Every finding on record at Meadowbrook at Black River Falls

Based on observation, interview and record review, the facility did not ensure the preparation of food in a clean and sanitary environment and food was not properly stored with the potential to affect 36 of the 39 residents in the facility as 3 of the residents received tube feeding.Surveyor observed staff taking a dirty plate from the dining room back to the hot food service and placing more food on the dirty plate.Surveyor observed food items stored less than 6 inches from the floor.Findings:Facility policy titled, Storage, Prepare, Distribute and Serve Food revised April 2020, stated in part, 2. Storage (Dry). b. All food must be stored away from walls, clear of ceiling sprinklers and at least 6 off the floor.6. Distribution and Service a. All food must be distributed using sanitary procedures.On 01/13/2026 at 12:05 PM, Surveyor noted a box of fortune cookies and a box of oyster crackers on a shelf only 2 inches off the floor. There was a box of honey scooters, a bag of pancake mix and 3 bags of cranberries stored on the bottom shelf 4 inches off the floor.On 01/13/2026 at 12:09 PM, Surveyor observed Dietary Aide (DA) E bring a plate back in from the dining room and said, They want more, and set the plate on top of hot service line window. [NAME] F took the plate and placed more meat, vegetables and noodles on the plate and handed it back to DA E, who then delivered it back out to the resident in the dining room.On 01/13/2026 at 1:13 PM, Surveyor interviewed Dietary Manager (DM) G about the observations made in the kitchen. DM G indicated that all food items need to be at least 6 inches off the floor. DM G was asked about the plate of food brought back into the kitchen. DM G replied, That plate should have never made it into the kitchen. The staff should have noted that it was dirty and taken it directly to the dirty dishes. They should've used a clean plate.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 39 residents (R),Staff transported clean laundry from laundry area through the facility to resident rooms without covering the clean clothing which could lead to contamination of clean laundry. Staff did not perform appropriate hand hygiene and glove use during tube feeding administration for R17. This affected 1 out of 3 sampled residents for tube feeding.Staff performed medication pass on two separate residents on contact precautions but did not put on personal protective equipment (PPE) (R9, R12).Staff did not perform hand hygiene before glove use when administering eye drops to R9. Example 1 The facility policy, titled Handling Linens and Laundry, dated January 2026, states in part: Purpose to provide a process for the safe and aseptic handling, washing and storage of linen. Policy does not address transporting clean linen. On 1/13/26 at 1:07 PM, Surveyor observed Housekeeping (HK) K returning clean linen to resident rooms transported on an uncovered rolling hanging cart. On 1/13/26 at 1:09 PM, Surveyor interviewed HK K regarding transportation of clean and dirty laundry. HK K stated we cover dirty and the clean linens and towels when we deliver. HK K stated we do not cover the clean clothes. No one has ever told me we have to. On 1/13/26 at 1:11 PM Surveyor interviewed DON B who stated dirty laundry should be bagged and clean laundry should be covered going back out. Surveyor asked clarifying questions if there was any difference between linen and towels or personal clothing. DON B stated both linen and personal clothing should be covered when transported. Example 2 The facility policy titled, Care and Treatment of Feeding Tubes, dated December 2025, states in part, Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Guidelines. 7.Directions for staff on how to provide the following care will be provided: d. Use of infection control precautions and related techniques to minimize the risk of contamination. The facility posted CDC poster titled, Enhanced Barrier Precautions Everyone Must, no evident date, states in part: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Device care or use: central lines, urinary catheter, feeding tubes, tracheostomy, wound care: any skin opening requiring a dressing. R17 was admitted to the facility on [DATE] and has diagnoses that include: stroke, hemiplegia, history of pressure ulcers, and coronary artery disease. R17's Minimum Data Set (MDS) assessment, dated 10/17/25, indicates R17 is severely cognitively impaired and dependent for all mobility and activities of daily living or personal cares. R17's Care Plan, last reviewed 12/28/25, states in part: Resident requires tube feeding r/t Dysphagia, hemiplegia and hemiparesis affecting the left side. Interventions include Staff to follow Enhanced Barrier Precautions r/t feeding tube. Resident has nutritional problem or potential nutritional problem r/t need for enteral feedings, stroke. Interventions include: EBP precautions r/t tube feeding se enhance barrier precautions (gloves and gown) during the following activities.2. Tube Feeding On 1/13/26 at 12:12 PM, Surveyor observed Licensed Practical Nurse (LPN) J set up R17's tube feeding. LPN J walked into R17's room with 2 bottles of Jevity, placed them on the counter, completed hand hygiene, put on gloves but no gown, and walked over to where the graduate was sitting on the counter. Without all required personal protective equipment (PPE) in place, LPN J took syringe out of its dated package, walked over to resident, exposed abdomen, opened up the PEG tube port (PEG tube is a Percutaneous Endoscopic Gastrostomy tube inserted into his abdomen) and inserted the syringe and aspirated resident's tube. LPN J confirmed placement by aspirating gastric juices. LPN J put syringe back in its bag and poured the two bottles of Jevity, or 474cc of high protein liquid formula, into the enteral feeding bag. LPN J uncovered tubing, primed the tubing, and connected to peg tube. Container and supplies were put back. LPN J completed hand hygiene and left the room. At 12:41 PM, Surveyor observed LPN J enter R17's room, complete hand hygiene, and put on gloves but no gown. LPN J took graduate from the counter and opened the bathroom door. LPN J filled graduate from sink right next to the toilet and filled with 480cc of water, measured in graduate. Without all required PPE in place, LPN J went to feeding tube bag and poured water into bag and opened to flush. LPN J took off gloves, put graduate on counter, completed hand hygiene and left the room. At 12:53 PM, Surveyor observed LPN J complete hand hygiene, put on gloves, no gown and enter R17's room. LPN J disconnected R17's feeding tube from his PEG tube. LPN J disconnected the tubing, put cap on end of tubing, wrapped it around pole so it was not touching the floor and pushed pole to the side. LPN J took off her gloves, completed hand hygiene and left the room. On 1/13/26, between 12:44 PM and 12:52 PM, Surveyor observed LPN J who provided cares for multiple residents going in and out of rooms with same scrubs on, exposing self to others per job description and routine. On 1/13/26, between 12:18 PM until 12:41 PM, Surveyor observed LPN J who provided cares for multiple residents going in and out of rooms with same scrubs on, exposing self to others per job description and routine. At 12:36 PM, LPN J entered room of R36 and R6 without a gown. Their room had contact precaution signage. Contact signage is on door because R36 has MRSA, wounds, and a Foley catheter. On 1/13/26 at 1:00 PM, Surveyor interviewed LPN J regarding tube feeding process and infection control. When asked what kind of precautions R17 is on, LPN J stated she doesn't think he is on any. I know he has the tube so standard precautions. LPN J accurately stated standard precautions need hand hygiene and gloves. Surveyor asked LPN J how she knows who needs precautions and who does not. LPN J stated I'd look in his chart. LPN J took a few minutes to look through R17's orders, care plan and electronic chart. LPN J did not find anything. LPN J stated I guess it would be in the chart, but I do not know where it is. Surveyor asked LPN J the kinds of precautions there are. LPN J stated droplet, contact, standard and airborne. Surveyor asked if there was anything else. LPN J stated I can't think of one. LPN J was able to list the required PPE for each of the precautions she listed accurately. Surveyor asked if there is another precaution type needed for catheters and feeding tubes and things like that. LPN J stated oh, enhanced barrier precautions, that would be R17 because of his feeding tube. Surveyor asked how that differs from standard precautions. LPN J stated it requires a gown to be worn. LPN J stated I didn't follow that; we should have a sign on the door. (Surveyor observed a sign on the door of R17's room upon start of the survey process.) On 1/14/26 at 7:06 AM, Surveyor observed Registered Nurse (RN) I administer medications to R17 via his PEG tube. No concerns with medication preparation or administration technique. Surveyor observed RN I prep medication, complete hand hygiene, open up closest PPE storage cart, pull out a gown and put it on, pulled out gloves, pick gloves off the floor, put in pocket, walk down hall to another cart to get more gloves, and put them on. No hand hygiene after touching floor, multiple PPE carts and putting on her gloves. RN I entered room with PPE that included the soiled gloves, obtained her supplies, looked at label and expiration of the Jevity formula, poured into bag and primed the tubing. RN I then touched bed control, adjusted bed to raise R17's head, exposed PEG tube, opened, and aspirated to check placement. RN I then mixed water with each medication, dissolved medication, administered via PEG tube, flushed tubing and started over for all 3 medications. RN I then connected the feeding tube, opened the roller clamp to allow feeding to run by gravity. RN I took off gown and gloves. RN I went into bathroom, washed hands, and left room. At 7:31 AM, Surveyor observed RN I complete hand hygiene, put on a gown, and take gloves, a new dressing and a cup of wound wash into R17's room. RN I put supplies down, put on her gloves, and touching bathroom doorknob, went into bathroom and filled graduate with 480cc of water to flush feeding tube. RN I poured water into enteral feeding bag and flushed the tube feeding. RN I proceeded to remove the old dressing, took off gloves, no hand hygiene, and put on new gloves. With contaminated hands, RN I washed the ostomy site, threw the garbage away, opened a new 4x4 and placed on the ostomy site with the same contaminated gloves. RN I took off gloves, noticed the flush was done and put on new gloves with no hand hygiene prior to new gloves. With contaminated hands, RN I disconnected the tubing. RN I pulled fluid into syringe, touched PEG tube, inserted the syringe, and flushed it with the water. RN I closed cap on PEG tube, took off her gloves and gown, completed hand hygiene and left the room. RN I obtained supplies, put on PPE, taped and labeled dressing, took off PPE, completed hand hygiene and left the room. On 1/14/26 at 7:37 AM, Surveyor interviewed RN I regarding infection control practices, tube feeding practices and dressing changes. RN I stated hand hygiene with alcohol is required before patient cares, in between patient cares and you should wash your hands if soiled before wound care. Surveyor asked if hand hygiene or washing hands should be at any other time. RN I stated yes, between clean and dirty tasks and before and after tube feedings. RN I stated no, gloves do not replace hand hygiene. Hand hygiene should be done before you put new gloves on and after. RN I stated after you remove the old dressing, I would do hand hygiene. Surveyor asked if RN I did that. RN I stated I did not. Surveyor asked RN I about observation of seeing hand hygiene, then picking gloves off the floor, touching two carts to find new gloves, and putting on new gloves and if there was a time hand hygiene should have been done. RN I stated yes, I should have washed hands before I put on the new gloves. On 1/14/25 at 11:02 AM, Surveyor interviewed DON B regarding infection control and tube feedings. DON B stated hand hygiene should have been completed in between patient care, entering a room, and before and after gloves. Hand hygiene should be done before you put new gloves on and after you take them off. DON B stated RN I should have completed hand hygiene when going from the dirty dressing to the clean dressing. Surveyor shared observation of RN I picking something off the floor, putting on gloves and providing cares. DON B stated RN I didn't wash or do hand hygiene before going in, and she should have. DON B stated Enhanced Barrier Precautions are expected when doing tube feedings, catheter cares or things like that. That means wearing gown and gloves. Hands should be clean also. Example 3 Facility policy titled, Isolation Precautions, revised January 2026, stated in part: Contact Precautions .3. Prior to entering the isolation room, the flowing steps are required: Perform hand-hygiene and apply gloves and gown prior to entering room; While providing direct resident care, wear gloves and wash hands after coming in contact with infectious material; Remove gloves and perform hand -hygiene before leaving room. R9 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score that was unable to complete. R9 had diagnoses of Alzheimer's and dementia. R12 was admitted to the facility on [DATE] with a BIMS of 15 indicating R12's cognition was intact. R12 had diagnoses of sacral pressure wound and Methicillin Resistant Staphylococcus Aureus (MRSA) in the wound. On 01/13/2026 at 7:30 AM, Surveyor observed LPN H carry a cup of medication and grab two different color pressure boots into room [ROOM NUMBER] which had a contact precaution sign on the door, and LPN H was not wearing any Personal Protective Equipment (PPE). On 01/13/2026 at 7:35 AM, Surveyor observed LPN H remove medications from medication cart for R9. Surveyor did not observe LPN H perform any hand hygiene. LPN H administered all of R9's oral medications to R9. Then LPN H put on single use gloves without performing any hand hygiene and administered R9's eye drops to both of R9's eyes. On 01/13/2026 at 7:44 AM, Surveyor observed LPN H administer medications to R12 who is on contact precautions without wearing any PPE. LPN H was observed touching R12's bed linens, bed side table, open up the bathroom door and went into the bathroom. On 01/13/2026 at 9:39 AM, Surveyor shared these observations with the facility's Infection Preventionist (IP) who is also the facility's Director of Nursing (DON) B. Surveyor asked DON B, What are your thoughts about these observations with [LPN H]? DON B replied, LPN H should have performed hand hygiene with glove use with the eye medication, and she should have put on PPE during medication administration of residents on contact precautions. On 01/14/2026 at 7:35 AM, Surveyor was unable to determine who was on contact precautions in room [ROOM NUMBER] as there were two residents in that room. Surveyor asked DON B, Who was on contact precautions in room [ROOM NUMBER]? DON B replied, There was a resident in that room who was on contact precautions for Clostridium Difficile but is no longer. Surveyor asked DON B, Then why was there a contact precautions poster on the doorway yesterday? DON B replied, I don't know.

