R3 wants only showers and it bothers R3 that R3 does not receive showers. On 2/4/26 at 2:42 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-S who stated if a resident's MAR/TAR is checked off, it means a shower and skin check were completed. LPN-S stated there should not be any blanks in the MAR/TAR which indicate a shower/bath was not completed. On 2/4/26 at 1:23 PM, Surveyor Interviewed Director of Nursing (DON)-B who stated showers/baths are documented on a resident's MAR or TAR. DON-B stated if a resident refuses a shower/bath, the nurse should document the reason. DON-B stated a resident's MAR/TAR should not be left blank and staff should document that a shower/bath was offered instead of leaving a blank which indicates it wasn't completed. DON-B stated blank documentation is misleading and indicated if a resident's MAR/TAR is checked off, a skin check and shower/bath were completed. DON-B stated shower/bath preference is usually asked upon admission and residents should receive what they prefer.

Based on staff, resident, and resident representative interview and record review, the facility did not ensure grievances were thoroughly investigated and resolved for 3 residents (R) (R1, R4, and R5) of 4 sampled residents.Family Member (FM)-I filed a grievance on behalf of R1 on 1/7/26 that included concerns about a missed appointment, wound care, and assistance with cares. The facility did not investigate or provide resolution for the grievance. R4 reported in September 2025 that R4 did not receive scheduled showers. The facility did not document, investigate, or provide resolution for the grienvance.R5 reported to staff that Registered Nurse (RN)-R swore at R5. Staff reported to the concern to a supervisor; however, the facility did not file a grievance or follow-up on the concern. Findings include: The facility's Policy and Procedure for Grievances indicates: .The facility fosters an environment of direct communication, prompt resolution, and continuous process improvement. Grievances may be brought to any staff member at any time orally, in writing, or made anonymously. Grievances will be forwarded to the designated Grievance Officer and investigated through the Quality Assurance Performance Improvement (QAPI) Committee .B: Formal Grievance: 1. All staff have access to a formal Grievance Form. A Formal Grievance is to be submitted to the Grievance Officer upon completion. 2. The Grievance Officer will log all formal complaints onto the Grievance Tracking Log. The Grievance Officer will provide a Quality Assurance designee with the written Grievance Form and keep a copy. The Quality Assurance designee will assign a manager to complete the investigation. 3. The assigned manager will investigate the grievance and respond to the individual, Guardian, and/or individual representative within five working days, unless further investigation is needed. 4. The investigation will be reviewed through the Quality Assurance Committee. Process Improvement Projects will be chartered as appropriate to ensure systemic improvements .6. Investigations of Grievances will be kept for three years . 1.On 2/2/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including complete paraplegia, diabetes mellitus type 2, anxiety, obesity class 3, neuromuscular dysfunction of bladder, and neurogenic bowel. R1's most recent Minimum Data Set (MDS) assessment, dated 12/24/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. On 2/2/26, Surveyor reviewed the facility's grievance file which contained a grievance, dated 1/7/26, from FM-I. The Receipt of Grievance form indicated the concern was reported to Referral Specialist (RS)-J. A section that stated Describe concern using factual terms had Please see attached written below. The remainder of the document was incomplete. An attachment contained the following concerns expressed by FM-I and written by RS-J: ~ FM-I communicated the need in advance for hired transport to take R1 to a scheduled appointment for suprapubic catheter placement. Transportation was not scheduled and R1's appointment had to be rescheduled. ~ R1's pressure injury worsened and another pressure injury was discovered when R1 was admitted to the hospital. The facility did not have the correct wound care supplies to care for R1's pressure injury. ~ R1 was observed on multiple occasions with a soiled brief and stool dripping on the floor. ~ Staff did not return FM-I's phone calls. On 2/2/26 at 12:30 PM, Surveyor interviewed Registered Nurse Consultant (RNC)-C who confirmed FM-I called the facility and reported the concerns. RNC-C stated R1 was not going to return to the facility at that time. RNC-C confirmed the facility did not complete an investigation or follow-up on FM-I's concerns. On 2/3/26 at 12:30 PM, Surveyor interviewed RS-J who stated FM-I was not happy when FM-I called on 1/7/26 and reported the concerns. RS-J stated grievances should be documented on a Receipt of Grievance form. After RS-J filled out what RS-J could, RS-J provided the form and attachment to Nursing Home Administrator (NHA)-A. (Of note: The facility did not provide additional documentation for the grievance. An NHA and Director of Nursing (DON) change occurred in January 2026.) 2. On 2/4/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side. R4's MDS assessment, dated 12/11/25, had a BIMS score of 15 out of 15 which indicated R4 had intact cognition. The MDS assessment also indicated R4 was dependent on staff for showers. R4 was R4's own decision maker. On 2/4/26 at 3:22 PM, Surveyor interviewed R4 who stated R4 filed a grievance about not receiving a shower for three weeks in September (2025). R4 did not recall anyone asking R4 about the concern. R4 stated R4 informed FM-L (who worked at the the facility) about the missing showers. On 2/4/26 at 4:10 PM, Surveyor interviewed FM-L who stated FM-L informed the facility that R4 did not receive showers and complained about it. FM-L did not recall if there was an investigation. FM-L stated R4's showers were back on track after FM-L reported the concern; however, R4 did not receive any showers in November and December (2025). On 2/4/26 at 4:43 PM, Surveyor interviewed NHA-A, DON-B, and RNC-C regarding a grievance for R4 from September (2025). RNC-C indicated the facility would check to see if there was a grievance and get back to Surveyor by the end of 2/6/26. RNC-C indicated if Surveyor had not received information from the facility by 2/6/26, a grievance was not filed. At the time of this writing, Surveyor had not received any information. 3. On 2/4/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, morbid obesity, peripheral vascular disease, history of pulmonary embolism, and dependence on supplemental oxygen. R5's MDS assessment, dated 12/11/25, indicated R5 was dependent on staff for toileting, bathing, dressing, hygiene, and transfers and required set-up assistance for eating and oral hygiene. R5 had a BIMS score of 15 out of 15 which indicated R5 had intact cognition. R5 was R5's own decision maker. On 2/4/26 at 11:20 AM, Surveyor interviewed R5 who stated RN-R entered R5's room on 1/9/26 at approximately 11:30 PM and tried to stick a spoon with medication in R5's mouth. R5 stated R5 could feed R5's self and R5's oxygen tubing needed to be changed. R5 stated RN-R turned around and walked out. R5 indicated RN-R returned at 1:30 AM and attempted to give R5 medication again. When R5 grabbed the spoon, RN-R stated, I'm not going to take your shit. RN-R then changed R5's oxygen tubing and walked out. R5 stated when the AM shift arrived, R5 reported the incident to RN-P and Certified Nursing Assistant (CNA)-O. R5 stated no one followed-up with R5 and all R5 wanted was for someone to say they were sorry. On 2/4/26 at 2:36 PM, Surveyor interviewed RN-P who verified R5 told RN-P that R5 and RN-R argued and RN-R swore at R5. RN-P stated RN-P reported the incident to an AM nurse who reported it to a supervisor. RN-P was not sure if there was any follow-up. On 2/4/26 at 2:42 PM, Surveyor interviewed CNA-O who stated R5 mentioned that RN-R called R5 stupid or something the night before. CNA-O stated CNA-O reported the information to Licensed Practical Nurse (LPN)-E. CNA-O was not sure if there was any follow-up. On 2/4/26 at 2:56 PM, Surveyor interviewed LPN-E who stated R5 was angry and thought RN-R swore at R5. LPN-E stated RN-R was an international nurse with a heavy accent and was hard to understand. LPN-E told R5 that LPN-E did not think RN-R swore at R5. LPN-E stated R5's accent could have caused a misunderstanding since RN-R denied that RN-R swore at R5. LPN-E stated there should be a progress note about the incident. (Of note: R5's medical record did not contain a progress note related to the incident). LPN-E reported the allegation to LPN-E's supervisor. On 2/4/26 at 3:16 PM, Surveyor interviewed RNC-C who verified a concern was reported that RN-R swore at R5. RNC-C verified RN-R had a heavy accent and stated it was a possible misunderstanding. RNC-C stated the facility did not complete an official investigation or a file a grievance. RNC-C stated someone spoke with RN-R and it was determined that RN-R's accent caused a misunderstanding. RNC-C was not sure if someone followed-up with R5.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R5) of 3 sampled residents received oxygen therapy.R5's oxygen tubing was changed on 1/9/26. Following the change, staff did not turn R5's oxygen back on. As a result, R5 was without supplemental oxygen for approximately 6 hours. Findings include:The facility's undated Standard Respiratory Protocol indicates: Problem: Impaired or potential impairment of gas exchange related to chronic respiratory disease. Goal: Individual will have an effective respiratory rate, depth, and rhythm. Registered Nurse: .Apply oxygen, continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) as ordered.On 2/4/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, morbid obesity, alveolar hypoventilation, peripheral vascular disease, history of pulmonary embolism, and dependence on supplemental oxygen. R5's Minimum Data Set (MDS) assessment, dated 12/11/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. The MDS assessment also indicated R5 was dependent on staff for toileting, bathing, dressing, personal hygiene, and transfers and required set-up assistantce for eating and oral hygiene. R5 was R5's own decision maker. R5's Treatment Administration Record (TAR) contained the following orders:~ Oxygen 2-4 liters via nasal cannula to keep saturation greater than 90% every shift. (Documentation for 1/9/26 indicated R5's oxygen saturation level on the night shift was 98%.)~ Change and date oxygen tubing every 7 days and as needed.On 2/4/26 at 11:20 AM, Surveyor interviewed R5 who stated Registered Nurse (RN)-R changed R5's oxygen tubing on the night of 1/9/26 but did not turn R5's oxygen back on. R5 stated R5 turned on the call light and called the nurses' station but nobody answered. R5 stated Certified Nursing Assistant (CNA)-O turned R5's oxygen back on in the morning. On 2/4/26 at 2:42 PM, Surveyor interviewed CNA-O who stated when CNA-O checked on R5 on the morning of 1/9/26, R5's oxygen was not on. CNA-O turned R5's oxygen on and confirmed that R5 stated RN-R changed R5's oxygen tubing but did not turn R5's oxygen back on. CNA-O stated R5 was without oxygen most of the night. On 2/4/26 at 3:16 PM, Surveyor interviewed Regional Nurse Consultant (RNC)-C who was not aware that R5 went without oxygen.

Based on staff and resident interview and record review, the facility did not ensure an opportunity to create a Power of Attorney (POA) document or a document that designated an alternate decision maker in the case of incapacity was provided for 1 resident (R) (R1) of 5 sampled residents.The facility did not offer R1 an opportunity to create a POA document or any document to designate a decision maker if R1 became incapacitated.Findings include:The facility's Individual Advanced Care Planning policy, dated 2/21/24, indicates: .A. Upon admission: .2. Per the Patient Self Determination Act, information about Wisconsin advanced health care directives will be provided to individuals upon their admission to the facility .B. Upon admission/re-admission, change in condition, and at care conferences: 1. Advanced care planning will be discussed and/or verified. 2. The resources available in the skilled nursing facility to treat symptoms and conditions will be discussed as appropriate.On 10/6/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including spina bifida, paraplegia, anxiety disorder, rectocele, neuromuscular dysfunction of bladder, neurogenic bowel, retention of urine, severe sepsis, and stage 4 pressure ulcer of sacral region. R1's Minimum Data Set (MDS) assessment, dated 8/6/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1's cognition was intact. R1 was responsible for R1's healthcare decisions. On 10/6/25 at 2:13 PM, Surveyor interviewed R1 who was uncertain if R1 had a POA document or its location. R1 stated a family member previously served as R1's activated POA but the designation was revoked by Adult Protective Services (APS). R1 expressed discomfort with making healthcare decisions and stated R1 cannot read or write and does not complete or fill out forms which the facility should be aware of. R1 indicated the process is overwhelming and expresed a desire for a Guardian or a POA to assist with decisions. R1 indicated Social Worker (SW)-E discussed a Guardian upon R1's initial admission, however, R1 was not aware if anything was started. On 10/6/25 at 3:51 PM, Surveyor interviewed SW-E who was unaware that R1 could not read or write. SW-E confirmed SW-E discussed completing a POA document with R1 but was uncertain about whether a document already existed. SW-E attempted to obtain POA information from APS; however, APS declined to provide information about R1's history, Guardianship, or POA status.On 10/7/25 at 10:08 AM, Surveyor interviewed APS Social Worker (APS)-F who stated R1 previously had an activated POA that APS-F voided. APS-F verified R1 was R1's own decision maker and was entitled to complete a new POA document if R1 wanted. APS-F was aware that R1 found R1's healthcare situation overwhelming and confirmed that R1 was illiterate. APS-F stated the facility should use its resources to support R1 with completing a new POA document. APS-F had not spoken with SW-E but did speak with Nursing Home Administrator (NHA)-A. APS-F did not recall if the capacity to make decisions was discussed during that conversation.On 10/6/25 at 5:30 PM, Surveyor interviewed NHA-A via phone with SW-E present in the room. During the interview, NHA-A indicated NHA-A had spoken to APS-F but denied asking if APS-F was aware that R1 requested an advocate or representative. NHA-A stated APS-F made it clear that R1 was R1's own decision maker. SW-E and NHA-A indicated no further action had been taken to fulfill R1's request to complete a new POA document.

Based on staff and resident interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R1) of 1 sampled resident. R1 reported to staff that another staff call R1 stupid. The allegation of abuse was not reported to the SA.Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program policy indicates: It is the poliy of the facility that each resident will be free from abuse .The Executive Director or designee will report abuse to the State Agency per state and federal requirements .G. Reporting and Response: .The facility will ensure that all alleged violations involving abuse .are reported 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 not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility and to other officials (including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility .Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Executive Director .On 10/6/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including spina bifida, paraplegia, anxiety disorder, rectocele, neuromuscular dysfunction of bladder, neurogenic bowel, retention of urine, severe sepsis, and stage 4 pressure ulcer of the sacral region. R1's Minimum Data Set (MDS) assessment, dated 8/6/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1's cognition was intact. R1 was responsible for R1's healthcare decisions.On 10/6/25 at 11:13 AM, Surveyor interviewed R1 who stated there is a Certified Nursing Assistant (CNA) that I don't like. R1 did not know the name of the CNA but stated the CNA provided assistance to R1 quite a few times and would say, Hi, stupid! when the CNA walked into R1's room. R1 also stated the CNA addressed R1 as stupid which a couple of staff members heard when the CNA brought R1 a dinner tray. R1 told an unidentified staff about the name calling who said they would inform Social Worker (SW)-E and instruct the CNA not to work with R1 that day. On 10/6/25 at 12:31 PM, Surveyor interviewed SW-E who was not aware that a CNA called R1 stupid. SW-E stated SW-E would interview R1 and initiate an investigation. SW-E was not aware of any similar allegations from R1 or other residents. On 10/6/25 at 1:07 PM, Surveyor and SW-E entered R1's room. R1 described the CNA's physical appearance and stated the CNA worked with R1 four times; one weekend two weeks ago and then again after R1 told staff that the CNA called R1 stupid. R1 provided a physical description of the staff that R1 reported the incident to which matched Scheduler (SCH)-G. R1 stated, I'm getting a little frustrated and upset because (he/she) called me that. The police were contacted and arrived at 1:22 PM.On 10/6/25 at 1:28 PM, Surveyor interviewed SCH-G who stated R1 told SCH-G that an unidentified staff called R1 stupid in September of 2025. SCH-G relayed the information to Director of Nursing (DON)-B at that time. SCH-G informed Surveyor that R1 asked SCH-G that day (10/6/25) at approximately 10:30 AM (of note, the reported time was prior to Surveyor's first interview with R1), Do you remember when I told you about the CNA? R1 then provided a name to SCH-G (which was not the correct CNA). SCH-G informed R1 that SCH-G would relay the concern to the AM supervisor or SW-E.On 10/6/25 at 5:00 PM, Surveyor interviewed DON-B and SW-E who stated the previously named CNA was incorrect. The correct CNA was identified and suspended based on the facility's investigation. DON-B stated DON-B was not aware of the allegation of abuse until 10/6/25 and stated if the allegation was reported sooner, DON-B would have initiated an investigation.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R1) of 1 sampled resident observed during the provision of care. Licensed Practical Nurse (LPN)-C and Certified Nursing Assistant (CNA)-D did not wear appropriate personal protective equipment (PPE) during wound care for R1. In addition, LPN-C did not complete proper hand hygiene or ensure a treatment cart and supplies were free from infectious agents during and after the provision of wound care. Findings include: The facility's Enhanced Barrier Precautions policy and procedure, dated 2/6/25, indicates: The organization will promote decreased transmission of Centers for Disease Prevention and Control (CDC)-targeted and epidemiologically important multidrug-resistant organisms (MDROs) by utilizing Enhanced Barrier Precautions (EBP) .a. The infection Prevention and Control Program establishes EBP to reduce transmission of MDROs utilizing targeted gown and glove use during high-contact resident care activities. b. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. c. EBP is indicated for residents with any of the following: .ii. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. 1. Wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. However the intent of EBP is to focus on residents with higher risk of acquiring an MDRO over a prolonged period of time. This includes residents with chronic wounds, not those with only shorter lasting wounds, such as skin breaks or skin tears covered with a band-aid or similar dressing. Examples of chronic wounds include .pressure ulcers, diabetic foot ulcers. and chronic venous stasis ulcers .e. For residents whom EBP is indicated, EBP is employed when performing the following high-contact resident care activities: .viii. Wound care: any skin opening requiring a dressing .The facility's Hand Hygiene policy and procedure, dated 12/5/24, indicates: The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections .A. Specific Indications for Hand Hygiene: 1. Immediately before touching a patient; 2. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. 3. Before moving from work on a soiled body side to a clean body site on the same patient; 4. After touching a patient or the patient's immediate environment; 5. After contact with blood, body fluids, or contaminated surfaces; 6. Immediately after glove removal .The facility's Personal Protective Equipment policy and procedure, dated 12/5/24, indicates: The organization will provide personal protective equipment (PPE) to staff and visitors to reduce the spread of communicable disease, as indicated or directed .A. Standard precautions are indicated for all individuals. B. Additional transmission-based precautions will be used to the extent required and will be disease specific. C. Barriers will be available .1. Gloves: Clean, disposable gloves are worn during direct contact with blood/body fluids, mucous membranes, non-intact skin, or any other potentially infectious material. They are also worn when exposure is planned or anticipated for the following: a. Blood or body fluids; b. Stool; c. Saliva; d. Mucous membranes; e. Wound drainage; f. Non-intact skin; g. When performing veni-puncture or invasive procedures .2. Masks: a. Must be worn when it is anticipated that blood or body fluids could splash back exposing employee mucous membrane to potential infection. b. In accordance with CDC guidance. c. In accordance with the entity's Respiratory Protection Program Policy. 3. Gowns should be worn any time there is potential for soiling employee clothing with blood/body fluids. 4. Eye protection should be worn: a. When the potential for splash-back of contaminated blood/body fluids exists. b. In accordance with CDC guidance. On 10/6/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including spina bifida, paraplegia, anxiety disorder, rectocele, neuromuscular dysfunction of bladder, neurogenic bowel, rentention of urine, severe sepsis, and stage 4 pressure ulcer of the sacral region. R1's Minimum Data Set (MDS) assessment, dated 8/6/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1's cognition was intact. R1 was responsible for R1's healthcare decisions.On 10/6/25 at 10:00 AM, Surveyor observed LPN-C and CNA-D complete wound care for R1 who was on EBP as indicated by a sign posted near R1's door. LPN-C and CNA-D entered R1's room without donning gowns. LPN-C brought a treatment cart into the room and placed a gauze package, a bottle of wound cleanser, and bandage scissors on R1's bedside table. LPN-C did not disinfect the table or place a barrier between the supplies and the table surface. LPN-C and CNA-D then donned gloves. During the provision of wound care, LPN-C and CNA-D's clothing was in contact with R1's environment, including R1's bed linens. During the observation, LPN-C removed gloves and did not sanitize hands after completing the soiled portion of wound care. LPN-C then put a clean dressing on R1's wound and donned a glove on the left hand. LPN-C's bare right hand was in contact with R1's skin, linens, and environment while using a roll of tape. LPN-C put two dressing packages on R1's bedside table that were not used. LPN-C retrieved clean gloves from the treatment cart and did not complete hand hygiene after removing the left glove. LPN-C placed clean gloves on R1's bedside table, donned a glove on the right hand, and assisted R1 onto the left side. LPN-C removed a used absorbent pad, removed the right glove, unrolled tape, and stuck the tape to a second bedside table. LPN-C donned a clean glove, put a dressing on R1's wound, and taped the dressing in place. LPN-C then moved R1's electronic tablet, put a clean brief on R1, assisted R1 onto the right side, taped the dressing in place, and fastened R1's brief. LPN-C then removed the glove, sanitized hands, and put a clean sheet over R1. On 10/6/25 at 10:59 AM, LPN-C rolled the treatment cart from R1's room to the nurses' station. LPN-C donned gloves and disinfected the bandage scissors, wound cleanser, and top of the cart with hydrogen peroxide-based wipes.On 10/6/25 at 11:03 AM, Surveyor interviewed LPN-C who thought gowns were worn during wound care and stated LPN-C was nervous. LPN-C verified the treatment cart is used for all residents and stated LPN-C sanitizes the cart after it leaves each room. LPN-C was not aware of the sanitizing product's dwell time (amount of time that a disinfecting product needs to stay wet on an item in order to properly disinfect) of one minute. LPN-C verified LPN-C put the bandage scissors and wound cleanser in the cart before ensuring a minute had passed. LPN-C verified R1's wound care items were in the treatment cart and stated LPN-C should have put the items in a treatment bag. Surveyor and LPN-C verified the EBP sign outside R1's door indicated staff shoud wear a gown and gloves during high-contact resident care, including wound care. LPN-C stated LPN-C should have worn a gown because R1 had an open wound and a Foley catheter.On 10/6/25 at approximately 11:30 AM, Surveyor interviewed CNA-D. When asked if CNA-D wears a gown during cares for R1, CNA-D stated, Sometimes, sometimes not. CNA-D then stated, We just forgot to put one on, I think. On 10/6/25 at 3:00 PM, Surveyor interviewed Director of Nursing (DON)-B who veriifed LPN-C and CNA-D should have worn gowns during wound care for R1. DON-B also indicated LPN-C should have taken the amount of gauze needed and placed the gauze on a clean surface with a barrier. When Surveyor informed DON-B of missed hand hygiene opportunities and cross-contamination of wound care products, clothing, and the environment, DON-B stated DON-B had educated staff on infection control. DON-B verified items used in R1's room should not be used on other residents, including the tape or gauze.

Based on observation, interview, and record review, the facility did not ensure 2 of 3 residents (R3 and R1) reviewed for accidents received adequate supervision and assistance devices to prevent accidents. R3 is being cited at severity level 3 (actual harm). R3 experienced a fall with major injury. Surveyor observed fall interventions not in place. The facility did not complete a root cause analysis for 12 falls and did not implement appropriate interventions for R1's falls. Evidenced by: The facility policy, Falls, reviewed 12/5/24, states, in part; .Prevention measures are put in place to reduce the occurrence of falls and risk of injury from falls .c. A licensed nurse will determine the individuals' risk for falls and individualized care needs. If the individual is at risk for falls, then create a falls care plan .b. The care plan will be updated with an identified intervention . Example 1: R3 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes, anxiety disorder, adult failure to thrive, expressive language disorder, depression, weakness, and muscle weakness. R3's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/30/25, indicates R3 has a Brief Interview for Mental Status (BIMS) score of 08 indicating R3 is mildly impaired. R3 has an activated power of attorney. R3's Care Plan (CP) states, in part; .The resident is moderate risk for falls r/t deconditioning, gait/balance problems, incontinence, seizure disorder, 1/31/25. Risk of falls/falls with injury will be minimized 2/6/25 .Interventions: Anticipate and meet the resident's needs 1/30/25 .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance 1/30/25 .Bed against wall 2/11/25 .Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs 1/30/25 .ensure that the resident is wearing appropriate footwear- shoes, or non-skid socks when ambulating, transferring or mobilizing in w/c (wheelchair) 1/31/25 .Follow facility fall protocol 1/30/25 .PT/OT evaluate and treat as ordered or PRN 1/30/25 .Side rail on exit side of bed 2/13/25 .The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items within reach 1/30/25 .TOILET USE: The resident is totally dependent on 2 staff for toilet use/bedpan/check and change q 2-3 hr (every two to three hours) and prn (as needed) initiated 1/24/25, revision 2/10/25 .TRANSFER: 2A (two assist) with hoyer lift (full body lift) 1/24/25 . R3's fall report states, in part; .2/7/25, location: Resident's room. Nursing Description: CNA (Certified Nursing Assistant) was on the resident's L (left) side of bed, rolling resident to the right side of bed (his strong side) to wash him up. CNA reported that he thought the resident was holding on, but then the resident rolled onto the floor on his back. CNA notified the nurse. Description: Resident neuro checks started .New intervention: Staff education provided about checking care plans before taking care of residents to ensure safety. Bed against wall. Side rail on exit side of bed. Resident sent to ED for evaluation for R (right) hip pain, x-ray results show R hip fx. Surgical nailing of R hip done Notes Recommend side railings and using 2 assist with cares. (Of note: R3's CP indicates R3 is totally dependent on two (2) staff for toilet use/bedpan/check and change q 2-3 hr and prn initiated 1/24/25, revision 2/10/25 .TRANSFER: 2A with hoyer lift (full body lift) 1/24/25 .) Nursing Progress Note, states, in part; .2/7/25 .At this time resident c/o pain to CNA, to which they came to nurses station to report his is 10/10. Was reported to writer that res had a fall around 2000-ish (~8:00PM). Entered res room and told res that the sheet is going to be rolled off to exam bilateral legs. Bilateral (legs) are stiff like sticks, res has pain to Rt (right) hip rated 10/10 but can't bend legs d/t stroke with no deformity rotation or shortening noticed. Just had pain At this time PM nurse explained about res fall and now Rt hip pain, to which APNP (Advanced Practice Nurse Practitioner) ordered to send res to be seeing [sic] in ER . R3's CNA Kardex states, in part; .Bed Mobility .Bed against wall .Toileting .TOILET USE the resident is totally dependent on 2 staff for toilet use/bedpan/check and change q 2-3 hr and prn . On 4/10/25 at 2:30 PM, CNA C (Certified Nursing Assistant) indicated he was the CNA that was in R3's bedroom at the time of R3's fall on 2/7/25. CNA C indicated he was assisting R3 in cleaning up, rolled R3 towards the window (left side of resident) while standing behind resident on right side. CNA C indicated prior to fall CNA C was repositioning resident with 1 staff and that CNAC had done this many times. CNA C indicated R3 rolled on the floor and that CNA C immediately called for the nurse. CNA C indicated R3 was pretty new to the facility during this time and that this was his only fall. CNA C indicated CNA C did receive education after the incident. CNA C indicated the education was about the fall, what not to do in the future, following care plans, and new interventions for R3. CNA C indicated new interventions in place are 2 staff at all times and side rail on side of bed for resident to utilize when rolling. CNA C and Surveyor walked into R3's bedroom. R3's bedroom door had been closed. Surveyor observed R3's call light on the ground and R3's bed positioned in the middle of bedroom. CNA C indicated R3 was unable to call for anyone because call light was on ground. Surveyor asked CNA C if call light should be within reach. CNA C indicated it should be near resident. (Of note: R3's bed was not against the wall and the call light was not within reach per R3's care plan.) On 4/10/25 at 4:49 PM, Director of Nursing B (DON) indicated CNA C's education was regarding following and checking care plans prior to assisting residents. DON B indicated the education was also regarding the concern that CNA C rolled R3 away from CNA C. DON B indicated she could provide education documentation. Surveyor reviewed CNA's education. DON B provided documentation of education that was provided to all staff that work with R3 and documentation from All Staff meeting in February as well. (Of note: Surveyor observed R3's care plan not being followed on 4/10/25) On 4/10/25 at 6:20 PM, Director of Nursing B (DON) indicated she would expect that fall interventions to be followed and in place. DON B indicated she would expect call lights to be within resident reach. DON B indicated R3's bed had been moved right after the fall. DON B indicated R3's bed is no longer against the wall. (Of note: R3's bed against the wall remains on R3's care plan and CNA Kardex.) The facility failed to ensure residents assistance devices are in place to prevent accidents. 49436 Example 2: R1 admitted to the facility on [DATE] with diagnoses including lymphocytic leukemia (a type of blood cancer), dementia, and right hip fracture. R1's 12/7/24 Brief Interview for Mental Status (BIMS) had a score of 8, indicating R1's cognition is moderately impaired. R1's comprehensive care plan includes the following: Focus: R1 has an ADL self-care performance deficit (initiated on 12/3/24 and revised on 3/11/25). Interventions: Bed mobility: 1 assist (initiated on 12/3/24 and revised on 2/18/25). Toilet use: 1 assist, urinal within reach (initiated on 12/3/24 and revised on 2/18/25). Transfer: pivot transfer with assist of 1, front wheeled walker and gait belt (initiated on 12/3/24 and revised on 2/12/25). Wheelchair for distance (initiated on 12/3/24). Focus: R1 has impaired cognitive function related to Dementia (initiated 1/4/25). Interventions: Anticipate and meet needs (initiated on 1/4/25). Focus: R1 uses psychotropic medications related to Dementia with behaviors (initiated 12/31/24 and revised on 3/11/25). Interventions: Monitor/document/report PRN (As Needed) and adverse reactions of psychotropic medications: unsteady gait, shuffling gait, and frequent falls (initiated on 12/31/24). Focus: R1 is at risk for falls related to need for assist with mobility, balance concerns, impulsivity, and poor safety awareness (initiated on 12/3/24 and revised on 3/11/25). Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance (initiated on 12/3/24 and revised on 3/10/25). Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (initiated on 12/3/24). Ensure that the resident is wearing appropriate footwear when ambulating, transferring or mobilizing in wheelchair (initiated on 12/3/24). Follow facility fall protocol (initiated on 12/3/24). PT/OT (Physical Therapy/Occupational Therapy) evaluate and treat as ordered and PRN (As Needed) (initiated on 12/3/24). The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; personal items within reach (initiated on 12/3/24). NOC (night) shift to offer toileting 4:00 AM - 6:00 AM as well as NOC rounds (initiated on 1/12/25 and revised on 2/17/25). Offer toileting upon rising, before/after meals, at HS (Hours of Sleep/bedtime), and PRN (initiated 1/14/25). Visual cues placed in resident's room to remind resident to call for assistance (initiated on 1/19/25). Don't leave resident unattended while awake in room, bathroom (use privacy curtain), church, activities, nurses station, and/or dining room (initiated 1/23/25). Encourage resident to be in room only during sleeping hours (initiated on 2/17/25). HS (Hours of Sleep/bedtime) Seroquel (antipsychotic medication) increased (initiated on 2/21/25). Ensure resident is wearing grippy socks while in bed (initiated 2/26/25). Resident's room moved closer to nurse's station (initiated on 2/28/25). Incident 1 R1's incident report dated 12/11/24 includes the following: Unwitnessed fall on 12/11/24 at 7:10 AM. Location: Resident's room. Nursing Description: Staff found resident on floor in room. Resident Description: Resident combative and unable to answer. Description of Action Taken: Nurse tried to assess both hips, appeared all was wnl (Within Normal Limits). Sent out to the ER (emergency room ). New Intervention: offer and encourage toileting every 2 hours and as needed. Notes: Resident was alert but yelling, and swinging at staff. Yelled yes to paibn [sic]. Other: He is Easy stand (Mechanical lift used to aid in transferring residents). He was in bed transferred self. [NAME] is across room, and call light is on bed. He usually yells if don't answer is [sic] light when he is using it Staff normally anticipate his needs ahead time. R1's 12/11/24 after visit summary from the Emergency Department states, in part: He (R1) has had x-rays done and we are seeing an acute mildly displaced subtrochanteric periprosthetic fracture of the proximal left femur .nonsurgical. He will be sent back to the nursing facility with outpatient clinic follow up with orthopedics. On 4/10/25 at 5:00 PM, Surveyor interviewed DON B (Director of Nursing) regarding R1's fall (incident 1). DON B indicated a root cause analysis is performed using a QA (Quality Assurance) form. DON B indicated a root cause is only done when there is an injury. Surveyor asked about the root cause for R1's fall on 12/11/24 that resulted in a left femur fracture. DON B indicated there was not one. Surveyor asked DON B what the facility's process for toileting residents with dementia. DON B indicated the standard of practice is to offer toileting every 2 hours and as needed. Surveyor asked DON B if she would consider the intervention offer and encourage toileting every 2 hours and as needed an appropriate intervention for a fall since that is the standard and was already being done for R1. DON B indicated it was not an appropriate intervention. Of note, there was no intervention placed on the care plan following this fall. Incident 2 R1's incident report dated 1/8/25 includes the following: Unwitnessed fall on 1/8/25 at 5:30 AM. Nursing Description: Resident found in room lying supine (lying face upward) on the floor. Legs pointed toward the toilet, torso in front of the door. New intervention: Offer toileting with every NOC (night) round while awake. Education: Recommended resident use call light to ask for help with transfers rather than do them unassisted. On 4/10/24 at 5:00 PM, Surveyor interviewed DON B regarding R1's fall. DON B indicated a root cause analysis was not completed. DON B indicated that offering toileting on night rounds is a standard of practice and not a new intervention. DON B indicated this is not an appropriate intervention. Incident 3 R1's incident report dated 1/12/25 includes the following: Unwitnessed fall on 1/12/25 at 8:30 AM. Nursing Description: Res (R1) calling out. Observed res (R1) sitting on buttocks outside bathroom door. No shoes. Had brief and t-shirt on. Res attempting to self-transfer to toilet. No injury noted. Resident Description: Resident was requesting to use toilet. Description of Action Take: 2 assist with hoyer off floor. CNA (Certified Nursing Assistant) toileted and put him in his recliner. Neuro checks started. NOC shift to offer toileting 4:00 AM - 6:00 AM. On 4/10/25 at 5:00 PM, Surveyor interviewed DON B regarding night shift rounds. DON B indicated staff offer toileting on rounds as a standard of practice. DON B indicated offering toileting between 4:00 AM and 6:00 AM would not be a new intervention as staff should have been doing this as a standard of practice already. Incident 4 R1's incident report dated 1/14/25 includes the following: Unwitnessed fall on 1/14/25 at 6:25 AM. Nursing Description: Resident found on floor at 6:25 AM. Resident was incontinent of urine. No injury observed. VSS (Vital signs stable). Neurological checks initiated. Resident Description: Resident is unaware of what happened. Description of Action Taken: Resident transferred into wheelchair. New intervention: Offer toileting upon rising, before/after meals, at HS (hours of sleep), and PRN (As needed). On 4/10/25 at 5:00 PM, Surveyor interviewed DON B. DON B indicated offering toileting upon rising, before/after meals, at HS, and PRN is standard of practice and staff should have already been doing this. DON B indicated this would not be considered a new intervention for R1. Incident 5 R1's incident report dated 1/23/25 includes the following: Unwitnessed fall on 1/23/25 at 1:45 AM. Nursing Description: Resident found in his room lying on the floor in the supine position near his BR (Bathroom). Description of Action Taken: Encouraged resident to use his call light to ask for assistance when needing to use the BR. New intervention: Don't leave resident unattended while awake in room, bathroom (use privacy curtain), church, activities, nurses station, and/or dining room. Incident 6 R1's incident report dated 2/16/25 includes the following: Unwitnessed fall on 2/16/25 at 3:00 PM. Nursing Description: Resident found laying on his back in the middle of room. Active rom (Range of Motion) and able to move all extremities. No injuries noted. New intervention: Resident assisted into w/c (wheelchair) with 2 assist and gait belt transferred with some shakiness. Encourage resident to be in room only during sleeping hours. Of note, the previous intervention added on 1/23/25 states Don't leave resident unattended while awake in room, bathroom (use privacy curtain), church, activities, nurses station, and/or dining room. Incident 7 R1's incident report dated 2/20/25 includes the following: Unwitnessed fall on 2/20/25 at 4:30 AM. Nursing Description: Found lying on LT (left) side on floor at FOB (Foot of Bed). Description of Action Taken: Assisted back to bed. Reminded resident to use call light for assistance. New intervention: HS (Hours of sleep) Seroquel (antipsychotic medication) increased. Fall mat on exit side of bed. Of note, the intervention fall mat on exit side of bed was not added to the care plan. Incident 8 R1's incident report dated 2/25/25 includes the following: Unwitnessed fall on 2/25/25 at 12:00 AM. Nursing Description: CNAs came to nurses station 1 to inform the nurses about a fall. Observed resident whit [sic] his knees to chest, and then resident put himself laid [sic] on the ground on his back. Observed w/c between the foot of the bed, and walker was between TV, that is on dresser and the closet. He was barefooted. Called light within reach clipped to her [sic] bedsheet but not on. Res then does not follow directions. Res was yelling I have to pee I need the bucket. New intervention: Ensure grippy socks are on while resident is in bed. Incident 9 R1's incident report dated 2/27/25 includes the following: Witnessed fall on 2/27/25 at 3:50 PM. Location: Lounge. Nursing Description: Res was put in recliner as res appeared tired/restless. He appeared relaxed in the beginning but shortly after being put in the recliner, he moved himself towards the foot of the recliner and rolled onto the floor. Res noted to be lying on his back on the floor. New intervention: Room was moved closer to nurses station. Of note, this fall occurred in the lounge while being supervised. R1 was not in his room at the time of the fall. Incident 10 R1's incident report dated 3/4/25 includes the following: Unwitnessed fall on 3/4/25 at 8:00 PM. Nursing Description: Resident had unwitnessed fall. CNA found resident sitting on the floor in his room at 8pm [sic]. Of note, no new intervention was added. Incident 11 R1's incident report dated 3/6/25 includes the following: Unwitnessed fall on 3/6/25 at 4:00 AM. Nursing Description: Resident found lying on his Rt (Right) side propped up on Rt elbow at Rt side of his bed. Resident states he hit his head and has a headache. Description of Action Taken: New intervention: Resident signed onto hospice 3/7/25. Incident 12 R1's incident report dated 3/19/25 includes the following: Unwitnessed fall on 3/19/25 at 6:15 AM. Nursing Description: Nurse was in room (room number) and heard R1 yelling. Nurse went in his room right away he was on floor facing the door with the bed on left side and wheelchair tipped on its side. He was holding his head up. New intervention: Offer toileting at 6:00 AM. Of note, R1 has previous interventions of being toileted on night rounds and toileting between 4:00 AM and 6:00 AM. On 4/10/25 at 5:00 PM, Surveyor interviewed DON B regarding R1's falls. DON B indicated during the facility's morning meeting, the interdisciplinary team reviews all facility falls. DON B indicated during this meeting; interventions are reviewed along with staff statements regarding the fall. DON B indicated a root cause analysis is completed if a fall results in injury. Surveyor asked DON B if the interdisciplinary team had noticed R1 had repeated falls with no new interventions being put in place when the interdisciplinary team discussed falls in their morning meeting. DON B stated it probably didn't come up in the morning meeting. Of note, the facility did not find a root cause for the continued falls for R1. The facility did not implement or add to the care plan appropriate interventions to prevent further falls from occurring.

Based on the comprehensive assessment of a resident, the facility must ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and do not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 3 (R24) residents reviewed for pressure injuries. R24 had a Controlled Ankle Movement (CAM) boot applied for an ankle fracture. The facility did not implement interventions to remove the boot and assess her skin. R24 developed unstageable pressure injuries to her left heel and top of foot. Findings include: R24 admitted to the facility on [DATE] and has diagnoses that include End Stage Renal Disease, dependence on renal dialysis, Peripheral Vascular Disease (PVD), absence of left leg below knee, osteomyelitis, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Atherosclerotic Heart Disease, chronic Congestive Heart Failure, Atrial Fibrillation, Osteoporosis. The facility Pressure Injury Prevention and Managing Skin Integrity Policy and Procedure reviewed 8/10/23 documents (in part) . . I. Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries. II. Procedure: 1. Risk Assessment a. Upon admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. b. Re-evaluation: Braden Scale will be completed upon change of condition and quarterly. c. Based on the individual's Braden Scale score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record. 2. Identify Interventions and Care Plan a. Identify Interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary team (IDT) regarding the presence of breakdown and the intervention plan. 2. When indicated, a referral to additional resources (ie Wound Care Specialist, Registered Dietician, Physical Therapist, Occupational Therapist) may occur. 3. Identification of risk factors present or acquired that compromise skin integrity will be considered. b. Care Plan i. In developing a plan of care, the following will be considered: 1. Individual Pressure Injury History 2. Cognitive changes or impairment of the individual 5. Risk for pressure ulcer development (Braden Scale). 3. Skin checks a. Skin check will be done upon admission, readmission or as clinically indicated. b. While providing routine care, a licensed nurse is to monitor the skin condition of each individual weekly and document the skin check in the medical record. R24's Braden score dated 7/9/23 documented a score of 15, at risk for pressure injuries. R24 had a previous unstageable pressure injury with osteomyelitis to her right heel dating back to 2022. R24's Quarterly Minimum Data Set (MDS) dated [DATE] documents bed mobility and transfer as extensive 1 person assist. R24's Care Plan documents: Potential for skin breakdown/pressure ulcer development r/t (related to) need for assist with mobility, HTN (Hypertension), HLD (Hyperlipidemia) PRN (as needed) narcotic, Anemia, anti-platelet use, wound healing needs, anxiety/depression with psychotropic medication, PVD, Lymphedema and incontinence - initiated 10/17/22, revised 8/7/24. Use of CAM boot was added as revision on 10/11/23. Interventions include: Educate the resident/family caregivers as to causes of skin breakdown; including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning - 10/17/22. Follow facility policies/protocols for the prevention/treatment of skin breakdown - 10/17/22. Monitor/document/report PRN any changes in skin status; appearance, color, wound healing, s/sx (signs or symptoms) of infection, wound size (length x width x depth), stage - 10/17/22. RestQ mattress - 6/2/23. Bilateral heel boots at all times as resident tolerates, or float heels while in bed - 11/9/22. Staff to assist with turning and repositioning - 4/1/24. Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes - 4/1/24 The resident requires a pressure relieving/reducing device on bed/chair - 10/17/22. Surveyor noted no revisions to the care plan regarding removal of the CAM boot or increased monitoring of R24's skin underneath the boot. On 9/24/24 at 1:55 PM, Surveyor asked Consultant-C for information regarding R24's left heel pressure injury, and when it was identified. Consultant-C advised Surveyor the facility began utilizing new program in April and will have to do some research. Consultant returned and advised Surveyor she determined R24's left heel pressure injury goes back to October 2023 and advised Surveyor where to locate documentation in the electronic health record. Surveyor asked for documentation of the initial comprehensive assessment and measurements when the pressure injury was identified and asked if she had knowledge of how the pressure injury developed. Consultant-C stated: I want to say it was from her boot (Consultant-C looked at Nursing Home Administrator (NHA)-A), right? NHA-A stated: I believe so. Surveyor was unable to locate information regarding R24's CAM boot and asked the facility for information; when it was applied and why. After much record review and multiple discussions with the facility, Surveyor was provided an Orthopedics consult dated 9/19/23 which documented: Patient presents to orthopedics with left ankle fracture. Xrays repeated today and show fracture in similar position as previous images. Discussed non-operative treatment with pt (patient). Use tubigrip and elevate as much as possible for swelling/pain. CAM boot in place at all times except for hygiene and icing. On 9/24/24 at 2:30 PM, Consultant-C advised Surveyor the Wound Advance Practice Nurse Practitioner (APNP) and facility wound nurse do wound rounds together and document, therefore some entries are by the APNP and some are by the wound nurse. Consultant-C advised Surveyor documentation confirms the left heel pressure injury was identified on 10/11/23. Surveyor review of R24's progress notes noted the first documentation regarding R24's left heel pressure injury on 10/11/23 which documented: 10/11/23 Wound Care Follow up APNP. Wound assessed and noted to have new area to dorsal aspect of left foot with ruptured blister, skin intact. Treatment plan discussed with treatment nurse and patient. Left heel unstageable Pressure injury Measuring 3.9 cm (centimeters) x 4 cm with 100% eschar, no drainage, periulcer skin intact blanchable redness. Status: Stable. Plan: Betadine daily. Stage 2 pressure injury to left dorsal foot, blister Measuring 3 cm x 4 cm, 100% epithelial, blister flush to skin without fluid. Scant serous drainage, peri ulcer skin with blanchable redness. 10/25/23 Wound Care Follow up APNP. Left heel unstageable pressure injury measuring 4.5 cm x 3.9 cm with 100% eschar, no drainage, peri skin intact blanchable redness. Status: Stable. Stage 2 pressure injury to left dorsal foot measuring 3 cm x 4 cm, 100% eschar, periulcer skin with blanchable redness. Status: Stable. Surveyor noted the wound documentation on 10/25/23 incorrectly documented the left dorsal foot pressure injury as a stage 2 with 100% eschar, it should have been staged unstageable. Review of R24's October, 2023 Treatment Administration Record (TAR) documented: Left Heel: Skin prep daily in the evening for DPTI (Deep Tissue Injury) - Start Date 10/5/23 which was signed out as completed. Surveyor noted documentation indicated the pressure injury was present as early as 10/5/23 and not identified on 10/11/23 as previously reported by Consultant-C. On 9/24/24 at 3:00 PM, during the daily exit meeting, the facility was notified that documentation revealed evidence R24's left heel pressure injury was present as early as 10/5/23 as evidenced by documentation and treatment implemented on the TAR. Surveyor asked for documentation of a comprehensive assessment and measurements of the pressure injury prior to those completed on 10/11/23. On 9/24/24 at 3:45 PM, Surveyor was provided an orthopedic consult dated 10/3/23 which documented: Patient seen in orthopedics clinic. Developing pressure ulcer to L (left) heel. Skin irritation noted to anterior ankle. Old boot removed. Placed heel-bo pad to heel and wrapped with ace wrap. Fit patient for larger size boot with extra padding to protect skin. Staff should examine skin and provide wound care at least Once daily. Frequently reposition to take pressure off heel. OK to remove boot at rest to prevent ulcer to heel. OK to open/remove boot for icing. NWB (Non-Weight Bearing) LLE (Left Lower Extremity). Surveyor was provided the facility 24 hour board documentation for 10/5/23 which documented R24's left heel Deep Tissue Injury (DTI) to include measurements 3 x 4.3. Consultant-C pointed out there was writing at the bottom of the page, which Consultant-C explained indicates someone must have done an audit, but noted nothing was documented for R24. The facility also provided a text message communication between the facility and the Wound APNP which read: Wed, [DATE]:00 PM (R24) just returned. Her right heel is resolved, left heel has DPTI. Can I use skin prep to left heel? She has a broken left ankle in a cam boot. Surveyor noted there was no evidence the facility completed comprehensive assessment of R24's left heel pressure injury when identified by ortho on 10/3/23. A comprehensive assessment was not completed until she was seen by the Wound APNP on 10/11/23 which documented the left heel unstageable pressure injury and left dorsal foot stage 2 pressure injury. On 9/25/24 at 10:19 AM, Surveyor spoke with Consultant-C. Surveyor asked if R24's care plan was revised to include increased monitoring of the skin under the boot. Consultant-C stated: I hope so. Surveyor noted R24 was issued a CAM boot on 9/19/23. No revisions were made to the care plan to include the CAM boot. The boot was ordered to be worn at all times except for hygiene and icing. The care plan was not revised to include increased monitoring of R24's skin under the boot. R24 was determined to be at risk for pressure injuries and had an actual pressure injury to her right heel dating back to 2022. The facility continued with only weekly skin checks. The most recent skin check on 9/29/23 included no documentation of abnormalities. R24 was followed by the facility wound nurse and Wound APNP weekly and subsequently seen by an outside wound clinic. Treatment was adjusted accordingly and completed as ordered. Despite this, R24's wounds failed to heal, and subsequent testing was completed. 12/28/23 Radiology report: Critical lower limb ischemia. Left - mild stenoses of the proximal and distal superficial femoral artery. Multifocal high grade 70-80 percent stenoses of the above knee popliteal artery. There is three vessel runoff, but there are also high grade stenoses of the tibioperoneal trunk and proximal anterior tibial artery. 2/28/24 Peripheral intervention - Critical limb ischemia. Diagnosis: PVD. LLE angiogram, lower extremity nonhealing wounds. Chronic renal insufficiency on dialysis who has had wounds on her left foot that have not healed. She had abnormal noninvasive studies showering severe disease in her left SFA (Superficial Femoral Artery) anterior tib, tibioperoneal trunk. 7/11/24 LLE angiography: The left SFA shows that there has about a 20% proximal lesion over the course of 1 centimeter. The left popliteal has a 10% mild stenosis and a 30-40% stenosis at the joint in the P2 section, this is over the course of about 2 cm. The anterior dorsalis pedis does not feed the pedal loop. The Tibioperoneal trunk has a 30% proximal lesion over the course of 1-2 cm. Conclusion: Severe single-vessel below the knee stenosis. The SFA has mild proximal disease. The popliteal artery has mild to moderate disease. The anterior tibial has severe proximal disease. The dorsalis pedis does not feed the pedal loop. The tibioperoneal trunk has mild proximal disease. The posterior tib has an irregular course but no focal stenosis, peroneal artery is normal. Hospital Medicine Progress note dated 7/18/24 documents: Chronic LLE foot ulcer. Boot in September of last year that caused some irritation and subsequent ulcerations to the top of her left foot. These have now been present for several months without healing. She has a history of prior vascular disease with prior stenting. On 9/25/24 at 12:09 PM, Surveyor advised Consultant-C of concern R24 was issued a CAM boot to be worn at all times. The care plan was not revised to include increased monitoring of R24's skin under the boot. R24 developed unstageable pressure injuries on her left foot. Consultant reported she is aware of the concern. On 9/26/24 at 7:59 AM, Surveyor spoke with Consultant-C and advised of the following concerns: R24 was determined to be at risk for pressure injuries and had an actual pressure injury to her right heel dating back to 2022. The facility continued with only weekly skin checks. R24 was issued a CAM boot on 9/19/23. The boot was ordered to be worn at all times except for hygiene and icing. No revisions were made to the care plan to include the CAM boot and the care plan was not revised to include increased monitoring of R24's skin under the boot. R24 developed unstageable pressure injuries to her left foot, which were identified by ortho on 10/3/23. A comprehensive assessment of the pressure injuries was not completed until she was seen by the APNP on 10/11/23. In addition, the 10/25/23 assessment of R24's dorsal foot pressure injury was incorrect. Documentation indicated it was stage 2 with 100% eschar was present, which would indicate the pressure injury was unstageable. Consultant-C stated: I know, I understand the concern. I just want you to know we did a complete skin sweep last night for any/all residents with any type of boots, splints, or binders - everything was in place and no areas were found.

Based on interview, and record review the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (R10 and R222) of 5 residents reviewed. *R10 had an unwitnessed fall on 11/25/2023 and did not have neurological checks completed as scheduled per the facility policy. R10's Fall Risk Care Plan was not updated after R10's fall on 11/25/2023. On 1/19/2024, R10 was transferred by Certified Nursing Assistant (CNA)-W with a Sara Steady (an assistive device used for transferring residents). CNA-W did not have assistance from another staff member when R10's care plan documented 2 assist should be used with transferring R10. R10 fell from the Sara Steady and fractured R10's left tibia. R10 was hospitalized from 1/19/2024 through 1/22/2024 and required a Closed reduction of R10's left leg while under sedation. *R222 had a fall on 6/6/2024 that the facility did not thoroughly investigate. Findings include: The facility policy entitled, Falls, with a review date of 6/13/2023, documents, in part: Prevention measures are put in place to reduce the occurrence of falls and risk of injury from falls . Licensed nurse completes electronic documentation of the Fall Incident Report. The care plan will be updated with an identified intervention. Registered Nurse reviews and completes the fall assessment and interventions. Fall follow-up assessments completed as indicated . The Interdisciplinary Team (IDT) will review Fall incident report and utilize root cause analysis to make further recommendations. Director of Nursing (or designee) and Executive Director to review and sign Fall incident Report. Quality Assurance and Process Improvement Committee reviews facility fall incidents and trends . The facility policy entitled, Safe Individual Handling Program, with a review date of 6/13/2023, documents, in part: . Transfer Assessment-Individuals will be assessed according to ability per transfer and movement objective criteria. Nursing will perform this assessment in collaboration with therapy as applicable. Once the assessment is completed, the appropriate transfer status will be determined. Care Plan-Individual specific transfer status will be addressed on the Care Plan to include specific equipment type if applicable. All staff to transfer according to the Care Plan unless it is determined by the Registered Nurse (RN)/ Licensed Practical Nurse (LPN)/ Certified Nursing Assistant (CNA) at the time that the transfer is not a safe transfer for either the individual or the staff member . Employee Training-Employees will be trained upon hire and when deemed appropriate. Training to include: Safe Individual Handling Policy Overview . Proper transfer techniques using the equipment with return demonstration . The facility policy entitled, Neurological Observation, with a review date of 6/13/2023, documents, in part: Licensed nurse will monitor and record an individual's Neurological status as indicated . Neurological observation is to be done per the following Neurological Check Schedule, unless otherwise specified by a physician order: At the time of event. Every 15 minutes x4. [Every] 30 minutes x4. [Every] 1-hour x4. [Every] 4 hours x4. Then every shift up to 72 hours . Notify the provider of any changes in neurological status . 1.) R10 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis affecting Left side following a stroke, Cerebral edema, Dementia, Depression, Anxiety, Osteoporosis, Muscle weakness, and Presence of Left artificial Knee Joint. R10's Admission Minimum Data Set (MDS) assessment, dated 11/22/2023, documents R10 has a Brief Interview for Mental Status (BIMS) score of 14, indicating that R10 is cognitively intact. R10 requires substantial/maximal assistance for transfers. R10's Care Area Assessment (CAA) for falls dated 11/22/2023, documents . [R10] has balance issues with transitions due to hemiplegia [status post stroke]. [R10] is [wheelchair] bound. [R10] needs assist with all mobility. [R10] continues at risk [related to] weakness, hemiplegia [status post stroke], anti-depressant use, dementia, depression, anxiety, [Osteoporosis], [Osteoarthritis], and chronic pain syndrome. R10's fall risk assessment dated [DATE], documents a fall risk score of 10, indicating that R10 is at a high risk for falls. R10's At risk for falls care plan includes, in part, the following interventions initiated on 11/20/23: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear shoes, or non-skid socks when transferring or mobilizing in [wheelchair]. Follow facility fall protocol. R10's ADL (activities of daily living) care plan includes, in part, the following intervention initiated on 11/20/23: 2 [assist] sit-to-stand transfers. R10's progress note, dated 11/25/2023 at 8:46 AM, documents, in part: [R10] had an unwitnessed fall at [6 AM] . [Vital Signs within normal limits]. Neuro-check initiated per protocol . Surveyor reviewed R10's 11/25/23 fall investigation completed by the facility. R10 was attempting to sit at the edge of the bed without assistance. R10 then slid out of bed onto the floor onto R10's buttock. R10 did not obtain an injury due to this fall. The fall investigation documented a new intervention: wheelchair to be left at bedside with brakes locked to help prevent future falls. Surveyor reviewed R10's care plan. This new intervention was not added to R10's care plan. On 9/26/2024 at 7:35 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-B. Surveyor asked if R10's care plan had an intervention added after R10's fall on 11/25/2023. ADON-B stated that the care plan was not updated. ADON-B stated that it is an expectation that an intervention should have been added to R10's care plan after the 11/25/2023 fall. On 1/19/2024, R10 had another fall. R10's late entry progress note, dated 1/19/2024 at 8:56 PM, documents, in part: CNA came to the writer to report [resident] is on the floor. [Writer] entered the room to observed that the [NAME] steady lift was in front/between the [resident] and [wheelchair] was by the bed (back of [wheelchair] facing bed) and the brakes were on . [R10's] [left] leg contracted with knee/thigh is bent away from body and when touching/trying to straight leg [resident] yelling in pain but when not touched/moved [resident] was not in pain . The fall was witnessed by CNA who was moving [resident] from toilet to [resident's] [wheelchair] . CNA was putting [resident] in [NAME] steady lift and when trying to put the 2 seats down so [resident] can sit, [resident] was impatient and when CNA tried to move the 2 seats together [resident] was on the floor and a cracking noise was heard and CNA called for help. After writer assessed [resident], to which [resident] was placed into bed with 4 staff members with Hoyer lift . R10's progress note, dated 1/19/2024 at 8:24 PM, documents: [7:41 PM]- [Resident's sister/Power of attorney] was called informed of [R10's] fall and going to [emergency room ]. [8:24 PM]- received the copy of the result of the x-ray of the [left] leg. [8:39 PM]-911 was called. [8:44 PM]- EMS (emergency medical services) here and was given report. [8:51 PM]-[R10] on stretcher with EMS and have left the facility. R10 was taken to the ER and was hospitalized from 1/19/24 until 1/22/24. R10's Hospital Discharge Summary dated 1/22/2024 documents: Brought in by EMS from nursing home for left leg pain. Patient is non-ambulatory, and injury likely happened while transferring. She was found to have a left knee proximal tibia periprosthetic fracture, prosthetic dislocation. She underwent closed reduction under sedation 1/20/24. Surveyor reviewed R10's fall investigation completed by the facility. CNA-W's undated witness statement documents: Was getting resident off the toilet while using the [NAME] Steady. After washing her bottom and putting the brief and [R10's] pants on, [R10] was ready to go to [R10's] chair. While [R10] was standing, I pulled the [NAME] Steady out of the bathroom while [R10] was standing on it. [R10] started to go down slowly, went behind [R10] to help ease [R10] to the ground. Realized I didn't put the seat down for [R10] to sit. Never used or seen a [NAME] Steady before. Did ask and only got told how to use it. Surveyor notes CNA-W was unavailable for interview. On 9/25/24 at 9:39 AM, Surveyor interviewed, CNA-X. CNA-X stated that CNA-X was not in the room when the fall occurred but was working at the time of R10's fall. CNA-X stated that CNA-W told CNA-X that CNA-W forgot to put the seat to the Sara Steady down during R10's transfer and that is why R10 fell . Surveyor asked what R10's transfer status was at the time of the fall. CNA-X stated that R10 required 2 assist with the Sara Steady. Surveyor asked if CNA-W asked CNA-X for help. CNA-X stated CNA-X was not asked to help transfer R10. CNA-X stated that they work as a team, and they were doing the best they could. Surveyor asked if CNA-X was trained to use the Sara Steady. CNA-X stated that CNA-X was trained, and that CNA-X had trained CNA-W on how to use the Sara Steady days before the fall occurred. CNA-X stated that the fall was a complete accident. On 9/25/24 at 2:01 PM, Surveyor interviewed Physical Therapist (PT)-V. Surveyor asked what R10's transfer status was prior to R10's fall on 1/1/9/2024. PT-V stated that PT-V recommended using the Sara Steady with 2 assists for all transfers. PT-V stated that PT-V always recommends 2 assist when using the Sara Steady. Included in R10's fall investigation was the following time line completed by ADON-B on 1/22/2024: 1045: Obtained written statement from [CNA-W]. 1047: [CNA-W] didn't know how to find Kardex in [EMR]. [CNA-W] did state she had log in. When writer had [CNA-W] log into [EMR], [CNA-W] did not have access to [facility], only had access to [assisted living facility]. Writer changed location to ALL and then [facility] but there was no access for [CNA-W] to see [facility]. [CNA-W] stated [CNA-W] did message [Scheduler-G] on Saturday to request access. 1054: Spoke with [CNA-X] and [CNA-W]. [CNA-X] stated [CNA-X] did show [CNA-W] how to use the Sara Steady. [CNA-W] then stated she did not remember this. 1055: Had [CNA-X] demonstrate use of Sara Steady and no concerns noted. 1056: [CNA-W] reenacted transfer. [CNA-W] showed writer unlocking breaks after [R10] stood. Pulling Sara Steady back out of the bathroom and letting [R10] know that there was a bump in the threshold. When [CNA-W] had the Sara Steady over the threshold, [CNA-W] stopped the machine. [CNA-W] said [R10] started to sit at this time and [CNA-W] realized [CNA-W] had not put the paddles in place. [CNA-W] went around the machine and assisted [R10] to the ground. Then went to get help. 1123: Writer called [name of staff] who created a ticket to expand [CNA-W] access [in EMR] . On 9/25/2024 at 10:45 AM, Surveyor interviewed ADON-B. Surveyor asked about R10's fall on 1/19/2024. ADON-B stated that through the investigation, ADON-B recognized that R10's transfer was not completed as care-planned. Surveyor asked what R10's transfer status was prior to R10's fall on 1/19/2024. ADON-B stated they would get back to Surveyor. Surveyor asked when staff are trained on the Sara Steady and lifts. ADON-B stated that staff are trained on Sara Steady and lifts during orientation. In addition, staff are trained on who to go to with any questions. On 9/26/24 at 7:35 AM, ADON-B returned to Surveyor. ADON-B stated that the facility identified errors in R10's transfer. R10 should have been assisted by 2 staff members and staff should have put the seat of the Sara Steady down. ADON-B indicated that CNA-W had been trained on how to use the Sara Steady during orientation, the week prior to R10's fall on 1/19/2024. ADON-B stated that ADON-B educated CNA-W about how to get into the CNA Kardex/Care plan the week prior to R10's fall on 1/19/2024. ADON-B stated that the Sara Steady was removed from the floor until all staff members were re-trained. Surveyor reviewed the Facility QAPI (Quality Assurance and Performance Improvement) Meeting notes dated 1/22/2024 which documents, in part: . Identified concern: Staff used the Sara Steady incorrectly by not putting the butt paddles down to prevent a fall and did not follow the care plan. What we did: What corrective action will be accomplished for those residents found to have been affected by the deficient practice. ~Resident will be reassessed for transfers upon return. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. ~All other residents using Sara Steady were assessed for appropriateness and to ensure not care planned for 2 person assist. What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur. ~Staff member that did the transfer was re-educated and asked to re-enact how she used the lift and following the care plan. ~All CNA staff were re-educated before working next shift on use of Sara Steady and following the care plan. How do you plan to monitor performance to make sure that solution is sustained. ~Audits of those using a Sara Steady transfer will be audited for 4 weeks then frequency determined. When will this be completed. ~1/22/2024. This plan was discussed, developed, and reviewed by the QAPI team (Sign below including Medical Director). Surveyor reviewed the weekly audit outlined in the QAPI plan. For each week of the audit, the following was documented: No patients currently using the Sara Steady. On 9/26/24 at 10:53 AM, Surveyor notified Nursing Home Administrator (NHA)-A of the concerns regarding R10's fall. R10 was transferred with one assist when the care plan indicated that R10 should be transferred with 2 assist. CNA-W did not use the Sara Steady properly and did not put the seat down while transferring R10. NHA-A stated that the facility recognized the issues regarding R10's fall and developed a QAPI plan. NHA-A indicated that this fall should qualify as past-non-compliance. Surveyor explained that because there was non-compliance related to falls after R10's fall, that this accident does not qualify for past-non-compliance. No further information was provided. 49011 2.) R222 was admitted to the facility on [DATE] from the hospital with a primary diagnosis of encounter for surgical aftercare following surgery on the digestive system; and other diagnoses which include, in part, pneumonitis, muscle weakness, and polyneuropathy. R222's discharge Minimum Data Set (MDS) with an assessment reference date of 6/27/24 indicated R222 had a Brief Interview for Mental Status score of 13 (fully intact memory). R222 is able to make decisions for themselves. R222's MDS showed that no behaviors were noted. For toileting R222 requires supervision or touching assistance, is occasionally incontinent of bladder and always continent bowel. The MDS noted one fall since admission. On 09/26/24, at 08:21 AM, Surveyor reviewed R222's care plan and noted the following: R222 is at risk for falls r/t (related to) weakness post hospitalization for Ileocecal mass with resection and Aspiration Pneumonia with hypoxic respiratory failure, need for assist with mobility, Neuropathy, HTN (hypertension), OA (open area), Hyperthyroidism, balance concerns, and translocation. Date Initiated: 05/30/2024 R222 had a goal of: Risk of falls/falls with injury will be minimized Date Initiated: 05/30/2024 Target Date: 08/26/2024. Interventions include: o Be sure The resident's call light is within reach and encourage the resident to use it for assistance Date Initiated: 05/30/2024 o Encourage resident to use call light when feeling weak and/or during the night. Date Initiated: 06/06/2024 o Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility Date Initiated: 05/30/2024 o Ensure that The resident is wearing appropriate footwear when ambulating, transferring or mobilizing in w/c. Date Initiated: 05/30/2024 Revision on: 06/28/2024 o Follow facility fall protocol. Date Initiated: 05/30/2024 o PT/OT evaluate and treat as ordered or PRN. Date Initiated: 05/30/2024 o The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Personal items within reach Date Initiated: 05/30/2024 R222's activities of daily living care plan notes the following pertinent interventions: o TOILET USE: 1A Date Initiated: 05/30/2024 o TRANSFER/AMB (ambulation): Up ad lib in room and hall with FWW post cares during waking hours Date Initiated: 05/30/2024 On 09/24/24, at 12:50 PM, Surveyor reviewed a progress note written on 6/6/2024, at 06:11am, At 0605am Pt sent to (name of hospital) (sic) Ambulance for unwitnessed fall and c/o (complaints of) neck pain. Surveyor requested fall investigation information from the Facility and reviewed it. There was a Witness Statement Form completed by Licensed Practical Nurse (LPN)-M CNA found (R222) on floor. (R222) laying face down facing side bed. C/O neck and lt (left) knee pain. Night Staff stated (R222's) independent we don't check her, (R222) stated this was at about midnight, found her at 0535. On 09/25/24, at 07:44 AM, Surveyor interviewed LPN-M and asked about the fall. LPN-M remembers hearing about it but was not at the Facility at midnight. Surveyor reminded LPN-M that they wrote a statement as resident was sent out at 5:35am when they were there. LPN-M states they wrote down what staff told them. On 09/25/24, at 12:58 PM, Surveyor interviewed Nurse Supervisor (NS)-F who stated that is what was reported to them, that the day shift certified nursing assistant found R222 laying on stomach. R222 had been getting up to go to the bathroom and fell . Surveyor asked how long the resident was on the floor before being discovered. NS-F was not sure how long R222 laid on the floor. NS-F stated that rounding is done on a schedule. Night shift should have checked on R222. NS-F stated that night shift should do rounds at least twice during the shift. After this fall the action taken by NS-F was that they verbally talked to night shift about rounding and peeking on residents. On 09/25/24, at 02:20 PM, Surveyor spoke with LPN-M again to see if anything was remembered about the fall. LPN-M stated being 90 percent certain R222's door was open so staff should have seen the resident. LPN-M remembers R222 did not tell staff not to check on them. On 09/25/24, at 03:13 PM, NS-F followed up with Surveyor that in conclusion they don't know how long R222 was on the floor. NS-F states that on the 24-hour board for 6/5/24 it is written that R222 is up ad lib and check on at night, fall happened then that night and education was done on 7/2/2024. Surveyor was given the written education staff were to read and sign off on. The education was staff should be checking and changing resident throughout their shift and PRN, ex: beginning, middle, and end of shift. If a resident is sleeping, please wake up resident to offer a check and change (unless a resident specifically doesn't want to be woken up, ex: on NOC shift and have a sign on door). If resident refuses at time of offer, re-approach at a different time, or ask the resident around which time would work better. If resident still refusing, let your floor nurse know so it can be documented accordingly. On 09/26/24, at 08:02 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-J who wrote statement that they found R222 on the floor. CNA-J remembers hearing R222 yelling so walked into room and found R222 laying on stomach on the floor by bed. R222 did not say how long there. CNA went and got nurse, did notice R222 had rug burn on knee. On 09/26/24, at 09:17 AM, CNA-J followed up with Surveyor and stated that the door was shut, R222 liked the door shut. Surveyor asked if that meant R222 should not have been checked on to which CNA-J responded R222 should have been checked on a couple times at night. Surveyor reviewed the form Fall Data Collection Tool. Many lines were left blank. For instance, Time of Fall, Last time resident had a wellness check, Last time resident was toileted were all not completed. Surveyor notes there was no documentation provided as to when R222 had last been checked on. There was no documentation as to whether door was open or shut. On 09/26/24, at 09:24 AM, Surveyor interviewed CNA-I who was working the unit on the night of the fall. CNA-I states had checked on R222 between 1:30-2am. R222 had been pressing light all night and CNA-I was going in each time light was pressed. Between 2:00-5:30am they were answering call lights and busy, but at 2:00am R222 was asleep in bed. CNA-I stated they sat with R222 till emergency medical services arrived and that R222 stated had been on floor awhile, had been on floor since midnight and was in pain. A new Witness Statement Form was provided to the Surveyor dated 9/26/2024, at 9:19am, written by NS-F as a verbal over the phone interview of CNA-I. Writer called (CNA-I) who was working on 6/6 when (R222) fell . (CNA-I) reports resident was on her call light a few times that night. Resident was checked on at these times. Last toilet check was at 1:30-2am due to doing rounds/answering lights. CNA did peek head into resident's room frequently. On 09/26/24, at 11:02 AM, Surveyor interviewed Occupational Therapist (OT)-U who reviewed therapy notes and stated that from 5/30/24 to 6/4/24, R222 was a stand by assist, per the notes on 6/5/24 and 6/6/24 cannot be sure, but starting 6/7/24 R222 was switched to up at lib with walker. On 09/26/24, at 11:25 AM, Surveyor spoke with Nursing Home Administrator-A and Regional Consultant-C regarding fall concerns for R222 as there was a lack of thorough investigation. The last time R222 was checked on was not documented, so how long on floor cannot be determined. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure that 1 R (Resident) (R12) of 6 residents reviewed for accidents had adequate supervision to prevent accidents. On 3/13/21, R12 eloped from the facility on foot and was found on the ground by the side of the road approximately 0.1 miles from the facility by citizens driving on the road who witnessed R12 fall. R12 was transported to the hospital and diagnosed with a fracture to right ankle. On 4/19/21 at 10:57 AM, Surveyor observed R12 elope from the facility again on foot through the 100 wing end door. R12 was outside approximately three minutes before staff responded to the alarm that had been set off. The facility's failure to ensure R12 received adequate supervision to prevent elopement and accidents created a situation of Immediate Jeopardy (IJ), which began on 3/13/21. Surveyor formally notified AIT (Administrator in Training)-B of the IJ on 4/20/21 at 11:30 AM. The IJ was removed on 4/20/21. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: HHS.gov website notes Federal hearing decisions have repeatedly held that section 483.25(h) obligates a facility to take, all reasonable steps to ensure that a resident receives supervision and assistance devices that meet his or her assessed needs and mitigate foreseeable risks of harm from accidents. Though a facility has flexibility to choose the methods of supervision and assistance used to prevent accidents, it must also provide supervision and assistance devices that reduce known or foreseeable accident risks to the highest practicable degree, consistent with accepted standards of nursing practice.Where a facility policy or a resident's care plan requires staff to take specific measures in caring for a resident, the Board has repeatedly held that those measures reflect the facility's own determination of what it must do to attain or maintain the resident's, highest practicable physical, mental, and psychosocial well-being as required by the overarching quality-of-care requirement . https://www.hhs.gov/sites/default/files/board-dab-2829.pdf The facility's policy with a review date of 10/21/20 and entitled Elopement Prevention, indicated the facility will have interventions for wandering prone residents will be individualized to maximize their independence, safety and well-being. Upon admission, ask the resident, resident representative, family members and past caregivers if the resident has a history of wandering or elopement. An Elopement Risk Evaluation will be completed upon admission. A facility staff member will take a picture of the resident for any high risk for elopement evaluation and have readily available for staff. Interdisciplinary Team (IDT) will initiate a plan of care for high risk residents that will include facility specific measures as well as resident specific measures to be included in the care plan. Interventions of wanderguard devices and monitoring will be initiated as deemed necessary by the IDT and documented in the care plan. On 4/19/21, Surveyor reviewed R12's medical record. R12, who is 73-years-old, was admitted [DATE] after a fall at home. R12 has diagnoses to include rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood and cause kidney damage), weakness, unspecified dementia, panic disorder, anxiety, hypertension (high blood pressure), history of falling, and [CONDITION(S)] (group of lung diseases that block airflow and make it difficult to breathe), [CONDITION(S)], [CONDITION(S)] (clouding of the normally clear lens of the eye), and [CONDITION(S)]. R12's MDS (Minimum Data Set) assessment dated [DATE] documented R12's BIMS (Brief Interview for Mental Statues) score at 3 out of 15 indicating severe cognitive impairment. This assessment noted R12 was not steady with walking or turning around but was able to stabilize without human assistance. R12's Elopement Score dated 1/22/21 indicated a score of 2.0 indicating R12 was at risk of elopement. The Elopement Risk Evaluation indicated R12, Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Wanders: Yes. Wandering behavior, a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self/others: Yes. R12's care plan initiated on 1/23/21 Focus: [R12] has impaired cognitive function/dementia or impaired thought processes related to disease process, impaired decision making. [R12] is known to be impulsive with wandering within the health center. Surveyor reviewed R12's interventions on the care plan and no interventions observed to address R12's elopement risk or wandering tendencies despite the above assessments. R12's progress note by LPN-G dated 3/13/21 at 8:45 PM, stated, Writer was notified at 1940 (7:40 PM) that [R12] was missing. Staff did room to room search on all three stations and [R12] was no where (sic) to be found. Writer received a phone call from outside source at 1956 (7:56 PM) that [R12] was a block down the street from facility. Writer ran to exact location where [R12] was found and was met by two police officers and ambulance that was in route to take [R12] to hospital. Police officers informed writer that [R12] was found on the ground in the road and c/o (complains of) hip and knee pain. Resident was sent up to hospital for further evaluation. On call DON (Director of Nursing) notified. Writer called hospital for updates. Scans may indicate small left ankle fracture (ankle fracture was actually on right ankle). Staff at hospital stated that resident will be returning to facility sometime tonight. Hospital will call when resident is ready for pick up. Incident report completed by Watertown Police Department reviewed for incident involving R12. The times on the police report indicate reported date and time as 3/13/21 at 7:36 PM and arrival date and time as 3/13/21 at 7:43 PM. Information obtained by the individuals who stopped vehicle to help R12 indicated they found R12 on the side of the road and R12 had fallen down. R12 was complaining of hip pain. R12 was able to communicate name but unable to answer other questions. Individuals who stopped knew people who worked at the facility and called them to see if R12 was a resident at the facility. LPN-G responded to the scene and reported that R12 was missing for approximately 10 minutes. R12 was transported to the hospital by EMS (Emergency Medical Services). On 3/13/21 at 11:55 PM, Elopement Assessment completed and indicated R12 at High Risk for elopement. Wanderguard bracelet applied to R12's right wrist (3/13/21 Physician order for Wanderguard.). On 4/20/21, Surveyor reviewed R12's medical records from hospital visit on 3/13/21. R12 was noted to have [CONDITION(S)] (swelling) to lower extremities and avulsion fracture of right medial malleolus (bony bump on inner side of the ankle). R12's radiology report impression indicated: Tiny age indeterminate avulsion fracture of the medial malleolar tip. Diffuse soft tissue swelling/[CONDITION(S)] of the imaged right lower extremity. On 3/14/21 at 8:45 PM, progress note by LPN-G stated, F/U (follow up) Fall: [R12] alert and confused per baseline. [R12] refuses to stay seated. [R12] ambulating/wandering around the facility independently. Wanderguard in place on RT (right) wrist. [R12] frequently attempting to break Wanderguard off. AROM (active range of motion) x4. PERRL (pupils equal round reactive to light). No shortening or rotation noted. Refer to Neuro assessment. R12's care plan updated on 3/14/21 specified Focus as, risk for wandering/elopement identified due to recent elopement from facility. Goal was listed as, resident will remain safe in facility with no elopement. Interventions were listed as, identify if there is a certain time of day wandering/elopement attempts occur. Provide reorientation to surroundings, environment. Schedule time for regular walks/appropriate activity. Wanderguard bracelet placement. On 4/20/21 at 2:34 PM, Surveyor interviewed LPN-G regarding 3/13/21 elopement of R12. LPN-G indicated staff were searching the facility and in the process of conducting a head count when LPN-G received the call from an outside person regarding R12 being located outside of facility. LPN-G reported that R12 was missing for 10-15 minutes from the time was last visualized. LPN-G indicated facility having written statements completed by staff that provided care to R12 and called and updated DON. LPN-G verified R12 did not have a wanderguard in place before incident that occurred 3/13/21. On 4/20/21, Surveyor drove to location R12 was found on 3/13/21. Resident was found on Pleasant St. Surveyor noted no sidewalks and the area is in a residential neighborhood. Google maps indicates location is 0.1 miles from the facility. Weather report data indicated the local low temperature was 21 degrees F outside on 3/13/21 and sunset was at 5:59 PM. Google Maps indicates the Rock River approximately 5 blocks from the facility and Highway 16 is approximately 3-4 blocks from the facility. On 4/19/21, Surveyor reviewed R12's medical records and on the following dates progress notes indicate R12's elopement attempts: -4/5/21 at 5:50 PM, progress note stated, Left message on R12's POA (power of attorney) phone to call facility re: elopement this afternoon. Res (resident) also attempted to go outside through 300 sunroom door around 18:40 (6:40 PM. Res did not go outside; was between doors. Easily redirected into facility. -4/7/21 at 10:45 AM, progress note state, Pt (Patient) observed going out exit door by day room. Wanderguard sounded. Staff member with pt and able to redirect pt back into facility. -4/12/21 at 2:46 PM, progress note stated, Pt noted to be exit seeking all shift. Reported that pt went out 100 unit exit door. Staff was right behind pt and brought pt back into building without incident. -4/19/21 at 11:03 AM, progress note stated, Door alert sounded off, on 100 wing, less than 10 sec Speech therapist went to assist resident back into facility Late note added at 4/20/21 0903 (9:03 AM). (This attempted elopement was prior to the elopement witnessed by Surveyor below.) On 4/19/21 at 10:57 AM, Surveyor observed R12 leave facility through the 100 wing end door. Facility exit door opened immediately as R12 pushed it open and alarm sounded immediately as door opened. Surveyor observed R12 in a short sleeve shirt, pajama bottoms and slippers. R12 was walking down the sidewalk in front of the facility. Surveyor did not observe staff responding to R12 or the door alarm. On 4/19/21 at 11:00 AM, Surveyor walked down 100 wing hall to alert staff that R12 had left facility and observed Director of Nursing (DON-B) coming down the hall to respond to door alarm. R12 was escorted back into the facility. On 4/22/21, Surveyor paced off location R12 was located outside when staff responded to door alarm and distance was approximately 122 feet from 100 wing end door to location approximately 5 feet from the nearest road (Hill St.) On 4/19/21 at 11:50 AM, Surveyor interviewed AIT (Administrator in Training)-C regarding expectation of staff to respond to door alarms and AIT-C stated the expectation that staff respond immediately. AIT-C discussed facility will not put door code in and just go after resident. AIT-C reported R12 has wandering tendencies and believed R12 has a Wanderguard. Surveyor asked AIT-C for any investigation on elopements from the facility and AIT-C reported they did not have any. On 4/20/21 at 4:11 PM, Surveyor interviewed ST (Speech Therapist)-I regarding 4/19/21 elopement by R12. ST-I discussed was going down the hall to see another resident when ST-I saw R12 exit door and door alarm went off. ST-I reported R12 was visualized the whole time and R12 was easily redirected back to facility. ST-I reported placing R12 in a common area in front of TV and nurses were all around to supervise. ST-I reported R12 elopement attempted occurred between 10:00 AM - 10:30 AM but reports that it could have been earlier (prior to the elopement observed by Surveyor at 10:57 AM.) On 4/19/21 at 12:45 PM, Surveyor interviewed DON-B and DON-B discussed R12 exit seeking behavior. DON-B stated that DON-B did not hear anyone responding to door alarm and went to find R12. DON-B indicated R12 will go in streaks with exit seeking and if noticing more agitation or exit seeking behavior staff will do 1:1 observations. DON-B indicated response to door alarms should be immediately. On 4/19/21 at 3:20 PM, Surveyor asked DON-B for any information regarding R12's elopement and fall on 3/13/21. No information was provided to Surveyor. In addition, no information was provided related to 1:1 observations being provided to R12 related to exit seeking. On 4/19/21 at 5:03 PM, Surveyor asked AIT-C for any information regarding R12's elopement and fall on 3/13/21. Specifically, any facility self-report, police report, hospital discharge summary, radiology report and incident report. Surveyor was provided with radiology report and police report on 4/20/21. On 4/20/21 at 2:50 PM, Surveyor interviewed DON-B regarding systems in place to alert staff for who is at risk for elopement. DON-B reported there was currently nothing in place to alert staff besides care plans or elopement risk screen on computer. DON-B verified no pictures of residents or alerts for staff to be aware of residents at risk for elopement. On 4/20/21 at 3:00 PM, Surveyor interviewed AIT-C regarding R12 and multiple attempts to elope on 4/19/21. AIT-C verified R12 had exited the facility two times that day through the 100 wing end door. (The first incident was responded to by ST-I and the second was witnessed by the Surveyor at 10:57 AM.) On 4/21/21, Surveyor reviewed R12's progress note dated 4/20/21 at 6:22 PM that reported R12 again attempted to elope on 4/20/21: Writer was at the station one nurses station when 100 door alarms began to go off. Writer immediately ran down the hallway to find [R12] outside standing on the sidewalk. Writer was successfully able to redirect [R12] back into the facility. [R12] A&O (alert and orientated) to person only with clear nonsensical speech per baseline. [R12] escorted back to resident room 204 for dinner. Redirected [R12] back to his room. Utilized distraction and companionship interventions awaiting his meal. Q (every) 15 min checks in progress. Bright yellow sign placed on 100 wing doors advising residents to remain inside. Facility failure to prevent R12 from eloping created a reasonable foreseeability that serious harm could occur from a fall outside on uneven and/or slippery terrain, from traffic, or from cold weather. According to the National Institute of Health, Older adults are especially vulnerable to hypothermia, which can be deadly if not treated quickly.Older people also are at risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature. http://www.nih.gov/news/health/jan2009/nia-16.htm The article, For Elderly, Even Short Falls can be Deadly, notes that even short falls can be harmful to the elderly. While simple falls, such as slipping while walking off a curb, may seem relatively harmless, they can actually lead to severe injury and death in elderly individuals, according to a new study published in The Journal of Trauma: Injury, Infection, and Critical Care .In contrast to falls from greater heights, ground-level falls - essentially falls from a standing position, with feet touching the ground prior to the fall - have traditionally been considered minor injuries. But, the new study found elderly adults - [AGE] years or older - who experience ground-level falls are much more likely to be severely injured and less likely to survive their injuries compared to adults younger than [AGE] years. Elderly patients are three times as likely to die following a ground-level fall compared to their under-70 counterparts. http://www.urmc.rochester.edu/news/story/index.cfm?id=3020 According to the article The Problem of Pedestrian Injuries and Fatalities, Unsafe pedestrian behavior is a major factor in pedestrian injuries and fatalities. In a recent study of 7,000 pedestrian-vehicle crashes in Florida, researchers discovered that pedestrians were at fault in 80 percent of these incidents. Similarly, in a U.K. study, pedestrian behavior accounted for 90 percent of crashes where a vehicle struck a pedestrian. This article notes that Given a crash, the faster the vehicle the more severe the injury to the pedestrian. For example, a pedestrian hit at 40 miles per hour has an 85 percent chance of getting killed, whereas the likelihood goes down to 45 percent at 30 miles per hour and 5 percent at 20 miles per hour. https://popcenter.asu.edu/content/pedestrian-injuries-fatalities-0 The facility's failure to ensure R12 received adequate supervision to prevent accidents created a situation of Immediate Jeopardy. The facility removed the jeopardy on 4/21/21 when it completed the following: 1) R12 was placed on 15 minute checks, to further monitor elopement and wandering patterns. Will also initiate 1:1 staffing outside of meal periods, sleep times and personal in room time, based on a person centered approach. R12's care plan was updated to reflect 15-minute check intervention and 1:1 intervention. 2) Audit completed of current patients with Wanderguard placement to ensure proper orders and care plans are in place and reviewed or a risk vs benefits is completed. Audited completed of all residents in house for elopement assessment within 90 days and for any change and updated as needed. 3) Staff will be educated 4/20/21, remainder of staff will be educated prior to their next working shift on elopement prevention and missing resident policy and procedure 4) Audits of daily documentation to be reviewed via 24-hour report in Point Click Care, and 15 minute checks will be completed and reviewed daily to ensure safety of residents. 5) Elopement and missing residents drill will be completed weekly times 4 weeks and monthly x 3 months. 6) QAPI team will monitor audits for compliance and trends.