Based on interview and record review, the facility did not ensure that 4 of 5 residents (R)(R2, R8, R3, and R4) reviewed for receiving a psychotropic medication were free from unnecessary drugs.R2 was prescribed Quetiapine (Seroquel), an antipsychotic, without adequate indication or diagnosis.R8 was administered diphenhydramine-APAP (Benadryl/Tylenol) on a routine basis for sleep without adequate indication. R8 was administered lorazepam, an anti-anxiety medication, without adequate indication.R3 was prescribed Sertraline, an antidepressant, and Risperidone, an antipsychotic, without appropriate indication from a psychiatric provider.R4 was prescribed Cymbalta, an antidepressant, without adequate indication or diagnosis.This is evidenced by: Facility policy titled, Psychotropic Management, with a revised date of 12/2025, states in part: The facility will use psychotropic medication therapy only when clinically indicated to enhance the quality of life, while maximizing functional potential and well-being of the resident. Psychotropic medications are not administered unless they are necessary to treat a specific condition as diagnosed and documented in the resident's medical record. Gradual dose reductions of psychotropic medications and behavioral or non-pharmacological interventions are attempted, uncles clinically contraindicated, in an effort to discontinue the medications, if appropriate.Unnecessary Drugs and Psychotropic Drugs: Gradual dose reductions and non-pharmacological interventions are implemented, unless contraindicated, prior to initiating or instead of continuing psychotropic medications. Example 1 R2 was admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia without behavioral disturbance and unspecified signs and symptoms involving cognitive function. R2's most recent admission Minimum Data Set (MDS) assessment, dated 12/01/25, noted a Brief Interview of Mental Status (BIMS) score of 05/15, indicating severe cognitive impairment. R2 had no signs of delirium, no hallucinations, delusions, physical or verbal behaviors, and no wandering behaviors. R2 received antipsychotic medications on a routine basis only, no GDR was attempted, and a physician has not documented GDR as clinically contraindicated. R2's physician orders include: -Quetiapine Fumarate Oral Tablet 25 MG Give 1 tablet by mouth one time a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY. -Antipsychotic- Resident is prescribed an antipsychotic medication. Document number of times the resident exhibits the following behaviors: Delerium, paranoia, hallucinations, mood swings, or agitation. If symptoms are present, document interventions completed in progress notes 1. Distraction 2. Redirection 3. 1:1 every shift. Surveyor reviewed R2's behavior monitoring for 11/2025 – 01/2026 and noted no behaviors were documented. On 01/14/26 at 11:02 AM, Surveyor interviewed Chief Nursing Officer (CNO) D regarding R2's psychotropic medication. CNO D stated that R2 was admitted to the facility with the order for quetiapine. Surveyor asked CNO D how medications are reviewed on admission. CNO D stated the nurse, provider, and pharmacist review meds to ensure need. Surveyor asked CNO D why R2 was prescribed this psychotropic medication with the indication noting dementia. CNO D stated she didn't know, because this is not an appropriate indication for use. CNO D stated the facility definitely had room for improvement in psychotropic medication management. Example 2 R8 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, major depressive disorder, and insomnia. R8's most recent significant change MDS assessment, dated 11/08/25, noted a BIMS score of 11/15, indicating moderate cognitive impairment. R8 had no hallucinations, delusions, physical, or verbal behaviors. R8's physician orders include: -Citalopram Hydrobromide Oral Tablet 20 MG (Citalopram Hydrobromide) Give 20 mg by mouth one time a day related to ANXIETY DISORDER, UNSPECIFIED. -Anxiety- Resident is prescribed a medication for anxiety. Document number of times the resident exhibits the following behaviors: Nervousness, restlessness, sweating, increased heart rate, difficulty sleeping, or trouble concentrating. If symptoms are present, document interventions completed in progress notes 1. 1:1 2. offer activity 3. allow alone time every shift related to ANXIETY DISORDER, UNSPECIFIED. -Lorazepam oral concentrate 2mg/ml give 0.25 ml by mouth every 4 hours as needed for anxiety/terminal restlessness. -Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for Pain and Shortness of breath. -diphenhydrAMINE-APAP (sleep) Oral Tablet 25-500 MG (Diphenhydramine-Acetaminophen (sleep)) Give 1 tablet by mouth one time a day for insomnia. Start date of 11/20/25. -Monitor hours of sleep one time a day. Surveyor reviewed R8's sleep monitoring and noted an average of 7 hours of sleep per night prior to the start date of diphenhydramine-APAP. No sleep assessment was documented. Surveyor reviewed R8's behavior monitoring and noted no behaviors documented. Surveyor reviewed R8's medication administration record (MAR) and noted lorazepam was administered during 12/2025 on the following dates: 12/23/25 at 12:04 AM; medication was documented as Effective. 12/24/25 at 12:01 AM; medication was documented as Effective. 12/28/25 at 11:33 PM; medication was documented as Effective. 12/29/25 at 10:56 PM; medication was documented as Effective. 12/31/25 at 3:02 AM; medication was documented as Effective. Of note: no behaviors were documented prior to the administration of medication. On 01/14/26 at 10:38 AM, Surveyor interviewed Director of Nursing (DON) B regarding R8's medications. Surveyor asked DON B why R8 was prescribed the diphenhydramine-APAP. DON B stated she thought it was for itching but was not sure. Surveyor asked DON B why the orders indicated this medication was for insomnia. DON B stated she was not sure and would have to check. On 01/14/26 at 11:02 AM, Surveyor interviewed CNO D regarding R8's medications. CNO D stated she reviewed R8's record and found documentation noting the diphenhydramine-APAP was originally ordered for itching. Surveyor asked CNO D why a medication for itching would be administered on a scheduled basis. CNO D stated R8 has a known issue with itching and hives. Surveyor asked CNO D to show documentation of this condition. CNO D was unable to provide documentation of this. Surveyor asked CNO D if it would be appropriate to administer this medication for sleep or itching on a scheduled basis without adequate documentation to demonstrate need. CNO D stated no, that documentation should establish the basis and R8's did not demonstrate that. Surveyor asked CNO D about R8's lorazepam being administered without behaviors noted. CNO D stated the facility should do a better job of documenting behaviors to indicate need. Example 3 R3 was admitted to the facility on [DATE] with pertinent diagnoses of paranoid schizophrenia and drug induced subacute dyskinesia. R3's most recent annual MDS assessment, dated 10/10/25, noted a BIMS score of 10/15, indicating moderate cognitive impairment. R3 had no hallucinations, delusions, physical, or verbal behaviors. Antipsychotics were given on a routine basis only, no GDR was attempted, and no physician documentation for contraindication of GDR. R3's physician orders include: - Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to SCHIZOPHRENIA, UNSPECIFIED (F20.9) give with 50 mg. - Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to SCHIZOPHRENIA, UNSPECIFIED (F20.9) give with 100 mg. - risperiDONE Oral Tablet 1 MG (Risperidone) Give 2 tablet by mouth two times a day related to SCHIZOPHRENIA, UNSPECIFIED. - Antipsychotic- Resident is prescribed a medication for anxiety. Document number of times the resident exhibits the following behaviors: Delerium, paranoia, hallucinations, mood swings, or agitation. If symptoms are present, document interventions completed in progress notes 1. involve in activity 2. 1:1 3. reassurance every shift. - Psychiatry consult as needed. Surveyor reviewed R3's behavior monitoring and noted no behaviors documented. Surveyor reviewed R3's medical record and noted no psychiatric consults or assessments since admission. On 01/14/26 at 10:38 AM, Surveyor interviewed DON B regarding R3's psych consult. DON B stated that no documentation could be found to demonstrate R3's refusal to be seen by psychiatry or that a consult had been completed. Example 4 R4 was admitted to the facility on [DATE] and has the diagnoses of type 2 diabetes mellitus without complications, pain, chronic atrial fibrillation, history of transient ischemic attack (TIA), acute kidney failure, age related physical debility, and unspecified hearing loss, bilaterally. Major depression, single episode. R4's Minimal Data Set (MDS), most recent dated 11/20/25, documents that R4 has an absence of hearing and no hearing aid. R4's speech is unclear and slurred, R4 is rarely understood, and usually R4 understands but misses some part /intent of the message but comprehends most conversation. R4's physician orders include: Cymbalta (Duloxetine HCL) Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9). Current RX was started on 10/1/25. Cymbalta Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9). Current RX was started on 8/30/24 and discontinued on 9/30/25. Depression - Resident is prescribed a medication for Depression. Document number of times the resident exhibits the following behaviors: Crying, tearfulness, social isolation, changes in appetite, mood swing, or difficulty sleeping. If symptoms are present, document interventions completed in progress notes 1. 1:1 2. activity 3. alone time every shift related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9) - Start Date 01/30/2025 1500 Resident's target behavior: increased sleeping, refusing to eat meals. Enter if resident had this target behavior three times a day Y for behavior exhibited N for not exhibited - Start Date 03/30/2022 1400 R4's Care Plan, states in part: R4 has depression. Intervention: Monitor/document/report every shift any s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Pharmacy review monthly or per protocol. The resident will have no evidence of behavior problems r/t depression Administer medications as ordered. Monitor/document for side effects and effectiveness Assist the resident to develop more appropriate methods of coping and interacting Surveyor reviewed R4's behavior monitoring from 10/1/2025 through 1/13/2026. Documentation has row for number of behaviors. Surveyor noted: For first 12 days of January 2026, resident monitoring scored a 0 or NA, no behaviors. For 31 days in December 2025, resident monitoring scored a Y one day but did not document what the behavior was. For 31 days from February 2025 through November 2025, resident monitoring scored a 0 or NA, no behaviors. Surveyor reviewed behavior tracker started on January 29, 2025 and resident scored a 0, no behaviors the 3 out of 9 shifts remaining in the month. The other 6 shifts did not complete the task of monitoring. On 1/14/26 at 12:20 PM, Surveyor interviewed Certified Nursing Assistnat (CNA) L regarding R4's behaviors. CNA L stated R4 does not hear well but if you do not startle him, talk slow and clear he is fine. CNA L stated CNA L does not recall the last time she charted he had behaviors. On 1/14/26 at 11:22 AM, DON B brought Surveyor documentation and R4's treatment record. DON B stated R4 has depression and needs the Cymbalta. DON B was unable to find documentation of behaviors or a diagnosis other than depression, single episode.

Based on interview and record review, the facility did not ensure residents (R)(R42, R4, R31, and R44) received a written notice of transfer to include reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman and did not notify Ombudsman of transfer/discharge. 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. This affects 4 of 4 residents reviewed for transfers and hospitalization.R42 was transferred to the hospital on [DATE] and 11/19/25. No written notice of transfer or Ombudsman notification for either date. No bed hold notice for transfer out on 11/18/25. R4 was transferred to the hospital on 8/11/25 and 9/2/25. Documentation of written notice of transfer, Ombudsman notifications, and bed hold notices were not consistently kept for both dates.R31 was transferred to the hospital on [DATE] and 01/02/26. No written notice of transfer or bed hold notice was documented. Ombudsman was not notified of transfer.R44 was transferred to the hospital on [DATE] and did not return to the facility. No written notice of transfer or bed hold notice was documented. Ombudsman was not notified of transfer or discharge.As evidenced by: The facility policy titled, Bedhold Notification, dated December 2025, states: Synergy Senior Care requires that when a resident is transferred to a hospital or requests a therapeutic leave, the center will provide written notice to the resident and/or resident representative regarding the resident's bed hold rights and the centers bed hold policy. A statement will be given to the Resident outlying the Facility's bed hold policy at the time fo transfer to the hospital or at the beginning of a leave. The facility policy titled, Transfer and Discharge (including AMA), dated December 2025, states: 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. 5. The facility will maintain evidence that the notice was sent to the Ombudsman. Example 1 R42 was admitted to the facility on [DATE] and discharged on 11/24/25, with the diagnoses of epilepsy, diabetes, and chronic renal failure/end stage renal disease. Record review identified R42 was transferred to the hospital on the following dates: 11/18/25 R42 was sent to the local hospital with altered mental status, lethargy, and weakness. Resident had a head Computed Tomography (CT), chest x-ray and urinalysis completed while in the emergency room. Head CT and chest x-ray did not identify new issue or concern. He was sent back for monitoring and pending urinalysis. 11/19/25 with altered mental status, lethargy, and weakness. This transfer was to hospital in larger city north of facility per family's request. R42 was hospitalized for pneumonia, COVID, and UTI. No written bedhold, transfer notice, or notification of Ombudsman for 11/18/25 transfer. No complete written bedhold, transfer notice, or notification for Ombudsman for 11/19/25 transfer. Example 2 R4 was admitted to the facility on [DATE] and has the diagnoses of type 2 diabetes mellitus without complications, pain, chronic atrial fibrillation, history of transient ischemic attack (TIA), acute kidney failure, age related physical debility, and unspecified hearing loss, bilaterally. R4's MDS, most recent dated 11/20/25, documents that R4 has an absence of hearing and no hearing aid. R4's speech is unclear and slurred, R4 is rarely understood, and usually R4 understands but misses some part/intent of the message but comprehends most conversation. Record review identified that R4 was transferred to the hospital on the following dates: 8/11/25 due to decreased interactivity reported by nursing home staff, increased weakness and decline over the past week. 9/2/25 due to complaint of chest pressure at nursing. R4 had non-ST elevated myocardial infarction (NSTEMI). No written notice of transfer for 8/11/25 and 9/28/25 transfer. No bed hold for 9/28/25 transfer. The Ombudsman was not notified. On 1/13/26 at 4:16 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated that Ombudsman notifications were not happening. The social worker quit last Wednesday and let NHA A know at that time that he had not been notifying the Ombudsman. Surveyor asked how long the Ombudsman has not been notified. (Surveyor had asked to see August, September, November and December notices to Ombudsman.) NHA A stated back to May. NHA A stated we learned of it last week. I started a PIP and was going to bring it to the next QAPI meeting. The QAPI meeting was supposed to be this week, but we canceled because you were here. PIP was not in place when providers arrived on Monday 1/12/25. NHA A stated she would check on if there were any transfer notices or bed hold notices for 8/11/25 and 9/2/25. On 1/13/26 at 4:33 PM, Director of Nursing (DON) B came to find Surveyor and stated there are no transfer notices for residents. DON B provided copies of the eINTERACT form that were completed to show communication with accepting facility. DON B handed a printout of a progress note for R4 that stated, Consent for bed hold obtained. DON B said there is no written bed hold for 9/28/25 signed or showing the rate and rights of the resident. On 1/14/26 at 2:35 PM, DON B stated there are no written transfer notices or written bed hold notices for 11/18/25 and 11/19/25 related to R42. The Ombudsman was not notified. Example 3 R31 was admitted to the facility on [DATE] with pertinent diagnoses of postprocedural hematoma of a genitourinary system organ or structure following a genitourinary system procedure, hypertensive chronic kidney disease stage 4, gastroparesis, and benign prostatic hyperplasia without lower urinary tract signs or symptoms. Record review identified R31 was transferred to the hospital on the following dates: -12/10/25 for decreased urinary output. -01/02/26 for new onset urinary tract pain. No written notice of transfer, bed hold notice, or Ombudsman notification was documented. Example 4 R44 was admitted to the facility on [DATE] with pertinent diagnoses of encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below knee, weakness, fluid overload, and anxiety disorder. Record review identified R44 was transferred to the hospital on [DATE] for altered mental status. R44 left the hospital against medical advice (AMA) and did not return to the facility. No written notice of transfer, bed hold notice, or Ombudsman notification was documented.