Based on observation, interview, and record review, the facility failed to prevent abuse or the likelihood of abuse for 1 of 3 residents (R2) reviewed for abuse. R2 does not have the ability to consent to a relationship with R3 and did not have a history of engaging in an intimate physical relationship with other men during his life. The facility did not put measures in place to keep R2 safe from the sexual advances of R3, despite a 9/11/19 action plan that R2 and R3 Will only be allowed to socialize in supervised areas. On 12/12/19, staff observed R3 in R2's room kissing R2. The facility did know how long they were in the room alone, except one certified nursing assistant (CNA) who, when interviewed, estimated less than 10 minutes. The facility's failure to keep R2 free from sexual abuse created a repeat finding of Immediate Jeopardy (IJ) beginning on 12/12/19. NHA A (Nursing Home Administrator) was notified of the IJ at F600 on 1/3/2020 at 12:25 PM. The IJ was removed on 1/3/20. The deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. As evidenced by the following: The facility's policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 8/28/17, states as follows: I. Policy: It is the policy of the facility that each resident will be free from Abuse. The term Abuse will be used throughout this Policy and Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program to relate to: mental, sexual, or physical Abuse; neglect; exploitation; involuntary seclusion; misappropriation of resident property; injuries of unknown origin; corporal punishment; or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purpose of discipline or convenience and that are not required to treat the resident's medical condition. Centers for Medicaid and Medicare Service (CMS) - Definitions Definitions of Abuse and neglect: Abuse and neglect exist in many forms and to varying degrees. The following are the approved CMS definitions of Abuse and neglect from the Draft State Operations Manual Appendix PP effective (MONTH) 28, (YEAR). ii. Sexual Abuse is non-consensual sexual contact of any type with a resident According to Wisconsin Case Law the following are guidelines for determining a person's ability to consent to sex: 1. The person understands the distinctively sexual nature of the conduct .the acts have a special status as sexual. 2. The person understands that their body is private and that they have the right to refuse. 3. The person understands there may be health risks associated with the sexual act. 4. The person understands there may be negative societal response to the conduct. According to the State Operations Manual (SOM) sexual abuse is defined, in part: as non-consensual sexual contact of any type with a resident, as defined at 42 CFR 483.5. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. (Please note the SOM states unwanted intimate touching of any kind.) Previous history cited from (MONTH) 2019 On 6/11/19 at 4:24 PM, SW K (Social Worker), the previous SW that is no longer employed at the facility, entered the following Progress Note in R2's medical record: Spoke with resident's POA (Power of Attorney) who is FM C (Family Member). Resident was kissed by another resident. Resident did not seem upset by kiss and does not recall incident. However, due to resident's dementia, POA would like them separated if staff sees them together. On 6/18/19 at 1:29 PM, SW I (Social Services), the current Social Worker, entered the following Progress Note in R3's medical record: SW spoke with resident regarding an incident that took place on 6/18/19. Nurse reported to previous SW K that resident and another resident were kissing in the hall. SW discussed with resident that this is not appropriate and should not happen as consent cannot be achieved. Resident acknowledged understanding verbally. (Further interviews showed it was kissing on the mouth.) Cross reference previous citation F600 9/19/19. R3, a [AGE] year old male, was admitted to the facility, on 8/28/18, with [DIAGNOSES REDACTED]. R3 is divorced and identified himself as bisexual, meaning he was attracted to both men and women. R3's BIMS (Brief Interview for Mental Status), completed on 3/10/19 and 9/10/19, indicated he scored a 13/15 (thirteen out of fifteen), indicating he is cognitively intact. R3's care plan included the following approaches: 6/21/19 offer common areas for resident and friend to visit; 6/21/19 redirect resident when attempting to visit with friend (R2) in his room or friends room; 9/11/19 document attempts to seek out companionship from peers; 9/11/19 started 15 minute checks; 9/11/19 if physical contact with resident (R2) contact administrator immediately; if resident's observed visiting with (R2) document there was no physical contact; social interaction with (R2) without physical contact is allowed. On 9/16/19, the facility placed on R3's Medication Administration Record [REDACTED]. Also document any changes in demeanor every shift. This is signed by nursing staff every shift since it started. R2 is an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. R2 has been married to his wife for [AGE] years and identified himself as heterosexual, meaning he was attracted to women. R2's BIMS, completed on 7/11/19, indicates he scored a 2/15 and on 10/11/19 scored a 3/15, indicating he has severe cognitive impairment. R2's POA is activated with FM C as his PO[NAME] On 1/2/20 at 9:30 AM, Surveyor interviewed R2 in his room. When Surveyor entered, R2 was watching his television. R2 was smiling during the conversation. Surveyor asked him how he was doing and he replied that he was watching this show. Surveyor introduced herself and asked, What is your name? R2 stated in response, Very good right now. R2's care plan included the following approaches: 6/21/19 redirect resident when attempting to visit with friend (R3) in his room or friends room; 9/11/19 if physical contact with resident (R3) contact administrator immediately; If resident's observed visiting document there was no physical contact; Social interaction with resident (R3) without physical contact is allowed; 9/11/19 started 15 minute checks; document attempts to seek out companionship from peers. On 9/16/19, the facility placed on R2's MAR indicated [REDACTED]. Also document any changes in demeanor every shift. This is signed by nursing staff every shift since it started. R2's Progress Notes include as follows: 9/25/19 2:16 PM SW met with resident in activity. Resident was visibly upset as visualized by resident punching the air, scowl/frown on face, and jerky movements with upper extremities. Resident not his usual self as evidenced by the above actions when usually resident would smile and make statements such as God Bless You and Good Luck Today. SW follows up with spouse. 9/30/19 5:47 PM Peer (the note does not identify who the peer was) visited R2 in the lounge during activity. He took R2's hand and R2 kissed the hand. R2 said you're good. Peer replied and left minutes later. R2's Physician Visit note, dated 10/24/19, states the following: R2 is a married [AGE] year-old male with a 4+ year history of dementia. He has developed anxiety and agitation recently which have caused difficulties for caregivers. He is a poor historian with prominent [MEDICAL CONDITION]. Information is gathered from the medical record and discussion with his wife (FM C). .He has developed some anxiety and agitation over the past few months. He was placed at (the facility) in (MONTH) of 2019 due to dementia and difficulty with cares at home. His wife reports that since he has been admitted to (the facility) he has done okay. At first he repeatedly requested to come back home, but more recently seems to have settled in. However, she has also noticed that he has been more agitated at times. The patient has also developed some behaviors which he did not have at home. For instance, when he goes to meals he will frequently put silverware in his pants or socks and take them back to his room. Due to his [MEDICAL CONDITION] it is difficult for him to explain why he is doing what he is doing, but he says that he feels safer when he does that. He has not used the silverware in a threatening manner, but there is concern that by doing this he places himself at risk for harm since he forgets that the silverware is even there. I tried talking with the patient about some of these things, but he is unable to discuss concepts of any complexity. He is significantly aphasic, but he reports that he is usually happy and has pretty good luck most of the time. His affect and disposition appear to be pleasant during this examination. According to his caregivers, the patient has also developed a relationship with another male at (the facility). By report, R2 would actively reach out to the other male, and engaged in some behaviors which were of concern to family. For instance, the patient and other individual would touch frequently, and at one point they kissed as well. R2 did not appear to be distressed or disturbed by the other individual's attention, and there was no sexual activity. However, since the behaviors occurred, the two individuals have been separated to farther rooms, and attention has been taken that they do not have the same interactions. After the separation, he seemed to experience perhaps some increase in agitation temporarily, but has seemed to come back to his baseline. Staff support that R2 is social and likes to be with people. He sometimes appears to be lonely, although his wife does visit nearly every day. He has punched at the air when frustrated, but has not been aggressive with other people. His wife reports that R2 has never been very depressed, but she has been disturbed by agitation that has come up recently. She does think that he is anxious about things he cannot do. After some discussion, she was agreeable to starting an antidepressant medication which may help with some of the behaviors he has developed and potentially reduce some of the agitation he has also had. R2's Progress Notes continue: *12/10/19 4:42 PM Other, resident observed having conversation with resident and was observed with peer rubbing head and back of neck, no inappropriate touching, resident left dining room and R2 stayed and finished supper. (Note: If this was R3, the facility did not follow R2's care plan, 9/11/19 if physical contact with resident (R3) contact administrator immediately.) 12/10/19 5:07 PM Observed sitting in the dining room close to R3. Behavior appropriate; talking and both were smiling. Once his food came R3 went over to his own seat at the other end of the table. *12/12/19 2:00 PM resident visiting with peer in common area outside of dining room prior to start of meal service. Resident observed in room after meal with peer by CNA who informed nurse. Writer redirected peer out of room. R3's Progress Notes include the following: 9/12/19 4:00 PM Resident (3) was in the dining room this pm with another resident (R2) and was talking to him. He reached over and touched the other residents face lightly. Resident reminded that he needs to respect other peers space. Resident verbalized understanding. The two residents were separated with no further concerns. 9/15/19 4:17 PM Resident (3) was in the DR (dining room) sitting at the table with (R2) reached over and put his hand on residents shoulder. (R3) started patting resident (R2) on the back. Service aide interviewed and reminded them not to have physical contact. Residents were compliant. No further contact between residents. 9/16/19 4:29 PM 15 minute checks have been reviewed and removed. Patients will be allowed to have dinner together in the dining room with staff present. If they wish to continue visiting those visits will be supervised visits. Patient shows signs/symptoms of withdrawal which may be contributed to loss of friendship conversations. The facility self-report summary states: On 12/12/19 a staff member witnessed (R3) kissing (R2) on the forehead. The investigation included the following items: CNA G's statement, dated 12/12/19, states: I saw (R2) sitting in a chair at the end of wing 600 by the lunch room and (R3) was sitting in his wheelchair and was facing (R2) and (another resident). At 10:58 (AM) I walked (R2) to the dining room and (R3), and (the other resident) followed into the dining room. I sat them down in the dining room and got there (sic) ticket orders and then I sat next to (R2) until another aide came into the dining room so they were not alone together. I witnessed (R3) trying to grab his (R2's) hand, it was nothing inappropriate, and I pushed his hand away. (R2) was calm and showed no distress. RN H's (Registered Nurse) statement, dated 12/12/19, states: I was walking into the dining room and when I got behind (R2) I saw (R3) move from a forward leaning position to a more upright position. (R2) was sitting up to the table and (R3) was next to him not sitting up to the table, but facing (R2). I saw (R3) put his hand on (R2)'s shoulder but nothing inappropriate during there (sic) conversation. (R2) was laughing and conversing back with (R3). At one point I saw (R3) put his hand on the top of (R2)'s head, (R2) remained calm and happy during there (sic) interactions. I stood by them talking with another resident to monitor them. (R3) was whispering things to (R2) so I could not hear what they were talking about. After (R3) whispered a few things to (R2) I then saw (R3) go talk with some other residents dining room then he came back to the table and sat at the table to eat. Both (R3) and (R2) were eating and other staff were in the dining room to monitor so I left the dining room. (Note: per care plan, there is supposed to be no physical contact between R2 and R3 and staff is to contact the administrator immediately if physical contact is observed.) CNA D's statement, dated 12/12/19, states: I was walking down the 300 hallway with another resident and his wife. The other resident was agitated and I wanted to ensure his safety. When I was walking down the hallway I was looking in other rooms as I passed them per my usual and I saw (R3) in (R2)'s room. I stopped at the doorway and asked them to come out of the room. (R3) was yelling something at me and I was unable to understand him. (R3) started to come out to the doorway. At this point I assumed that he was coming all the way out but I had to keep moving with the other resident as he was agitated and a fall risk. I alerted the nurse to ensure the situation was handled between (R2) and (R3), as I am aware that they are not to be visiting in unsupervised areas, and the nurse (RN E) ran down to the room to ensure it was handled. What I saw in the room was (R2) sitting in his recliner and (R3) was sitting in front of him in his wheelchair talking. I did not see them touching each other. (R2) did not seem uncomfortable when I went past the room. I had last seen the two of them about 10 min (minutes) prior in the dining room eating lunch. On 1/2/20 at 5:08 PM, Surveyor interviewed CNA D who had visualized R3 in R2's room on 12/12/19. CNA D stated she was helping out on the 300 wing (where R2 resides) by walking in the hall with another resident at risk for falls and anxious. She said she was assisting the resident to walk to the dining room and on the way she saw R2 and R3 talking face-to-face in R2's room. She stated, It may have been maybe 10 minutes from the last time I saw them in the dining room until I saw them in his (R2's) room. CNA D stated she was able to redirect R3 to come to the doorway of the room then continued to walk a resident down the hall to the nurses station where she told RN E. CNA D stated RN [NAME] went to R2's room immediately. CNA D stated she did not see any touching between R2 and R3, they were just talking. RN E's statement, dated 12/12/19, states: At around 10:45 (AM) I witnessed (R2) following (R3) coming up 300 hallway. I met them at the nurses station and they said they were going to the dining room. They decided to sit in the chairs outside the lunch room at the end of 600 wing. (R2) sat down and I left (R2), (R3), and (another resident) with (CNA G) to visit and be supervised. I was notified by (CNA D) that I needed to go to (R2)'s room because she was directing (R3) to come out of (R2)'s room as (R3) was in (R2)'s room visiting. (R3) was not fully out of room when she had to continue assisting another resident and she knew they were not to be visiting alone. I went down to the room immediately and observed (R3) with his hands around (R2)'s neck kissing him on the forehead. I then said Gentlemen we can't be visiting in the room but you are welcome to visit outside of the room. (R3) asked (R2) if he wanted to continue visiting outside of the room and (R2) decided to stay in his room and rest. (R3) then went to his room to take a nap as well. When (R3) and I came out of the room (R3) had to ask me how to get to station 3 to his room and I directed him. When I left the room (R2) was comfortable and relaxed in his recliner ready to take a nap and showing no signs of distress. On 1/2/20 at 2:00 PM, Surveyor interviewed RN [NAME] who went to R2's room after CNA D told her that she had observed R2 and R3 in the room together. RN [NAME] stated that she had been sitting at the 300 wing nurses station and immediately went to the room when told. She said CNA D had said that R3 was on his way out of the room. RN [NAME] said when she entered the room the light was on and R3 had his hands on both sides of R2's neck/shoulders with R3's fingers toward R2's back and thumbs in front. R3 was kissing R2 on the forehead. RN [NAME] explained that R2 was sitting in his recliner. RN [NAME] agreed that they were not supposed to be alone together in a room. She explained that the interventions that were in place to keep them from being alone in rooms together were: supervision intermittently, to redirect if in the other resident's room, and keeping them supervised. RN [NAME] stated that once they were separated and safe she immediately notified NHA [NAME] NHA A interviewed R2 on 12/12/19 which stated: I stopped and spoke with (R2) about his day. He told me that he was looking for the boys to make sure they were okay. I asked him how was his day he said it was busy a little here and a little there. I asked if he was visiting with his friend and he said yes a few times. I asked him if it bothered him when we separated him from his friend and he said yes. I asked him if his wife came today and he said yes they had a nice time. I asked him if he visited with the police today and he said yes. (R2) then was getting anxious and wanted to get going. One of the staff came by and they asked (R2) to follow them and (R2) acted out like he was in shackles and had to follow them. I told (R2) if he does not want to go with them that would be okay but he chose to follow the staff. R3's interview, dated 12/12/19, states: What made you go into his (R2's) room today if you knew you shouldn't have? I was helping him find his door because he can't find it. Did he ask you to help him find his room? He doesn't know enough to ask for help, but I feel sorry for him so I help him. I think he has brain damage. What else made you actually go into his room once you showed him the door? Sometimes he wants to lie down or sit in his chair, so I helped him arrange his chair today. I told him to lay it back so that he could take a nap. On 1/2/20 at 9:40 AM, Surveyor interviewed R3 in his room. R3 said that they (facility staff) spoke to him about molesting him (R2). I never molested anybody, I'll swear to that. He stated he is not supposed to be near him. R3 reiterated that he never touched him sexually. Surveyor asked if he had any recent interaction with R2. R3 explained he had found R2 standing outside the dining room in the hall. R3 explained R2 didn't know which way to go and nobody, I mean nobody was around. Surveyor clarified with R3 and he agreed that he meant there were no staff around, even at the nurses stations on 700 or 300 unit. R3 said, So I walked him to his room. R3 said the door to R2's room was open a few inches and he (R2) couldn't find the light. R3 said he could not reach the light switch to turn it on. R3 said he asked R2 if he wanted to go to bed and R2 said he wanted to sit in his recliner. R3 said he was helping R2 sit in his recliner when staff entered and told him to leave R2 alone. R3 said he thought that he shouldn't leave R2 alone because he might get lost. Surveyor asked when this happened. R3 said 4 or 5 days ago but he couldn't remember. He continued that when one of the aides came in, he could not remember who, they made a big deal about it. R3 said it was after an evening meal and he remembers that no staff were around. He stated that he was accused of molesting him. I never touched him. Surveyor asked R3 if he had kissed R2. R3 said, I kissed him a couple times. Surveyor asked when he kissed R2. R3 said, A long time ago. He denied kissing R2 after helping him to his room. R3 explained that they don't want him to be around, help, or talk to R2. R3 said he was just trying to help him. R3 said he was not going to help people anymore. SW I's statement, dated 12/12/19, states: I visited with (FM C) regarding (R2) and (R3)'s recent interaction. FM C stated that 'I cannot believe this is happening.' FM C reports that she enjoys having (R2) at (the facility) and feels that they have made many friends. I asked about (R3) and (R2)'s friendship and how she felt about it. FM C stated that she is OK with them being friends and visiting outside of (R2)'s room. She stated that (R3) shakes her hand when they are greeting and visiting during activities and meals. I discussed comfort and placement. FM C states that she appreciates all the care that (the facility) has given. FM C stated that she is upset that (R2) and (R3) were in (R2)'s room. FM C stated that she felt that 'this situation' was resolved. She stated that she did not believe that (R2) was upset by any other the 'situation' but she struggles with (R2) and (R3)'s interactions. SW I also noted alternate placements for R2 and FM C said she would discuss it with her family and let SW I know. On 1/2/20 at 2:45 PM, Surveyor interviewed FM C, who is POA for R2, regarding concerns at the facility. FM C explained that one time back in (MONTH) or (MONTH) (2019) she witnessed the following: When she walking into R2's room, she had seen R3 rubbing R2's arms and sides up and down with his hands, R3's hands were behind R2's head and in his hair. She stated that when R3 realized she was in the room with them he immediately stopped and quietly left the room. She stated she had not witnessed them be alone together since (MONTH) 2019. She said that a Social Worker told her last Monday that they found R3 rubbing R2's leg. She said she didn't know how the facility was ensuring they weren't alone in a room together. She explained they had been doing room checks as she had been in R2's room when staff came popping in when she visited. She stated, I don't kiss (R2) anymore because she is concerned that R3 may have given R2 something and she doesn't want to catch anything. She explained she is stressed out and only sleeps 2 or 3 hours a night worrying if those things take place. Surveyor asked if she had spoken to anyone about moving R2. FM C explained that R2 likes it here and both of them have made friends here and like the staff. She said that she does not want to move R2. On 1/3/20 at 8:10 AM, Surveyor again interviewed FM C, who is POA for R2, regarding concerns at the facility. FM C indicated that 3 incidents have happened prior to the recent one on 12/12/19. FM C stated, I want this to stop. This is not doing R2 any good. I don't think he wants these advances by this man (R3) as he can't say no. R2 has never been involved with a man ever in his entire life. FM C indicated she does not want to move R2 from the facility as he has adjusted and likes it here. FM C then stated, It is a sexual assault, R3 forcing himself on R2. R2 does not have the capacity to consent. Surveyor asked FM C if the facility has suggested that R2 be moved. FM C indicated she spoke with NHA A and one of the Social Workers (SW) telling them she does not want to move R2. FM C indicated the facility suggested that she move R2 to a memory care unit or to AL (Assisted Living). FM C stated, Why does R2 have to move? He is not the aggressor, R3 is. FM C indicated R3 still sneaks in R2's room even though their rooms are on the opposite ends of the building. FM C indicated R2 can't find his way around the facility. FM C indicated there are undocumented incidents that are occurring at the facility. Surveyor asked FM C what she meant by that. FM C indicated R3 was kissing and rubbing R2's leg in the hallway. FM C indicated a SW told her this on 12/29/19. FM C indicated the SW said the facility will have to keep R2 and R3 separated more. FM C indicated she and R2 attended activities yesterday and the only available spots to sit were across from R3. FM C indicated R3 was ok, as there were a lot of people watching them. FM C stated, This has to stop for R2's health and safety. FM C indicated that R3 does not follow the rules. He has been told to stay out of R2's room but continues to go in. Surveyor asked FM C if she spoke with the police officer after the last incident on 12/12/19. FM C indicated yes, the police officer said she gave R3 a stern warning and told him he had to follow the rules or he would get kicked out. FM C stated, After the three previous incidents, NHA A told me to sign a paper that indicated R2 and R3 were over friendly and this was not sexual. FM C indicated she refused to sign this paper as This was foreplay that leads to sex. FM C indicated NHA A has stopped speaking to her. FM C then stated, The facility has to live up to their part of the bargain, protect the residents. SW J's statement, dated 12/12/19, states in part: I received a call from (NHA A) to fill me in on the contact witnessed between R2 and R3 on 12/12/19 . The police arrived (no time noted) . (The Officer) introduced herself (to R3) and explained that I had called her because I was concerned about what happened that day between him and R2. R3 admitted he knew he was wrong to go in R2's room and knew he had made a mistake. (The Officer) said the facility is not saying him and R2 cannot see each other just that they should interact in a supervised area. I told R3 that we were not there to yell at him but to remind him of the guidelines of the facility. R3 stated he understood and said he 'felt sorry for the man.' . .I explained (to FM C) that RN [NAME] had witnessed R3 with his arms around R2 while R2 was in his recliner, and that R3 had also kissed R2 on the forehead. FM C stated she was surprised and said she thought this was taken care of already. I empathized with her as she explained that this situation has been very difficult for her. I told her that the police had been contacted to talk with both R2 and R3 about the situation. FM C said she did not trust R3 and that the two of them should not have been left unsupervised. I told her they had been interacting in a supervised area and staff had intervened as quickly as possible once they realized the two of them were in R2's room and that I was working on following up with the situation more. .(The Officer) began to ask R2 some questions, but R2 responded with gibberish answers. I asked R2 if he remembered R3 coming to visit him earlier that day, and his answer was again gibberish. FM C asked R2 if he remembered R3 visiting, and R2 responded with something I couldn't understand, but I did hear him ask several times, 'Where is my brain?' . R2 had an assessment completed, 12/19/19, entitled, IDT (Interdisciplinary) Team Decision Guide-Resident Ability to Consent to Physical Sexual Expressions. This assessment concluded: Consent Guideline The resident understands what sexual contact means. No The resident recognizes her/his body is private and that s/he has the right to refuse to engage in sexual activity. No The resident recognizes the sexual contact may create possible health risks and physical consequences. No The resident need to understand there may be negative social or societal response to the sexual behavior. Yes If any answer to the above guidelines are no, The individual has demonstrated the inability to consent. R3 had an assessment completed, 12/19/19, titled, IDT Team Decision Guide-Resident Ability to Consent to Physical Sexual Expressions. This assessment concluded: Consent Guideline The resident understands what sexual contact means. Yes The resident recognizes her/his body is private and that s/he has the right to refuse to engage in sexual activity. Yes The resident recognizes the sexual contact may create possible health risks and physical consequences. No The resident need to understand there may be negative social or societal response to the sexual behavior. Yes If any answer to the above guidelines are no, The individual has demonstrated the inability to consent. On 1/2/20 at 11:25 AM, Surveyor observed R2 and R3 in the main dining room. R3 sat at a table with 5 other residents and went to three additional tables talking to various other residents at each table. R2 was eating at a table where 1 other resident was seated. When the other resident had left the dining room R3 approached the table where R2 sat by himself eating. Surveyor observed three staff walk up to the table initially then continue to watch R2 and R3. R3 asked R2 if he was going to Bingo later in the afternoon. R2 said he would be going. They both were smiling and laughing during the exchange. R2 patted R3's forearm leaning forward in his chair toward the end of the exchange. R3 then approached Surveyor stating they don't want me to help him. Surveyor did observe staff walk with R2 back to his room after the noon meal. On 1/2/20 at 3:50 PM, Surveyor interviewed NC F (Nurse Consultant). NC F agreed that R2 and R3 are not supposed to be alone in a room together. Surveyor asked what the facility did to ensure that did not happen. NC F explained that the staff provide redirection if they see either resident attempt to be alone with the other resident. Surveyor asked how did it happen that R2 and R3 were found alone together in a room. NC F explained that staff redirection had been working until that date (12/12/19) and that both residents had been seen in the dining room [ROOM NUMBER] minutes prior to being found alone. Surveyor asked her if R3 is able to understand that he is not to seek out to be alone with R2. NC F stated that with the recent cognitive assessments R3 might not always remember that. She explained other things the facility did after consulting the Ombudsman: developed a new relationship facility policy, did staff education on sexuality, and made a plan to do more extensive education with staff in a live setting in the future. She explained that the nurses document on the MAR indicated [REDACTED]. She stated that both R2 and R3 were assessed to be unable to consent to a sexual relationship and

Based on observation, interview, and record review, the facility failed to prevent abuse to 4 of 31 residents (R61, R10, R23 and R75) reviewed for abuse. R61 does not have the ability to consent to a relationship with R29 and did not have a history of engaging in an intimate physical relationship with other men during his life. The facility did not put measures in place to keep R61 safe from the sexual advances of R29. The facility's failure to keep R61 free from sexual abuse created a finding of Immediate Jeopardy (IJ) beginning on 6/11/19. On 9/11/19 at 11:40 AM, NHA A (Nursing Home Administrator) was informed of the I[NAME] The IJ was removed on 9/11/19. The deficient practice continues at a scope/severity level of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its removal plan and as evidenced by the following: Housekeeper G posted a video on Snapchat with R10 and R23 visible in the video. Service Aide H posted a picture of R75 on Snapchat to another coworker. Evidenced by: The facility's policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 8/28/17, states as follows: I. Policy: It is the policy of the facility that each resident will be free from Abuse. The term Abuse will be used throughout this Policy and Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program to relate to: mental, sexual, or physical Abuse; neglect; exploitation; involuntary seclusion; misappropriation of resident property; injuries of unknown origin; corporal punishment; or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purpose of discipline or convenience and that are not required to treat the resident's medical condition. Centers for Medicaid and Medicare Service (CMS) - Definitions Definitions of Abuse and neglect: Abuse and neglect exist in many forms and to varying degrees. The following are the approved CMS definitions of Abuse and neglect from the Draft State Operations Manual Appendix PP effective (MONTH) 28, (YEAR) ii. Sexual Abuse is non-consensual sexual contact of any type with a resident According to Wisconsin Case Law the following are guidelines for determining a person's ability to consent to sex: 1. The person understands the distinctively sexual nature of the conduct .the acts have a special status as sexual. 2. The person understands that their body is private and that they have the right to refuse. 3. The person understands there may be health risks associated with the sexual act. 4. The person understands there may be negative societal response to the conduct. According to the State Operations Manual (SOM) sexual abuse is defined, in part: as non-consensual sexual contact of any type with a resident, as defined at 42 CFR 483.5. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. (Please note the SOM states unwanted intimate touching of any kind.) Example 1 R29, a [AGE] year old male, was admitted to the facility, on 8/28/18, with [DIAGNOSES REDACTED]. R29 is divorced and identifies himself as bisexual, meaning he is attracted to both men and women. R29's BIMS (Brief Interview for Mental Status), completed on 3/10/19, indicates he scored a 13/15 (thirteen out of fifteen), indicating he is cognitively intact. R61, an [AGE] year old male, admitted to the facility, on 4/5/19, with [DIAGNOSES REDACTED]. R61 has been married to his wife for [AGE] years and identifies himself as heterosexual, meaning he is attracted to women. R61's BIMS, completed on 7/11/19, indicates he scored a 2/15, indicating he has severe cognitive impairment. While conducting record review, Surveyor noted the following entries in R61's medical record: On 6/11/19 at 4:24 PM, SW U (Social Worker), the previous SW that is no longer employed at the facility, entered the following Progress Note in R61's medical record: Spoke with resident's POA (Power of Attorney). Resident was kissed by another resident. Resident did not seem upset by kiss and does not recall incident. However, due to resident's dementia, POA would like them separated if staff sees them together. On 6/18/19 at 1:29 PM, SS K (Social Services), the current Social Worker, entered the following Progress Note in R29's medical record: SW spoke with resident regarding an incident that took place on 6/18/19. Nurse reported to previous SW U that resident and another resident were kissing in the hall. SW discussed with resident that this is not appropriate and should not happen as consent cannot be achieved. Resident acknowledged understanding verbally. As part of its investigation, the facility obtained the following witness statements. CNA AA (Certified Nursing Assistant) wrote the following statement: On 6/11/19 I noticed that R61 and R29 were having a conversation in the hallway. At first glance it looked harmless but I later noticed that R29 started to touch R61's upper leg and then continued to pull R61 down and kiss him once. R61 came up to the desk and asked me where his room was so I gave him is (sic) room number. R61 went back to his room and R29 followed him. MR V (Medical Records) was walking passed (sic) and she noticed that they were kissing again. The PM Nurse was notified and they were separated. This typed statement was signed by CNA AA on 6/14/19. (It is important to note when reading CNA AA's statement (above), R29 was touching R61's upper leg (thigh) and continued to pull R61 down to kiss him. R61 then went to the desk and asked where his room was; likely attempting to remove himself from the situation, and then R29 followed him into his room and kissed him again. The facility failed to protect R61 from R29's unwanted sexual advances.) MR V wrote the following statement: On 6/11/2019 I thought I may have witnessed an inappropriate interaction between R29 and R61 but there was a cart in the way on 300 wing hall. R29 went into R61's room with him and I felt uncomfortable so I followed them and saw them kissing. I notified the social worker who went down there immediately. The residents were separated. This typed statement was signed by MR V on 6/14/19. (It is important to note in CNA AA's and MR V's statements above, that R29 is in R61's room on the 300 unit, which is on the other side of the building from where R29's room is located. This demonstrates that R29 is seeking out R61.) On 9/10/19 at 4:25 PM, Surveyor spoke with MR V who has been employed at the facility for [AGE] years. Surveyor asked MR V if she hand wrote a statement or typed the statement. MR V stated she typed the statement, but it has been revised. Surveyor asked MR V who revised your statement. MR V stated that Corporate Consultant BB revised the statement. MR V stated the meaning was not changed by the revision. Surveyor asked MR V if she could tell me what she witnessed. MR V stated she witnessed R29 kiss R61 and thought it may be inappropriate; MR V stated I wasn't sure. I did go down there; I did separate R29 and R61 and got the Social Worker involved. Surveyor asked MR V where the kiss was. MR V stated, It was on the mouth, R29 initiated it (the kiss). MR V stated R29 was sitting in his wheelchair, R61 was sitting on the end of the bed, and R29 had his arm around R61's neck. Surveyor asked MR V how she would describe the kiss. MR V stated that it was more than a quick peck. MR V stated it was not a tongue make-out kiss, but it was definitely longer than a peck. Surveyor asked MR V how did R61 react when you saw them. MR V stated R61 was not embarrassed or upset. (Note, this demonstrates that R61, who identifies himself as heterosexual, likely does not understand the distinctly sexual nature of the conduct (kissing) .and that the acts have a special status as sexual.) Surveyor asked MR V if R61 didn't want something, could he make himself known. MR V stated she does not know if he could. Surveyor asked MR V if she has seen R29 kissing R61 at other times after her observation. MR V stated, no, she hasn't seen it, but she heard that it has happened. MR V stated that R29 and R61 are not supposed to be in a room or in private areas together. Surveyor asked MR V if there are other staff that observed this incident or other incidents between R29 and R61 that may have knowledge of the incident/s. MR V stated that CNA S saw the incident as well. On 9/10/19 at 4:40 PM, Surveyor spoke with CNA S. CNA S has been employed at the facility for 3 years. CNA S regularly works on the 300 unit where R61 resides and is very familiar with R61. Surveyor asked CNA S if she would tell me what she observed. CNA S stated a few months ago she observed both R29 and R61 coming back from Activities. R61 went to his room and R29 followed him into his room. CNA S stated, when she walked in the room, R29 had his hands at R61's waist and, he looked like he was trying to take off R61's pants. CNA S stated I yelled, Don't do that! CNA S stated I don't know what was going to happen, but I intervened. CNA S stated she told DON B (Director of Nursing) and ADON CC (Assistant Director of Nursing). Surveyor asked if CNA S wrote a statement. CNA S stated she hand wrote a statement and gave it to ADON CC. CNA S stated she has observed R29 pat R61 on the back at supper and that is just friendly. CNA S stated the care plan was changed so that R29 and R61 could only be in common areas together. CNA S stated R61 is the type of person that goes with the flow. CNA S stated that as she is passing R61's room, he will sometimes say, Good luck! to her and other staff at random times, not in relation to any particular situation. CNA S stated she loves it when he does that and R61 is a very likable person. Surveyor asked CNA S if she thought R61 was affected by this incident. CNA S stated, no, I didn't see it. CNA S added, He always acts the same. He's more confused at times but that's normal. CNA S stated if you want him (R61) to do something you need to repeat instructions. CNA S gave an example of when it's time for R61 to put on his pajamas, first she needs to say let's put on your pants. After R61 gets his pants on she'll say let's put on your shirt now. CNA S stated R61 is perfectly able to do anything by himself; however, he requires a lot of cueing. Surveyor asked CNA S if she has ever observed R61 seeking R29 out. CNA S stated R61 is unable to find the dining room on his own and would be unable to find R29's room on the other side of the building. Surveyor asked CNA S if there are any other staff members that saw the incident or may have further knowledge. CNA S stated that CNA Q has observations of R29 kissing R61. On 9/11/19 at 9:28 AM, Surveyor spoke with CNA M and CNA P. CNA M and CNA P indicated staff is to redirect R29 and R61 if they see them go into a room together and R29 and R61 are to only visit together in common areas. CNA M and CNA P indicated R29 wanders and seeks out R61, but R61 never seeks out R29 and does not have the capability to do this. CNA M indicated R29 sometimes wants to kiss R61 a little. Surveyor asked CNA M where R29 kisses R61. CNA M stated, On the lips. CNA P stated, (R29) is with it. (R61) is not. Surveyor asked how many times CNA M and CNA P observed the two residents to be kissing on the lips. CNA M stated, I have seen them kissing more than one time. CNA P stated she has not witnessed the two residents kissing, but has heard they do. Surveyor asked if CNA M noted R61's comfort level while observing this interaction. CNA M replied, I don't think he has enough knowledge to consent or to choose to participate. If it gets to be bad, I report to nurse. Surveyor asked CNA M to describe the last time she observed R29 and R61 kiss on the lips. CNA M stated, I haven't seen any contact recently. It was a while ago I saw them kissing on the lips. I separated them and I believe I reported it to the nurse. CNA M indicated she was not asked by management to provide a witness statement regarding the incident. On 9/11/19 at 9:40 AM, Surveyor spoke with CNA N. CNA N stated, R61 never seeks out R29. He (R61) doesn't have the ability to remember a room number or his way around. On 9/10/19 at 4:55 PM, Surveyor spoke with FM T (Family Member) who is R61's wife of [AGE] years and APOAHC (Activated Power of Attorney for Healthcare). R61 answered only in short sentences and was barking and making various noises throughout our conversation. Surveyor asked FM T if R61 is able to share his feelings if he doesn't want something. FM T stated, I know when something isn't right or bothering him. Surveyor asked R61 if he has any special friends. R61 looked at Surveyor confused and was unable to answer the question. FM T asked R61, R29 is one of your friends, right? R61 stated, Yes. Surveyor asked R61 if he likes R29. R61 stated, He's ok, as he shrugged his shoulders, tilted his head, and had an indifferent expression on his face. Surveyor asked R61 if he likes spending time with R29. R61 stated, Yeah. Surveyor asked R61 what he and R29 do together. R61 stated they laugh a bit together. On 9/10/19 at 5:05 PM, Surveyor spoke with FM T in private. Surveyor asked FM T how she would describe her husband. FM T stated outgoing, social, likable. FM T stated the interaction between R29 and R61 concerned her and that's why she watched the situation more. FM T stated she was only notified of 1 incident where R29 kissed R61. FM T stated the previous SW U (Social Worker) saw R29 and R61 and stated to her that, There was a lot of touching and feeling. FM T stated SW U thought R61 was upset and agitated with what R29 was doing (kissing and touching). FM T stated SW U stated to her she thought it was moving toward, More sexual things, as she described it. FM T stated after the first incident, the facility wanted to know what to do. FM T stated she and the SW U thought we should keep them separated so it doesn't escalate further. FM T stated, on 7/9/19, there was another incident that she observed when she came to visit R61. FM T stated when she arrived to R61's room, his door was closed and she walked in on R29 and R61 in an embrace. FM T stated, The arms were around the neck - rubbing the neck and down the arms (R29 had his hands on the back of R61's neck and was rubbing the back of his neck and rubbing down his arms.) FM T stated, It was more than just slapping your buddy on the back kind of thing. FM T stated R61 was, Just sitting there, allowing it to happen. FM T stated R61 can get agitated, but doesn't know if he has the ability to say Stop! FM T stated, When R29 left R61's room, he looked sheepish when he went out the door. FM T stated, I told R61, You know better. FM T stated that R61 did not answer her. FM T stated to Surveyor, I don't think R29 could have known better. FM T stated in this society men don't kiss. In France, that's ok. Surveyor asked FM T how did R61 look and react to the situation. FM T stated, He just stood there. There was no visible agitation. There was no real emotion on his face - he was emotionless, maybe he didn't understand what was happening. Surveyor asked FM T what level of contact between R29 and R61 is acceptable to you. FM T stated, A pat on the back, a slap on the arm, what buddies do. Surveyor asked FM T if she was comfortable with R29 kissing R61. FM T stated she is not comfortable with R29 kissing R61. FM T stated R61 has never kissed any of his friends. FM T stated, That's not normal for him. FM T stated the only people R61 kissed throughout his life were me and our kids. FM T stated, in the 3 years before R61 was admitted to the facility, he did not kiss her at all, not even a goodnight kiss. FM T stated R61 will kiss her, but she has to ask for a kiss. (Note, per staff interviews, R61 will follow instructions when they are provided.) FM T stated, What I saw worried me, of course. Surveyor asked FM T if any staff told you where (on the mouth or cheek) R29 kissed R61. FM T stated, No, they didn't say where. FM T stated, I don't want to see this, it upset me terribly and I didn't think R61 was involved. FM T stated, I thought the aggressor was R29. FM T further explained that's why she wanted their communication to be in a public place, not private, where these things can't happen. FM T added, R61 doesn't need to be used or taken advantage of. FM T stated they're supposed to be keeping R29 away from R61's room. (It is important to note based on the interview with FM T, who is R61's APOAHC, she had not been informed that R29 has been kissing R61 on the mouth. Surveyor asked FM T how many incidents of kissing has the facility notified you of. FM T stated, One. The facility did not fully inform FM T that R29 has been kissing R61 on the mouth, and according to the facility notes, FM T was notified of both incidents (6/11/19 and 6/18/19); however, FM T states she was only notified of 1 incident.) On 9/10/19 at 5:45 PM, Surveyor spoke with SS K. SS K stated she has not witnessed any incidents between R29 and R61 first hand. SS K stated she knew that R29 and R61 have kissed. Surveyor asked SS K where the kissing occurred (mouth or cheek). SS K stated she's not 100% sure where the kiss occurred. Surveyor asked SS K what the facility did when the first incident occurred. SS K pulled up Social Service Notes on the computer. SS K stated R29 and R61 were separated and R61's wife was notified. Surveyor asked SS K when previous SW U left the facility. SS K stated mid-June. SS K stated R61 is always smiling, happy, encouraging and likes to say good luck to people. SS K stated, when R61 says good luck, it's a blanket statement, not in relation to any specific situation. SS K stated with situations such as these it comes down to whether they (the residents involved) can say yes or no. Surveyor asked SS K in your professional judgement, what is the correct way to handle this situation. SS K stated that's what I've gone back and forth with; that's why I talked with the Ombudsman and did the assessments. Surveyor asked SS K what was your conclusion. SS K stated, I let them (clarified Administration) take it over. SS K added she is unsure how to correctly handle this situation. SS K stated R61's wife has stated she is ok with them (R29 and R61) visiting in common areas. SS K stated the previous SW U told me they're (R29 and R61) going to be friends. SS K stated her contact with R61's wife, since previous SW U left, was when she gave her a brochure regarding Dementia resources and support groups while passing her in the hall. SS K stated I told her, I found this resource, here you go. Surveyor gave SS K an example of a resident-to-resident incident with 2 residents kissing, and one resident is extremely cognitively impaired, what would you do. SS K stated, Probably have them go to a common area until things are figured out. (It is important to note that SS K could not verbalize to Surveyor how this situation with R29 and R61 should be handled, or how to protect a cognitively impaired resident from the advances of a cognitively intact resident from sexual abuse and/or having the boundaries crossed between friendship and a sexual relationship.) On 9/11/19 at 2:14 PM, Surveyor spoke with DC O (Dietary Charge) who indicated R29 propels his wheelchair up to R61 at times to talk, but she has never observed the two kiss or hold hands. DC O also indicated it is ok for two residents to kiss in privacy of their own rooms. (Note, this demonstrates that all staff are not aware that R29 and R61 are only to visit in public areas.) On 9/12/19 at 9:25 AM, Surveyor spoke with CNA Q who has been employed with the facility for 7 months. CNA Q regularly works on the 300 unit where R61 resides and is very familiar with R61. Surveyor asked CNA Q if she has had observations of R29 and R61 interacting. CNA Q stated, yes. CNA Q stated we've been having issues with them that began 2-3 months ago. We told the SW, she spoke with R61's wife. R61's wife stated it's ok for them to be with the other resident, but not in each other's rooms. CNA Q stated, according to what R61's wife wanted, they are not to be in each other's rooms. R29 and R61 need to be where we can keep an eye on them. Surveyor asked CNA Q if R61 has the ability to seek out R29. CNA Q stated she only saw R29 in R61's room on 1 occasion. CNA Q is unsure if R61 has the ability to intentionally locate R29's room. CNA Q stated she observed R61 in R29's room, R29 grabbed R61's face and was holding his face, while pulling him down toward him (his face), when CNA Q walked in the room and separated R29 and 61. CNA Q told R61, let's go find your wife. CNA Q stated R61 followed me without a problem. CNA Q stated I didn't say anything to his wife, just my Nurse, RN DD. (It is important to note this is not documented.) Surveyor asked CNA Q if R61is able to tell you yes and no answers. CNA Q stated, No. CNA Q stated, I don't think he knows the difference between what's right and what's not right. CNA Q stated if she gives him ideas for lunch, he agrees; CNA Q added, R61 agrees to everything, he doesn't say, no. CNA Q stated, I don't think he realizes. Surveyor asked CNA Q if she has noticed a decline in R61's cognitive status. CNA Q stated, He has been very confused. CNA Q stated, for example, when it's time for R61 to get dressed, she needs to cue him each step of the way, otherwise he will put his shoes on before his socks and his pants on before his underwear. CNA Q stated, since his admission, she has observed that R61 has flashbacks about the military and most of his thinking is about military and when he killed children and all the things he saw. Surveyor asked CNA Q if she thinks R61 has the ability to say no to a kiss on the mouth. CNA Q stated, I don't think so, he will basically do what you tell him to do. CNA Q added, With R61, he'll say it's his friend (R29), I don't think he actually knows what R29 is doing. CNA Q stated after R61 is in the dining room or Activities, staff come to get R61 and walk him to his room. CNA Q stated she tries to keep R61 busy and his wife also takes him out some days. In summary, it is important to note that due to R61's disease process and severe cognitive impairment, he does not have the ability to consent to a relationship with R29 or understand the sexual nature of the kissing that has occurred. Based on staff interviews, R61 does not have the ability to seek out R29 and staff stated R61 does not understand what his friend is doing to him. Staff stated R61 Goes with the flow. When staff were asked if R61 has the ability to say no, staff stated No and I don't think so, he will basically do what you tell him to do. CNA Q stated, With R61, he'll say it's his friend (R29), I don't think he actually knows what R29 is doing. FM T stated, when R29 is kissing R61, she doesn't know if R61 has the ability to say Stop! FM T stated when she walked into R61 room and saw them kissing (7/9/19), There was no real emotion on his (R61's) face - he was emotionless, maybe he didn't understand what was happening. FM T added, R61 doesn't need to be used or taken advantage of. The facility did not put measures in place to prevent R61 from the advances of R29 or protect R61 from having the boundaries crossed between friendship and a sexual relationship. On 9/10/19 at approximately 9:30 AM, NHA A stated, on 7/24/19, she received the Sexuality and Consent in LTC (Long Term Care) power point for an upcoming meeting and shared it with the social workers who then contacted the Ombudsman regarding the situation for guidance. NHA A stated the Ombudsman gave us the tools to help assess the relationship between R29 and R61. After assessing their relationship, on 7/26/19, the facility determined that R29 and R61 are able to engage in an intimate relationship sharing war stories and engaging in a hug and kiss in public areas. NHA A also noted, R61 would not be able to consent to a sexual relationship and with his confusion we will keep their relationship in viewing areas. On 9/11/19 at 11:40 AM, NHA A stated to Surveyor she defines kissing as intimacy and not sexual, regardless of whether the kiss is on the cheek or on the mouth. Beyond kissing on the mouth, which is behavior R61 did not engage in with other adult males during his life, it should be noted, based on one of the statements, R29 also had his hand on R61's upper leg in addition to pulling him toward him and kissing him, as well as following him to his room. FM T stated SW U stated to her she thought it was moving toward, More sexual things, as she described it. CNA S stated, when she walked in the room, R29 had his hands at R61's waist and he looked like he was trying to take off R61's pants and she yelled, Don't do that. R61 was unable to voice how the sexual advances of R29 made him feel. Consequently, the survey team used the reasonable person concept. R61 has been married for [AGE] years and it is unlikely he would have consented to what was occurring if he understood it and understood the consequences. It would be very distressing to a reasonable person to be engaging in intimate activity with a person of the same sex when he did not understand what was happening and did not know if he could refuse and had never engaged in such behaviors with another man prior to the onset of [MEDICAL CONDITION]. Although R61 has not displayed reactions or behaviors like those identified in the psychosocial guidelines at severity level 4, the potential existed for such reactions to occur if R61 understood what was happening. A reasonable person could feel extreme anger at not being protected and could become combative with a person who was taking advantage of him. A reasonable person also could feel extreme humiliation for engaging in behavior that was contrary to any behaviors he had shown in his lifetime. The facility's failure to protect R61 from sexual abuse created a situation of IJ, which was removed, on 9/11/19, when the facility implemented the following action plan: 1. R61 and R29 will only be allowed to socialize in supervised areas. 2. Targeted behavior will also be started on both R29 and R61 for seeking out companionship from other residents and their mood. 3. Other interviewable residents will be interviewed to ensure they feel safe and they feel free from abuse and exploitation. 4. All staff will be immediately educated prior to their next working shift on: a. Abuse policy to include definitions of abuse, what constitutes abuse, reporting abuse immediately, to the NHA but no later than 2 hours after the allegation was made immediately protecting the resident/s from further abuse, ensuring residents are protected during investigation, investigating the allegation thoroughly including statements from anyone with firsthand knowledge, and reporting the incident to the State Agency, and law enforcement as applicable. b. Reasonable suspicion of a crime policy. c. Training on Sexuality and Intimacy and what is required for individuals to consent to a sexual relationship. 5. Audits of daily documentation, targeted behaviors, and 15 min (minute) checks will be completed to ensure safety of residents. 6. QAPI (Quality Assurance and Program Improvement) team will monitor audits for compliance and trends. The deficient practice continues at a scope/severity of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its action plan and as evidenced by the following. Example 2 On 8/19/19, the facility discovered that Housekeeper G posted a video with R10 and R23 visible on Snapchat. The investigation of the incident included interviews with R10 and R23 who did not want police involved and showed no negative effect. R10's Minimum Data Set (MDS), completed on 5/23/19, has a Brief Interview for Mental Status (BIMS) score of 12, indicating she is moderately impaired. R23's MDS, completed 9/2/19, shows a BIMS score of 12. On 9/4/19 at 4:12 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and viewed the video in which R10 was viewed from behind her right shoulder and had no discerning features in the video. Surveyor viewed R23 in the video who was fully clothed, sitting in her recliner from R23's left side, with an over bed table in front of her. Isn't she cute? was heard as R23 was viewed in the video. The entire video was blurry and difficult to discern R23's or R10's identity. NHA A stated the video was sent to them by an anonymous source. NHA A questioned her staff and identified R23 by the view out her window, which is visible in the video. NHA A explained another staff member identified R10 by the sweater and barrette visible from the photo. The investigation showed the facility protected the residents as Housekeeper G was not allowed to be with residents, was interviewed, then immediately had her employment termed by the facility. NHA A showed Surveyor the orientation training Housekeeper G had gone through and that it contained training that taking pictures on personal devices was prohibited on 6/18/19. The facility provided education to the entire staff that taking pictures on personal electronic devices were prohibited, starting 8/19/19, and continued until all staff was trained prior to their next working shift. On 9/5/19 at 7:07 AM, Surveyor interviewed R10 and asked her if she remembered anyone speaking about staff taking pictures of her and posting them on Snapchat. She stated she did not remember anything like that. Surveyor asked her how she would feel if a staff member took her picture and posted it on the internet without her permission. R10 stated she might be a little upset, shrugging her shoulders, then went on to discuss other topics. On 9/4/19 at 11:58 AM, Surveyor interviewed R23. Surveyor asked her if staff has ever taken pictures of her. R23 said they did and it was the person who cleans. R23 explained she was sitting in her recliner when they took the picture. Surveyor asked R23 if she knew what the staff did with the pictures taken of her. R23 said they put them (the pictures) in a folder. Surveyor asked what was done with the pictures and R23 said she was not sure, but thought they were sent to other facilities. R23 stated she is not afraid and does not feel harmed in any way. R23 felt bad the person didn't have her permission. She did not show any signs of depression during the interview and stated she has not changed anything she does, such as activities she attends or where she eats. Surveyor had asked how her mood was and she said 1 time a month she felt depressed. Surveyor asked what that would look like and she said she wouldn't talk to anyone. Surveyor asked what thoughts she would have and R23 described that her mind would be without thoughts. Example 3 On 9/12/19 at 7:08 AM, NHA A approached Surveyor and explained Service Aide H had posted a picture of R75 on Snapchat the previous evening. R75's MDS, completed on 7/26/19, shows he has severe cognitive impairment and had his Power of Attorney (POA) activated. NHA A showed a documented interview with R75's POA who had received a copy of the picture of R75 that was posted to snapchat. The documentation showed the POA did not want the police notified. Surveyor viewed the picture of R75. R75 was sitting in a recliner. The picture was taken from behind the recliner, his hair, right arm and clothed legs and feet were visible in the picture. There were no distinguishing features displayed in the picture and no caption was in the photo. The investigation showed the Service Aide H sent the Snapchat picture with R75 to Service Aide I. Service Aide I viewed the photo, returning from break, and immediately took a screen shot of the photo for evidence and showed RN J (Registered Nurse) her supervisor. RN J immediately found Service Aide H and put her in an empty room and notified NHA [NAME] NHA A stated she was