Based on interview and record review, facility did not ensure pharmacy recommendation reports were acknowledged by a physician for 3 of 5 residents (R) (R8, R3, and R4) reviewed.R8 had pharmacy recommendations to review medications for contributing to recent falls and the provider did not respond.R3 had pharmacy recommendations to attempt a gradual dose reduction (GDR) of psychotropic medications and the provider did not respond.R4 had pharmacy recommendations to attempt a gradual dose reduction of a psychotropic medication and the provider did not responsd.This is evidenced by: Facility policy titled, Medication Regimen Review, with a revised date of 01/2026, states in part: Procedure: 1. Medication Regiment Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. 7. Timelines and responsibilities for MRR: b. The pharmacist shall communicate any recommendations and identify irregularities via written communication within 10 working days of the review. f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Example 1 R8 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, major depressive disorder, and insomnia. R8's physician orders include: -Citalopram Hydrobromide Oral Tablet 20 MG (Citalopram Hydrobromide) Give 20 mg by mouth one time a day related to ANXIETY DISORDER, UNSPECIFIED. -Lorazepam oral concentrate 2mg/ml give 0.25 ml by mouth every 4 hours as needed for anxiety/terminal restlessness. -Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for Pain and Shortness of breath. -diphenhydrAMINE-APAP (sleep) Oral Tablet 25-500 MG (Diphenhydramine-Acetaminophen (sleep)) Give 1 tablet by mouth one time a day for insomnia. Surveyor reviewed R8's fall incidents and noted: On 11/24/25 at 7:30 PM, R8 had an unwitnessed fall without injury. On 12/23/25 at 4:15 PM, R8 had an unwitnessed fall without injury. On 12/29/25 at 2:45 AM, R8 had an unwitnessed fall without injury. On 12/31/25 at 12:45 PM, R8 had an unwitnessed fall without injury. Facility completed an incident investigation to determine root cause, implemented new safety interventions, and updated care plan. No review of R8's medications were noted as possible contribution to falls or fall risk. On 12/15/25, MMR was completed and the pharmacist noted: R8 recently experienced a fall. A comprehensive review of medical record was conducted, identifying the following meds which may contribute to falls: Benadryl, lorazepam, morphine, citalopram. RECOMMENDATION: please evaluate these meds as possibly causing or contributing to fall. -No provider response was documented. On 01/14/26 at 10:38 AM, Surveyor interviewed Director of Nursing (DON) B regarding MMR recommendations. DON B stated MMRs are reviewed by the facility and forwarded to the provider for review and the expectation is for the provider to respond within 30 days. Surveyor asked DON B if the provider had responded to R8's MMR for medications possibly contributing to falls. DON B stated no. Surveyor asked if this should have been reviewed more quickly due to the risks related to potential falls and/or injury. DON B stated yes. Example 2 R3 was admitted to the facility on [DATE] with pertinent diagnoses of paranoid schizophrenia and drug induced subacute dyskinesia. R3's physician orders include: - Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to SCHIZOPHRENIA, UNSPECIFIED (F20.9) give with 50 mg. - Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to SCHIZOPHRENIA, UNSPECIFIED (F20.9) give with 100 mg. - risperiDONE Oral Tablet 1 MG (Risperidone) Give 2 tablet by mouth two times a day related to SCHIZOPHRENIA, UNSPECIFIED. Surveyor reviewed R3's monthly medication review (MMR) and noted: -05/12/25: pharmacist recommended GDR for risperidone 2mg and sertraline 150 mg. -05/14/25: Provider response: Review with NP. -05/15/25: noted by RN. No additional follow-up documented. MMR completed monthly through 12/15/25 repeated this recommendation with no provider response. On 12/29/25, provider responded to pharmacy recommendation that GDR is clinically contraindicated as it is likely to impair function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. No additional documentation was noted by provider. On 01/14/26 at 10:38 AM, Surveyor interviewed DON B regarding R3's GDR recommendation. DON B stated this GDR recommendation should have been addressed. Example 3 R4 was admitted to the facility on [DATE] and has diagnoses of type 2 diabetes mellitus without complications, pain, chronic atrial fibrillation, history of transient ischemic attack (TIA), acute kidney failure, age related physical debility, and unspecified hearing loss, bilaterally, and major depression, single episode. R4's Minimal Data Set (MDS), most recent dated 11/20/25, documents that R4 has an absence of hearing and no hearing aid. R4's speech is unclear and slurred, R4 is rarely understood, and usually R4 understands but misses some part/intent of the message but comprehends most conversation. R4's physician orders include: Cymbalta Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9). Current RX was started on 10/1/25. Cymbalta Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9). RX was started on 8/30/24 and discontinued on 9/30/25. Duloxetin3 HCL Capsule Delayed Release Particles 60mg Give 1 capsule by mouth one time a day for depression related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9). RX started 6/23/2021 and stopped on 8/29/2024. Depression - Resident is prescribed a medication for Depression. Document number of times the resident exhibits the following behaviors: Crying, tearfulness, social isolation, changes in appetite, mood swing, or difficulty sleeping. If symptoms are present, document interventions completed in progress notes 1. 1:1 2. activity 3. alone time every shift related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9) -Start Date 01/30/2025 1500 Resident's target behavior: increased sleeping, refusing to eat meals. Enter if resident had this target behavior three times a day Y for behavior exhibited N for not exhibited -Start Date 03/30/2022 1400 R4's care plan states in part: R4 has depression. Intervention: Monitor/document/report every shift any s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Pharmacy reviews monthly or per protocol. Surveyor reviewed R4's monthly medication review (MMR) binder that starts with April 2025 reports and progress notes. Monthly pharmacist reviews completed routinely. MMR to note include: 2/11/25 Progress Note states: Pharmacy Note: DRR (drug record review) completed Request Cymbalta GDR (Gradual Dose Reduction) No consultation report available in binder. 4/16/25 Progress Note states: Pharmacy Note: DRR completed. Resent Duloxetine GDR rationale. April 2025 Consultation Report states, Provider declined the consultant pharmacist's recommendation on 2/2/25 to perform a GDR of Duloxetine for R4 but did not provide documentation to support that a GDR is clinical contraindicated. Please provide rationale for declining a dose reduction of Duloxetine as required per CMS regulations. Space for physician documentation and signature is blank. 9/11/25 Progress Note states: Pharmacy Note: DRR completed. No irregularities. September 2025 Consultation Report states: GDR tracking- Major Depressive Disorder Duloxetine: stated 6/22/21, last GDR 8/29/24, next 10/27/25. 11/20/25 Progress Note states: Pharmacy Note: Med review complete; see report. No November Consultation Report in binder, nor is R4 listed in no irregularities document. Surveyor requested the Consultation Report from DON B. On 1/14/26 at 11:22 AM, DON B provided Surveyor with a Consultation Report for November 1, 2025. Reports states: 11/1/25 R4 has received an antidepressant, duloxetine 30mg qd, which is due for GDR consideration. Please attempt a GDR of duloxetine to 20mg qd to determine the lowest effective dose. If unable to change, please provide clinical rationale for continued use. Physician response is blank, form is unsigned. MMR completed monthly through December 12/15/25 with repeated recommendation for GDR. No provider response. No GDR attempted.

Based on record review and interview, the facility did not conduct a Preadmission Screening Resident Review (PASRR) Level II screen for R3, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure he received care and services to meet his needs. The facility practice affected 1 of 1 resident (R)(R3) reviewed.This is evidenced by:According to the State of Wisconsin Department of Health Services (DHS), PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual/developmental disability (ID/DD) and/or mental illness. This is a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require they receive additional services for their ID/DD and/or mental illness. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an ID/DD and/or mental illness for PASRR purposes. This is a Level II Screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care. If the State program permits the use of the exceptions specified in S483.20(k)(2), and the resident remains in the facility longer than 30 days, the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASRR evaluation and determination. NOTE: under 42 CFR 483.106(b)(2)(ii), If an individual who enters a NF as an exception (an exempted hospital discharge) is later found to require more than 30 days of NF care, the State mental health or intellectual disability authority must conduct a Level II resident review within 40 calendar days of admission.R3 was admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia. R3 was prescribed the following psychotropic medications: Sertraline and Risperidone.On 01/02/25, a Level 1 PASRR was completed noting R3 had a serious mental illness and was receiving psychotropic medications. A hospital discharge exemption-30 day maximum was noted and stated R3 was not to be staying in the facility longer than the permitted exemption period.R3 remained in the facility after the exemption period. No additional PASRR screenings were completed.On 01/13/26 at 8:30 AM, Surveyor interviewed Social Services (SS) C regarding R3's PASRR. SS C stated that he was not in this role during this time and could not state reasoning why another PASRR was not completed following the 30-day exemption period. SS C stated this should have been completed.

Based on facility policy review, record review, and interview, the facility failed to provide the necessary care to ensure residents' activities of daily living (ADLs) needs were met, which affected 1 (Resident #2) of 3 residents reviewed for ADLs. Specifically, the facility did not transfer Resident #2 out of bed for several hours due to the slings for the mechanical lift used to transfer the resident being unavailable.Findings included:A facility policy titled, Lift and Transfer Policy, revised 10/2020, indicated, All resident care will be provided in a safe, appropriate, and timely manner in accordance with the resident's care plan.An admission Record indicated the facility admitted Resident #2 on 11/15/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, chronic pain, anemia, and abnormalities of gait and mobility.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/24/2025, indicated Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #2 was dependent on staff for transfers. The MDS indicated Resident #2 did not refuse care during the assessment period.Resident #2's Care Plan Report, included a focus area initiated 11/20/2023, that indicated the resident had limited physical mobility related to dementia and weakness. Interventions indicated that the resident required assistance from two staff for transfers (initiated 11/18/2024) and indicated that staff were to use a full body lift to transfer the resident (revised 02/01/2025).During an interview on 10/22/2025 at 12:51 PM, Resident #2's Responsible Party (RP), RP C, stated that they arrived at the facility to visit the resident at around 2:00 PM on 08/17/2025. RP C stated staff had told them that Resident #2 had been in bed for about an hour before they (RP C) arrived. The RP stated staff came in at around 5:00 PM and told them that the slings for mechanical lifts were still being washed, so they could not get Resident #2 out of bed. The RP stated that they did not think Resident #2 should stay in bed from 1:00 PM until the following day. RP C stated that staff did not get Resident #2 out of bed for the remainder of that evening and stated that they (RP C) left the facility at 7:00 PM that evening.During an interview on 10/22/2025 at 12:16 PM, Certified Nurse Aide (CNA) A stated she had gotten Resident #2 out of bed on the morning of 08/17/2025 and put the resident back in bed at around 1:00 PM. CNA A stated Resident #2's sling had been soiled, so staff put it in the wash. CNA A stated Resident #2's RP asked about getting the resident back up after lunch, and she told the RP that the slings were all being washed, so they could not get the resident up. CNA A stated she did not get Resident #2 up the remainder of her shift and had given report to the incoming CNA that Resident #2 wanted to get up, but the slings were still drying.During an interview on 10/22/2025 at 2:18 PM, CNA B stated that they did not get Resident #2 out of bed on the evening of 08/17/2025 because there were no clean slings available for the lift.During an interview on 10/22/2025 at 11:14 AM, the Director of Nursing (DON) stated she expected residents who were dependent on staff for transfers to be out of bed just like everyone else. The DON stated that the facility received a complaint from Resident #2's RP that there was an incident on 08/17/2025 in which staff had left Resident #2 in bed despite wanting to get up. The DON stated staff told Resident #2 that the slings for the lift were all being washed, so they could not get the resident out of bed. The DON stated that all the slings should not have been washed at the same time.During an interview on 10/22/2025 at 2:03 PM, the Administrator (ADM) stated she expected staff to assist residents out of bed when they requested and per their care plan. The ADM stated she expected staff to get residents up and out of bed for meals, activities, and as desired.