Based on record review and staff interview, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 Residents (R) (R1 and R13) of 5 residents reviewed for accidents and supervision. R1 incurred a fall on 11/15/18, due to a malfunction of R1's auto-locking wheelchair brakes. R1 incurred two additional falls and a [MEDICAL CONDITION] before R1's brakes were fixed. Hospital discharge paperwork, dated 11/20/18, recommended increased monitoring of R1. That intervention was not implemented or added to R1's care plan. R1 incurred three additional falls, a forehead abrasion, facial bruising and a hematoma above the right eye before R1 was discharged from the facility. (This example is being cited at the G level; actual harm.) R13 incurred a fall out of bed on 3/10/19. Staff education following the fall indicated R13's bed should be kept against the wall in a locked position. That intervention was not added to R13's care plan. In addition, R13's care plan contained an intervention to keep R13's bed in a low position. That intervention was not consistently implemented. Findings include: On 3/13/19, the Surveyor reviewed R1's medical record. R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's most recent admission MDS (Minimum Data Set) assessment, dated 12/20/18, documented R1 was cognitively impaired, experienced [MEDICAL CONDITION], exhibited behaviors and required extensive assistance of staff for bed mobility and transfers. R1's Risk for Falls care plan, revised 12/01/18, indicated R1 was at risk for falls due to unsteady gait and use of a wheeled walker. R1's care plan included an intervention for auto-locking wheel chair brakes. An SBAR (Situation, Background, Assessment, Recommendation) report, dated 11/15/18 at 2:45 PM, documented, Resident found lying on floor between bed and bedside table. Denies injury. Unable to state what was doing when fell . Wheelchair by bed .Resident unable to state initially, but when asked again stated that (R1) slid off the bed when getting up to get in (R1's) wheelchair. Wheelchair roll back mechanism appears to not be working when checked. The Interventions section stated, Have wheelchair evaluated. Mechanism for preventing rolling backward when resident sits appears to not be functioning at this time. Evaluation of transfer from bed to wheelchair by therapy. The report indicated R1's care plan had been updated. The Surveyor reviewed R1's care plan following this fall and noted no additional new interventions were implemented after R1's fall. In addition, the Surveyor noted R1 had not been evaluated by therapy following this fall. A Therapy Screening Form documented R1 had not been evaluated by therapy staff until 11/26/18. An SBAR report, dated 11/18/18 at 3:45 PM, documented, Resident found in room on floor. Unable to state what mechanism caused fall. Noted 2 cm (centimeter) (laceration) to right occipital (back of head) area. Awake and talkative .2 cm scalp laceration to occipital scalp with surrounding swelling; bleeding controlled. The Intervention section stated, Auto-lock brakes on (wheelchair) need to be checked since last fall. Still not functioning. Check if PT (physical therapy) has evaluated mobility since being on [MEDICATION NAME] (an antipsychotic medication). Evaluation [MEDICATION NAME] dosing as has fallen twice since 10/14. Dosage increased to 25 mg (milligrams) on 10/14. The report indicated R1's care plan had been updated. The Surveyor reviewed R1's care plan following this fall and noted no new interventions were implemented following this fall. In addition, the Surveyor noted R1 had not been evaluated by therapy staff. A Therapy Screening Form documented R1 had not been evaluated by therapy staff until 11/26/18. An SBAR report, dated 11/18/18 at 8:20 PM, documented, Resident found on floor between bed and wheelchair seated on floor by staff. Occipital [MEDICAL CONDITION] from prior fall noted to be bleeding .appeared to be transferring to wheelchair .Send to ED (emergency department) for evaluation. The Interventions section stated, Maintenance called to evaluate wheelchair for safety. Evaluation of transfer ability since new meds started by PT (emailed). Evaluation of response to increase in [MEDICATION NAME]. The report indicated R1's care plan had been updated. The Surveyor reviewed R1's care plan following this fall and noted no new interventions were implemented following this fall. In addition, the Surveyor noted R1 had not been evaluated by therapy staff. A Therapy Screening Form documented R1 had not been evaluated by therapy staff until 11/26/18. A CT (computed tomography) Scan (imaging of head) dated 11/19/18 states in part; No acute intracranial finding; no fracture is seen on bone windowed images. R1's hospital discharge paperwork, dated 11/20/18, documented Dermabond (an adhesive used for wound closure) was applied to a 3 cm occipital [MEDICAL CONDITION]. R1 was noted to have a UTI and an excoriated (damaged skin) groin with yeast present. The MD (Medical Doctor) recommended increased peri-care with antifungal creams and [MEDICATION NAME]. The Assessment section stated, Suspect that the increased falls with weakness are due to acute UTI. (R1) should be monitored frequently as (R1) remains a fall risk. The Surveyor reviewed R1's MAR (medication administration record) and noted a PRN (as needed) order for [MEDICATION NAME] (a topical antifungal used to treat skin infections) 1 gm (gram) to affected area was added on 11/20/18. From 11/20/18 - 12/03/18, the MAR indicated [REDACTED]. R1's Urinary Incontinence care plan, dated 10/27/17, was not updated to reflect R1's current status and did not include the intervention for increased peri-care as per written by the MD on R1's hospital discharge paperwork. On 11/05/18, MS (Maintenance Staff)-F created a work order, with a priority level of medium and a due date of 11/02/18. The work order indicated R1's wheelchair had been repaired on 11/05/18. An additional work order had been created on 11/19/18, by MS-F with a priority level of critical and a due date of 11/19/18. Documentation indicated R1's anti-rollback device had been adjusted on 11/19/18. An SBAR report, dated 11/27/18 at 3:00 PM, documented, Fall in room .Sitting at the edge of the bed .Arrived to (resident's) room, observed resident sitting on floor, facing the window, with legs crossed in front of the black foot stool. Noticed a bump above right eyebrow measured 5 cm (length) by 2.5 cm (width). Wheelchair, foot pedals facing bed. Resident is impulsive and a safety risk due to self transfers even after reminders and cueing with no effect . The Intervention section stated, Remove the black chair with foot stool and replace with recliner .Care plan updated. A nursing note, dated 11/28/18 at 5:27 AM, documented, Bruising, abrasion and swelling noted to right forehead and just above right eye. Abrasions noted to both knees. The report indicated R1's care plan had been updated. The Surveyor reviewed R1's care plan following this fall and noted no new interventions were implemented following this fall. An intervention that indicated R1's black rocker was removed from the room had been added on 12/01/18. An SBAR report, dated 11/28/18 at 6:29 AM, documented, Found on knees in room .Resident claimed that (resident) got onto the floor to pick something up. No injuries noted. The Interventions section stated, Orthostatic BPs (blood pressures). A nursing note, dated 11/29/18 at 3:28 AM, documented, Bruising, swelling and abrasion noted to right side of forehead. Abrasions noted to both knees . The report indicated R1's care plan had been updated. The Surveyor reviewed R1's care plan following this fall and noted no new interventions were implemented following this fall. An intervention for orthostatic blood pressures PRN (as needed) was added to the care plan on 12/01/18. A physician's orders [REDACTED]. R1's medical record did not include documentation that the MD had been notified of the results of R1's orthostatic blood pressures. An SBAR report, dated 11/29/18 at 1:15 PM, documented R1 incurred six falls in the previous 30 days and stated, Resident found on side in room .Resident denies weakness or balance issues, but has needed further assistance since a week ago .No new injuries from what was received in the previous falls .Resident seems weaker and has less support when tries to transfer. Resident does not use call light. Resident has orthostatic [MEDICAL CONDITION] (a form of low blood pressure that happens when standing up from sitting or lying down) (is being evaluated this week). The Interventions section stated, Decreased [MEDICAL CONDITION] medication. The report indicated R1's care plan had been updated. The Surveyor reviewed R1's care plan following this fall and noted no new interventions were implemented following this fall. An intervention for a medication review PRN had been added to the care plan on 12/01/18. A nursing note, dated 11/29/18 at 23:02 (11:02 PM), documented, Hematoma on right eye has extended from the top to completely surrounding the right eye. A nursing note, dated 12/01/18 at 12:05 AM, documented, (R1) was noted to be sitting on edge of bed leaning far over (R1's) overturned wheelchair, partially taken apart, with chair contents scattered .Safety is a concern. Encouraged to use call light which is in easy reach. A nursing note, dated 12/03/18 at 3:58 PM, documented, Resident admitted to Watertown Senior Behavioral Unit for monitoring and assessment . R1's hospital admission paperwork, dated 12/03/18, documented, Upon arrival to triage ED, charge RN (Registered Nurse) attempted to call SNF (skilled nursing facility) for report. No answer at facility at this time. Patient has bruising noted to right eye with hematoma on forehead. Patient unable to tell writer what happened (Patient) presents from local nursing home to the ER (emergency room ) for medical clearance so (patient) can be admitted to the geropsych unit. The patient fell on ,[DATE] and sustained a head contusion (bleeding under the skin) and has ecchymoses (discoloration of the skin due to bleeding underneath) to (patient's) head .(Patient) will need repeat imaging . A consult note, dated 12/03/18, stated, CT (computed tomography) scan of the head reveals no acute intracranial (within the skull) injury. Maxillofacial (relating to the jaws and face) CT reveals no acute fracture. (Cervical) spine CT reveals a questionable fracture of C2 (second vertebra of the spine) - lateral mass on the left .I spoke with (MD-H), the spine surgeon on call .(MD-H) did not feel the patient had any significant fracture . CT Scan of the cervical spine dated 12/3/18 states in part; C2 (second cervial vertebrae) could potentially represent a nondisplaced fracture. Impression: Questionable nondisplaced [MEDICAL CONDITION] lateral mass of C2. Of note this is a change from the CT scan dated 11/19/18. R1 had 4 additional falls between the CT scan on 11/19/18 and 12/3/18. On 3/13/19 at 12:31 PM, the Surveyor interviewed AC (Anonymous Complainant)-D via telephone. AC-D indicated after R1's fall on 11/27/18, (AC-D) had not been informed of the severity of the situation. AC-D stated, I was made to believe it was nothing at all. AC-D stated before (R1) could be admitted to the geropsych unit, (R1) had to be assessed in the ER per the geropsych unit's policy. AC-D stated, The ER was very concerned they hadn't seen (R1) sooner. Regarding the facility's interventions for R1, AC-D stated, They put a sign on (R1's) wall that (R1) should use the call light. (R1) is confused. I told them (R1) never used the call light in previous nursing homes, even when (R1) wasn't confused. They were supposed to be checking on (R1) more often according to (DON (Director of Nursing)-B). I have no proof it was done On 3/13/19 at 3:10 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-A regarding R1's wheel chair brakes. NHA-A stated, I'll check why the anti-rollback device wasn't fixed or entered as a work order until 11/19. On 3/13/19 at 4:50 PM, the Surveyor interviewed ADON (Assistant Director of Nursing)-C regarding R1's wheelchair brakes. ADON-C stated, I sent an email to (MSD (Maintenance Staff Director)-E) who would've delegated it to (MS-F). ADON-C stated the facility had a new work order processing system (TELS) which ADON-C was unfamiliar with when the email was sent. ADON-C was unsure of what became of the email prior to a follow-up call made to MSD-E after R1's second fall on 11/18/18. Regarding R1's orthostatic blood pressure monitoring and MD notification, ADON-C stated, I updated (MD-I) on 11/30 with medications. As far as updating with orthostatic blood pressures, I was trying to rule out whether (R1's) [MEDICAL CONDITION] meds were affecting (R1) and causing (R1's) falls. I was trying to eliminate another cause factor. It wasn't an MD order to do orthostatic blood pressures. There was no need to update the doctor because the blood pressures were within normal limits. When asked if the facility staff had discussed increased monitoring for R1 after R1's discharge from the hospital on [DATE], ADON-C stated, I'm not sure about increased monitoring. On 3/13/19 at 5:10 PM, the Surveyor interviewed MSD-E regarding R1's wheelchair. MSD-E stated (MSD-E) vaguely remembered an email from ADON-C and stated, I would've forwarded it to (MS-F). On 3/13/19 at 5:20 PM, the Surveyor interviewed DON-B regarding fall interventions and monitoring for R1. DON-B indicated the facility could not implement 1:1 monitoring and stated 15 minute checks set the staff up for failure. Regarding 30 minutes checks, DON-B stated, Thirty minute checks don't necessarily mean (R1) wouldn't have fallen anyway. DON-B stated, We offered a room change, but family didn't want it. DON-B verified there was no documentation regarding the conversation with R1's family or the family's refusal. Regarding MD notification of R1's orthostatic blood pressures, DON-B stated, I'm not sure why the nurse didn't notify the MD of the orthostatic blood pressures (on 11/30/18). DON-B verified the order stated to update the MD, but didn't state notification was not necessary if blood pressures were within normal limits. DON-B stated the order appeared to be an MD order, but according to ADON-C, it was a nursing order. DON-B verified R1 had not been evaluated by therapy staff until 11/26/18. On 3/14/19 at 8:30 AM, the Surveyor interviewed MS-F and MSD-E regarding R1's wheelchair. MS-F stated (MS-F) couldn't recall R1 or R1's wheelchair. When asked about the details of the 11/02/18 work order, MS-F stated, I don't recall the work order. I didn't write any specifics. It makes me think someone stopped me in the hall and asked me to fix it because I entered (the work order) myself. When asked about the priority level, MS-F stated, It's a medium level priority. Usually things related to wheelchairs and safety are critical levels and need to be fixed right away. I think (the work order) from (11/19) is the wires loosened up on the back of the wheels for the brakes and they needed to be tightened. Again, I entered that one .not sure if someone stopped me in the hall and asked me to fix it, but I would guess that. MSD-E stated, We had problems with our internet. Usually if we get (a work request) via email or TELS, I enter it. Example 2 On 3/13/19, the Surveyor reviewed R13's medical record. R13 was admitted to the facility with [DIAGNOSES REDACTED]. R13's most recent Quarterly MDS assessment, dated 1/28/19, documented R13 was cognitively impaired and required extensive assistance of staff for bed mobility and transfers. R13's Risk for Falls care plan, dated 4/13/18, indicated R13 was at risk for falls related to dementia, balance issues and weakness. R13's care plan contained an intervention, dated 3/06/19, for a low bed and air mattress with bolsters. An SBAR report, dated 3/10/19, documented, Found on knees on the floor .Bed was not against the wall. Was found on knees between the bed and wall, facing the head of the bed. Bed was in low position on the floor .Re-educate staff that bed needs to be against the wall and bed locked. As a result of the fall, R13 incurred a 3 cm area of redness to the right knee. The Surveyor noted R13's care plan had not been updated following this fall. On 3/13/19 at 3:18 PM, the Surveyor observed R13 in bed. R13's bed was against the wall and 3 of the 4 bed wheels were locked; however, the bed was not in a low position. On 3/13/19 at 3:20 PM, the Surveyor interviewed RN (Registered Nurse)-G regarding the position of R13's bed. RN-G verified 3 of the 4 wheels were locked and stated R13's bed should be in a low position. RN-G lowered the bed and pulled the bed away from the wall approximately 3-5 inches. Regarding R13's bed position, RN-G stated, It would be a restraint to put (R13) against the wall. Regarding a potential entrapment hazard between the wall and the bed, RN-G indicated R13 hadn't rolled out of bed as far as RN-G knew. RN-G stated (RN-G) was unaware R13 had a fall and the intervention to keep R13's bed against the wall, as the intervention had not been added to R13's care plan.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 3 sampled residents (R1). R1, who is receiving an anticoagulant, experienced a Change in Condition with symptoms indicative of rectal bleeding. The facility did not complete a full nursing assessment, including abdominal assessments and vital signs. Subsequently, on [DATE], R1 had two episodes of [MEDICAL CONDITION] activity. During transfer to the emergency room (ER) R1 coded and was revived. R1 was diagnosed at the emergency room as being in hypovolemic shock, secondary to blood loss. The facility's failure to assess R1, when R1 was noted to be experiencing a Change in Condition, exhibiting symptoms of a rectal bleeding, created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. On [DATE] at 2:40 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ. The IJ was removed on [DATE]; however, the deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Evidenced by: According to Chapter N6 of the Wisconsin Nurse Practice Act, An RN (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment: Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient, which includes goals and priorities derived from the nursing diagnosis . AMDA (American Medical Directors Association) Protocols for Physician Notification includes, in part: Condition: Bleeding, rectal - Physical Data: 1. Vital signs. 2. Orthostatic blood pressure and pulse. 3. Estimate amount of bleeding (in cc's-cubic centimeters). 4. Test stool for occult blood if not obviously tarry. 5. Visual assessment of rectum. 6. Abdominal and digital assessment of rectum. 7. Pain assessment. (Location and character, severity). Medical History: 1. Patient's age and sex. 2. Medical history, including history of ulcer or [MEDICAL CONDITION] ulcer disease. 3. All active diagnoses. 4. All current medications, especially anticoagulants, NSAIDS ( Non-steroidal anti [MEDICAL CONDITION] drugs) and [MEDICATION NAME] (Chemicals found in plants and are a major ingredient in aspirin and other pain relieving medications). R1's [DIAGNOSES REDACTED]. R1 is Dependent on [MEDICAL TREATMENT]. R1 is a Full Code (resuscitate if respirations or heartbeat cease). R1's Quarterly MDS (Minimum Data Set), dated [DATE], indicated that R1 was cognitively intact, needed extensive assistance of two for transferring and toileting, and was frequently incontinent of bowel and occasionally incontinent of bladder. R1's care plan problem: Potential for bleeding related to anticoagulant therapy, with a revision date of [DATE], includes, in part: Goal: Will exhibit no signs or symptoms of active bleeding. Will maintain therapeutic goal as healthcare provider specifies. Approach: dated [DATE], Observe for signs of active bleeding (nose bleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis). Approach: dated [DATE], See standard protocol. R1's CNA (Certified Nursing Assistant) Care Plan, without a date, does not indicate monitoring R1 for bleeding. Column under bowel is blank. R1's Task Message, dated [DATE] at 7:15 AM (morning), per RN G, includes, in part: R1 was readmitted yesterday. R1 was to have remaining 6 teeth extracted on [DATE]. FM F (Family Member) cancelled the appointment. R1's [MEDICATION NAME] remains on hold per Discharge Summary, due to supratherapeutic level on [DATE], which they felt was due to malnutrition and R1 had maroon stools. R1's INR (International Normalized Ratio - INR measures how quickly the blood clots; measurements above the therapeutic range indicate the blood is clotting more slowly), on [DATE], was 4.18. R1 was given 1 dose of vitamin K IV (Intravenous). R1 is taking [MEDICATION NAME] 2.5 mg (milligram) M-W-F (Monday, Wednesday, Friday), 5 mg T-TH-Sat-Sun (Tuesday, Thursday, Saturday, Sunday). MD C's (Medical Doctor) response to this Task Message, on [DATE] at 9:33 AM, includes, in part: Please resume previous dosing. Watch very closely and monitor for dark stools. I will review next week. R1's Progress Notes, dated [DATE] at 8:56 PM (evening), per RN E, includes, in part: R1 noted to have pink tinge in stool this PM. FM F contacted and indicated R1 had this when in the hospital a week ago and had a colonoscopy. FM F indicated some polyps were removed and were sent for testing, No abdominal pain and BS (Bowel Sounds) x (times) 4. MD C tasked to update. R1's Task Message, dated [DATE] at 3:06 PM, per RN E, includes, in part: INR 2.3, is on 2.5 mg Monday and Friday and 5 mg all other days. Will schedule INR for 2 weeks. (Of note: there is no documentation that R1 had a pink tinged stool or that R1's vital signs were assessed on this Task Message.) R1's Task Message, dated [DATE] at 9:02 PM, per RN E, includes, in part: R1 noted to have a pink tinged stool this PM. FM F indicated R1 had this when in the hospital about a week ago and had a colonoscopy done. BP (blood pressure) ,[DATE] P100 (Pulse) R20 (Respirations) T98.3 (temperature). Will continue to monitor. On [DATE] at 7:31 AM, MD C's response to R1's Task Message indicated he agrees. On [DATE] at 12:16 PM, MD C's response to R1's Task Message indicated please check a CBC (complete blood count). If R1 decompensates, please send to the hospital right away. R1's Progress Notes, dated [DATE] at 10:33 PM, per RN E, includes, in part: R1 noted to have a medium BM (bowel movements) this PM. It was noted to be pink tinged. CBC ordered for tomorrow. (Of note: there was not a nursing assessment or vital signs when R1 had another pink tinged stool.) R1's Task Message, dated [DATE] at 9:31AM, per RN H, includes, in part: CBC result: HGB (Hemoglobin - protein stored in red blood cells) 9.3 (previously 8.1) & HCT (Hematocrit - how much of your blood is comprised of red blood cells) 31 (previously 27). FYI (for your information): On [DATE], colonoscopy results: Cecal Ulcer and reactive changes, negative for [DIAGNOSES REDACTED] or malignancy. R1's Progress Notes, dated [DATE] at 5:25 AM, per RN I, includes, in part: R1 had two medium loose stools this shift. Was pink tinged. R1 is on anticoagulation and has a history of GI bleed and a history of supratherapeutic lab values; this is the third day R1 has had pink-tinged stools. There is no nursing assessment, including an assessment of R1's abdomen, or a check of vital signs. If the abdomen is firm, for example, it could be a sign of obstruction, gas, bleeding into the abdomen or a mass. A drop in blood pressure could indicate that bleeding is occurring. A nursing assessment is key to getting a complete understanding of what might be occurring. R1's Progress Notes, dated [DATE] at 3:49 AM, per RN I, includes, in part: R1 had two incontinent pink tinged stools. (Of note: there was not a nursing assessment, including an abdominal assessment or a check of vital signs.) On [DATE] at 8:38 AM, MD C's response to R1's Task Message indicated gradual improvement. R1's Progress Notes, dated [DATE] at 2:14 PM, per RN K, includes, in part: R1 refused [MEDICAL TREATMENT] today. Episode of rectal bleed x 1. (Of note: there was not a nursing assessment or check of vital signs when R1 had a rectal bleed x 1.) R1's Progress Notes, dated [DATE] at 12:23 AM, per RN I, includes, in part: R1 had a medium soft formed dark bloody stool. See vital signs, no complaints of pain. (Of note: there was not a nursing assessment done including an abdominal assessment following the dark bloody stool.) R1's Progress Notes, dated [DATE] at 10:51 AM, per LPN D (Licensed Practical Nurse) includes, in part: R1 had one episode of dark red, no clots bleeding with non - formed stool into brief. (Of note: there was not a nursing assessment or a check of vital signs when R1 had another episode of bleeding with his stool.) R1's Progress Notes, dated [DATE] at 7:15 AM, per RN G, includes, in part: R1 had a small amount of bright red blood in the toilet and a small amount in the brief. Nursing Home to Hospital Transfer Form, dated [DATE] at 1:40 PM, per RN G, includes, in part: [MEDICAL CONDITION] activity, blowing respirations, moaning, hard jerking of UE's (upper extremities) - 2 episodes, 1st lasted 1 minute at 8:05 AM, second one at 8:10 AM, lasted approximately 2 minutes. No history of [MEDICAL CONDITION]. Also has bright red blood in toilet and brief. On [MEDICATION NAME]. (INR 2.3 on [DATE]). Vital signs documented at 7:15 AM, BP ,[DATE], P88, R18, and T97.5 Oxygen Saturation 98%. The facility's Medical Transport Form, dated [DATE], without a time stamp, per RN G, includes, in part: R1 is unresponsive and requires monitoring and transport by ambulance. R1's Progress Notes, dated [DATE] at 8:55 AM, per RN G, includes, in part: 911 (emergency) called and R1 left the facility via ambulance, approximately 8:15 AM, and remained in the parking lot until 8:50 AM. On [DATE] at 9:16 AM, RN G sent the following Task Message: R1 noted to have 2 [MEDICAL CONDITION] this morning. No history of [MEDICAL CONDITION]. R1 is a Full Code. 911 were called and R1 left the facility at approximately 8:30 AM. (Of note: There is no documentation to indicate R1 had rectal bleeding.) The facility's SBAR (Situation, Background, Assessment and Review), dated [DATE] at 1:11 PM, per RN G, includes, in part: change in L[NAME] (Level of Consciousness) - blowing respirations, moaning, and then hard jerking of UE. First episode lasted approximately 1 minute the R1 had a second episode at 8:10 AM, which lasted 2 minutes. No previous history of [MEDICAL CONDITION]. Also bright red blood noted in toilet / brief. R1 complained of dizziness after second episode. 911 called and R1 was transported to the hospital. R1's Progress Notes, dated [DATE] at 9:45 AM, per RN G, includes, in part: R1 has lost a heartbeat once already and they started compressions. R1's Progress Notes, dated [DATE] at 11:19 AM, per RN G, includes, in part: received a call from the pharmacy and are requesting R1's MAR (Medication Administration Record) as R1 is being admitted . R1's INR is almost 10 and has [MEDICAL CONDITION](rapid heartbeat). On [DATE] at 9:41 AM, Task Message response indicated acknowledged. Hospital emergency room (ER) Notes, dated [DATE] at 2:38 PM, includes, in part: R1 presented to the ER after an episode of [MEDICAL CONDITION] and brief [MEDICAL CONDITION]. At the time of arrival in the ER, R1 was intubated. Per EMS (Emergency Medical Services) report, R1 had an episode of [MEDICAL CONDITION] and then lost pulse .In the ER, cardiology was consulted and a temporary transvenous pacemaker via the right femoral vein was placed. Labs were significant for hemoglobin of 4.4. R1 was given 3 units of packed red blood cells and 1 unit of FFP (Fresh Frozen Plasma). (FFP - blood product used when clotting factor are low such as an INR > 1.5). R1's INR was noted to be 9.9; R1 was given 10 mg vitamin K IV. R1 was transferred to the Intensive Care Unit for [MEDICAL TREATMENT], close monitoring, and ventilator management. Assessment /Plan: [MEDICAL CONDITION]/[MEDICAL CONDITION] - present on admission. [MEDICAL CONDITION] corrected with 3 units packed red blood cells and 1 unit FFP. [MEDICATION NAME] (anti - arrhythmic medication) drip started. Shock- present on admission. Evidence of hypovolemic. Acute [MEDICAL CONDITION]- present on admission. Continue ventilator until shock is resolved. Anion gap metabolic acidosis- present on admission. Due to lactic acidosis in setting of shock. [MEDICAL CONDITION] on [MEDICAL TREATMENT]- present on admission. Undergoing [MEDICAL TREATMENT] today. Acute blood loss [MEDICAL CONDITION]- present on admission. Likely due to lower GI bleed. Reverse INR with 10 mg vitamin K IV and [MEDICAL CONDITION] above. Disposition: R1 remains critical condition in the Intensive Care Unit. Hospital Discharge Summary, dated [DATE] at 11:09 AM, includes, in part: R1 is tolerating PO (oral), doing well on HD ([MEDICAL TREATMENT]) with a stable HGB and back to baseline per FM F. R1's [MEDICATION NAME] and ASA (Aspirin) have been stopped. R1's [MEDICATION NAME] has been increased to 75 mg BID (twice daily) for better control of Afib ([MEDICAL CONDITION]). FM F is now R1's AHCPOA. (Activated Healthcare Power of Attorney) and R1 remains a Full Code. Final Diagnosis: [REDACTED]. Hypovolemic Shock secondary to acute blood loss [MEDICAL CONDITION] - present on admission. Coagulopathy - present on admission. Acute [MEDICAL CONDITION]- present on admission. R1's Progress Notes, dated [DATE] at 1:10 PM, per RN J, includes, in part: R1 planned re-admission today. Will initiate Medicare criteria for rehab s/p (status [REDACTED]. Will monitor labs, bleeding and respiratory status for stability. (Of note: R1's potential for bleeding - Nursing and CNA Care Plan have not been revised or updated to reflect monitoring for bleeding since R1's re-admission to the facility on [DATE].) On [DATE] at 2:45 PM, Surveyor asked DON B if the nurses should have assessed R1 when resident was experiencing pink tinged or bloody stools and obtained vital signs. DON B indicated yes. DON B indicated she spoke to LPN D regarding the Task Message to MD C on [DATE], regarding holding the [MEDICATION NAME] and asked if LPN D clarified the Task Message with MD C. DON B indicated LPN D thought MD C was aware of the bleeding and gave the order to give the [MEDICATION NAME]. DON B indicated LPN D misunderstood the Task Message. The facility's failure to assess R1 as condition changed prevented staff from getting a comprehensive picture of R1's clinical condition and, thus, prevented them from taking appropriate follow-up action, such as prompt consultation with the physician, with complete information about the resident's condition. This failure created a situation of Immediate Jeopardy, which was removed on [DATE] when the facility implemented the following action plan. 1. All front line staff will be re- educated prior to their next scheduled shift on immediately reporting bleeding to licensed staff. 2. All licensed staff will be re- educated prior to their next scheduled shift to then check if the bleeding resident is on an anti-coagulant and complete a full assessment and update the physician. 3. All licensed staff will be re-educated prior to their next schedules shift on Change of Conditions and physician notification. 4. Care plans including CNA care plans will be updated to include monitoring for signs of bleeding for the residents who are on any anti-coagulants. 5. Daily nurses note review and 24 - hour report board review to ensure the nurses are calling the physician with Change of Conditions and completing proper assessments will be done for one week, then weekly for four weeks, then random based on QAPI (Quality Assessment and Performance Improvement) review. 6. QAPI team will monitor audits for compliance and trends. Cross Reference F580 J

Based on interview and record review, the facility did not promptly consult with the resident's physician when 1 of 3 residents (R1) had a significant change in medical condition. Additionally, when staff did send a Task Message to the physician over the computer, staff did not give all pertinent information. R1, who is receiving anticoagulant therapy to prevent blood clots, was having pink tinged stools, dark red bleeding with stools, and documented rectal bleeding. The MD (Medical Doctor) was not consulted. On [DATE] at 2:14 AM (morning), R1 had 1 episode of rectal bleeding. On [DATE] at 12:23 AM, R1 had a medium dark bloody stool, and at 10:51 AM, R1 had an episode of dark red, no clots bleeding with a non- formed stool. This was a significant change in R1's condition and the facility did not immediately contact R1's physician. On [DATE] at 2:34 PM (evening), LPN D (Licensed Practical Nurse) sent a Task Message to the physician that includes, in part: Would you like us to hold R1's [MEDICATION NAME] today, due to rectal bleeding? It is 5 mg (milligrams) due today. On [DATE] at 4:28 PM, MD C replied to the Task Message stating, No, since there was none today. The facility did not contact MD C to question MD C's response, as R1 has had two episodes of rectal bleeding on that day and 1 episode the day prior. On [DATE] at 7:15 AM, R1 was noted to have bright red blood in the toilet and in brief. R1 had 2 episodes of [MEDICAL CONDITION] activity and 911 (emergency) was called. R1 became pulseless in the ambulance, but was revived. R1 was in hypovolemic shock, secondary to blood loss, when arriving at the emergency room . The facility's failure to timely consult with R1's physician when R1 had a significant Change in Condition created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. On [DATE] at 2:40 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ. The IJ was removed on [DATE]; however, the deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Evidenced by: The facility follows AMDA (American Medical Directors Association) Know It All before you call Data Collection System guidelines. The facility created a condensed list of medical conditions, but this does not include rectal bleeding for physician notification. The AMDA Clinical Practice Guideline for Acute Change of Condition in the Long - Term Care Setting includes, in part: Condition: Bleeding: Uncontrolled or repeat episode within 24 hours, Bloody stools not from hemorrhoids - Report Immediately. R1's [DIAGNOSES REDACTED]. R1 is Dependent on [MEDICAL TREATMENT]. Per the medical record, R1 is Full Code (wanting resuscitation if R1 becomes pulseless and non-breathing). R1's Quarterly MDS (Minimum Data Set), dated [DATE], indicated that R1 was cognitively intact, needed extensive assistance of two for transferring and toileting, and was frequently incontinent of bowel and occasionally incontinent of bladder. R1's care plan problem: Potential for bleeding related to anticoagulant therapy, with a revision date of [DATE], includes, in part: Goal: Will exhibit no signs or symptoms of active bleeding. Will maintain therapeutic goal as healthcare provider specifies. Approach: dated [DATE], Observe for signs of active bleeding (nose bleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis). Approach: dated [DATE], See standard protocol. R1's CNA (Certified Nursing Assistant) Care Plan, without a date, does not indicate monitoring R1 for bleeding. R1's INR (International Normalized Ratio), on [DATE], was 4.18, which was above the goal range of ,[DATE]. (INR measures how quickly the blood clots; measurements above the therapeutic range indicate the blood is clotting more slowly.) R1 was given 1 dose of vitamin K IV (Intravenous). R1 is taking [MEDICATION NAME] 2.5 mg M-W-F (Monday, Wednesday, Friday), 5 mg T-TH-Sat-Sun (Tuesday, Thursday, Saturday, Sunday). R1's Progress Notes, dated [DATE] at 10:33 PM, includes, in part: R1 had two medium BM's (bowel movements) this PM (evening). It was noted to be pink tinged. CBC (complete blood count) ordered for tomorrow. Pink-tinged or red stool can indicate that internal bleeding is occurring. R1's Progress Notes, dated [DATE] at 5:25 AM, per RN I (Registered Nurse), includes, in part: R1 had two medium loose stools this shift. Was pink tinged. R1's Progress Notes, dated [DATE] at 3:49 AM, per RN I, includes, in part: R1 had two incontinent pink tinged stools. R1's Progress Notes, dated [DATE] at 2:14 PM, per RN K, includes, in part: R1 had 1 episode of rectal bleed. (Of note: the physician was not consulted or advised of the pink tinged stools or the episode of rectal bleeding.) R1's Progress Notes, dated [DATE] at 12:23 AM, per RN I, includes, in part: R1 had a medium soft formed dark bloody stool. (Of note: the physician was not consulted regarding the dark bloody stool.) R1's Progress Notes, dated [DATE] at 10:51 AM, per RN H, includes, in part: R1 had one episode of dark red, no clots bleeding with non - formed stool into brief. On [DATE] at 2:34 PM, LPN D sent MD C the following Task Message: Would you like us to hold (R1's) [MEDICATION NAME] today, due to the rectal bleeding? It is 5 mg due today. This message did not provide all pertinent information concerning the number of times R1 had stools that were pink-tinged or red. On [DATE] at 4:28 PM, MD C responded to the Task Message stating, No, since there was none today. The facility did not contact MD C to inform him that R1 had had two episodes of rectal bleeding today and 1 yesterday. [MEDICATION NAME] was given as scheduled on [DATE] per R1's Medication Administration Record. R1's Progress Notes, dated [DATE] at 7:15 AM, per RN G, includes, in part: R1 had a small amount of bright red blood in the toilet and a small amount in the brief. Nursing Home to Hospital Transfer Form, dated [DATE] at 1:40 PM, per RN G, includes, in part: [MEDICAL CONDITION] activity, blowing respirations, moaning, hard jerking of UE's (upper extremities) - 2 episodes, 1st lasted 1 minute at 8:05 AM, second one at 8:10 AM, lasted approximately 2 minutes. No history of [MEDICAL CONDITION]. Also, has bright red blood in toilet and brief. On [MEDICATION NAME]. INR 2.3 on [DATE]. R1's Progress Notes, dated [DATE] at 8:55 AM, per RN G, includes, in part: 911 called and R1 left the facility via (by) ambulance approximately 8:15 AM, and remained in the parking lot until 8:50 AM. Hospital emergency room (ER) Notes, dated [DATE] at 2:38 PM, includes, in part: R1 presented to the ER after an episode of [MEDICAL CONDITION] and brief [MEDICAL CONDITION]. At the time of arrival in the ER, R1 was intubated. Per EMS (Emergency Medical Services) report, R1 had an episode of [MEDICAL CONDITION] and then lost pulse .In the ER, cardiology was consulted and a temporary transvenous pacemaker via the right femoral vein was placed. Labs were significant for hemoglobin of 4.4. R1 was given 3 units of packed red blood cells and 1 unit of FFP (Fresh Frozen Plasma). (FFP - blood product used when clotting factor are low such as an INR > 1.5). R1's INR was noted to be 9.9; R1 was given 10 mg vitamin K IV. R1 was transferred to the Intensive Care Unit for [MEDICAL TREATMENT], close monitoring, and ventilator management. Assessment /Plan: [MEDICAL CONDITION]/[MEDICAL CONDITION] - present on admission. [MEDICAL CONDITION] corrected with 3 units packed red blood cells and 1 unit FFP. [MEDICATION NAME] (anti - arrhythmic medication) drip started. Shock- present on admission. Evidence of hypovolemic. Acute [MEDICAL CONDITION]- present on admission. Continue ventilator until shock is resolved. Anion gap metabolic acidosis- present on admission. Due to lactic acidosis in setting of shock. [MEDICAL CONDITION] on [MEDICAL TREATMENT]- present on admission. Undergoing [MEDICAL TREATMENT] today. Acute blood loss [MEDICAL CONDITION]- present on admission. Likely due to lower GI (gastrointestinal) bleed. Reverse INR with 10 mg vitamin K IV and [MEDICAL CONDITION] above. On [DATE] at 1:00 PM, Surveyor interviewed DON B regarding physician notification. DON B indicated the facility does not have a policy for physician notification, but follows a condensed version of the AMDA guidelines. DON B gave Surveyor a copy of the guidelines the facility follows. Surveyor asked DON B if she would expect the nurse to contact MD C when R1 was experiencing pink tinged stools on [DATE]. DON B indicated she could not find a message that MD C was contacted . DON B indicated that the nurse should send a Task Message to MD C as MD C prefers a Task Message over a phone call. Surveyor asked DON B if she would expect the nurse to contact MD C, on [DATE], when R1 continued with pink tinged stools. DON B indicated the pink tinge could be from moisture associated [MEDICAL CONDITION]. Surveyor asked DON B if MD C should have been consulted when R1 had the episode of rectal bleeding and the dark bloody stool on [DATE]. DON B indicated if there was a second one. Surveyor asked DON B, when R1 experienced rectal bleeding on [DATE], 2 bloody stools on [DATE], and was experiencing pink tinged stools prior, if MD C should have been consulted. DON B indicated MD C was updated by the Task Message. Surveyor asked if MD C was contacted, as R1 had 2 bloody stools, and MD C indicated not to hold the [MEDICATION NAME] since there was none today. DON B was unclear if the nurse contacted MD C, as there was no documentation and review of the MAR (Medication Administration Record) indicates the [MEDICATION NAME] was given on [DATE]. DON B indicated there should be documentation and the nurse should have sent another Task Message. DON B indicated she is creating a change of condition / physician notification policy. On [DATE] at 1:49 PM, Surveyor reviewed the Task Message with MD C, dated [DATE] at 4:28 PM. MD C indicated he must not have read the message clearly and would have expected the facility to clarify this with him via Task Message and indicate on the message that R1 had 2 bloody stools today. MD C indicated he has educated the facility staff in the past on when to call him versus send a Task Message. The facility's failure to notify R1's physician for Change in Condition prevented earlier intervention and allowed R1's condition to worsen. This created a situation of IJ, which was removed on [DATE] when the facility implemented the following action plan. 1. All front line staff will be re- educated prior to their next scheduled shift on immediately reporting bleeding to licensed staff. 2. All licensed staff will be re- educated prior to their next scheduled shift to then check if the bleeding resident is on an anti-coagulant and complete a full assessment and update the physician. 3. All licensed staff will be re-educated prior to their next schedules shift on Change of Conditions and physician notification. 4. Care plans including CNA Care Plans will be updated to include monitoring for signs of bleeding for the residents who are on any anti-coagulants. 5. Daily Nurse's Note review and 24 - hour report board review to ensure the nurses are calling the physician with Change of Conditions and completing proper assessments will be done for one week, then weekly for four weeks, then random based on QAPI (Quality Assurance and Performance Improvement) review. 6. QAPI team will monitor audits for compliance and trends. Cross reference F684 J