Based on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not create a comprehensive assessment and plan of care to address substance use disorder (SUD) for 1 of 1 resident (R5) reviewed for SUDs. Findings: The facility's policy, titled: Safety for Residents with Substance Use Disorder, undated, states: It is the policy of this facility to create an environment that is as free of accident hazards as possible, for residents with a history of substance use disorder. The facility policy further states under the section Policy Explanation and Compliance Guidelines, in part: -Residents with a history of SUD but will be assessed for risks including the potential use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. -Residents with SUD may try to continue using substances during their stay in the nursing home. Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance that include, but are not limited to: a. Frequent leaves of absence with or without facility knowledge. b. Odors. c. New needle marks. d. Change in resident behaviors, especially after interaction with visitors of absences from facility such as unexplained drowsiness, slurred speech, lack of coordination, mood changes. -The facility will make an effort to prevent substance use, which may include providing substance use treatment services, such as behavioral health services, medication assisted treatments, Alcohol/Narcotics Anonymous meetings, working with the resident and the family, if appropriate, to address goals related to their stay at the nursing home, and increase monitoring and supervision. R5 was admitted to the facility on [DATE] with diagnoses that included methamphetamine use disorder, moderate, in early remission, alcohol use disorder in remission, major depressive disorder, recurrent episode, cerebrovascular disease and brain aneurysm. R5's Brief Interview for Mental Status (BIMS), dated [DATE], has a score of ,d+[DATE], indicating R5 is cognitively intact. R5's care plan, dated [DATE] with a resolved date of [DATE], for having adjustment issues to the admission did not include concerns/monitoring of SUD use. R5's behavior management care plan, dated [DATE] and a cancelled date of [DATE], did not include concerns/monitoring of SUD use. On [DATE], the facility initiated a care for impaired coping care plan related to cerebral infarction, substance abuse, recurrent substance abuse with a goal of Resident will demonstrate effective coping mechanisms. The care plan did not include concerns or what to monitor for that would indicate substance use. R5's physician orders since admission indicated no monitoring/assessing for the risk for substance use in the facility per policy. On [DATE], Surveyor reviewed the facility's investigation of incident that occurred on [DATE]. On this date R5 was found to have used methamphetamine. The facility conducted education to R5 and staff on methamphetamine use which did not include assessing, monitoring and ways to identify substance use. On [DATE] at 11:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D who stated she received education regarding opioid use and behaviors of agitation and outburst, and to make sure residents are safe, call management, start CPR if needed, and indicated the facility has Narcan available if needed as well. On [DATE] at 12:01 PM, Surveyor interviewed Certified Nursing Assistant (CNA) C who stated she received education for change in behaviors related to drug use after incident and staff conducted 15-minute checks for several weeks after the incident. CNA C could not identify specific things to look for to identify methamphetamine use. On [DATE] at 1:16 PM, Surveyor interviewed Nursing Home Administrator A and Director of Nursing (DON) B regarding education provided to staff. They were unable to provide documentation to support identifying, assessing and monitoring for potential substance abuse of residents with current or history of SUD.

Based on observations, interviews, and record reviews, the facility did not provide anticoagulation therapy for 2 of 3 residents (R) (R1 and R8) reviewed. -Facility failed to verify and transcribe new physician orders with increased Warfarin dose which resulted in R1 not receiving the correct Warfarin dose. This resulted in R1 being sent to the Emergency Department (ED) needing an intravenous (IV) drip of heparin for adequate warfarin anticoagulation, and lovenox bridging until the international normalized ratio (INR) was back in therapeutic range. This example is cited at actual harm. -Facility failed to verify and transcribe R8's new physician orders with increased Warfarin dose changes. Findings include: The facility policy titled Anticoagulant Therapy, revised May 2020, states: .Effectively monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physician orders. #3. Confirm with the physician the desired INR and/or PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. #4. Initiate and order anticoagulant therapy labs per physician's order. #6. Upon receipt of lab results, review INR and/or PT lab results for abnormal values. #8. Report lab results and current medication order to physician. #9. Throughout anticoagulant therapy monitor the resident for signs and symptoms of bleeding. #11. Document lab results, current dosage, and physician orders on the anticoagulant therapy flow sheet. Documentation: #1. Physician order #2. Nurses' notes. #3. Anticoagulant therapy flow sheet #4. Medication administration record. #5. Resident Care plan. #6. Key documentation elements: c. Pertinent lab results . On 01/22/25, Surveyor reviewed R1's medical record. R1 was admitted to facility on 09/27/24 with diagnoses including in part: Heart failure unspecified, presence of prosthetic heart valve, long term current use of anticoagulants, history of transient ischemic attacks (TIA) and cerebral infarction without residual effects, weakness, hyperlipidemia, chronic kidney disease, and bradycardia. R1's Minimum Data Set (MDS) assessment, dated 10/03/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R1 had intact cognition. MDS section GG for functional ability indicated R1 had impairment to one side upper extremity: impairment to both lower extremities. R1 needed setup for eating, setup for oral hygiene, partial/moderate assistance for dressing, partial/moderate assistance for rolling, sitting to lying, toilet transfer, and sit to stand. Surveyor reviewed R1's care plan initiated on 09/03/24. Surveyor did not find an anticoagulant care plan in place. Surveyor reviewed R1's physician orders, which stated in part: -On 10/01/24 Warfarin Sodium 2mg tablet, give 1 tablet by mouth one time a day related to presence of prosthetic heart valve. -On 10/29/24 draw INR. Surveyor reviewed clinic lab result, dated 10/29/24, which indicated R1's INR result 1.3; goal is 2.0-3.0; Order to increase warfarin dosing to 4mg Tuesdays (starting today) and 2mg all other days; recheck INR in 2 weeks. Surveyor observed that the new order for R1 with warfarin increase to 4mg was not transcribed into physician orders or the Medication Administration Record (MAR). Surveyor reviewed R1's October 2024 MAR which stated in part: -On 10/29/24, 10/30/24, 10/31/24, 11/01/24, and 11/02/24, R1's medication order of Warfarin 2mg give 1 tablet by mouth one time a day was blank and not signed out on R1's MAR. Surveyor did not find that R1's Warfarin medication was given on 10/29/24, 10/30/24, 10/31/24, 11/01/24, or 11/02/24. Surveyor reviewed R1's Treatment Administration Record (TAR) and did not find that anticoagulant therapy was being monitored for side effects of bleeding or adverse reactions to medication administration of anticoagulants. Surveyor reviewed progress notes which stated in part: On 11/03/24 at 7:59 PM, Writer noticed R1 did not have warfarin on MAR. Order stated he was to have INR on 10/29/24. Writer than found INR results and new orders under the document tab. MD on call notified of the doses of warfarin missed. MD gave new warfarin orders, recheck INR on 11/05/24. DON notified. R1 updated. -On 11/05/24 at 12:37 PM, nursing progress note states R1 was at lunch and nurse noted R1 couldn't open left eye, was asked to smile and R1 couldn't, and R1 was not able to squeeze nurse's hands tightly. Facility called an ambulance and R1 sent to ED for evaluation. -On 11/05/24 at 9:48 PM, writer called rural hospital for an update on resident. ER staff stated resident was being transferred to higher level of care hospital with diagnosis of TIA. -On 11/05/24 at 10:13 p.m., R1 was admitted to the hospital. CT showed Carotid Terminus Aneurism (a bulge or dilation in the wall of the internal carotid artery at its termination point) and high-grade stenosis of distal right M1 (a narrowing of the right side of the brain's main blood vessel near its furthest point of origin, potentially impacting blood flow to the brain tissue supplied by that artery). CT showed no acute intracranial findings but chronic infarcts of both cerebellar hemispheres and right occipital lobe noted. R1 required IV administration of heparin 50 units/ml in 1/2 normal saline (NS) continuous because of the mechanical valve without adequate warfarin anticoagulation, and lovenox bridging of 0.8 ml under the skin every 12 hours until the international normalized ratio (INR) was back in therapeutic range. Following discharge on 11/08/24 at 9:42 a.m., R1's orders included: follow-up with neurology, schedule consult to neurosurgery for right carotid aneurysm and distal M1 stenosis, lovenox injections until INR is therapeutic, Warfarin dose on discharge-4mg Tuesday and 2 mg all other days, recheck INR on 11/11/24, repeat echocardiogram in 1 month and primary care provider (PCP) follow-up. R1's speech was mildly slurred upon admission and at discharge. Hospital documentation stated speech is mildly slurred but could be R1's baseline, no obvious aphasia noted, and patient moves all four extremities. -On 11/08/24 at 3:32 PM, R1's admission orders included: Lovenox twice a day, Warfarin 2mg a day except for 4 mg on Tuesdays. Lab is to draw INR on 11/11/24. Surveyor requested facility's investigation of R1's missed anticoagulation therapy medication on 10/29/24, 10/30/24, 10/31/24, 11/01/24, and 11/02/24, which stated in part: . In conclusion a medication error occurred, resident missed doses of Warfarin on 10/29/24, 10/30/24, 10/31/24, 11/01/24, and 11/02/24. [LPN D] failed to process new warfarin orders on 10/29/24 when received from Clinic. [LPN D] noted on 11/03/24 that she had made the error. MD updated with new orders obtained. [R1] assessed for adverse effects of missed doses on 11/03/24 with no findings . On 01/22/25 at 1:06 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B to explain the event on 11/05/24 that happened to R1 when Warfarin medication was not given on 10/29/24, 10/30/24, 10/31/24, 11/01/24, and 11/02/24. DON B indicated that Licensed Practical Nurse (LPN) D had missed the new order for Warfarin dose change on 10/29/24 and did not transcribe the order in the computer before leaving evening shift. DON B indicated that R1 did not receive 5 doses of Warfarin. DON B indicated that R1 had to be transferred out to emergency room (ER) on 11/05/24. Surveyor asked DON B what DON B's expectation of timeframe is when nurses process INR results and any new physician orders related to Warfarin dose changes. DON B indicated that nurses are to process the INR results and physician orders right away on their shift. DON B indicated that DON B's expectation is that two nurses are always reviewing the INR results and processing new physician orders pertaining to Warfarin. DON B indicated the second nurse has to sign off in the Warfarin binder. On 01/23/24 at 9:32 AM, Surveyor interviewed Nurse Practitioner (NP) H and asked if NP H has knowledge of R1 missing Warfarin doses on 10/29/24, 10/30/24, 10/31/24, 11/01/24, and 11/02/24. NP H indicated NP H was not aware when the missed doses were happening, but facility made NP H aware on 11/03/24. NP H said that missing Warfarin doses was not ok and could have contributed to R1's TIAs. R1 has a mechanical valve in place and needed to be anticoagulated appropriately. Example 2 On 01/22/25, Surveyor reviewed R8's medical record. R8 was admitted to facility on 05/26/2021 with diagnoses including in part: Chronic atrial fibrillation, type 2 diabetes mellitus, and atherosclerotic heart disease. Surveyor reviewed R8's physician orders, which stated in part: -On 01/21/25 Check INR one time. -Warfarin Sodium oral tablet 6mg, Give 6mg by mouth one time a day every Monday, Tuesday, Wednesday, Friday, Saturday, and Sunday with end date 01/21/24. Surveyor reviewed R8's January MAR which stated in part: .Warfarin Sodium give 6mg by mouth one time a day every Monday, Tuesday, Wednesday, Friday, Saturday, and Sunday. End date 01/21/24. Surveyor did not find any additional Warfarin orders on R8's MAR. On 01/22/24 at 12:15 PM, Surveyor observed Anticoagulant Binder at the nurses' station. Surveyor opened the book to find R8's communication sheet in the binder not fully completed. Surveyor observed communication sheet to be missing two nurse signatures for validation of processing new physician orders on 1/05/24, 11/26/24, 12/24/24, and 01/21/25. Surveyor reviewed Warfarin communication sheet which stated in part: .On 01/21/25, Hold coumadin today 01/21/25 and then continue 4mg every Thursday and 6mg every other day. Next INR draw is 02/04/25 . On 01/22/25 at 12:20 PM, Surveyor observed only one nurse signature that verified new physician orders of Warfarin. Surveyor reviewed MAR and physician orders and found no documentation of the new orders from the Warfarin communication sheet from the day before. On 01/22/25 at 12:41 PM, Surveyor interviewed DON B and asked what DON B's process is for receiving, verifying, and transcribing new Warfarin orders and lab INR results. DON B indicated that when INR results come in from the lab, two nurses verify lab results, notify appropriate provider, and receive new physician orders. One nurse is to write this down on the Warfarin communication sheet and transcribe in the Electronic Health Record (EHR), then the second nurse verifies the accuracy and signs the Warfarin communication sheet. Surveyor asked DON B if there have been two nurses reviewing Warfarin dose changes and INR results for R8 as the Warfarin communication binder shows that there have not been two nurses signing off on INR results or physician orders on the anticoagulant flow sheet located in binder at nurses' station since November 5, 2024. DON B indicated that two nurses are supposed to be, but DON B can see this is not being done appropriately. Surveyor indicated to DON B that Surveyor did not find the new Warfarin orders in the MAR for R8 in R8's EHR. Surveyor also noted that Surveyor could not find the new Warfarin order in the physician orders in the EHR that is due this evening 01/22/25 with the Warfarin dose change. DON B indicated the new Warfarin order is not transcribed in R8's EHR. DON B indicated that DON B would have gotten to the order later today after auditing the Warfarin communication binder. Surveyor asked DON B when does DON B audit the Warfarin communication binder. DON B indicated that DON B reviews it daily Monday through Friday. Surveyor asked why DON B has not caught that R8's Warfarin communication sheet in the binder does not have two nurses' signatures verifying the accuracy of the medication changes since November 5, 2024. DON B indicated that DON B did not realize there have not been two nurses verifying and that DON B will need to audit that better going forward.

Based on observation, interview and record review, the facility did not ensure medications were administered in a safe and effective manner for 1 out of 6 residents (R2). RN set down Resident (R) 2's medications on tray table and left the room. There is a Self-Administration Assessment by the facility stating R2 is incapable of self-administering medications. When RN came back to the room resident had to tell her she took medications already when RN attempted to administer. This is evidenced by: The facility policy, titled Self-Administration of Medications dated May 2020, states: Each resident as the right to self-administer medication if he or she can do so. 2. If a resident desire to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate by completing a Medication Self Administration Assessment UDA. 6. The nurse will obtain a physician's order for each resident self-administering medication. The facility policy, titled Medication Storage dated January 2023, states: It is the policy of this facility to ensure all medications housed on our premised will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure . security. 1. General Guidelines: . C. During a medication pass, medications must be under the direct observation of the person administering medication or locked in the medication storage area/cart. R2 was admitted to the facility 12/11/24 and has diagnoses that include, but not limited to, paranoid schizophrenia; major depressive disorder, single episode; unspecified, anxiety disorder; chronic kidney disease, stage 4 (severe); chronic respiratory failure with hypercapnia, other specified disorders of nose and nasal sinuses. R2's Minimum Data Set (MDS) assessment, dated 12/18/24, indicated R2 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R2 was cognitively intact. R2's Self-Administration of Medication Assessment, completed 12/11/24, showed that R2 is capable with assistance to administer her own medication. R2 was scored as not capable opening/closing, accurately telling time to take medication, administering nasal sprays or drops, administering inhalants or inhalers and other areas of the assessment. On 01/22/25 at 10:26 AM, Surveyor observed Director of Nursing (DON) B pass medications to R2. At this time R2 was to receive Deep Sea Nasal Spray (saline) 1 spray each nares (nostril) and ProAir Albuterol Inhaler 2 puffs inhalation orally every 4 hours DON B obtained and took medications to R2 in her room. DON B was called by another staff member. DON B set the nasal spray and inhaler on the tray table in front of R2 and left the room. Surveyor observed R2 administer 4 saline sprays to each nostril and self-administer 2 puffs of her Albuterol. When DON B came back to the room, she picked up the spray and started to take cap off when R2 informed her she already took it. DON B stated oh, well let's get your inhaler. R2 informed DON B she took that also. DON B took both meds back to the medication cart, and came back with a glass of water so R2 could rinse her mouth. On 01/22/25 at 3:03 PM, Surveyor interviewed DON B regarding self-administration of medications. DON B stated self-medication assessments and mini-mental assessments are completed on residents interested in self-administering medications. DON B stated her expectation would be to not leave medication with someone who did not pass self-administration assessment.

Based on observation, interview and record review, the facility did not ensure medications were stored securely and in accordance with currently accepted professional practice. The medication cart was left unlocked in 1 out of 2 medication carts. This is evidenced by: The facility policy, titled Medication Storage dated January 2023, states: It is the policy of this facility to ensure all medications housed on our premised will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure . security. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, . On 01/22/25 at 10:03 AM, Surveyor observed an unattended medication cart unlocked outside R5's room on 300 hall. On 01/22/25 at 10:06 AM, Surveyor observed 5 different staff members walk by the unlocked, unattended medication cart. On 01/22/25 at 10:10 AM, Surveyor observed Licensed Practical Nurse (LPN) C walk out of R5's room and grab the unlocked medication cart and walk down the hallway. On 01/22/25 at 10:12 AM, Surveyor interviewed LPN C and asked what LPN C's normal process is when leaving the medication cart unattended outside a resident's room. LPN C indicated that the medication cart is usually locked when it is unattended. LPN C indicated that LPN did not lock the medication cart before entering R5's room and shutting the door. On 01/22/24 at 3:00 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for medication carts unattended and unlocked. DON B indicated that DON B's expectation is that all medication carts are not to be left unattended and unlocked for any reason. DON B indicated that LPN C should have locked the medication cart before going into R5's room and shutting the door.

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 31 residents residing in the facility. The facility's Dietary Manager (DM) is currently enrolled but has not started classes to be a Certified Dietary Manager. The Dietary Manager has been in the position for approximately two weeks. The facility does not have a full-time Registered Dietician at the facility. Findings include: On 12/17/24 at 9:40 AM, Surveyor toured the kitchen with DM D and asked what qualifications they held that allowed them to assume the role of Dietary Manager. DM D stated they had just started in the position approximately two weeks ago and did not hold any certifications to be a dietary manager. DM D stated they were supposed to be enrolled in a training program but did not think that had happened yet. On 12/17/24 at 2:33 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if DM D was qualified to serve as the director of food and nutrition services. NHA A stated they thought DM D was enrolled in a Certified Dietary Manager program. Surveyor asked if the Registered Dietician was full time and provided oversight of the kitchen. NHA A indicated the dietician was there 1 day a week and they were available by phone. NHA A stated DM D also had the assistance from a Certified Dietary Manager from a sister facility one day per week. NHA A later provided documentation that DM D had been enrolled in a Certified Dietary Manager program. The enrollment documentation was dated 12/17/24. The facility's Dietary Manager is not a Certified Dietary Manager or a Certified Food Service Manager.

Based on observation, interview and record review, the facility did not ensure the preparation of food in a clean and sanitary environment. This has the potential to affect all 31 residents in the facility. Staff did not consistently date or label food items when opened. Staff did not consistently test or document parts per million (PPM) of the quaternary sanitizing solution. Staff did not consistently document refrigerator and freezer temperatures. Staff did not consistently test or document dish machine temperatures. Staff observed touching ready to eat food with contaminated gloves. Staff observed delivering trays to resident rooms with uncovered food items on the tray. Findings include: Labeling open foods: According to facility policy and procedure entitled, Labeling Food and Date Marking, .Foods from processing plants are marked at the time the original container is opened and if the food is held for more than 24 hours, the date or day by which the food is to be consumed or discarded is indicated . On 12/17/24 at 9:40 AM, Surveyor conducted a tour of the kitchen with Dietary Manager (DM) D. During the tour Surveyor observed three containers of juice in the refrigerator with no date prepared or opened, and no discard date on the containers. Surveyor asked DM D if the containers should be labeled with dates. DM D replied the containers should be labeled with dates so the staff knows when they should be discarded. Surveyor also observed an opened gallon of milk on the shelf in the walk-in cooler. The carton was approximately 3/4 full. There was no opened date marked on the container. Surveyor asked DM D if the opened milk container should be labeled with the date opened. DM D replied the container should be labeled with the date opened so staff knows when to discard the contents if not consumed by the recommended discard date. Testing and documenting chemical levels in sanitization buckets: According to facility policy and procedure entitled, Chemical Cleaning and Sanitization, .To ensure that .sanitizing solution in buckets and spray bottles is at a level of 200-400 ppm, as per product guidelines and State of Wisconsin regulations .Dip test strip in solution. Hold for a minimum of 10 seconds. Remove and read strip according to guide on package. Test sanitizing solution in Kleen-pails by the same method throughout the day. Change solution as needed if below 200 ppm. Record results in designated area on Sink Temperature and Sanitizer Log . During the kitchen tour on 12/17/24, Surveyor observed a bucket of sanitizing solution sitting in a sink. Surveyor asked DM D if staff tested the solution to ensure it was at the correct PPM. DM D stated staff was supposed to check the chemical in the sanitizing buckets with a test strip each time they filled the bucket and record it on the log. DM D showed Surveyor the test log. The log was blank for December 1, 2, and 11. No tests were recorded for those dates. The log had an entry for only the AM column on December 3, 13, and 16. No tests were recorded for the PM column on those dates. The log had no tests recorded on the AM column for December 4, 5, 6, 10, 14, and 15. DM D stated the staff has not been following the facility policy for testing and logging the chemical in the sanitization buckets. Refrigerator and Freezer temperatures: According to facility policy and procedure entitled, Refrigerator/Freezer Temperature Log, To ensure all foods, but especially potentially hazardous foods, are stored at appropriate temperatures to prevent food borne illness. Refrigerator/Freezer temperatures shall be recorded by the A.M. [NAME] or designee at the beginning of the morning shift .All temperatures must be initialed by A.M. [NAME] or designee on the Refrigerator/Freezer Temperature Log. The following guidelines shall be used: a. Refrigerator: At or below 41 degrees F. b. Freezer: At or below 0 degrees F. During the kitchen tour on 12/17/24, Surveyor observed the Refrigerator/Freezer temperature Logs for December had many blanks. There were no temperatures logged for any refrigerators or freezers on December 1, 2, 11, 13, 14, and 15. There were no temperatures logged for refrigerator 2 and freezer 2 on December 3, 4, 5, 6, 7, and 8. Surveyor asked DM D about the missing entries on the log. DM D stated the staff was not following the facility policy for checking and logging refrigerator and freezer temperatures. Dish Machine Temperatures: According to facility policy and procedure entitled, Dishwashing Procedure, To ensure that dishes and utensils are properly washed and sanitized to prevent spread of food borne illness .Check temperature prior to first rack. Wash and rinse temperatures must reach required temperatures (see FS-2) prior to running any loaded racks through . Facility policy and procedure entitled, Dishwashing Temperature Log, states in part, .Wash and rinse temperatures shall be documented for each meal on the Dish Machine Temperature Form . During the kitchen tour on 12/17/24, Surveyor observed the December Dish machine Temperature Log had many blanks. There were no wash and rinse temperatures recorded for December 1, 2, and 4. The log had only the wash temperature recorded for supper on December 3. All other columns for that date were blank. Every other date from December 4th through December 16th were missing entries. Surveyor asked DM D about the facility expectation for checking dish machine wash and rinse temperatures prior to washing and sanitizing dishes and utensils. DM D stated the staff was not following facility policy and they should be checking and logging the wash and rinse temperatures for each meal. Touching ready to eat foods: Facility policy and procedure entitled, Glove Usage, states in part, Gloves used for handling food and eating surfaces are changed whenever an un-sanitized item or surface is touched, such as a refrigerator door handle, when they become soiled or torn or before beginning a different task . On 12/17/24 at 11:56 AM, Surveyor observed kitchen staff set up and serve the lunch meal. During the set-up for serving, Surveyor observed [NAME] E carry a large roaster and place it on the steam table. [NAME] E was wearing disposable gloves when carrying the roaster. [NAME] E took the cover off the roaster and picked up a knife. [NAME] E cut a piece of the roast and picked up the cut piece with the gloved hand that had carried the roaster and removed the lid of the roaster. [NAME] E said the roast was too hot, opened a drawer and took out a serving tongs. [NAME] E returned and placed food on a resident's plate with serving utensils. [NAME] E then took the cover off a silver container on the table and reached in with the same gloves on, picked up a piece of buttered bread and placed it on top of the resident's plate. [NAME] E continued to dish up residents' food and pick up the bread for each plate with the same contaminated gloves. During the observation, Dietary Aide (DA) G was wearing disposable gloves and touching multiple surfaces with those gloves. DA G stated a resident was served a plate without bread. [NAME] E picked up a piece of bread with the same contaminated gloves and handed it to DA G. DA G carried the slice of bread to the resident in the gloved hands that had touched multiple surfaces. Following the observation of meal service, Surveyor interviewed DM D and explained the observation of staff touching the ready to eat food with potentially contaminated gloves. DM D stated staff should only touch ready to eat foods with clean gloves or should use a utensil to handle food. Uncovered foods delivered to rooms: Facility policy and procedure entitled, Tray Service and Transport, states in part, .Foods, beverages and eating utensils are covered with lids, plastic wrap or other suitable covering if trays are carried through patient care and public areas . During observation of lunch service on 12/17/24, Surveyor observed DA F placing dessert bowls on the meal trays that were to be delivered to resident rooms. The dessert bowls were not covered when placed on the trays and delivered to resident rooms. Following the observation of meal service, Surveyor interviewed DM D and asked if the dessert bowls on the trays delivered to residents' rooms should have been covered. DM D stated they did not have covers for that size bowl and were in the process of ordering new items. DM D stated until they had covers that fit, the dessert bowls should be covered with plastic wrap when they are delivered to residents' rooms.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Staff did not follow proper personal protective equipment (PPE) procedures when doing wound care for a resident (R) on enhanced barrier precautions (EBP) and did not sanitize bandage scissors and marking pen prior to and after use. This affected 1 of 2 residents (R) observed for wound care. (R3) Findings include: According to CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, last revised April 12, 2024, to prevent cross-contamination ensure all wound care equipment is properly cleaned and disinfected between patients. On 12/17/24 at 1:22 PM, Surveyor observed Registered Nurse (RN) H provide wound care for R3. Surveyor observed a sign on R3's door identifying that R3 was on Enhanced Barrier Precautions. The sign indicated all staff must wear a gown and gloves for high-contact resident cares. RN H used hand sanitizer and put on a gown and gloves in the hall before entering R3's room. RN H placed packages of supplies on the bedside table, removed gloves, washed hands and put on clean gloves. RN H opened a barrier pad and placed it on the bed under R3's hips. RN H opened another barrier drape and placed it on the bedside table. RN H opened dressing packages and placed them on the barrier. RN H reached under the gown and reached inside uniform pocket with the same gloves on, took out a bandage scissors and placed it on the barrier. Surveyor did not observe RN H clean or sanitize the scissors. RN H used the scissors to cute strips of tape and placed them back on the barrier. After cleansing the wound per proper procedure, RN H removed gloves, used hand sanitizer and put on clean gloves. RN H wet a piece of collagen prisma dressing with normal saline and placed it on the open wound. RN H then picked up the scissors and cut a piece of aquacel dressing and placed it on the wound. Surveyor did not observe RN H sanitize the scissors before or after use, and placed them back on the drape. RN H applied zinc oxide to surrounding skin, removed gloves, used hand sanitizer, and put on clean gloves. RN H placed folded gauze pads in wound bed, covered with an ABD pad and taped it in place. With gloves on, RN H reached under gown into uniform pocket, took out a marker and dated the tape on the dressing. RN H put the marker on the barrier on the table and removed gown and gloves and washed hands. RN H put dressing supplies away and picked up scissors and marker and placed them back in uniform pocket. Surveyor interviewed RN H immediately following observation and asked if RN H cleaned or sanitized the scissors or marker before or after use. RN H stated they did not, but should have. Surveyor asked if RN H should have reached into uniform pocket to retrieve items when wearing gloves that were used for wound care. RN H stated they should have removed gloves and washed hands before reaching into uniform pocket to avoid potentially contaminating uniform. On 12/18/24 at 9:51 AM, Surveyor interviewed Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C. Surveyor explained the observation of RN H providing wound care for R3. Surveyor asked DON B and ADON C if RN H followed correct infection control procedures during the wound care observation. DON B stated RN H should not have reached into uniform pocket with gloves on and should have sanitized the scissors and marker before and after use for wound care.