Based on interview and record review, the facility did not consult with the resident's physician when there was a change in the resident's physical condition or a need to alter treatment for 1 of 11 residents (R11) reviewed. R11 was experiencing bright red colored stools and there were multiple episodes documented of red/bloody discharge in his brief. R11's physician was not contacted to report the symptoms R11 was experiencing. (It is important to know that R11 is taking [MEDICATION NAME], a blood thinning medication.) This is evidenced by: The facility's policy Clinician Notification, with a revision date of 5/17/12, includes in part, a resident experiencing acute changes will be assessed by a licensed nurse and clinical data collected. The clinical data and condition will be reported to the clinician using the American Medical Director Association (AMDA) suggested guidelines for notification. 2. Clinical problems will be communicated to the clinician immediately by telephone. According to the AMDA guidelines entitled Acute Change of Condition in the Long Term Care Setting an immediate MD notification for bleeding includes repeat episodes within 24 hours and bloody stools not from hemorrhoids. R11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R11 has an activated health care power of attorney (HCPOA) and is full code status. Review of R11's progress notes include in part: On 5/8/17, at 12:18 PM, R11 noted to have blood in incontinence pad with scant amount of loose Bowl Movement (BM). Medical doctor (MD) updated. Verbal orders to continue to monitor if blood increases and have complete blood count (CBC) drawn this week on the same day as PT/INR ([MEDICATION NAME] - international normalized ratio - blood test to determine how long it takes the blood to clot). On 5/8/17, at 9:00 PM, R11 had a small amount of active rectal bleeding at the beginning of the shift and then only had light pink streaking in his brief X1 (one time) after that. R11's BM Record indicates on 5/9/17, at 4:48 PM, R11 had a small bright red BM. R11's physician was not informed. On 5/9/17, at 9:26 PM, R11 continues with small amount of bright red fluid in brief; labs to be drawn on 5/12/17. On 5/10/17, at 5:01 AM, small amount of rectal bleeding observed in the brief on Noc (night) shift. On 5/10/17, at 3:07 PM, R11 continues with bloody discharge from anus, mild amount no increase from first day noted. Lab ordered 5/12/17. On 5/11/17, at 4:18 AM, R11 had a small amount of rectal bleeding observed with brief change. On 5/11/17, at 10:06 PM, R11 continues with small amount of bright red fluid in brief. It is important to know that the MD was not contacted regarding the rectal bleeding that occurred on 5/9/17- 5/11/17. The facility uses the INTERACT Version 4.0 tool (this is an algorithm care pathway for GI symptoms). The INTERACT tool entitled Care Path Gastrointestinal (GI) Symptoms algorithm states in part: Evaluate Symptoms and Signs for Immediate Notification - signs and symptoms under this tab include blood in stool or vomitus - if a sign or symptom is present and the reader chooses yes, the algorithm directs a reader to Notify MD/NP/PA. R11 presented with blood in stool and bleeding from rectum for 3 additional days after the initial MD notification. R11 was receiving [MEDICATION NAME], an anticoagulant medication, and was presenting with continued rectal bleeding. The MD was not notified of R11's continued rectal bleeding on 5/9, 5/10, and 5/11/17. On 5/12/17, at 9:22 AM, MD was updated with INR result of 5.7 (INR therapitic range is 2.0-3.0), orders received to hold the [MEDICATION NAME] for 3 days. There is no evidence the MD was updated, regarding the continued rectal bleeding on 5/9/17 - 5/11/17, when MD was updated with INR results. On 5/14/17, at 2:26 PM, R11 noted to be bleeding this AM from his lip. It did take 10 minutes to stop. Staff report R11 had a small amount of rectal bleeding and his bruising to his left arm is worse. Call placed to MD on call to report bleeding and orders obtained. On 5/14/17, at 4:00 PM, R11's family is here and inquiring about the elevated INR. Daughter indicated if further intervention is needed to send R11 to the hospital. On 5/14/17, at 6:00 PM, R11 was noted to have mottling (purplish or blotchy red-blue coloring) on his knees and inside of right foot. R11 is alert and trying to mumble. R11 answered yes when asked if he was in pain but could not elaborate. R11's abdomen was very firm and slightly distended. R11 had a soft BM which was rust colored. Vital signs are stable except for his oxygen saturation of 84% on room air. On 5/14/17, at 6:20 PM, call placed to on-call MD. On 5/14/17, at 6:30 PM, on call MD called back and was informed R11 is a full code and orders received to send to the emergency room . On 5/14/17, at 6:40 PM, R11 was transported to the emergency room via ambulance. On 5/14/17, at 7:10 PM, daughter informed of transport to the emergency room and the INR result today of 8.3. Review of the Hospital emergency room progress notes, dated 5/14/17, at 9:58 PM, includes in part: R11 was noted to have rectal bleeding over the last week. R11 is on [MEDICATION NAME] for [MEDICAL CONDITION] and this was held a couple of days ago. Despite that, R11 had rectal bleeding this evening. R11 was found to be hypertensive (elevated blood pressure) and [MEDICAL CONDITION] (rapid heart rate). Abdomen was firm and distended. There was a large amount of blood in his depends and rectal exam revealed gross blood. CT (CAT scan) performed revealed a large fecal impaction of the rectum. This caused urinary outflow obstruction and R11's bladder was markedly distended. R11's INR was elevated to 10.2 and his creatinine (test to check kidney function) was elevated at 2.7. R11 was given vitamin K (causes the blood to clot) and KCENTRA (reverses the effects of blood that is unable to clot) in the emergency room . R11 did have additional bleeding in the emergency room , a foley catheter was placed, and approximately 2 liters of urine was drained. Assessment: Principal problem: Blood in the stool. Active Problems: [MEDICATION NAME] - induced coagulopathy (condition affecting the blood's ability to coagulate). Fecal impaction. Acute [MEDICAL CONDITION]. Acute kidney injury. Urinary outflow obstruction. Leukocytosis. Ischemic stroke. Plan: 1. Fecal impaction: This seemed to be the nidus (site of origin) of multiple other problems. R11 will require fecal disimpaction (manual removal of stool from the rectum) at some point but this was not performed tonight, secondary to elevated INR and rectal bleeding; will consult general surgery in the morning to discuss options. 2. Acute Lower GI (gastro-intestinal) bleed: Likely related to fecal impaction. 3. [MEDICATION NAME] - induced coagulopathy: INR 10.2 on admission; given vitamin K and KCENTRA on admission. 4. Acute [MEDICAL CONDITION] secondary to outflow obstruction; This was secondary to fecal impaction. Foley catheter placed and 2 liters of urine removed from the bladder. 5. Acute kidney injury: This is secondary to [MEDICAL CONDITION]. 6. Leukocytosis: Related to stress and does not truly represent an infection. 7. Recent stroke with non-verbal state and right side neglect. Review of the Surgery Consult Note, dated 5/15/17, at 8:57 AM, includes in part: Recommend R11 undergoes manual disimpaction followed by enema therapy. If this is unsuccessful, recommend [MEDICATION NAME] enema. Once this is complete, recommend a dedicated bowel motility regime including soluble fiber supplements and stool softeners. On 7/20/17, at 5:30 PM, Surveyor interviewed ADON C (Assistant Director of Nursing) regarding Physician notification. Surveyor asked ADON C when a physician should be contacted. ADON C indicated that if a resident had a drop of blood in his stool she would not contact the MD. ADON C indicated if a resident had a large amount of blood in the stool or the stool was bright red, the MD should be contacted. ADON C indicated the MD should have been contacted when R11 had the bright red stool. The facility did not contact the MD when R11 was experiencing repeated episodes of rectal bleeding, which may indicate a potential [MEDICAL CONDITION].

Based on interview and record review, the facility did not provide the necessary assessments and evaluations to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 11 residents (R11) reviewed. R11 receives [MEDICATION NAME], an anticoagulant. R11 was noted to have bleeding from the rectum with rust colored to bright red stools. Four days prior to R11's hospitalization , R11 was having small bowel movements (BM). There is no evidence in the medical record indicating nursing staff completed a GI (gastro-intestinal) assessment. The facility failed to notify the physician with R11's continued rectal bleeding, rust colored stools, and 4 day history of only a small BM. R11 was admitted to the hospital with [REDACTED]. This is evidenced by: The facility's Bladder and Bowel Elimination policy, dated 12/3/09, includes in part: the facility staff will collect bladder and bowel elimination data to meet state and federal regulatory requirements and to contribute to assessment of disease states or change of condition. Procedure: 2. a bowel elimination diary is initiated by nursing at the following points of a resident stay. A. PRN (when necessary) for assessment. 3. Bladder and bowel elimination will be documented every shift by Certified Nursing Assistants (CNA) care givers as they are able to observe and gather this data. R11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R11 is a full code. R11's admission Minimum Data Set (MDS), dated [DATE], includes: Brief Interview for Mental Status (BIMS) could not be completed as R11 has severe cognitive impairment. Section H0400 Bowel continence indicates that R11 is always incontinent. R11 requires extensive assist with 2 staff assist. R11's Comprehensive Care Plan Urinary incontinence, dated 5/5/17, includes in part: Incontinence related to: [MEDICAL CONDITIONS] with right sided weakness and inability to express desire to void (urinate), [MEDICAL CONDITION], need for assist with toileting, depression, laxative use, [MEDICAL CONDITION], diuretic, and calcium channel blocker. R11 returned from hospital with a catheter in place. Short term goal: R11 will have no untoward effects from incontinence; have BM every 1-2 days; catheter will remain patent during use. Approach: 2 assist with rounded toileting, complete bowel/bladder assessment after admission and PRN. Ensure adequate bowel elimination. Encourage fluids, laxatives, or other diet modifications as ordered or requested. (It is important to know that R11's care plan does not include GI assessments, monitor abdominal assessment, and non-pharmacological interventions on a bowel care plan.) R11 does not have a care plan for monitoring the [MEDICATION NAME] that he is taking even though R11 was experiencing rectal bleeding. Review of R11's admission assessment, dated 5/5/17, includes in part: urinary elimination -dribbles/stress incontinence; bowel elimination - constipation. Review of R11's Bowel diary, dated 5/13/17, includes in part: mental status-alert, aphasic, and cooperative. Usual elimination pattern - nothing is checked; consistency - soft/formed. History of constipation - no is checked; laxative use - yes; [MEDICATION NAME] suppository every 3 days. Physicians orders, dated 5/4/17, include in part: staff to document bowel movements every shift, [MEDICATION NAME] 5mg (milligram) once a day on Mon, Wed, and Fri. Diagnosis - constipation; [MEDICATION NAME] 5mg suppository 10 mg every three days PRN constipation; [MEDICATION NAME] ([MEDICATION NAME]) 2 mg every hs (bedtime). Milk of Magnesia 400mg/ 5 ml (milliliters) 15 ml once a day PRN constipation, Senna Plus 8.6 - 50 mg one twice a day PRN constipation. (Of note, R11's bowel diary indicates R11 does not have a constipation problem. Yet, R11 was prescribed [MEDICATION NAME] for the [DIAGNOSES REDACTED].) A Review of R11's Medication Administration Record [REDACTED]. Review of R11's BM record includes in part: 5.7.17 - Medium x 2 5.8.17 - Small - Medium bright red - of note MD was updated on 5.8.17. 5.9.17 - Small bright red - at 4:48 PM, R11 had a small bright red BM. R11's physician was not informed. There is no documentation to indicate how much blood was present with the small bright red BM. (Of note, there is no indication in the medical record indicating an assessment of R11's GI status including abdominal or rectal exam to assess the source of the rectal bleeding.) 5.10.17 - Medium formed - Large soft formed 5.11.17 - Small 5.12.17 - Small soft formed brown - at 2:59 AM. R11's INR was 5.7 and orders received to hold the [MEDICATION NAME] for 3 days. 5.13.17 - Small 5.14.17 - Small (Please note, there is no identification of consistency or color of BM's especially when blood had been present in previous stools.) Review of R11's progress notes include in part: On 5/8/17, at 12:18 PM, R11 noted to have blood in incontinence pad with scant amount of loose BM. MD updated. Verbal orders: to continue to monitor if blood increases; have complete blood count (CBC) drawn this week on the same day at [MEDICATION NAME] - international normalized ratio (PT/INR blood test to determine how long it takes the blood to clot). On 5/8/17, at 9:00 PM, R11 had a small amount of active rectal bleeding at the beginning of the shift and then only had light pink streaking in his brief X1 (one time) after that. On 5/9/17, at 9:26 PM, R11 continues with small amount of bright red fluid in brief; labs to be drawn on 5/12/17. On 5/10/17, at 5:01 AM, small amount of rectal bleeding observed in the brief on NOC (night) shift. On 5/10/17, at 3:07 PM, R11 continues with bloody discharge from anus, mild amount, no increase from first day noted. Lab ordered 5/12/17. On 5/11/17, at 4:18 AM, R11 had a small amount of rectal bleeding observed with brief change. On 5/11/17, at 10:06 PM, R11 continues with small amount of bright red fluid in brief. There is no evidence in the medical record indicating the facility completed a thorough GI/abdominal assessment on R11 despite R11 presenting with rectal bleeding and bright red to rust colored stools. R11 continued to present with rectal bleeding which is concerning for a potential GI bleed, especially in conjunction with anticoagulant usage. There is no evidence a thorough assessment was completed on R11. It should be noted R11 was aphasic (difficulty in forming words) due to a recent stroke and was not always able to communicate needs further heightening the need for a thorough assessment. On 5/14/17, at 6:00 PM, R11 was noted to have mottling (purplish or blotchy red-blue coloring) on his knees and inside of right foot. R11 is alert and trying to mumble. R11 answered yes when asked if he was in pain but could not elaborate. R11's abdomen was very firm and slightly distended. R11 had a soft BM which was rust colored. The facility failed to complete a thorough assessment of R11's GI status despite noting a firm and distended abdomen. There is no evidence the facility listened to R11's bowel sounds and there was no documentation indicating the facility completed a peri-rectal exam. R11 was noted to have a large amount of rectal bleeding upon admission to the hospital. On 5/14/17, at 6:20 PM, call placed to on call MD. On 5/14/17 at 6:30 PM, on call MD called back and was informed R11 is a full code and orders received to send to the emergency room . On 5/14/17, at 6:40 PM, R11 was transported to the emergency room via ambulance. On 5/14/17, at 7:10 PM, daughter informed of transport to the emergency room and the INR result today of 8.3. Review of the Hospital emergency room progress notes, dated 5/14/17, at 9:58 PM, includes in part: R11 was noted to have rectal bleeding over the last week. R11 is on [MEDICATION NAME] for [MEDICAL CONDITION] and this was held a couple of days ago. Despite that, R11 had rectal bleeding this evening. R11 was found to be hypertensive (elevated blood pressure) and [MEDICAL CONDITION] (rapid heart rate). Abdomen was firm and distended. There was a large amount of blood in his depends and rectal exam revealed gross blood. CT (CAT scan) performed revealed a large fecal impaction of the rectum. This caused urinary outflow obstruction and R11's bladder was markedly distended. R11's INR was elevated to 10.2 and his creatinine (test to check kidney function) was elevated at 2.7. R11 was given vitamin K (causes the blood to clot) and KCENTRA (reverses the effects of blood that is unable to clot) in the emergency room . R11 did have additional bleeding in the emergency room , a foley catheter was placed, and approximately 2 liters of urine was drained. Assessment: Principal problem: Blood in the stool. Active Problems: [MEDICATION NAME] - induced coagulopathy (condition affecting the blood's ability to coagulate). Fecal impaction. Acute [MEDICAL CONDITION]. Acute kidney injury. Urinary outflow obstruction. Leukocytosis. Ischemic stroke. Plan: 1. Fecal impaction: This seemed to be the nidus (site of origin) of multiple other problems. R11 will require fecal disimpaction (manual removal of stool from the rectum) at some point but this was not performed tonight; secondary to elevated INR and rectal bleeding; will consult general surgery in the morning to discuss options. 2. Acute Lower GI bleed: Likely related to fecal impaction. 3. [MEDICATION NAME] - induced coagulopathy: INR 10.2 on admission; given vitamin K and KCENTRA on admission. 4. Acute [MEDICAL CONDITION] secondary to outflow obstruction: This was secondary to fecal impaction. Foley catheter placed and 2 liters of urine removed from the bladder. 5. Acute kidney injury: This is secondary to [MEDICAL CONDITION]. 6. Leukocytosis: Related to stress and does not truly represent an infection. 7. Recent stroke with non-verbal state and right side neglect. Review of the Surgery Consult Note, dated 5/15/17, at 8:57 AM, includes in part: Recommend R11 undergoes manual disimpaction followed by enema therapy. If this is unsuccessful, recommend [MEDICATION NAME] enema. Once this is complete, recommend a dedicated bowel motility regime including soluble fiber supplements and stool softeners. Review of R11's Hospital Course, includes in part: R11 had fecal disimpaction and multiple suppositories with improvement in his fecal impaction. R11 should continue an aggressive bowel regime at the rehabilitation. R11's Hospital discharge medications, include in part: [MEDICATION NAME] S 8.6 - 50mg 1 tablet by mouth daily. Aspirin 325 mg 1 daily. [MEDICATION NAME] 5 mg tablet, 5 mg by mouth three X a week on MWF (Monday, Wednesday, and Friday). (Of note: R11 is no longer taking [MEDICATION NAME] and now is on daily scheduled laxatives.) On 7/20/17, at 5:30 PM, Surveyor interviewed ADON C (Assistant Director of Nursing) regarding when a physician should be notified and what assessments should be done if a resident is experiencing bloody stools. ADON C indicated that she would check for bowel sounds, check for a soft, flat vs firm, and distended abdomen. ADON C indicated she would check the BM record and look to see if the resident has a history of bowel issues. ADON C indicated that she would ask the CNA, working with the resident, if the resident was complaining of any abdominal pain, cramps, spasms, or had any changes in the stool. ADON C indicated, if the resident was having bloody stools, she would check to see what medications were given. Surveyor asked ADON C, when R11 was having bloody stools should the staff complete a GI assessment and document findings. ADON C indicated yes and this should have been documented in the progress notes or on an SBAR (situation, background, assessment, and recommendation) form. ADON C indicated, if a drop of blood was noted on the stool, the MD would not be called, but if the stool was bright red and a larger amount of blood or clots were noted the MD should be called. The facility failed to complete a thorough GI/abdominal assessment despite R11 presenting signs and symptoms of a GI bleed. The facility failed to develop a care plan for R11's [MEDICATION NAME] which should include an intervention to monitor for bleeding. R11's bowel care plan did not include non-pharmacological interventions and facility staff did not recognize R11's 4 day history of small BMs. These failures led to R11 being admitted to the hospital with [REDACTED].

Based on record review and interview the facility did not consult with the resident's physician timely when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications), or the need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) in 1 of 24 Rs (Residents) reviewed for change of condition (R22). R22 has significant co-morbidities which include [MEDICAL CONDITION] and [MEDICAL CONDITION]. The facility did not notify a practitioner timely when R22's weight significantly elevated. R22 was subsequently admitted to the hospital. This is evidenced by the following: AMDA's (American Medical Directors Association's) Acute Change of Condition in Long - Term Care Setting states, for the condition of [MEDICAL CONDITION] the practitioner should be notified immediately if: sudden onset in resident with lung, heart, or kidney disease: Accompanied by sudden onset of shortness of breath and / or chest pain, sudden onset in one leg, loss of sensation in swollen leg, sudden onset with tenderness and redness. The practitioner should be notified on the next office day if: known history of [MEDICAL CONDITION] with progressive unilateral or bilateral increase in severity, gradually progressive [MEDICAL CONDITION] accompanied by weight gain, skin changes associated with [MEDICAL CONDITION]. R22's [DIAGNOSES REDACTED]. R22 was admitted to the facility on [DATE] and was reviewed as a closed record. R22's record contains the following information regarding R22's weight: *8/10/16 202# (admission) *8/15/16 204# *8/18/16 207# *8/22/16 212# (weight increase 10# (4.7%) from admit (12 days). Practitioner notified. [MEDICATION NAME] increased.) *8/23/16 214# *8/24/16 216# *8/25/16 217# *8/26/16 218# (weight increase 16# (7.3%) since admit (16 days), 6# (2.7%) in 4 days. Practitioner notified. [MEDICATION NAME] increased.) *8/27/16 219# (Encouraged to keep legs elevated . Right hand [MEDICAL CONDITION] . R (right) calf measures 18 (inches), L (left) calf 18.5 *8/28/16 219# (BLE (bilateral lower extremities) 1 - 2 + [MEDICAL CONDITION], toes swollen, stockings on, encouraged to elevate legs when in recliner. R leg 18.5. L leg 18 3/4 .) *8/29/16 221# (Top of feet very swollen.) *8/30/16 No weight documented. (Lungs noted to have scattered crackles.) *8/31/16 222# (Lungs crackles bilaterally increased [MEDICAL CONDITION] in legs and feet.) *9/1/16 227# (BLE 1 - 2 + [MEDICAL CONDITION], toes swollen. R leg 18 3/4, L leg 19.) *9/2/16 227# (Lungs with bilateral crackles.) *9/3/16 228# *9/4/16 233# (weight increase 31# (13.3%) since admit (25 days), 15# (6.3%) in 9 days. Continues with lower extremity [MEDICAL CONDITION] +3. Note left for GNP (Geriatric Nurse Practitioner.) *9/5/16 236# (weight increase 34# (14.4%) since admit (26 days), 3# (1.2%) in 1 day. [MEDICATION NAME] increased per on call physician. Per Nurses Notes on 9/5/17 : Wife would like to prevent re - hospitalization if possible. Wife and writer agreed to wait and monitor resident but writer stated at any point resident becomes short of breath, he may need to be sent to hospital. *9/6/16 237# *9/7/16 238# (R22 hospitalized .) There is no documented evidence, and the facility was unable to provide evidence, a practitioner was notified between 8/26/16 and 9/5/16 when R22's weight continued to increase despite increase in the diuretic [MEDICATION NAME], R22's gradual increase (1-2+ to 3+) [MEDICAL CONDITION], and R22 with crackles to his lungs (8/30 which indicates a change of condition). R22 was hosptalized on [DATE] with admitting [DIAGNOSES REDACTED]. During this hospital stay R22 received Nephrology and Cardiology Consults with medication adjustment including IV (Intravenous) diuretic administration. R22 returned to the facility on [DATE] (6 day hospital stay.) R22's record contains the following information regarding R22's weight: *9/13/16 220.2# (Re admission weight. +1 [MEDICAL CONDITION] noted to BLE.) *9/14/16 220# (+2 - +3 [MEDICAL CONDITION] to BLE calves and feet.) *9/16/16 223# *9/17/16 221# *9/18/16 222# *9/19/16 223# *9/20/16 228# *9/22/16 230# (1 - 2 + BLE) *9/24/16 233# (weight increase 12.8# (5.4%) since readmission. Note left for GNP regarding weight and [MEDICAL CONDITION].) *9/25/16 232# *9/26/16 229# (New orders to monitor for shortness of breath and chest pain, increase [MEDICATION NAME], encourage to elevate legs, and labs.) On 3/30/17 at 4:55 pm Surveyor spoke with DON (Director of Nursing) B regarding R22. DON B was not employed at the facility during the time R22 was a resident at the facility. DON B stated she would expect staff to notify a physician if there was greater than a 5# gain in a matter of a couple days. DON B stated she would have expected the physician to have been called certainly by 9/1 (2016). In addition, on 3/30/17 at 5:20 pm DON B stated she would expect staff to document lung sounds, [MEDICAL CONDITION], and vital signs before calling the doctor for new orders. On 3/31/17 at 10:19 am Surveyor spoke with via telephone to Physician V who followed R22 while in the facility. Physician V stated he was aware of R22's weight gain, but could not tell Surveyor specifically when he had become informed of this weight gain (before or after the 9/7/15 hospital stay.) Surveyor reviewed R22's weights with Physician V (prior to R22's hospital admission on 9/4/16.) Surveyor asked Physician V if he would have expected facility staff to have called a physician with the increasing weights. Physician V stated Yes, I would have anticipated a call sooner. Surveyor asked Physician V if he would have expected staff to call a practitioner sooner when R22's weight again began to rise after his hospital stay with staff waiting until 9/24/16 to notify the GNP. Physician V stated in the absence of specific weight parameters, this time he would not have expected a phone call. On 4/3/17 at 9:35 am Surveyor spoke with ADON (Assistant Director of Nursing) C regarding R22. Together ADON C and Surveyor reviewed R22's MEDICATION ORDERS FOR [REDACTED]. ADON C stated, seeing a lack of documentation regarding the increase in medications: [REDACTED] (and medication increase.) Surveyor asked ADON C how and when physicians are is notified of condition changes in residents. ADON C stated if there is a concern after hours that needs immediate attention staff are to call the physician. If it can wait until the next day staff are to use a TASK tool (the facility's process for communicating non - emergently to practitioners.) ADON C stated the facility follows the AMDA guidelines. ADON C stated if it is the NP (Nurse Practitioner) the facility is trying to reach, she is in the facility Monday, Wednesday and Friday 8 am to 4 pm. If it is after hours the physician would need to be called. On 4/3/17 at 12:58 pm Surveyor spoke with ADON C and LPN (Licensed Practical Nurse) S. LPN S was working with R22 on 8/31/16 and documented of R22: Lungs (sic) crackles bilaterally . increase [MEDICAL CONDITION] in legs, feet, R leg is 18 (inches), left leg 18 . Surveyor asked LPN S if she called a physician given that R22's weight was up 4# in 5 days, R22 now had crackles to his lungs, and R22 had increased [MEDICAL CONDITION]. LPN S stated she did not call a physician and added she would call an RN (Registered Nurse) but did not do that on 8/31/16. Surveyor then asked ADON C what she would have expected staff to do given R22's increase weight, increase [MEDICAL CONDITION], and crackles bilaterally to his lungs as noted on 8/31/16. ADON C stated she would expect staff to document about [MEDICAL CONDITION], lung sounds, shortness of breath, breathing pattern and then call the MD.