Based on observations and interview, the facility did not ensure the daily nurse staffing information was posted at the beginning of each shift. This has the potential to affect all 31 residents in the building. The facility's nurse staffing sheets were not posted daily. Evidenced by: According to federal regulations, the facility must post the nurse staffing data on a daily basis at the beginning of each shift. Data must be posted as follows: Clear and readable format. In a prominent place readily accessible to residents and visitors. On 12/17/24, Surveyor was not able to locate the daily nurse staffing posting. At 12:22 PM, Surveyor asked Nursing Home Administrator (NHA) A where to find the daily staffing posting. NHA A stated it was their second day on the job and they did not know where it was located but would find out. Surveyor never received further information about the staff posting that day. On 12/18/24 at 7:30 AM, Surveyor was unable to locate the daily nurse staffing posting. Surveyor asked Assistant Director of Nursing (ADON) C for the daily nurse staffing postings from yesterday and today, and evidence of the postings saved since the last survey. At 7:50 AM, ADON C came back to Surveyor with a binder of old staff postings. ADON C stated they had just identified their previous NHA was responsible for doing the daily staff posting, and when they left, they never communicated that duty to anyone else. ADON C stated they had not been posting the daily nurse staffing data since October of this year. ADON C stated they will begin implementing this process today.

Based on record review and interview, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (R187) reviewed for accidents. R187 had an elopement from the hospital prior to admission and, following admission here, eloped from the building on 3 separate occasions. On the second elopement, R187 was missing for 2.5 hours, which required police and a K9 search to find R187. On the third elopement, R187 traveled 1.4 miles to a bridge, running through busy traffic, and attempted to jump off the bridge. Facility failure to provide adequate supervision created a finding of immediate jeopardy that began on 08/23/24. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 10/09/24 at 1:00 PM. The immediate jeopardy was removed on 08/26/24 and corrected on 08/27/24. This is being cited as past noncompliance. Findings: The facility policy titled Elopement dated June 2023, states, It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual care plan. The facility policy titled Elopement Management dated June 2023, states, Each resident is assisted in attaining or maintaining his or her highest practicable level of function by providing the resident with adequate supervision, activity/functional programs as appropriate, and safety interventions to minimize elopement risk. Signaling devices may be used if able and determined to be an appropriate intervention. The goal of the elopement management system is to identify residents with potential exit seeking behavior to assure the care plan and Kardex reflect effective and consistent interventions and safety measures and to assure staff are educated regarding the elopement management system and the resident's specific interventions. Practice guidelines: -Residents assessed on admission with the risk for elopement will have a. Interventions implemented to promote safety; and preventative measures implemented to mitigate elopement risk. R187 was admitted to the facility on [DATE] at 5:30 P.M. escorted by Adult Protective Service (APS), after being placed into Emergency Protective Placement on 08/21/24 at 3:57 PM while at the hospital. While waiting for treatment at the hospital, R187 had eloped. On 10/08/24 at 1:47 PM, Surveyor reviewed hospital emergency room documentation dated 08/21/24 which states in part, At 1453 the patient has eloped from the ER. Police called at 1554. Adult protective serves will be re-contacted. Per police report for hospital elopement, resident was located on [NAME] Street and complied with return to hospital. R187 had diagnoses of encephalopathy, unspecified amnesia, disorientation, acute abdomen, calculus of gallbladder without cholecystitis, alcohol use, unspecified in remission following elopement from hospital. Facility was unable to obtain a Brief Interview for Mental Status (BIMS) on admission as R187 refused to answer questions. Hospital records, dated 8/22/24, indicate the Montreal Cognitive Assessment (MoCA) (screening test for cognitive impairment) was given and R817 scored a 4. Less than 10: Indicates severe impairment. On 8/22/2024 at 11:40 PM, the facility documented a clinical admission note for R187 that states in part: -Admission Details: Arrived by - Other: Protective Services -Admission mode: walker. -Mental Status: Resident is experiencing signs of short-term memory loss. Oriented to person. Oriented to place. -Short-term memory loss: Unknown. -Level of cognitive impairment: Mild impairment (some confusion). Resident is coherent. Speech is clear. Language barrier: No. Resident makes self-understood. Resident understands others. -Mood and Behavior: Mood is pleasant, no unwanted behaviors witnessed. -Safety: Call light is within reach. -Physical restraints - none. -Able to move all extremities. Upper extremity ROM: No impairment. Lower extremity ROM: No impairment. -Gait is steady. -Balance is WNL (within normal limits). -Screening: Does the Resident currently or have a history of a substance use or been diagnosed with substance use disorder: No. -Education/Notification: Safety concerns - note: Elopement attempts while in hospital. On 8/22/2024 at 11:40 PM, the facility entered a nursing progress note that states in part: Screening: Resident has not faced a traumatic event or experience in the past. On 08/23/2024 at 12:04 AM, the facility completed an Elopement Evaluation, which showed a score of 5.0 (score above a 1 is at risk) based on answering Yes to the following questions: -Does the resident have a history of elopement or an attempted elopement while at home? -Does the resident have a history of elopement or attempted leaving the facility without informing staff? -Is the wandering behavior a pattern, goal directed i.e. specific designation in mind, going home, etc.? -Is the residence wandering behavior likely to affect the safety or well-being of self or other? -Has the resident been recently admitted or readmitted within the past 30 days and is not accepting the situation? Of note, the elopement assessment and wanderguard were not placed until over 6 hours after admission, putting R187 at risk of successful elopement during this time. Surveyor reviewed a nursing progress note from 8/23/2024 at 9:00 AM. Note Text: NEW ADMISSION: Res was awake all night. He couldn't rest early on the night shift and was coming to the window of the nurses station and asking questions with difficulty word finding, and word salad. One time wondered about sugar and diabetes. Another time said I am just going to my room, and I will die. Writer redirected res with conversation and a snack. Given a sandwich, and a soda and bag of chips. Res sat in lobby area, eating his snack. No further mention of death or dying. Res was concerned that he was not eating food away from staff or any others. Both staff left resident in lobby area eating, as he was content at approximately 0425. On 10/08/24 at 10:38 AM, Surveyor interviewed Dietary Manager (DM) F about R187's time at the facility and his elopements. DM F indicated on 08/23/24 at 4:30 AM, R187 was observed by DM F walking out the employee entrance which is off a hallway with administrative offices. Certified Nursing Assistant (CNA) N responded immediately and was able to convince R187 to return into facility and the incident was reported to NHA A at 4:43 a.m. On 10/08/24 at 1:47 PM, Surveyor requested from NHA A the facility's investigation for R187's elopements on 08/23/24. NHA A, provided a soft file investigation/conclusion summary dated 08/23/24 - 08/26/24 and signed by NHA A, regarding the second elopement, that states under the sections Conclusion/Root cause Summary: [R187] was admitted on [DATE] at approximately 4:30 PM. [R187] placed in room mid hallway from either exit door. On 08/23/24 at 4:30 AM, [R187] exited the employee door and an alarm sounded. [CNA N] responded and [CNA N] exited building with [R187]. [DM F] outside in parking lot when [R187] exited. [R187] aggressive and agitated. [CNA N] redirected and was able to escort [R187] into center after approximately 5 minutes. [R187] escorted to lobby for close supervision and wanderguard placed [CNA N] contacted [NHA A] via telephone. Television was on for [R187]. [R187] went to room stating was tired. [RN X] witnessed [R187] ambulating in hallway to room on hall 200. [R187] bypassed room and attempted to push open door at end of hall 200; however, it alarmed and [R187] closed door and retreated. [RN X] was in a resident's room and observed [R187] ambulating quickly toward hall 300. Hall 300 door sounded at approximately 5:30 AM. Staff responded to door. [CNA N] went out the door at end of hall 300 and began search for [R187]. [CNA N] on phone with [NHA A] during this time. Police contact immediately. [LPN K] updated resides local [DM F] took vehicle to begin neighborhood search for [R187]. Other managers contacted to come to center to assist. Police came to center within two minutes of calling. Police suspected [R187] was hiding in bushes as they responded within minutes. [R187] located two blocks from center near the church/courthouse. [R187] was sitting on the steps of the church police brought [R187] to the center. [R187] assessed by nurse. No injuries noted. [R187] taken to hospital by maintenance supervisor for further evaluation. [R187] returned to center approximately 1-1.5 hours later at approximately 10:30 AM. hospital emergency room for evaluation following elopement. Surveyor did not find any documentation in R187's medical record regarding the first and second elopements or evidence of increased supervision or additional interventions after the first and second elopement. Surveyor received and reviewed a written statement and signed event dated 8/23/24 by Registered Nurse (RN) X. RN X only worked this one shift for the facility. RN X's statement read: Approximately 4:30 AM, heard wanderguard alarm go off. [CNA N] and [RN X] both on Aspen wing ran to get alarm when [R187] exited the building and came back with [CNA N]. [RN X] was looking out windows and doors to see if [CNA N] needed help returning [R187] to facility. [RN X] was unable to see well, so opened emergency wing door at the end of Birch Hall. [CNA N] came to help [RN X] to shut off alarm as were looking for a key to silence the loud alarm. At opposite end of wing staff heard [R187] yelling out something about a fire but alarm was so loud not really able to hear [R187] who was walking very fast as [R187] went by the wing from [NAME] way toward lobby. Staff not sure when [R187] exited second time as the alarms were so loud and we were trying to silence them. We are also not sure what door [R187] exited. [CNA N] called NHA A at 4:43 AM to inform of inability to find resident [R187]. At this time [RN X], [CNA N] and [DM F] involved looking for resident soon another staff member [LPN K] came from other building to help look. [Assistant Director of Nursing (ADON) G] was phoned at 5:04 AM and asked for help. Maintenance man arrived and shut off alarm at 5:19 AM. Staff and police continually searching for [R187] outside of building as it was confirmed [R187] was not inside the building. At 7:10 AM by police staff noted when returned [R187] did not have the wanderguard on left wrist. [R187] did have wanderguard on left wrist when [R187] was eating sandwiches at 4:25 AM. Surveyor interviewed DM F regarding R187's second elopement. DM F indicated that at approximately 4:44 AM on 08/23/24, R187 attempted to elope out of 200-wing setting off emergency door alarm. R187 walked back toward nurses' station and DM F was asked by CNA N to assist RN X to shut off the 200-wing emergency door alarm as CNA N went to conduct morning cares on another resident. DM F returned to the nurses' station as was unable to assist shutting off 200 wing emergency alarm. RN X continued to attempt shutting off alarm. DM F then heard the 300-wing emergency door alarm activate and responded along with CNA N. Both quickly conducted a search inside the building and were unable to locate R187. Both DM F and CNA N notified RN X who called the police and then started looking outside and around the building to locate resident. CNA N contacted NHA A via telephone at 4:43 AM. Police were contacted at 4:49 AM by RN X. Maintenance was contacted and was able to shut off door emergency alarm at 5:19 AM. Of note, the nurse on duty was an agency nurse who was working her first shift and was not knowledgeable in how to operate the alarms. DM F indicated she got into car and drove around neighborhood on 08/23/24 from 4:45 AM to 7:18 AM but was unable to locate R187. On 08/23/24 at approximately 7:30 AM, police department brought R187 back to facility as R187 was found approximately 0.7 miles from facility sitting on church steps. R187 would need to cross several roads to get to the church. Weather was low of 63 degrees and R187 was dressed in hospital gown, underwear, and shoes. On 10/08/24 at 12:14 PM, Surveyor interviewed CNA O, who stated on 08/23/24 she came on shift at 6:00 AM. CNA O was told that a new admission came in on 08/22/24 and was missing for hours and around breakfast time police brought R187 back to facility. CNA O stated R187 did not have a wanderguard on nor was he on 15-minute checks. On 10/09/24 at 6:49 AM, Surveyor interviewed CNA N who indicated RN X was overwhelmed as it was the first time RN X has worked for facility. CNA N indicated R187 was a little restless during the shift and he heard the wanderguard alarm by employee entrance so CNA N went out and redirected R187 back into facility. CNA N indicated while that was happening RN X went down the 200 hall, as RN X thought R187 went out the emergency door which set off the emergency alarm. R187 became agitated and freaking out there was going to be a fire. We got R187 to remain calm. CNA N indicated he went to see if the emergency alarm would stop, but it needed a key. R187 then went out 300 hall door, setting off another emergency alarm which made the noise louder while CNA N was on the phone with NHA A and RN X was freaking out. The police arrived and searched for R187. CNA N indicated prior to R187 arriving to facility, staff were informed he was an elopement risk and stated there was definitely not enough staff, normally we have 2 CNAs. Surveyor received and reviewed a written statement and signed event dated 8/23/24 by CNA N, who wrote a statement of the two elopements on the morning of 8/23/24. Surveyor reviewed the facility soft file which included the written statement of CNA N