Based on record review and staff interviews, the facility did not ensure that 2 of 4 sampled residents (Residents 1 and 2) were free of significant medication errors. Resident 1 was admitted with a physician's orders [REDACTED]. The order was transcribed [MEDICATION NAME] tablets twice a day. Resident 1 received 12 tablets [MEDICATION NAME]. Resident 1 was hospitalized and received intravenous fluids (IVF) and [MEDICATION NAME]. The facility did not place a preventative measure to ensure that a like error did not re-occur. Resident 2 has diabetes and receives insulin. On 10/16/15, Resident 2 received the wrong dose, double the prescribed amount, of scheduled insulin during a morning medication pass. Evidenced by: Example 1 Resident 1 was admitted [DATE]. Resident 1's [DIAGNOSES REDACTED]. Resident 1's admission orders [REDACTED] Medications: 1.[MEDICATION NAME] tabs (tablets) twice a day for pain. On the bottom of Resident 1's admission orders [REDACTED]. Resident 1's Medication Administration Record (MAR), September 2015, includes the following entry: [MEDICATION NAME] Sodium (Aleve) 220 mg tablet, give 12 tablets (2640 mg (milligrams)) by oral route every 12 hours. Schedule every day at 8:00 AM and 8:00 PM. The [MEDICATION NAME] Sodium was signed out as given on 9/14/15 at 8:00 PM by Medication Administration Assistant (MAA) E and 9/15/15 at 8:00 AM by MAA D. Resident 1's Progress Notes include the following: 9/15/15, 13:20 (1:20 PM), Other: Call place to (RN C) to discuss [MEDICATION NAME] order. 9/15/15, 13:30 (1:30 PM), Other: Call place to (Resident 1's physician) to discuss [MEDICATION NAME] orders. New orders received. Talked with resident and family. Discussed [MEDICATION NAME] orders and new orders. Call placed to son (Resident 1's son's name), to discuss above. 9/15/15, 13:40 (1:40 PM), Initial Nutritional Interview: met with resident and sister was in the room. Sister states this is very unlike the resident to be so confused and lethargic. Resident 1 was unable to appropriately and accurately answer questions and was lethargic. States the food she has eaten has been good. Meal intakes have been very low, and resident had an emesis this morning after breakfast. 9/15/15, 18:00 (6:00 PM), Medicare: Resident in room with family. Encouraging fluids. Lab here to draw labs. No issue with lab draw. Resident alert and able to answer questions. States that she feels better than before and is waiting on meal currently. 9/15/15, 19:20 (7:20 PM), Labs: Received call from Lab. Critical sodium lab (121 L (low). Call to MD (medical doctor) for update. 9/15/15, 19:25 (7:25 PM), Labs: Received call from MD (Resident 1's physician) Continue to monitor and call Poison Control to see if they have further suggestions. 9/15/15, 19:45 (7:45 PM), Labs: Called and updated Poison Control on critical lab, they asked for more labs and information. Call placed to lab (Laboratory) to see about receiving other labs on BMP (Basic Metabolic Panel). All information given. 9/15/15, 20:05 (8:05 PM), Labs: Call to MD to update on poison control recommendation. Order to transport for fluid replacement and monitoring of labs. Paperwork completed. Call placed to family (Resident 1's son) to update him and nurse to nurse completed with Hospital (Hospital name). 9/15/15, 20:20 (8:20 PM), Transfer: (EMS name) EMS (Emergency Medical Service) here for transport. Resident was alive and well on transfer. Paperwork given. 9/15/15, 23:30 (11:30 PM), Received call from Hospital, resident being admitted d/t (due to) low sodium levels. Resident 1's laboratory results include the following: 9/15/15, 16:48 (4:48 PM), Sodium, 121. It is important to know that a normal sodium level is 135 - 145. Resident 1's History and Physical, dated 9/16/15, includes the following: . Patient has limitation in mental capacity most likely due to dementia. was sent from NH (nursing home) with report of medication overdose by error. Was given [MEDICATION NAME] (220 mg each) in AM. NH med (medication) list shows that possibly she was given totally x 3 times, 12 tabs each (2640 mg with each dose given). 9 days prior to admission: seen in ED (emergency department) for abdominal pain. Surprisingly, when EMS arrived they found the patient A & O (alert and oriented) x 4 Admission day: Today's labs done at NH, showed [MEDICAL CONDITION] (121). Repeated labs confirmed low Na (sodium) (118). Poison Center was contacted. F/u (follow up) abnormal labs, hydration recommended. admitted to medical floor: F/u BMP (Basic Metabolic Panel) showed increased Na (sodium) but BNP (B-type Natriuretic Peptide) also very high. Old 2d echo (echocardiogram) reviewed. Will stop IVF and will give [MEDICATION NAME]. Her [MEDICAL CONDITION] more likely is dilutional due to [MEDICAL CONDITIONS]. Will gently [MEDICATION NAME]. Assessment/Plan: Assessment: Patient is a [AGE] year old female sent for evaluation for medication administration error/NSAID (non-steroidal anti-[MEDICAL CONDITION] drug) overdose and [MEDICAL CONDITION] on labs. Plan: 1. [MEDICAL CONDITION]: I believe dilutional etiology due to water retention due to [MEDICAL CONDITION] is most likely. She is also on [MEDICATION NAME] which can cause GI (gastrointestinal) side effects. No new neurological sx (symptoms). I believe event started > (greater than) 48 hr. (hours). Will increase Na (Sodium) slowly. 2. Medical error [MEDICATION NAME] mg tab overdose. Given 12 tab x 3 (per NH medical record form). Poison center contacted. Supportive care, serial lab checks. 3. [MEDICAL CONDITION]. Present on admission. This is a new diagnosis. More likely heart failure with preserved LVSF (left ventricular systolic function). Will get 2 d echo in AM. Also check troponin. 10. Status: inpatient. Expect more than 2 midnights stay. Hospital Progress Note, dated 9/15/15, 22:32 (10:32 PM), includes, in part, the following: . Labs repeated confirm [MEDICAL CONDITION]. Prior labs reviewed. On 9/7 she had a normal sodium/chloride and this appears to be a new problem for her. The facility's Medication Error Report, dated 9/15/15, 13:30 (1:30 PM), for Resident 1 includes, in part, the following: Part I- Description of Error. Medication as ordered:[MEDICATION NAME] tabs BID (twice a day). Description of error (include name of medication, dose, route and time (s) administered): MAR reads [MEDICATION NAME] give 12 tabs by oral every 12 hours. Outcome to resident: Nausea. Vomiting. Corrective action taken: (No documentation/area left blank). Measures taken to prevent the recurrence of similar error(s): (No documentation/area left blank). Part II - Assessment and Summary of Error. Type of Error(s): Wrong dose. Reason for Error(s): Transcription error. Person making error: (No documentation/area left blank). Person finding/reporting error: (No documentation/area left blank). RN F's statement, dated 9/21/15, included the following: Describe interaction: I was working at ST (station) 1 and went to help (RN G) (with) an admission. I thought I put [MEDICATION NAME] as 2 tabs q (every) 4 (hours) PRN (as needed). Apparently the number one did not delete when I backspaced. I printed the med sheets and went back to my station. I did not proof them as I was behind on my team. On 11/24/15 at 2:50 PM Surveyor interviewed RN F via telephone. RN F stated she came to help RN G with Resident 1's admission. She put the orders into the computer, printed out the MAR and handed the MAR to RN G. RN F stated she then returned to her own station to complete her own work. RN F stated the orders should have been double checked. RN F stated she did not double check the orders as she was busy. MAA E's statement, dated 9/21/15, included the following: We had 2 admissions over at Station 3 and also had to split up Station 1 that night. I did resident's meds and noticed that order did not seem correct, no nurses were at station at the time and Resident 1 had been waiting for me, so I gave her 1 [MEDICATION NAME], took along 2. Seemed like that would be the normal dosage of [MEDICATION NAME] and so from there if it's more till check out order more thorough when speaking with nurse. Well in the meantime had to go finish at Station 1 and then forgot to get back to order at Station 3. On 11/24/15 at 1:20 PM Surveyor interviewed MAA E. MAA E informed Surveyor that she is an LPN (Licensed Practical Nurse), however works at the facility as a MAA because the facility does not use LPNs. MAA E stated she did not give 12 tablets of Aleve, however she did acknowledge the signature in the MAR is hers and that it does look like she gave 12 tablets of Aleve. MAA E stated she knew that 12 tablets [MEDICATION NAME] not a normal order, she should have questioned the nurse of the order, however she got busy and forgot to speak with the nurse. MAA D's statement, dated 9/16/15, includes the following: Writer started to prep (prepare) medications at Station 1 due to medications from pharmacy not being here. Writer started to prep medications with another med tech and writer saw the order for [MEDICATION NAME] give 12 tabs BID. Writer thought it was odd and was going to question it. Writer came back to Station 3 with Med Tech (Medication Technician). Med Tech went to say hi to grandpa, then was going to help me. Writer got back to cart, put meds in cart to question. Therapy and CNAs (Certified Nursing Assistants) came up to me with requests. Writer gave pain meds to people and then came back to (Resident 1's room). Writer started giving resident the medication and Med Tech watched her finish so writer could prep meds. Writer forgot to question 12 tabs of [MEDICATION NAME] due to being busy when writer got back to station. On 11/24/15 at 10:45 AM Surveyor interviewed MAA D. MAA D stated she gave Resident 1 12 tablets of Aleve, as that is what the order stated to give. MAA D stated that seemed like a lot of Aleve, she stated she should have talked with the nurse, but got busy and forgot. MAA D stated she had to get Resident 1's medication from the back up as they had not been delivered yet from the pharmacy. MAA D stated Resident 1 was not interviewable, she was confused. MAA D stated, later that morning Resident 1 started to have emesis and that is when it dawned on her to inform the nurse she had given Resident 1 12 tablets of Aleve. MAA D stated it was then that the nurse looked at the order and MAR and realized the order was for 2 tablets not 12 tablets. MAA H's statement, dated 9/16/15, includes the following: I went to help (MAA D) with passing meds. She told me to finish up on passing meds to a lady she already started passing meds to. RN I's statement, undated, includes the following: 9/15/15, Timeline of Events: 1500 (3:00 PM) - Initial assessment of resident. No issues noted. Resident was alert and oriented x (times) III (3). No bleeding noted. No nausea or vomiting at this time. She was not complaining of muscle cramping or any stomach issues. No heartburn noted. Resident was pleasant. Vital signs taken and recorded. Informed staff to encourage fluids at this time. 1600 (4:00 PM) - Family in to visit. I talked with family about what happened and offered my apologies. Stated that we had contacted the MD and that we were waiting for lab to come in and do stat labs. All questions were answered at that time. 1700 (5:00 PM) - Lab here for draw. Family was encouraged to push fluids also. Resident continued to be pleasant with writer. Stated that she felt better than she did earlier in the day. No complaints of nausea and vomiting. No muscle cramping or stomach pain. Lungs clear. No complaints of dizziness. No tremors noted. 1920 (6:20 PM) - Call from lab received. Critical lab of sodium (121 Low) reported. 1920 (6:20 PM) - Assessed resident for signs and symptoms of [MEDICAL CONDITION]. Resident did not have a headache and was still alert and oriented x III. She was pleasant and no nausea or muscle spasms or stomach cramps. 1925 (6:25 PM) - Call to (Resident 1's physician) with update of critical lab. Orders were to observe and have repeat labs in the AM. Also ordered for writer to call poison control and see if they have any further recommendations. 1930 to 2000 (6:30 PM - 8:00 PM) - Multiple calls to lab to get further results and poison control placed. Discussed case with (Poison Center Staff). Stated that she had a critical lab she was asymptomatic at this time. (Poison Center Staff) discussed with poison control center MD (Medical Doctor) even though she was asymptomatic, the recommendation from poison control was to send to ER for the critical lab and for fluid replacement. 2005 (8:05 PM) - Call to EMS placed for transport. 2020 (8:20 PM) - EMS here for transfer. Resident left alive and well. An email, dated 10/14/15, 8:42 AM, from Registered Nurse (RN) C To: Names included all RNs, MAAs, including Director of Nursing (DON) B, MAA D, MAA E, and RN F. CC: DON B and Nursing Home Administrator (NHA) A. Subject: Medication errors. After reviewing the medication error on (Resident 1) it was determined that the error went unnoticed during several steps; 1. Transcription by the pm nurse on admission. 2. Printing the MARs by pm team nurse. 3. MT (Medication Technician) on pm that gave medications. 4. Team nurse doing audit that NOC shift. 5. MT on AM shift that gave the medications. I realize staff are extremely busy however, this could have had even a worse outcome if it had been a different medication. If at any time you look at an order and it appears even slightly not right, pull the MAR and address it immediately. Remember the 6 R's when transcribing an order and when reading the order to give meds; 1. Right individual. 2. Right medication. 3. Right dose. 4. Right time. 5. Right route. 6. Right documentation. On 10/7/15 MAA D and MAA E were counseled. The counseling included the following: In future if there is an order that you question discuss with RN and correct immediately. On 10/8/15 RN F was counseled. The counseling did not include any documented corrective action. On 11/24/15 at 4:30 PM Surveyor interviewed Director of Nursing (DON) B. DON B stated when a resident is admitted the admission process includes a nurse enters the orders into the computer if there are any discrepancies the nurse is to make a note and hand it to the staff nurse. The staff nurse will check the orders and sign off that the orders are accurate. DON B stated one nurse transcribes, no one checks the transcription. DON B stated she would have expected MAA E to inform the nurse of the discrepancy. MAA E should not have given the [MEDICATION NAME]. DON B stated a night nurse will audit all new orders for the day and do a comparison. If the night nurse finds a discrepancy she will let DON B know. DON B stated the night nurse documents by signing in the MAR that the audit was completed. DON B stated that as part of the medication error investigation she did not check to see if an audit was completed. DON B stated MAA D should have questioned the nurse when she had any questions regarding Resident 1's medications. On 11/24/15 at 4:50 PM Surveyor interviewed Registered Nurse (RN) C. RN C stated she found documentation that Resident 1's MAR and orders were audited by the night shift during the 9/14 into 9/15/15 night shift as they should have been. Surveyor and RN C reviewed Resident 1's MAR, Medication and treatment orders audit, signed by RN J. RN C stated the facility does not have a good system to monitor medication errors. Example 2 The facility's policy Resident Centered Standardized Medication Administration, dated 10/28/14 states in part; Purpose: to ensure quality care is given in the preparation, administration and recording of medications and to accommodate resident preference as indicated. The 7 rights of medication pass are Right medication; right route; right time; right resident; right dose; right to refuse; and right documentation. Procedure: Staff that is administering medications is responsible for reading all direction posted on the medication label as directed by pharmacy. According to <http://products.sanofi.us/[MEDICATION NAME]/[MEDICATION NAME].html#section-5>, [MEDICATION NAME] (insulin [MEDICATION NAME] injection) Insulin [MEDICATION NAME] is a recombinant human insulin analog that is a long-acting, [MEDICATION NAME] blood-glucose-lowering agent (see Clinical Pharmacology (12) <http://products.sanofi.us/[MEDICATION NAME]/[MEDICATION NAME].html>). Insulin [MEDICATION NAME] is slowly released, resulting in a relatively constant concentration/time profile over 24 hours with no pronounced peak. This profile allows once-daily dosing as basal insulin [MEDICATION NAME]. Resident 2's [DIAGNOSES REDACTED]. Of note, Resident 2 does not speak and does not understand English. Resident 2's signed physician orders [REDACTED]. [MEDICATION NAME] 100unit/milliliter (ml) inject 18 units subcutaneously (SQ) one time a day. The facility's medication error report dated 10/16/15 states in part; time of error 9:00 AM. Medication as ordered: [MEDICATION NAME] 18 units. Description of error: Resident 2 received 40 units of [MEDICATION NAME]. Corrective action: Resident is being monitored 1:1 with staff. Reason for error: Did not triple check dose before giving. Resident 2's blood sugar 10/16/15 at 7:00 AM = 108 Nursing progress notes dated 10/16/15 at 9:25 AM state in part; call placed to Director of Nursing discussed insulin orders. Nursing progress notes dated 10/16/15 at 9:30 AM state in part; call placed to physician on call discussed Resident 2 insulin orders. New orders received to check blood sugars frequently. Nursing progress notes dated 10/16/15 at 9:50 AM state in part; call placed to son; discussed insulin orders and current treatment. [MEDICAL TREATMENT] communication form dated 10/16/15 states in part; Resident 2 received double the insulin he was supposed to get we are checking blood sugars every half hour and did give extra carbohydrates. Of note, the next recorded blood sugar is at 11:00 AM on 10/16/15 and is listed as 271. Nursing progress notes dated 10/16/15 at 3:15 PM state in part; [MEDICAL TREATMENT] nurse called and Resident 2's blood sugar was over 400 when he arrived and it gradually went down to 265 while at [MEDICAL TREATMENT]. Nursing progress notes dated 10/16/15 at 4:36 PM state in part; call received from [MEDICAL TREATMENT] Resident 2's blood sugars have remained stable and last check at 4:00 PM was 228. Of note Resident 2's blood sugar at 5:00 PM is listed as 292. Of note, the facility continued to check Resident 2's blood sugar every half hour to 1 hour through 10/17/15 at 6:15 AM. Resident 2's blood sugars remained above 146. On 11/24/15 at approximately 11:20 AM Surveyor spoke with Registered Nurse (RN) L regarding Resident 2's insulin error; of note, RN L was the nurse responsible for the insulin error. RN L stated that when she prepares insulin for administration she draws up all the insulins that are to be administered at one time. Each syringe of insulin is placed in a pill cup holder and a card with the Resident name is placed in front of the insulin syringe. (Of note the syringe is not labeled and the card in front of the syringe states only resident name, room number and administration time. The card does not list the insulin name or dose to be administered.) Surveyor asked RN L if this is the facility's normal practice RN L stated that it was the facility practice however the facility usually requires a sticker to be placed on the syringe with the residents name and this step was not completed on the date of the insulin error. Surveyor asked RN L how she kept track of which insulin belonged to which resident if there was no labeling. RN L stated she could usually eye ball which insulin syringe belong to which resident. Surveyor asked RN L how the error occurred on 10/16/15. RN L stated on the morning of 10/16/15 she had been interrupted and grabbed the wrong syringe and Resident 2 ended up with double the amount of [MEDICATION NAME]. Of note Resident 2 was to receive 18 units of [MEDICATION NAME] on 10/16/15 however, Resident 2 received 40 units of [MEDICATION NAME]. Surveyor asked RN L when the error was realized. RN L stated she realized she gave the wrong insulin immediately and placed a call to Director of Nursing (DON) B, the physician and family. RN L stated the physician stated to check blood sugars frequently and the staff gave Resident 2 extra carbohydrates. RN L stated the physician gave permission for Resident 2 to attend [MEDICAL TREATMENT] and the facility sent staff along for the transportation to monitor Resident 2 and alerted [MEDICAL TREATMENT] so blood sugars could continue to be monitored while Resident 2 was at [MEDICAL TREATMENT]. Surveyor asked RN L if the facility made changes in the insulin administration practice after the incident. RN L stated she was reminded to label the syringes. Surveyor asked RN L if she continues to draw up all insulins at once and RN L stated yes, but I label the syringe now. Surveyor asked RN L how she completes her checks prior to administration of the insulin RN L stated I complete them in the medication room once I draw the syringes up. RN L stated she also closes the door to the medication room when drawing up the insulin to prevent errors. On 11/24/15 at 1:55 PM Surveyor interviewed DON B regarding the medication error for Resident 2. DON B confirmed the facility practice of drawing up multiple insulins at one time and then labeling each insulin syringe. DON B stated RN L did not label the syringes and this lead to the error. DON B stated RN L was counseled on the correct procedure to prevent future errors. The facility failed to ensure staff completes the 7 rights of medication pass to prevent medication errors from occurring.

Based on interview, and record review the facility did not ensure that 1 (Resident 1) out of 10 residents reviewed for pain received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident 1 was admitted to the facility after knee replacement surgery and was prescribed [MEDICATION NAME] for her pain. Resident 1 was assessed by the facility to be in excruciating pain on 11/28/14 at 4:00 PM. The facility did not assess the resident's pain for the next nine hours. After the last [MEDICATION NAME] was used from contingency at 4:00 PM, the facility did not ensure that Resident 1's [MEDICATION NAME] medication for pain was available. If the facility had followed its procedure for ordering new medication from the pharmacy, Resident 1's [MEDICATION NAME] should have arrived at the facility on 11/27/14 at approximately 9:00 PM. When the resident began complaining of excruciating pain at 8:00 PM and when the [MEDICATION NAME] was unavailable, the facility did not contact the physician for another medication to relieve the excruciating pain the resident was experiencing. The resident experienced excruciating pain for five hours until the [MEDICATION NAME] arrived and staff was able to give it at 1:00 AM on 11/29/14. Evidenced by: The facility provided Surveyor the procedure for Controlled Substance ordering from pharmacy on 3/9/15. It states as follows: New Admission or new order 1. Fax script (prescription); 2. Call pharmacy to alert them of a new order and faxed script (make sure the narcotic division is aware of the new order); 3. Request authorization number for enough medication for up to 8 hours and request a STAT delivery; 4. Advise pharmacy which MD to call for authorization number if there is not a script and verbal order is received; 6. Re-call pharmacy to insure order received; 8. If STAT order is not received within 4 hours re-call pharmacy. The facility contingency box list updated 11/17/14 states there are 10 [MEDICATION NAME] in the narcotic box. Resident 1 was admitted to the facility on [DATE] for rehabilitation after a left knee replacement. Resident 1 was admitted with a physician's orders [REDACTED]. Resident 1's nurses notes states as follows: 11/27/14 - Staff will monitor for pain ... arrived to the facility at 1:45 PM. 11/28/14 written at 12:30 AM Resident 1 stated her pain at 7-8. (This indicates she had intense pain.) 11/29/14 written at 12:40 AM Resident 1 was "verbally upset at present time as she has been waiting since 8:00 PM for pain medicine - no [MEDICATION NAME] in back up and pharmacy was called on PM shift to have a stat run of med. Resident (1) threatened to call 911. Writer apologized for delay and promised to give med as soon as it arrives. Resident (1) scoffed and stated 'why should I believe you or believe anything will come since I've been waiting since 8:00 PM.' ... Ice applied to Left knee incision." 1:00 AM PRN [MEDICATION NAME] 2 tablets given at this time. 1:30 PM Resident 1 stated she was displeased about pain management through the night and informed the facility she would be discharging to another facility on this date. Resident 1's Medication Administration Record [REDACTED] It shows a pain rating scale where 0 is no pain, 1-2 is mild pain, 3-4 is discomforting pain, 7-8 is intense pain, and 9-10 is excruciating pain. 11/27/14 at 5:00 PM Resident 1 received 2 tablets of [MEDICATION NAME] for her knee pain. Resident 1 rated her pain as a 7 and after the [MEDICATION NAME] rated her pain at a 2. 11/28/14 at 12:01 AM Resident 1 received 2 tablets of [MEDICATION NAME] for her knee pain. Resident 1 rated her pain as a 7 when she took it. There is a dash where it would be marked if it was effective. At 6:00 AM Resident 1 received 2 tablets of [MEDICATION NAME] for her knee pain. She rated her pain as a 7 when she took it and was not rated if it was effective. At 11:00 AM Resident 1 received 2 tablets of [MEDICATION NAME] for her knee pain. She rated her pain as a 7 when she took it and rated it a 2 after. At 4:00 PM Resident 1 received 2 tablets of [MEDICATION NAME] for her knee pain. She rated her pain as a 10 (excruciating) when she took it and was not rated if it was effective. (This was the last [MEDICATION NAME] from the facility contingency. It is important to note that per the facility procedure if a STAT order was made to the pharmacy at this time it should have arrived by 8:00 PM for Resident 1's next dose time frame.) At 9:00 PM Resident 1 received 650 mg of [MEDICATION NAME] for her knee pain. Her pain was not assessed at that time or after it was given. 11/29/14 at 1:00 AM Resident 1 received 2 tablets of [MEDICATION NAME] for her knee pain. She rated her pain as a 10 (excruciating) when she took it and rated it a 2/3 after. It is important to note that this was the first documented assessment of Resident 1's pain since 4:00 PM on 11/28/14 - 9 hours earlier. It is also important to note that she could have received a [MEDICATION NAME] per her physician's orders [REDACTED].) The facility provided Surveyor with an email from the pharmacy dated 12/7/14 which stated as follows: 11/27/14 at 4:50 PM the facility contacted the pharmacy and requested an authorization number for Resident 1's [MEDICATION NAME] to be taken from the facility contingency. The authorization was received at 5:02 PM for 8 tablets. **(It is important to note that if a STAT order for Resident 1's [MEDICATION NAME] had been placed at this time per the facility procedure the facility would have received it by 9:00 PM on 11/27/14 and if they had not received it, they should have followed up at that time.) 11/28/14 1:50 PM the facility contacted the pharmacy and the pharmacy stated that Resident 1's [MEDICATION NAME] was scheduled to be delivered on their first delivery of the evening. The facility requested authorization for the last 2 [MEDICATION NAME] tablets from the facility contingency. The pharmacy gave authorization for the 2 tablets at 2:01 PM. At 7:59 PM the facility staff contacted the pharmacy again and stated Resident 1 did not have [MEDICATION NAME] available and the contingency was depleted and would need them stat. The pharmacy identified that its staff did not follow through with this stat request. The hard copy ticket has a time of 12:55 AM 11/29/14 that the facility received Resident 1's [MEDICATION NAME]. On 3/9/15 at 10:40 AM Surveyor interviewed RN C who worked on the night shift on 11/28/14 with Resident 1. RN C described that Resident 1 was in a "lot of pain" and "very upset". RN C stated she was very apologetic to Resident 1. RN C stated that Resident 1 asked her to call 911 and when RN C asked what for, Resident 1 stated because she was in so much pain. Resident 1 told RN C that she would call 911 herself. RN C stated she expected Resident 1 to call 911 and told other facility staff to direct emergency personnel to Resident 1's room if they arrived at the facility. RN C stated that she herself was devastated and understood why Resident 1 was so angry. RN C also stated that Resident 1 showed physical anger toward RN C. RN C stated that she gave Resident 1 the [MEDICATION NAME] as soon as it arrived and that Resident 1 did get relief from her pain after it was given. On 3/9/15 at 9:55 AM Surveyor interviewed Nursing Home Administrator A who agreed that if the facility staff would have made a STAT order for Resident 1's [MEDICATION NAME] at 2:00 PM on 11/28/14 that is should have been received by 6:00 PM before her next dosing time at 8:00 PM. On 3/9/15 at 1:00 PM Surveyor interviewed Director of Nursing B who stated that when the [MEDICATION NAME] was not available and the resident was in pain nurses should have called the physician to request another medication that may have relieved Resident 1's pain. This was addressed at the nurses education on 12/3/14. It is important to note that there was no additional education to address that Resident 1's pain was not assessed during the time she did not receive her [MEDICATION NAME] or that the facility procedures were not followed to obtain the initial order for [MEDICATION NAME].

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food under sanitary conditions. The facility served unpasteurized eggs that were uncooked to 1 of 10 made to order eggs for breakfast on 11/10/14 (Resident 13). The facility served unpasteurized eggs that were not fully cooked. Resident 13 indicated that he ate "runny eggs" each day of the week. Resident 13's finished breakfast plate was noted to be covered in runny egg yolk. Failure to ensure that eggs served were pasteurized or fully cooked created a finding of immediate jeopardy. The facility administrator was made aware of the findings of Immediate Jeopardy on 11/10/14 and was removed on 11/10/14. The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) based on the following: The facility kitchen was noted to be unsanitary. Dietary staff indicated that they do not have a process in place for ensuring that the internal temperature of the dish machine reaches the minimum requirements for proper sanitization. These had the potential to affect all 110 residents. This is evidenced by: The nursing home administrator indicated on 11/10/14 at 9:45 that they do not have a policy regarding the safe handling and/or cooking of shell eggs. ServSafe Course book, 6th Edition (2014) states in part, "Food Most Likely to Become Unsafe: TCS Food: Shell eggs (except those treated to eliminate [MEDICATION NAME] Salmonella. Populations at High Risk for Foodborne Illness: Elderly people; as people age, changes occur in their organs. For example, stomach acid production decreases as people get older. This allows more pathogens that previously may have been eaten to enter the intestines. A change in the stomach and intestinal tract also allows the body to store food for longer periods. This gives toxins more time to form. High-risk populations: Operations that serve high-risk populations, such as hospitals and nursing homes, must take special care when using eggs. Use pasteurized eggs or egg products when dishes containing eggs will be served raw or undercooked. " According to "Salmonella Enteritidid (Egg Salmonella FAQs)", "A person infected with the Salmonella enteritidis bacterium usually has fever, abdominal cramps, and diarrhea beginning 12 to 72 hours after consuming a contaminated food or beverage. The illness usually lasts 4 to 7 days, and most persons recover without antibiotic treatment. However, the diarrhea can be severe, and the person may be ill enough to require hospitalization . The elderly, infants, and those with impaired immune systems may have a more severe illness. In these patients, the infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics." The Center for Disease Control estimates that 1.4 million cases, 15,000 hospitalization s, and 400 deaths are caused by Salmonella infections in the U.S. every year. <http://www.about-salmonella.com/salmonella_incidence/> Example 1: During the initial tour of the facility on 11/10/14 at 8:45 AM, Surveyor asked Cook F what the observed shell eggs were used for. Cook F stated that the shell eggs were used for whole, boiled eggs and fried eggs that were made to order based on resident request. Cook F stated that he would use these eggs from the walk-in cooler to cook the made-to-order eggs. Surveyor interviewed Dietary Aide (DA) E at this time. DA E stated that she cooks the eggs (from the cooler) in whatever manner the resident requested the eggs. DA E stated that she served runny eggs this morning and there are a few residents who request sunny-side-up eggs. Surveyor noted two boxes of unpasteurized eggs containing 30 dozen eggs in the kitchen's large walk-in cooler at 9:41 AM on 11/10/14. The boxes were noted to read, "Egg safety and quality. Keep refrigerated at or below 45? F (Fahrenheit). Cook eggs until yolks are firm and cook foods containing eggs thoroughly." On 11/10/14 at 9:16 AM, Surveyor observed a container of broken shell eggs near the egg frying station in the kitchen. Surveyor observed that these shell eggs did not have the "P" mark on them, indicating that they were pasteurized eggs. At 9:17 AM, Surveyor spoke with DA G. DA G stated that she cooks over-easy eggs until the yolk is set. DA G stated that they are not hard-cooked, but more like poached eggs, so when you cut into them, the yolk would run out. On 11/10/14 at 9:22 AM, Surveyor observed a finished plate in the dining room of the facility. The plate was covered with runny egg yolk. Surveyor noted that the ticket next to the plate included Resident 13's name and an order for [REDACTED]." Surveyor spoke with Resident 13 on 11/10/14 at 10:35 AM. Resident 13 stated that he ate an egg for breakfast this morning and he did so each day for the last week or so as well. Resident 13 stated that he orders a made to order egg and that the egg is always runny when he breaks into it. Surveyor spoke with Nursing Home Administrator (NHA) A on 11/10/14 at 9:45. NHA A stated that one or two weeks ago, the facility switched out egg vendors and went with a local vendor. NHA A stated that the facility was not able to get pasteurized eggs from this vendor. NHA A stated that he informed the kitchen staff today that they cannot serve runny eggs anymore. NHA A stated that if there was a situation where a resident wanted unpasteurized non-fully cooked eggs, the facility would do risks and benefits with that resident and document this. NHA A stated that he cannot think of a time where this was done. On 11/10/14 at approximately 10:00 AM, Surveyor spoke with DA G who stated that the residents get a choice of egg each day, cooked to order. DA G stated that the facility had been cooking eggs in this manner for about 1.5 years. DA G stated that the facility had pasteurized eggs in the past but changed maybe one month ago. Surveyor spoke with Cook I on 11/10/14 at 2:10 PM. Cook I stated that the dietary staff used unpasteurized eggs this morning probably because they did not know there were pasteurized eggs available. Cook I stated that they (the facility) got eggs from a different vendor to make up for a period of time when the facility was switching contracts for their dietary department. Cook I stated that those eggs received during this time were unpasteurized, so there was a period of time when they did not receive pasteurized eggs but continued to serve made-to-order eggs. The failure to serve eggs in a safe manner created a finding of immediate jeopardy. The facility removed the Immediate Jeopardy on 11/10/14 by disposing of the non-pasteurized eggs and using only pasteurized eggs. In addition, all dietary staff were re-educated on using only pasteurized eggs. The deficient practice at F371 continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) as evidenced below: Example 2: On 11/11/14 at 8:10 AM, Surveyor toured the facility kitchen with Consultant Registered Dietician (RD) H and Cook I. Surveyor noted a spill on cereal on the floor of the dry storage room. Cook I stated that anyone could clean up the cereal and that cleaning the floors of the dry storage room was not on a cleaning schedule. Surveyor noted that the lower shelves of the middle food prep area were covered with debris. Surveyor noted a cart that contained a tray on the bottom shelf that housed multiple gallon-sized containers. One called "Browning Sauce" was noted to be covered in brown spillage. Surveyor noted that the stove top was soiled with rice. Cook I stated that the rice was made yesterday and should have been cleaned up. Surveyor noted a fryer next to the stove. The fryer contained oil that was filled with particles. Surveyor noted that the lids that cover that oil were crusted around the perimeter of the lids. Surveyor observed that the doors to the ovens were covered in yellow-colored grime. Cook I stated that the doors could be cleaned but were not on a cleaning schedule at the time. Surveyor observed that the blender was soiled with debris on the base of the device. Surveyor observed a shelf above the three compartment sink. It was observed to be soiled with debris and very unsanitary. Surveyor observed the dish room at 9:15 AM. Surveyor noted that the floors were soiled with debris and grime. It was noted that saturated paper products and food debris were on the floor. Example 3: On 11/11/14 at 9:20 AM, Surveyor observed Cook F send dishes through the large dish washer. Surveyor asked Cook F how he monitors the internal temperature of the dish washer. Cook F stated that he does not send anything through the dish washer that would measure temperature. Dietary Aide (DA) K stated that there used to be a tests strips and a log on the wall, but it is no longer there. At 9:30 AM, Cook I stated that the facility used to send the temperature test strips through the dish washer but former contract staff informed her that it was not necessary to send the strips through. Cook I stated that it has been about one year since this the strips have been sent through.