which stated, statement taken via phone: 4:30 AM [CNA N] heard the wander alarm go off. [CNA N] went to check the front door and saw [R187] walking down the management hallway. [CNA N] turned to follow [R187] out the employee exit. [R187] was very upset agitated and almost combative. [CNA N] was able to deescalate [R187] into coming back to the facility. Upon entering the building [CNA N] asked [R187] to sit in the lobby in a recliner while [CNA N] silenced the wander alarm. [CNA N], then saw [R187] get up and walking go towards [R187's] room. At 5:30 AM [CNA N] heard the door emergency alarm go off on the 200 hall. [CNA N] went to look down that hall then heard the 300-door emergency alarm go off [CNA N] walked out those doors and did a search around the building . On 10/08/24 at 11:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN) K, regarding R187's 2nd elopement attempt. LPN K indicated they were called in by NHA A on 08/23/24 at approximately 5:00 AM, as a department head to come to facility to assist with a missing resident. LPN K indicated that during search for R187, LPN K ran into 2 deputies from the [NAME] County Police station who were also looking for resident and were able to locate R187 and brought R187 to facility. LPN K indicated hearing that R187 had another elopement episode but was not involved in that event. On 10/14/24 at 12:45 PM, Surveyor interviewed Police Officer Q, via telephone, who returned R187 through the front door of the nursing home after 2nd elopement from facility on 8/23/24. Surveyor asked if officer was aware of R187 wearing a wanderguard bracelet or if alarms sounded when going through the front. Police Officer Q stated there was no alarm sounding when they brought R187 back into the facility at 7:30 AM. R187 was missing from facility for 2.75 hours. Surveyor reviewed the police report for the second elopement that included in part: On Friday, August 23, 2024, Reported 4:49 AM. The notes were as follows: [R187], PATIENT ABSCONDED, LOOKING FOR ASSIST WITH LOCATING [R187]. UNKNOWN WHICH DOOR LEFT OUT OF FACILITY WEARING A PATIENT GOWN, 6'. [Deputy T] indicated the subject, [R187], had dementia, was possibly placed at the nursing home through social services and left agitated thinking the building was going to blow up. The information from August 21, 2024, indicated [R187] was supposed to be at the Black River Memorial Hospital under the care of Adult Protective Services. [Deputy U] Supplemental Report: K9 report: It should be noted that while enroute to the call, I came upon the missing person. This report is a summary of those events. Initial: On Friday, August 23, 2024, at approximately 6:43 AM, I, [Deputy V]. While enroute to the call, I noted a person matching [R187's] clothing description near the intersection of [NAME] Street and N 5th Street, in the City of Black River Falls, [NAME] County, Wisconsin. I notified dispatch and made contact with the party who verbally identified self as [R187]. [R187] began to repeatedly ask me about a wallet that was lost. [R187] initially appeared agitated, so I began to ask [R187] about the wallet to calm [R187] down. Eventually [R187] calmed down at sat by the curb. I explained to [R187] that we were looking for [R187] and asked [R187] if we could give [R187] a ride back to the nursing home. [R187] agreed to this. [R187] eventually was picked back up by [Officer L], which ended my contact. At this time R187 was taken to the emergency room for evaluation. Emergency notes states: -Discharge Disposition: Patient will return to Meadowbrook facility where has been placed under and adult protective hold by adult protective services for [NAME] County. Patient has been medically cleared to return to that facility. Electronically signed 08/23/24 at 9:08 AM. On 08/23/24 at 9:48 AM, the facility entered a nurse's note that states in part, Wanderguard applied to resident's right wrist after returning from ER for eval. On 08/23/24, (no time stamp), a care plan was initiated which states, Focus: The resident is an elopement risk/wanderer. Disoriented to place, has a history of attempts to leave facility unattended, and has impaired safety awareness. Resident is protectively placed through [NAME] County due to emergency incapacitation from hospital. Adult protective services involved. Goal: the resident will not leave facility unattended through the review date. On 08/23/24 at 3:00 PM, treatment order for monitoring wanderguard was placed into chart for monitoring every shift of placement. Intervention/Tasks: Wander Alert - Wanderguard. Wanderguard will be checked every shift per MAR/TAR. On 08/23/24, the facility initiated 15-minute checks on R187 signed and time stamped by facility staff from 10:30 AM to 6:45 PM. Of note, R187's second elopement took place within 9 minutes from returning to building after the first elopement. The 15-minute check intervention had already proven to be an ineffective intervention for increased supervision to prevent R187 from eloping. 3rd elopement: On 8/24/2024 at 1:50 AM, a nurse's note was entered stating, Approximately 7:00 PM, [R187] walked out of room door; turned right; and walked through the alarmed door at the end of the 200 wing. Staff [CNA N] ran out the door following [R187] down the street. Another staff [DM F] got in car and followed [R187]. [NHA A] was called, as well as law enforcement since [R187] was not willing to come back with staff. Law enforcement took to HospitalER on a 72-hour hold. Protective Services was updated by law enforcement. Of note, ER states R187 presented to ER following event at 8:30 PM. On 10/08/24 at 12:14 PM, Surveyor interviewed CNA O regarding the third elopement. CNA O indicated later that evening on 8/23/24, she received a phone call at home from CNA P who was following R187 on foot. CNA P informed CNA O that R187 eloped and is really fast. CNA O got in car to assist in locating R187. CNA O stated R187 was observed weaving in and out of traffic on Main Street and was found at bottom of the Black River bridge. CNA O stated Civilian Z happened to be driving on the bridge and got out of car as well as CNA O. They approached R187 who was hanging onto bridge rails looking over into water and stated, If I jump here, I will survive, and making other comments about wanting to jump over bridge. Civilian Z scooped R187 up and moved R187 away from railing. Civilian Z and CNA O were able to calm R187 down and have him sit. Police arrived and took R187 to hospital. On 10/08/24 at 12:55 PM, Surveyor interviewed CNA P regarding the elopement event on the evening of 08/23/24. CNA P stated R187 was on 15-minute checks, not on 1:1 or line of sight that evening. CNA P stated she had clocked out of 12-hour shift (6:00 AM to 6:30 PM) but clocked back in because replacement CNA I, scheduled for 2:00 PM, had not yet shown up yet. When CNA I arrived at facility, CNA P saw R187 exit 200 wing emergency door and she followed R187 from the nursing home to the bridge on foot, while CNA I followed in car. R187 was running ahead of staff, dodging in front of cars, trying to get into parked cars, and walking down the middle of the road. On 10/15/24 at 1:54 PM, Surveyor interviewed CNA P via telephone regarding following R187 from facility to bridge. CNA P stated she was approximately a half block away from R187 and she was unable to prevent R187 from dodging between cars, attempting to get into cars or stop R187 from getting to the bridge. Police report for third elopement: On Friday, August 23, 2024, at approximately 7:08 PM, I, [Deputy V], was dispatched .for a report of a male party who had walked away from the nursing home. This male party was later identified as [R187]. It should be noted that I had previously dealt with [R187] earlier in the day when I was requested to come in and attempt a K9 track on [R187] as had left Meadowbrook Nursing Home but was later found. Dispatch advised Meadowbrook had called again stating had walked away from the building While enroute to the call, I heard [Trooper Y] advised was out with the [R187] near the intersection of Main Street and North Water where [R187] had attempted to jump off the bridge. Contact with [CNA O] and [CNA P]: Arrived at the above location and observed [R187] being held on to by [Trooper Y] and [Civilian Z]. During this time several unidentified individuals were on scene as well. I then asked to speak with [CNA P] who worked at the nursing home. [CNA P] explained to me that earlier in the day, [R187] had absconded from the nursing home which I was aware of. [CNA P] stated that evening, she went to go take care of another patient and saw [R187] just got up and took off. [CNA P] further stated that she then followed [R187] to where we currently were. I asked [CNA P] about [R187] jumping off the bridge to which she told me that [R187] kept saying that was going to do that and had attempted to do so. I asked [CNA O] if there were any locked doors or if [R187] could just walk out to which she told me [R187] could just walk out. I later learned [R187] had an alert bracelet that would alert staff if [R187] left the facility however, they would not physically stop a patient. [CNA O] stated that the facility did not have the manpower to deal with [R187] constantly running away. I asked [CNA O] where [R187] was before their facility to which she told me the hospital and [R187] had left there twice. Contact with [Civilian Z] I then spoke with retired officer [Civilian Z] who followed [R187] all the way from Falls Florists near South 7th Street and followed [R187]. [Civilian Z] stated as [R187] came near the intersection of Main and Water, [R187] then went into the oncoming lane and started making statements was going to jump off the bridge. [Civilian Z] stated since the nursing home staff was not close enough to stop [R187], [Civilian Z] intervened and stopped [R187] before [R187] made it over to the railing. [Civilian Z] stated once grabbed a hold of [R187] who stayed still. R187 was taken to the hospital at this time and did not return to the facility. On 10/09/24 at 6:43 AM, Surveyor toured the route as given per staff interviews and made these observations on what route R187 would have taken: R187 ran from the facility towards the bridge that overlooks the local river, approximately 1.4 miles from the facility. R187 would have been subject to traffic dangers as well, as this is a busy intersection with a three way stop and no stop-sign for vehicles leaving the downtown area. R187 made it to the bridge. The road is called I-94 alternative (intersection for state road 54 and 12 and is 40mph over the bridge and 25mph in the downtown area). The bridge overlooks the Black River and is over three stories high. The ground under the bridge is very rocky with a shallow river that comes from the Black River dam. The railing for the bridge is about 3' high and can easily be climbed over. There are no safety nets or high fences to prevent jumping. On 10/09/24 at 8:22 AM, Surveyor interviewed Chief Nursing Officer (CNO) M who first stated that facility was not aware that R187 eloped at the hospital prior to admission. At 9:10 AM, CNO M clarified the hospital referral paperwork indicated R187's elopement from the hospital. CNO M stated she had no idea why they accepted this resident. It was the job of DON AA to look at the acceptance paperwork, and DON AA left three days later; CNO M's assumption was that the acceptance paperwork was not looked at well. Surveyor asked CNO M if R187 had a wanderguard in place during the first and second elopements. CNO M stated that RN X referenced a wanderguard in written statement. Surveyor reviewed RN X's written statement. RN X's statement located in the facility soft file stated: Resident returned to facility at 7:10 AM, by police. Staff noted when returning to facility at 710 AM, by police, staff noted when returning he did not have the wanderguard on L wrist. [R187] did have wanderguard on L wrist when [R187] was eating sandwich at 4:25 AM. CNO M further indicated that RN X was new to the facility and when RN X heard the wanderguard, RN X was not aware where to look. CNO M indicated the facility should not have taken R187, as they did not have the staff to do 1:1 observations, which is why they did implement the 15-minute checks after the second elopement. On 10/16/24 at 2:44 PM, Surveyor interviewed Medical Director (MD) S, who has been the facility's medical director for the past [AGE] years. MD S stated has not been made aware of any resident elopements within the past few months. MD S stated would anticipate that the facility would work with the resident's primary physician to determine interventions in order to keep a resident safe. On 10/14/24 at 4:01 PM, Surveyor interviewed DON B regarding expectations of process to be completed upon becoming aware a resident is an elopement risk. DON B stated that when the facility is made aware of an elopement risk, especially when the Director of Nursing at the time was aware of R187's elopement attempts prior to admission, would expect an assessment would immediately be completed, a wanderguard placed on resident, documented in resident's chart, treatment record updated for every shift monitoring, physician made aware along with resident and/or representative, and would expect a baseline care plan developed that includes triggers and interventions. The facility's failure to ensure a resident with a known history of elopements had the supervision to prevent accidents created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 08/23/24. On 08/26/24, the facility identified the deficient practice that occurred when the facility staff did not provide increased supervision after a resident eloped from the building. The facility took steps to correct the deficient practice and ensure compliance starting on 08/26/24. The immediate jeopardy was removed on 08/26/24 and corrected on 08/27/24 when the facility completed the following: The immediacy was removed on 8/26/24 when all staff education was provided that included the following: When a resident displays exit seeking behavior, supervision should be provided. Supervision includes: -resident being assisted to a common area. -resident engaged in activities of interest. -resident provided psychosocial support. -resident family contacted and included if able. -increased visits from facility managers. -staff coordination on who will be providing the increased supervision and for how long and when to provide relief. -if resident behaviors continue increased 1:1 support may be needed per staff discussion which includes DON/NHA/designee. Wanderguard does not replace supervision. Staff should be proactive and increase supervision as needed when resident displays exit seeking behavior. Staff should contact DON/NHA/designee for additional support and guidance. All elopement risk assessments were updated. All elopement residents' care plans were updated. Based on this determination, the citation is being issued as past non-compliance