Based on medical record review, interview, observation and review of facility investigation, the facility has not ensured that each resident receives adequate supervision and assistive devices to prevent accidents for 2 of 13 residents (Residents 8 and 10) reviewed for falls. Resident 8's falls on 6/23/13, and 7/11/13 were not thoroughly investigated to determine the root cause of the falls in order to develop appropriate interventions to prevent future falls. Resident 8 fell on [DATE] which resulted in a right wrist fracture. This fall was not thoroughly evaluated to determine the root cause of the falls in order to develop appropriate interventions to prevent future falls. The facility did not ensure that interventions were put in place after her falls on 3/3/13, 4/29/13, and 6/23/13. The facility did not ensure appropriate interventions were in place after Resident 10's falls on 8/20/13, 9/7/13, or 9/9/13 to prevent further falls. As evidenced by: The facility policy Subject: Change of Condition #4-9-1153 revision date 5/17/12 states: Acute Change of Condition will be monitored by staff through follow-up assessments, communication of resident status and documentation of nursing interventions and plans. A. Acute Change of Condition include but are not limited to problems in the following categories: 5. All falls: with or without injury. 12. Acute changes in behavior placing resident at risk: ...Hallucinations, depression, anxiety status, delusions. B. Assessment: 1. All licensed staff are involved in the nursing assessment process and contribute to the collection of the data base, the planning of interventions and evaluation of resident's response to condition change. 2. An RN must be involved in the initial assessments and the follow-up evaluations as indicated by the complexity and stability of the resident's condition. 3. The RN data collection and assessments will be guided by AMDA (American Medical Directors Association) Guidelines and Lippincott Manual of Nursing Practice. 4. Nursing Supervisors will guide and assist with assessments and monitor symptom surveillance each shift. C. Documentation: 1. 24 Hour Report a. All resident meeting the criteria for acute change of condition should be entered on the 24 hour report by a licensed nurse. The RN will make the decisions as to when the resident's condition improves enough to be removed from report. b. Pertinent assessment data as well as plans for monitoring should be noted each shift ... c. Residents are charted in the nurses notes every shift while on report. 2. Nurses Notes for acute changes should address: b. Subjective information (signs, symptoms, residents response to illness). c. objective findings ... 3. Care Plans: a. Care plans must be updated with any changes of condition. b. Utilize the pertinent care plans for the appropriate temporary problem, individualizing them for the resident. c. If the care plan has an appropriate nursing diagnosis/problem already that the change of condition could fall under, just add an appropriate short term goal and interventions as needed. On 9/11/13 at 7:00 AM Surveyor interviewed RN P who is in charge of reviewing falls which was added to her responsibilities about in the past year. RN P stated the process after a resident falls is the nurse does a physical assessment of the resident, obtains witness statements, reviews the resident's medical record, and notifies the physician and family/guardian. The nurse who does the assessment is responsible for making an assessment of what the possible cause of the fall is and what needs to be done to keep the resident safe. RN P stated that this has been an ongoing uphill struggle to make sure this is done. RN P stated that the IDT (interdisciplinary team) reviews the falls every morning Monday through Friday and the on call supervisor is available to nurses on Saturday and Sunday. RN P stated if the IDT makes any changes they note it on the Resident Fall Report completed for each fall. The members of the IDT initial the form that it was reviewed. RN P stated that it is discussed in the IDT meetings if a resident has multiple falls. RN P stated that often the safety devices/interventions in place at the time of the fall are not complete. RN P agreed for Resident 8 and Resident 10 that the root cause of the fall is most often not identified. On 9/12/13 at 12:30 PM Surveyor interviewed Director of Nursing (DON) B who agreed reviewing Resident 8 and Resident 10's Resident Fall Reports do not identify the root cause of the falls. Surveyor requested evidence of the training that RN P received after being given the task of reviewing falls. None was provided as of 9/12/13 when the survey was completed. It is important to note that if the facility does not investigate to determine the root cause of a resident fall they cannot plan for meaningful interventions to prevent future falls for the resident. Example 1 Resident 8 was admitted to the facility with [DIAGNOSES REDACTED]. Her significant change Minimum Data Set completed 7/26/13 indicates she has severe cognitive impairment. Resident 8's Safety/Psychoactive Medication assessment dated [DATE] states she had increase in Seroquel to 25 mg in the AM on 3/25/13 in addition to the Seroquel 25 mg at HS for hallucinations. No increase in sedation or decrease in her daily function with this increase. She continues to have an occasional hallucination and/or delusion in which staff provides 1 to 1 if distressing to her. An additional note dated 4/10/13 states that Resident 8's family stated she was lethargic and wanted the AM Seroquel discontinued. The AM Seroquel was discontinued even though she continues to have hallucinations. Resident 8's physician order [REDACTED]. Resident 8's care plan dated 8/4/13 included the following (it is unclear when some of the interventions were added as the care plan updated 8/4/13 with all interventions): offer toileting assist 1 & 3 rounds at noc (night), up ad lib in room and halls - assess safety concerns, use of shoes or grippy socks - assist to apply as she will allow, evaluate cause of falls, 3/3/13 - 15 minute checks when resident anxious or having hallucinations, 4/30/13 encourage to go to bed prior to 10:00 PM, 4/30/13 PT evaluate and treat, 5/25/13 keep cell phone on bedside table within reach at HS, 6/24/13 husband wants whereabouts monitored frequently when restless, 7/15/13 CNAs to check room twice a shift to pick up obstacles. Resident 8's Resident Fall Report states she fell on [DATE] at 7:15 AM getting up with her walker to use the bathroom. The facility added the interventions to have grippy socks in bed and night shift to offer assistance to toilet in the morning. Resident 8's Resident Fall Report states she fell on [DATE] at 10:05 PM from her chair. Resident 8 reported to staff that she "was outside and tripped on a rock or something." The facility added the intervention of 15 minute checks when Resident 8 becomes anxious or paranoid. Surveyor requested the 15 minute checks documentation the facility did not provide evidence that any were completed after this fall. Resident 8's Resident Fall Report states she fell on [DATE] at 10:05 PM from her chair trying to lie down in her bed. The facility added the intervention to have Physical Therapy (PT) evaluate and treat her. Resident 8's Resident Fall Report states she fell on [DATE] at 4:55 PM from her chair going to the bathroom. She was found on the floor with her head leaning on the dresser and stated she hit her head. The PT evaluation the facility provided had a referral date of 5/3/13. It is important to note that the referral was not made after the fall on 4/29/13 as per the facility added intervention. A therapy note dated 5/9/13 for Resident 8 states they requested to "hold off" due to double vision and problems with depth perception. The next note 6/5/13 states Resident 8 had not yet received her corrective lenses. Resident 8's PT evaluation did not occur until 6/7/13. Resident 8's PT notes indicate Resident 8 received her new glasses on 6/27/13. Resident 8's Resident Fall Report states she fell on [DATE] at 4:00 AM from her bed and the facility added appropriate interventions. Resident 8's Resident Fall Report states she fell on [DATE] at 11:03 PM from her bed. Resident 8 stated she heard a box drop and was looking for her sister and wanted to "help with the baby." Resident 8 was found leaning against the nightstand. The report states that her Power of Attorney (POA) was contacted and "wants staff to continue to monitor her whereabouts frequently when restless." The care plan states Resident (8) is to be 15 minute checks when anxious/paranoid. And on 6/25/13 the IDT (interdisciplinary team) changed to 15 minute checks at all times, however, the facility had no evidence that 15 minute checks were completed for Resident 8 prior to 8/28/13. Resident 8's Resident Fall Report states she fell on [DATE] at 6:00 PM from her chair. Resident 8 reported to staff that she was going to the kitchen and referred to her mother. Resident 8 received an ice pack to the bump on the left side of her head. The facility spoke to her POA who "is aware of risks involved with Resident (8) being up ad lib. The report states, "No changes made to POC (plan of care)." The note also indicates that Resident 8 did receive a PRN (as needed) Seroquel at 2:00 PM and that her medications will be reviewed with her physician. It is important to note that the facility did not ensure that Resident 8 received adequate supervision or assistive devices to prevent future falls. Resident 8's Resident Fall Report states she fell on [DATE] at 8:00 PM. Resident 8 reported to staff that she was walking around her bed and stumbled on something. There were "no observed obstacles on the floor." She had an abrasion to her right elbow and the x-ray on 7/15/13 revealed a right wrist fracture. The facility spoke to her POA who "desires to accept risks of injury to (Resident 8) with being up ad lib with her walker" and that Resident 8 was talking to people who weren't there his entire visit" when he visited that day. The report states her POA did not want hip protectors added, Resident 8 has double vision, and will monitor for UTI signs/symptoms. Resident 8's Resident Fall Report states she fell on [DATE] at 6:45 PM. Resident 8 reported that she was missing a cabinet and that she hit her head. She was found leaning against the wall and sitting on a pair of shoes. The facility added the intervention to remove some of her shoes and check her room twice a shift to clear/clean room of obstacles. The facility sent a message to Resident 8's physician 7/15/13 at 7:02 PM stating, "Resident (8) fell and hit her head on the wall ... She has fallen 3 times in the last week. She is having a lot of hallucinations at HS (before bedtime) which is when most of her falls happen. Is there anything we can do with her meds to help with this problem?" Resident 8's Resident Fall Report states she fell on [DATE] at 6:40 PM. Resident stated she heard her doorbell ring and went to answer it. The facility added the intervention 15 minute checks; however, no evidence of 15 minute checks was provided. Additionally, this intervention has already been on Resident 8's care plan and Resident 8 continues to fall and the facility had no evidence that 15 minute checks were completed. On 9/11/13 at 7:00 AM Surveyor interviewed RN P who stated that the root cause of Resident 8's falls had not consistently been identified and agreed that precautions were not taken to make sure she was not injured. Example 2 Resident 10 has [DIAGNOSES REDACTED]. Her Minimum Data Set completed on 6/6/13 indicates she has severe cognitive impairment and requires extensive assistance of 1 staff for transferring. Resident 10's care plan dated 3/18/10 states she has the following interventions for falls: 3/18/13 sign placed in room to remind her to call for assistance, 4/15/13 Sweater will be offered and accepted per her choice, 6/12/13 offer sweater daily, 6/12/13 assist out of wheelchair in room, 9/7/13 encourage (Resident 10) to use call light and wait for assistance with cares and toileting, 9/9/13 encourage resident to leave stationary chair in same location throughout day Resident 10's Resident Fall Report dated 8/20/13 states she fell at 1:45 PM trying to sit in her chair in her room. It states no changes to her plan of care and restates make sure sweater is on as needed. Resident 10's Resident Fall Report dated 9/7/13 states she fell at 4:30 PM from her chair going to the bathroom. She sustained a ? inch long laceration to the left side of her head and tenderness to her right lower rib area. It states the change in her plan of care is to "Encourage (Resident 10) to use call light and wait for assistance with cares and toileting." It is important to note that the document was requested on 9/10/13 and reviewed on 9/11/13 by Surveyor and had not been initialed by the IDT as having been reviewed. Resident 10's Resident Fall Report dated 9/9/13 states she fell at 3:00 PM trying to sit in her chair that she thought was next to her floor lamp. She sustained a scrape/abrasion 7 cm by 1 cm to her right lower back. It states change in her plan of care is to "Encourage (Resident 10) to leave stationary chair in same location throughout the day." It is important to note that the document was requested on 9/10/13 and reviewed on 9/11/13 by Surveyor and had not been initialed by the IDT as having been reviewed. Resident 10's documentation from the hospital emergency roiagnom on [DATE] states her [DIAGNOSES REDACTED]. On 9/12/13 at 12:30 PM Surveyor interviewed DON B who agreed that Resident 10 has severe cognitive impairment. DON B stated that it was not appropriate to add the intervention of encouraging or reminding a resident who has severe cognitive impairment. DON B agreed that these interventions would not ensure Resident 10 is safe if she falls.

Based on observation, interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 9 residents reviewed (Resident 1, Resident 14, Resident 23 and Resident 10). The facility did not consistently assess behavior trends and identify root causes for unwanted self-transfers, did not consistently implement new interventions to prevent falls when past interventions had proven ineffective, and did not consistently implement care-planned approaches for preventing falls. Resident 1 sustained 14 falls at the facility. Three of the falls resulted in injury to Resident 1. The facility did not address Resident 1's trend of self transferring when in need of toileting, which resulted in falls and injuries (laceration, subarachnoid bleed, hip fracture, and fracture of the fibula). The facility did not place interventions to prevent falls after each fall in attempt to reduce the number of falls and injuries. Resident 14 fell from her bed on 12/24/11 resulting in a head laceration, on 1/2/12 resulting in facial contusion and skin tears, and a fall on 4/23/12 and the facility did not put any new interventions in place to keep her safe. After her fall on 4/24/12 where she hit her head with swelling, the facility said that Resident 14's bedside commode would be removed. On 4/26/12 Resident 14 fell with her commode at bedside. Resident 23 was admitted to the facility due to a history of falls with injuries. The facility assessed Resident 23 to be at risk for falls. Resident 23 had 29 falls between 2/10/12 and 6/6/12 and 17 of those falls the facility did not put any new interventions in place or put interventions in place but they were not timely to keep him safe. Resident 10 experienced 20 falls since his admission 5/1/12. Revisions were not consistently made to the plan of care to prevent the same or similar types of falls from re-occurring. The failure to provide appropriate supervision and assistive devices to prevent falls created a finding of immediate jeopardy, which began 10/17/11. The administrator, Director of Nurses and AM nurse supervisor were notified of this finding at 4:10 PM on 6/26/12. The facility removed the immediate jeopardy on 6/27/12; however, the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) until the facility has fully implemented its action plan. Findings as follows: The facility's policy titled "Fall/Restraint Committee" dated 4/9/12 states the following: " ...Purpose: To determine appropriateness of chemical/physical interventions while considering benefit of being without interventions versus risk of using interventions. III. Procedure: ...B. All residents are reviewed quarterly and as needed. C. Reduction trials will be considered. D. Completed safety/psychoactive medication assessments will be read and discussed. E. The least restrictive program will be considered while the safety of each resident and those in the facility affected by this resident will be considered also. F. Decision-making includes: 1. Resident capability for movement ...3. Resident medical needs. 4. Resident mental capacity. 5. Risks vs. benefits ...7. Rationale for current program ...G. Recommendations for more or less interventions, changes in environment, strengthening programs, enabling devices, etc are considered and discussed. H. Recommendation, are reviewed at interdisciplinary staffing or care plan meetings ..." On 6/11/12 at 2:00 PM Surveyor interviewed DON B and RN Supervisor C. DON B stated that after a fall the Fall report is completed by the nurse on duty, the physician and POA are notified. RN C explained that when the POA is contacted recommendations are made for interventions for the resident. DON B also stated that a resident's plan of care cannot be revised until after the reviewed with the POA. She further explained that there is not always going to be a new intervention after a fall. On 6/12/12 at 2:50 PM Surveyor interviewed Director of Nursing (DON) B, RN supervisor C, and Nursing Home Administrator (NHA) A. NHA A explained the Resident Fall Report is used to examine the root cause of the fall, then there needs to be a conversation with the resident or responsible party to put an intervention in place. DON B explained that the Resident Fall Report is completed by the nurse, crosses the shift supervising nurse's desk, Director of Nursing's desk and is reviewed by the Medical Director as well. DON B stated the Safety/Psychoactive Medication Review committee meets weekly to discuss risk factors and current interventions regarding residents' falls. Example 1 Resident 1 was admitted to the facility on [DATE] and has an activated healthcare power of attorney. According to "Resident [DIAGNOSES REDACTED]. The facility completed an initial Minimum Data Set (MDS) assessment with an assessment reference date of 9/19/11 that indicates that Resident 1 has short-term and long-term memory problems and severely impaired cognitive skills for daily decision-making, does not ambulate, requires extensive assistance with transferring and bed mobility, displayed physical behavioral symptoms toward self and others and which placed self and others at risk for physical injury, rejected cares 4-6 times but less than daily, had one fall with no injury, and is continent of bowel and occasionally incontinent of bladder. The facility completed a "Safety/Psychoactive Medication Assessment" on 9/11/11 that states, "unsteady on feet, loses balance ...history of falls ...poor vision ...alert, short attention span, disoriented, poor judgment ...poor vision ...Uses Appropriate Safety Devices: Call light-no, walker-no, locks w/c (wheelchair)- no ...(Resident 1) was admitted to hospital for a large right anterior interparenchymal hemorrhage on 9/6/11. She has been receiving speech, physical and occupational therapy ...Baseline she displayed aggressive, anxious behaviors-need reassurance and staff needed to explain prior to initiating. Redirect was not always effective ...She had a bed alarm on while at the hospital for impulsive behaviors ...She transfers/ambulates with 2A 10-15 feet ...has had multiple falls prior to her hospitalization ..." Resident 1's care plan at the time of admission to the facility states the following interventions: "Investigate cause of fall/review risk factors. Keep environment uncluttered. Notify MD/family of fall/status updates. Monitor (Resident 1) frequently. Use noodles, bed pillows etc to maintain positioning. Encourage to change positions when in bed. Reposition when in bed q 2-3 hours and more frequently as needed. Transfer with 2A (2 assist) and wheeled walker, wheelchair for long distance mobility-staff propel. Amb (ambulate) 2A and wheeled walker, doc (document) distance and tolerance. Monitor for fatigue. Reapproach prn (as needed). The facility completed "Resident Fall Report" for the each of Resident 1's falls. These reports contain the following information: 1. 9/13/11, 6:45 PM: destination was to bed, fell from the wheelchair, no injury. Facility added to use the recliner instead of the wheelchair to Resident 1's plan of care. 2. 10/17/11, 4:10 AM: Resident 1 fell from the bed, destination was to the commode. The facility implemented an intervention to remove the commode from the room, leave the walker at the bedside and leave the bathroom light on. It is important to note that Resident 1's care plan at the time of this fall already indicates an intervention of "10/10/11: walker in front of Res (resident) @ (at) all X (times) per dtr (daughter) request." Resident 1 did not sustain injury from this fall. Nurse's Notes dated 10/17/12 state the following: "0420: Res sitting on floor (near closet) c (with) knee bent. Pleasantly confused as usual. (Res self trans (transferred) from bed to bedside commode and voided). Denies pain. Denies hitting head. States, 'I made a miss step.' ROM (Range of motion) WNL (within normal limits) to all 4 extremities. No injury present. Did not use call light. No shoes on. Gripper socks applied ..." The facility did not add "gripper socks" to Resident 1's plan of care. 3. 10/17/11, 8:10 PM: Resident 1 fell coming from the bathroom and trying to get to the recliner. Resident 1 sustained skin tears to the left upper arm and a laceration to the head. Resident 1 was sent to the emergency room and admitted to the hospital for observation. Nurse's Notes from prior to the fall state the following: "1500 (3:00 PM) ...Self transferred many times this shift. Redirected/reminded to use call light." "History and Physical/Transfer Summary" dated 10/18/12 states the following: " ...Apparently, had 2 falls yesterday and initial CAT scan done in the emergency department clearly demonstrated a new right frontal subarachnoid hemorrhage ...Imaging: Pelvic x-rays were negative for any acute fracture, except osteopenia. Nondisplaced fractures were not completely ruled out ..." Nurse's Notes dated 10/18/12 state, "1838 (6:38 PM) Res returned to (Facility name) from (Hospital name) after head laceration ...2100 (9:00 PM) ...laceration to head c (with) 4 staples intact ..." After Resident 1's return to the facility, the facility added the following care plan interventions: "10/18/11: Step up program to maintain ROM (range of motion) and amb and assist c (with) decreasing falls. Staff assist c (with) ROM and Amb 7X (times) week ...10/18/11: Toilet q 3? (hours) night & day." It is important to note that the facility discontinued the intervention "Check with (Resident 1) every 2-3 hours regarding toileting needs" and added "Toilet q 3?" on 10/18/11. This is a decrease in the frequency in which Resident 1 receives care for her toileting needs. The facility completed a "Safety/Psychoactive Medication Assessment" on 10/18/11 that states " ...Committee Recommendation-Date: 11/1/1; reviewed. Resident now has concave mattress ..." 4. 11/10/11, 7:45 AM: Resident 1 fell out of bed and wanted to sit in the chair. The bed was noted to be wet. Resident 1 was last toileted at 5:20 AM, according to the "Resident Fall Report" but "CORP-Bowel and Bladder Detailed Entry Report" indicates that Resident 1 refused toileting at 5:21 AM. The facility does not address Resident 1 toileting needs and refusals to use the toilet. The facility had data available to become aware of Resident 1's refusals followed by self-transfer attempts to use the bathroom. Many of these instances resulted in falls. No changes were made to Resident 1's plan of care following this fall. The facility did not assess Resident 1's toileting patterns to determine if a more frequent toileting schedule would be appropriate. 5. 11/14/11, 4:10 PM: Resident 1 fell out of her chair attempting to get to the bathroom. No injury was noted. "Corp-Bowel and Bladder Detailed Entry Report" indicates that Resident 1 was toileted and was continent at 12:30 PM. This document does not indicate that Resident 1 had toileting activity from 12:30 PM until the time of the fall. The facility did not make changes to Resident 1's plan of care. The "Resident Fall Report" states, "Continue toileting Q (every) 3 hrs and last rounds." The facility did not assess Resident 1's exhibited need for more frequent than every 3 hour need for toileting assistance. The facility did not place interventions to prevent future falls. 6. 11/20/11, 10:45 PM: Resident 1 fell out of bed. Her destination was to the bathroom. "Resident Fall Report" indicates that Resident 1 was up to the bathroom at 9:30 PM and did not void. "Corp-Bowel and Bladder Detailed Entry Report" indicates that Resident 1 last voided at 6:33 PM. Nurse's Notes dated 11/20/11 (before the fall) state the following: "2145 (9:45 PM) Self transferred X 2. Reminded to call and wait for assistance." "Emergency Department Physician Documentation" dated 11/21/11 states: "Chief complaint: fall from bed; Extremity injury: Right hip ...Progress Note: Diagnosis: [REDACTED]. Pelvic fracture left." "Discharge Summary" dated 11/26/11 states the following: "admitted : 11/21/11 at 18:15 (6:15 PM), discharge date : [DATE]...Chief Complaint: R hip fx (fracture) ...Procedures: ORIF (open reduction internal fixation) R (right) hip fx 11/22/11." According to "Resident Fall Report", the facility added "Grippy socks at night" to Resident 1's plan of care in response to Resident 1's fall. 11/26/11 care plan intervention (after Resident 1's return from the hospital) was "BSC (bedside commode) at bedside & by stationary chair at all times. Call light in reach." It is important to note that this intervention was also added to Resident 1's plan of care on 10/22/11, "Commode at BS (bedside) @ HS (bedtime)." 7. 1/5/12, 11:30 PM: Resident 1 fell from her bed and per the "Resident Fall Report" the motivating factor related to the fall was "toileting needs." The facility interviewed Resident 1 after the fall. Resident 1 stated, "I was going over there" and pointed to the commode. Per the "Resident Fall Report," Resident 1 was last toileted at 8:59 PM, 2 hours and 31 minutes prior to the fall. Resident 1 did not sustain injury related to this fall. The facility decided to change toileting to "offer toileting q 2-3 hrs (hours)." Nurse's Notes dated 1/5/12 state, "2200 (10:00 PM): Alert. Needed 1:1 (one-on-one) very reluctant to move c staff ..." It is important to note that the facility did not address Resident 1's increased need for toileting and/or supervision. Adding the intervention to toilet every 2-3 hours does not ensure that Resident 1 will be toileted with greater frequency than every 3 hours. 8. 2/3/12, 11:20 PM: Resident 1 fell from her bed and did not sustain injury. The "Resident Fall Report" for this fall indicates that Resident 1's destination was to the commode, but was questionable. This report indicates that Resident 1 was last toileted at 2100 (9:00 PM), 2 hours and 20 minutes prior to the fall. The facility did not make changes to Resident 1's care to prevent future falls. 9. 2/11/12, 10:40 PM: Resident 1 fell from bed trying to get to her commode, according to "Resident Fall Report." Resident 1 did not sustain injury and was last toileted at 7:57 PM, 2 hours and 43 minutes prior to the fall. The facility did not place preventative measures to prevent falls for Resident 1. Resident 1 was not assessed for more frequent toileting needs or supervision. 10. 3/12/12, 4:30 PM: Resident 1 fell from her recliner. Resident 1 was toileted 22 minutes prior to the fall, according to "Resident Fall Report." Resident 1 sustained 2 skin tears to the right underarm area. The facility did not make changes to Resident 1's care in attempt to prevent futures falls and potential injury. 11. 3/16/12, 8:15 PM: According to "Resident Fall Report", Resident 1 fell from her recliner attempting to use the bathroom or commode. Resident 1 was last toileted at 6:27 PM. The facility interviewed Resident 1 after the fall. Resident 1 stated, "Don't ask me so many questions, I don't know. Yes, I have to use the bathroom." Resident 1 did not sustain injury. The facility added more body pillows to around her chair area. 12. 3/25/12, 3:45 AM: Resident 1 fell out of her bed trying to get to the bathroom, according to "Resident Fall Report." Resident 1 did not sustain injury from the fall. Resident 1 was last toileted at 2358 (11:58 PM) and refused toileting on "2nd rounds." The facility did not make changes to Resident 1's care to prevent future falls. It is also important to note that the facility did not develop a plan of care that addresses Resident 1's refusals for care and possible need for increased supervision, given that Resident 1 has historically displayed increased toileting needs and frequent self-transferring attempts that result in falls and injury. 13. 4/20/12, 7:45 PM: Resident 1 fell out of bed and stated she was trying to go to the bathroom, per the "Resident Fall Report". Resident 1 was last toileted at 1740 (5:40), 2 hours and 5 minutes prior to the fall. Resident 1 did not sustain injury from this fall. The "Resident Fall Report" states, "POA (power of attorney) is aware that res is at risk for falling. Can't think of any way to prevent res (resident) from falling." The facility did not make changes to Resident 1's care to prevent falls and injury. 14. 5/17/12, 9:20 AM: Resident 1 fell from her bed trying to get to the commode. "Resident Fall Report" indicates that Resident 1 stated, "Get me over there!" This document indicates that Resident 1 " ...per CNA 2 A (assist) pivot commode to bed poorly favored RLE (right lower extremity)-? (did not) bear wt (weight). Reassessed AROM (active range of motion) LLE (left lower extremity), RLE favoring would not bend knee, c/o (complaint of) pain with palpation anywhere on RLE and anxious c (with) palpation. RLE internal rotation of foot." The facility obtained an X-Rays on 5/17/12 for Resident 1 which indicated the following: "There are Nondisplaced fractures in the proximal medial and fibular metaphysis ..." The facility completed "Voiding Diary" for Resident 1 on the following dates: 9/17/11, 9/19/12, 10/25/11, 10/27/11, 12/2/11, 12/3/11 and 12/4/11. The facility did not analyze the data obtained in Resident 1's Voiding Diaries to determine a trend in toileting times and/or refusals. 12 of 14 falls sustained by Resident 1 were, according to the facility's assessment, related to toileting needs. 3 of the 12 falls related to toileting need resulted in substantial injury to Resident 1. The facility did not address Resident 1's evidenced need for increased toileting and/or supervision. The facility did not make changes to Resident 1's care after falls in effort to prevent other falls. Surveyor spoke with Family Member (FM) V on 6/7/12 at 10:00 AM. FM V stated that she visits (Resident 1) about two to three times per week and is involved with her care. FM V stated that the facility always calls her when there are falls and that she was not happy that the facility was not using alarms for (Resident 1). FM V stated that (Resident 1) knows when she needs to use the bathroom and that this was always the driving force and that this prompts her to get up and then she falls. FM V stated that the facility has tried different things and that it is very frustrating. FM V stated that one-on-one supervision would work but that the staff cannot be there all of the time. FM V stated that (Resident 1) was now on 2 hour toileting. Surveyor asked FM V about the body pillows on all sides of the bed and chairs. FM V stated that when you step down onto body pillows it is not stable and that it was common sense that these would be unstable for her and me (Surveyor ) to walk on. FM V stated that Resident 1 does not use her call light due to her age and dementia. FM V stated that the facility used to put Resident 1 in her wheelchair and then into the hallway so that the facility could see her. FM V stated that she was not happy about the falls at all. FM V stated that she did not think that the facility has tried to check on (Resident 1) more often and she would like that the door always stay open so that staff could see her. On 6/11/12 at 9:00 AM, Surveyor spoke with Director of Nursing (DON) B about Resident 1's falls. DON B stated that the facility does a fall risk assessment for residents quarterly and as needed and that the care plans are developed by staff and reviewed at committee meetings. DON B stated that the committee also includes insight from the restorative team. Surveyor asked DON B what the facility does for residents who have frequent falls. DON B stated that she does a trend review for those residents. DON B stated that the trend review includes reviewing all documentation and logging all of the dates of the falls. Surveyor requested a trend review for Resident 1 if one was completed. DON B stated that she would look to see if one was completed. Surveyor asked DON B what happens after a fall. DON B stated that after a fall, there is a structured incident report used to gather and assess data. DON B stated that staff provides this information and gathers it from assessing documentation. DON B stated that next the POA is called to discuss what might be done for the care plan. Surveyor asked about Resident 1's POA's involvement. DON B stated Resident 1's decision maker directs the plan of care and that she was a significant contributor. DON B stated that the care plan comes from the conversation from the nurse and the decision maker and that quite often the decision maker will say "no changes." DON B stated that if the facility is really concerned about that decision then more of a conversation would be had. DON B stated that the nurse provided all of the information to the decision maker and that they also discuss interventions. Surveyor asked if the facility ever does more frequent checks or supervision for residents with falls. DON B stated that the facility might do more frequent checks. Surveyor asked where the information was obtained on the "Resident Fall Report" related to toileting. DON B stated that information is gathered by the nurse through the Care Tracker system and by interview with the CNA. Surveyor asked DON B where the analysis of the Bladder Diaries is located. DON stated that changes based on that information would be on the resident care plan. Surveyor requested more information related to the facility's response to Resident 1's fall and toileting attempts. Surveyor spoke with DON B and RN Supervisor C on 6/11/12 at 12:45 PM. DON B stated that the care plan all comes down to the POA needing to direct the care plan for Resident 1. Surveyor asked how a toileting change from every 2-3 hours to every 3 hours was an adequate intervention, give that Resident 1 self-transfers to the toilet less than every 3 hours, as indicated by her fall reports. DON B stated that this was not less frequent because now Resident 1 was getting toileted every three hours. Surveyor asked DON B about care plan approaches for non-compliance. DON B stated that the best answer is that the POA is saying continue to toilet every three hours. Surveyor asked DON B if she found documentation related to the logging and trending of falls for Resident 1. DON B stated that she did not have this for Resident 1. Example 2 Resident 14 was admitted to the facility on [DATE]. Resident 14's [DIAGNOSES REDACTED]. Resident 14 has an activated power of attorney as of 10/2/07. Resident 14's 10/27/11 quarterly Minimum Data Set (MDS) assessment indicates that Resident 14 scored a 0 on her Brief Interview for Mental Status indicating she has severe cognitive impairment. Resident 14's MDS in Section G indicates she requires extensive assistance of at least 2 staff for transferring and bed mobility. Resident 14's Safety/Psychoactive Medication assessment dated [DATE] states she continues to be at risk for falls/injury due to medications, diagnoses, and history. She transfers and ambulates up ad lib with a wheeled walker. Interdisciplinary Team evaluation part of the form dated 11/10/11 indicates Resident (14)'s motivation to independently ambulate has diminished which is correlated to her anxiety symptoms. Resident 14's 1/26/12 annual MDS assessment indicates that Resident 14 scored a 2 on her Brief Interview for Mental Status indicating she has severe cognitive impairment. Resident 14's MDS in Section G indicates she requires extensive assistance of at least 2 staff for transferring and one staff for bed mobility. Resident 14's MDS Care Area assessment dated [DATE] for safety/falls states Resident 14 does require one staff to assist and at times two staff to assist with transferring. At times she needs the medimaid (mechanical lift) for transfers. She had 2 falls in the last quarter without any injuries noted. She is noted to be restless at different times of the day and continues to be as risk for injuries due to history, diagnoses, impulsiveness, and restlessness. Resident 14's Safety/Psychoactive Medication assessment dated [DATE] states she continues to be at risk for falls/injury due to medications, diagnoses, history, and behaviors with dementia progression. She is able to move independently in bed, but will often need one assist for bed mobility. She is up ad lib but very rarely will ambulate by herself. She will usually have one assist for ambulation and at times will need two assist. Resident 14's 4/26/12 quarterly MDS assessment indicates that Resident 14 has severe cognitive impairment. Resident 14's MDS in Section G indicates she requires extensive assistance of at least 2 staff for transferring and bed mobility. Resident 14's Safety/Psychoactive Medication assessment dated [DATE] states she has episodes of confusion/disorientation. She often looks for her husband and small children who are not there, and will attempt to self transfer in order to search for them ... Sometimes she attempts to use her bedside table instead of her walker. Resident 14 is 2 assist with transfers and ambulation. She will attempt to stand from her wheelchair without locking brakes. She does not use her call light appropriately. A note dated 4/23/12 titled Recommend: states no med changes. She is capable of transferring independently and ambulating independently. Her abilities vary moment to moment... Therapy Plan of Care for Resident 14 dated 10/10/11 states Nursing to continue per plan of up ad lib in room, transfers varying from independent to medimaid (mechanical lift) depending on (Resident 14's) compliance. Resident 14's Care plan last reviewed on 5/10/12 states the following: falls will be minimized: investigate cause of fall/review risk factors, offer toileting every 2 to 3 hours added 1/25/11, use grippy socks in bed added 2/26/11, 10/3/11 added abilities vary day to day, hour to hour, 1 to 2 staff assist for many cares and then she will transfer/ambulate independently, 3/27/12 changed to 2 assist with transfers, 4/6/12 mechanical lift PRN (as needed), 4/24/12 no use of bedside commode, 4/30/12 hip protectors at all times. The facility nurses note (NN) dated 12/24/11 at 12:30 AM states Resident 14 was found on the floor in her room with a posterior head laceration measuring 2 cm by 2.5 cm. The facility Resident Fall Report dated 12/24/11 for Resident 14 indicates she fell at 12:30 AM from her bed trying to get to the bathroom. Resident 14 could not state what she had been trying to do but was positioned half way to her bathroom. Blood spots were noted at the foot of the bed. She was sent to the hospital for evaluation and treatment. The report states "Change of Plan of Care: no changes at this time." The hospital report dated 12/24/11 indicates Resident 14 had a 3 cm scalp laceration and received 3 staples to repair it. The facility NN written by DON B dated 12/27/11 at 7:40 AM states reviewed (Resident 14's) and updated plan of care. It is important to note that it does not indicate any new interventions were put in place to keep Resident 14 safe. The facility NN dated 1/2/12 at 11:35 PM states Resident 14 was found on the floor in her room with a skin tear with depth to her right wrist The facility Resident Fall Report dated 1/2/12 for Resident 14 indicates she fell at 11:35 PM from her bed "going upstairs to tell them she was going to bed". Resident 14 was found incontinent of urine and had no shoes on. A skin tear was noted to her right wrist and was "actively bleeding". A skin tear to her left knee, bruising to both knees and left cheek, and abrasion to her left cheek and bridge of her nose were also noted. She was sent to the hospital for evaluation and treatment. The report states "Change of Plan of Care: grippy socks." It is important to note that this intervention was already added to her care plan on 2/26/11. No other new interventions were identified to prevent accidents or injuries. The hospital report dated 1/3/12 indicates Resident 14 had a facial contusion, skin tears to her right wrist and left knee, and bilateral knee contusions. Her right wrist would was irrigated and cleaned, the exposed fatty tissue was debrided. The facility Resident Fall Report dated 4/23/12 for Resident 14 indicates she fell at 9:45 PM from her bed stating "I am going home." She was incontinent of urine. Her commode was found near the door of her room and had been at her bedside. She had one grippy sock on and the other was on the floor by her bed. A superficial scratch to her right thigh was noted. The report states "Change of Plan of Care: none POA (Power of Attorney) accepts fall risks." It is important to note that the facility did not put any new interventions in place to keep the resident safe. The facility Resident Fall Report dated 4/24/12 for Resident 14 indicates she fell at 12:45 AM from her bed. Resident 14 stated to staff she was wondering where her husband is and that she hit her head. She was found lying on the bathroom floor with the commode partially blocking the door. The commode was noted to have been at her bedside and her grippy socks were in place. A bump with discoloration to the back of her head was noted. The report states " ... (POA) wanted bedside commode removed from room due to involvement/use with recent falls. Change of Plan of Care: remove bedside commode from room ..." Resident 14's Care plan regarding mobility was updated on 4/24/12 stating no bedside commode. The facility Restorative Nursing Progress Notes dated 4/26/12 states she started a restorative program for transferring on 4/25/12. The facility Resident Fall Report dated 4/26/12 for Resident 14 indicates she fell at 10:05 PM from her bed asking for her husband. Resident 14 was incontinent of urine and had spilled water on her bed. Her over bed table was to her left with a cup of water dumped over. Resident 14's commode and walker that had been near the side of the bed were noted to be pushed towards the wall by the bathroom. Grippy socks were found removed and near her feet. No injuries were noted. The report states Resident 14's POA accepts fall risks and "no changes recommended". "Change of Plan of Care: no changes." It is important to note that the commode was at bedside at the time of the fall after the facility had stated it was to be removed after her fall on 4/24/12. The facility Resident Fall Report dated 4/29/12 for Resident 14 indicates she fell at 6:00 AM from her unable to state where she was going speaking of family. She was incontinent. No injuries were noted. The report states "Change of Plan of Care: none at this time." The facility NN written by DON B dated 4/30/12 at 1:45 PM state the POA/family member BB was informed of hip protectors being added to the care plan. On 6/11/12 at 8:35 AM Surveyor interviewed Resident 14's family member/POA BB who stated the facility did contact him regarding Resident 14's falls. He stated he did recall recommendations that were made to remove the bedside commode and put hip protectors in place. When asked if he could recall any other interventions being suggested he stated he could not recall. On 6/11/12 at 2:00 PM Surveyor interviewed DON B and RN supervisor C. DON B stated that after a fall the fall report is completed by the nurse on duty, the physician and POA are notified. RN C explained that when the POA is contacted recommendations are made for interventions for the resident. DON B also stated that a resident's plan of care cannot be revised until after the reviewed with the POA. She further explained that there will not always going to have a new intervention after a fall. Surveyor requested all documentation of recommendations made to POA BB or other family members regarding interventions for falls/safety for Resident 14. On 6/12/12 at 2:50 PM Surveyor interviewed