Based on observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. Milk and juice, placed in the walk-in-cooler, had been opened but were not labeled with an opened date or use by date. Daily temperature logs for recording refrigerator and freezer temperatures had missing entries, resulting in the potential for foodborne illness to spread. This had the potential to affect 31 out of 32 residents that eat orally. Findings include: The facility's policy entitled Storage, Prepare, Distribute and Serve Food dated April 2020, states in part, 1. Temperatures a. Refrigerator/Freezer Temperature Log (FS-04/A) must be completed and reviewed on a daily basis . 3. Storage (Refrigerated) .c. All refrigerated and prepared food must be covered, labeled, and dated with a use-by date that is the maximum of 7 days from date of preparation. Label must include the name of the food and the date by which it should be used. On 10/06/24 at 10:33 AM during initial kitchen tour with Dietary Manager (DM) F, Surveyor observed two, gallon containers of opened milk and two, gallon containers of opened juice on a serving cart in the walk-in cooler. The milk and juice containers had not been labeled with an opened on or use by date by kitchen staff. On 10/06/24 at 10:42 AM, Surveyor requested to see the refrigerator/freezer logs. Upon review Surveyor noted that freezer entries for the dates of 10/05/24 were missing for freezer #1 and freezer #2. On 10/06/24 at 10:38 AM, Surveyor interviewed DM F regarding expectations for the opened milk and juice in the walk-in cooler. DM F said they would expect that milk and juice to be labeled with the used by date when it was opened, and the facility has stickers which they use to write used by dates on and stick on food when it is opened. On 10/06/24 at 10:45 AM, Surveyor interviewed DM F regarding temperature log expectations. DM F stated the expectation is that the temperatures of the refrigerators and freezers are recorded twice a day and that was not being done.

Based on interview and record review, the facility did not formulate an advance directive for the resident. Resident (R) 236 did not have orders for the advanced directive they elected for on file, or in a place for emergency personnel to retrieve the information if needed. This had the ability to effect 1 of 12 residents surveyed (R236). Findings include: The facility policy, entitled Advanced Directives, dated [DATE], states: Documentation . 1. Copied of any advanced directives are maintained in the residents clinical record. 2. The facility must document in a prominent part of the residents clinical record whether the resident has issues an advanced directive R236 was admitted on [DATE] to the facility and is able to be understood by peers and understands. On [DATE] at 1:39 PM, record review of R236's hard charts and electronic record could not produce an order for a Cardiopulmonary Resuscitation (CPR) or Do - Not - Resuscitate (DNR). Surveyor could not find a provider order related to advanced directives. On [DATE] at 1:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN) L regarding the process for determining a resident's advanced directives. LPN L stated they would first look at the electronic record; below the resident's picture there should be a gray area that states Do Not Resuscitate or Full Code. The other place they look is in the Post Book which has advanced directive documentation organized by room location. On [DATE] at 1:50 PM, Surveyor reviewed the hard charts again and did not find any advanced directive designations. Surveyor did not find the advanced directive documentation in the books by the nurses station either. On [DATE] at 2:00 PM, Surveyor asked LPN H to look and see if Surveyor had missed the advanced directive documentation in the books at the nurses station. LPN H did not see documentation and directed the Surveyor to another staff member whose role was to put the directives in the book. On [DATE] at 2:07 PM, Surveyor interviewed Medical Records (MR) C regarding hard copies of advanced directive notification. MR C said they could not initially find the yellow form, but normally they would expect the form to be placed in the advanced directive book at the nurses station immediately. On [DATE] at 2:35 PM, Surveyor interviewed Chief Nursing Officer (CNO) M regarding procedure for advanced directives. CNO M stated they would expect there to be doctor orders, face sheet documentation in the electronic medical record, and a Physician Orders for Scope of Treatment (POST) sheet located at the nurses station. CNO M further mentioned they also looked and could not find the items required for R236's advanced directives in the proper places.

Based on observations, interviews, and record reviews, the facility did not consult with a physician for 1 of 3 residents (R) R26 who had experienced a significant weight gain. This is evidenced by: The facility policy entitled Change in Condition Policy: dated August 2024 states: The purpose of this policy is to ensure the facility promptly consults the physician when there is a change requiring notification. Procedure - .The physician will be notified when there has been a change that is marked a difference in usual sign/symptoms. Specific information that requires prompt notification include . significant weight change gain or loss of 5% or more in the past 30 days, 7.5% or more in past three months, or 10% or more in the past six months. R26 was admitted to facility on 11/15/23, and has diagnoses that include Alzheimer's disease, hypertension, and chronic pain. R26 has a BIMS of 7, indicating moderately impaired cognitive level. R26's Quarterly Minimum Data Set (MDS) with target date of 05/23/24, Section K: weight 178#. R26's MDS with target date of 08/23/24, Section K: weight 189#. indicating a weight gain not on a physician prescribed weight gain regimen. R26's care plan dated 09/22/24, with a target date of 11/15/24, states: Resident has nutritional problem or potential nutritional problem d/t risk for variable intakes r/t Alzheimer's disease and chronic pain. Goal: Resident will maintain adequate nutritional status as evidenced by no significant weight changes. R26's physician orders dated 07/10/24 states: Weights weekly on shower day, every Sunday. On 10/07/24 at 12:40 PM, Surveyor reviewed R26's weight record which showed on 08/02/2024, the resident weighed 178.6 lbs and on 09/04/2024, the resident weighed 191.4., indicating R26 had a weight gain of 7.2% in one month. The facility was aware of the weight changes, as the record provides information of the percentage of weight changes as weights are entered into facility computer system. On 08/22/24 at 1:14 PM, R26's weight was recorded as166.6#, but was stricken out on 08/26/24 at 3:30 AM, by Nursing Home Administrator (NHA) A due to Data Entry Error. On 8/22/2024 at 1:17 PM, facility entered a Nursing Progress New order resident to have daily weights x 5 days to get an accurate weight. Resident showing weight loss. Primary Care Provider (PCP) updated with findings and to be updated after the 5 days of weight. Of note, R26's previous weight prior to PCP being updated was documented on 08/02/24 at 178.6#. R26's weights for the 5 days recorded shows: 8/23/2024 - 189.2 lbs 8/24/2024 - 190.4 lbs 8/25/2024 - 190.2 lbs 8/26/2024 - 191.8 lbs 8/27/2024 - 191.4 lbs On 10/07/24 at 12:40 PM, Surveyor reviewed R26's medical record and was unable to locate documentation to support PCP was updated of weight results. On 10/07/24 at 2:53 PM, Surveyor interviewed Assistant Director of Nursing (ADON) G regarding R26's significant change in weights from 09/08/24 - 09/20/24. ADON G, stated, I know, - the physician order to obtain weights for 5 days, was obtained due to weight discrepancies between 08/22/24 to 08/25/24. ADON G stated the PCP was not updated regarding weight gain after the 5 days per order. On 10/08/24 at 6:25 AM, ADON G reported to Surveyor that PCP was updated on 10/07/24 regarding R26's weight gain and is awaiting response.

Based on observations, interviews and record review, the facility failed to ensure each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident reviewed for restraints (R3). R3 had a lap belt in his wheelchair without a physician order for use, the medical symptom the lap belt was being used to treat, or an assessment to determine appropriateness of its use. The device was not indicated in R3's care plan. This is evidenced by: The facility's policy titled Restraint Management, read in part .If indicated, the least restrictive restraint is used for the least amount of time. In cases where restraints are implemented based on the resident's assessment, the facility will make reasonable efforts to reduce their use systematically and gradually. Physical restraints include, but are not limited to, leg restraints, arm restraints, soft ties, lap cushions, and lap trays the resident cannot remove easily. Also included as restraints are facility practices that meet the definition of restraint, such as .Using devices in conjunction with a chair, such as trays, table, bars or belts, that the resident cannot remove easily that prevent the resident from rising. Use of restraint upon admission. If the resident is admitted with orders for a restraint, the staff may accept the order for up to 72 hours pending completion of the Pre-Physical Restraint and Reduction Evaluation in the electronic medical record, provided that: the licensed nurse has consulted with the physician and documented the resident's history and the appropriateness of the restraint. The resident and/or his or her representative's authorization was received and documented, and the risks associated with restraint usage were reviewed. The reason for the restraint use was documented on the Nursing Initial Plan of Care. R3 was admitted to the facility on [DATE]; diagnoses included paralysis of left side of body following a stroke, inability to speak following a stroke, and dependence on wheelchair. The most recent Minimum Data Set (MDS) assessment competed on 07/15/24, confirmed R3 was unable to complete Brief Interview for Mental Status (BIMS), as he is rarely understood by others. Staff assessment for mental status was completed indicating R3's cognition was severely impaired. R3's Family Member (FM) E, is his activated Power of Attorney (POA). R3's MDS assessment indicated restraints were not used. R3 was dependent on staff for all activities of daily living (ADLs). R3's physician orders did not include an order to use a restraint. R3's care plan did not include use for a restraint. R3's electronic record did not include an assessment for indication for use of a restraint. On 10/06/24 at 1:41 PM, Surveyor interviewed R3 and FM E. Surveyor observed R3 sitting in a positioning wheelchair and wearing a seatbelt or lap belt across his waist. The belt was secured into a latch plate, similar to a seatbelt in a vehicle. FM E stated R3 received his wheelchair prior to being admitted to the nursing home. FM E stated the seatbelt was used, Because it came with the wheelchair, we just got in the habit of using it. I don't think he really needs it. Surveyor asked R3 and FM E if he was able to remove the seatbelt on his own. FM E prompted R3 to unlock the seatbelt. R3 moved his right hand towards the seatbelt but did not attempt to unlock or remove the device. On 10/07/24 at 12:12 PM, Surveyor interviewed Certified Nursing Assistants (CNA) I and CNA J. CNA I and CNA J reported they do use the seatbelt when placing R3 in his wheelchair. CNA I and CNA J were unable to report why R3 needed a seatbelt in his wheelchair. CNA I and CNA J stated R3 was able to release the seatbelt at one time, but R3 had not been able to do this for a while. On 10/07/24 at 1:26 PM, Surveyor interviewed Assistant Director of Nursing (ADON) G. ADON G reported the facility should be restraint free. If a resident did require a restraint, the resident should be assessed for use of the restraint, daily monitoring should be completed in the resident's treatment administration record, and re-assessments should be completed at least quarterly. ADON confirmed there was no documentation in R3's record to support the use of a restraint. ADON stated she assessed R3 and removed the restraint from his wheelchair, as R3 did not require the use of the restraint.

Based on interview and record review, the facility did not ensure that 2 of 3 residents (R1 and R6) at high risk for pressure ulcer development, received the necessary treatment and services needed to prevent the development of a pressure injury. R1 was admitted to the facility with a brace and ace bandage on her leg. R1 was identified as being at risk for pressure injuries and a care plan was not developed. The facility did not assess the skin under the brace/ace bandage routinely, which lead to multiple pressure injuries. The pressure injuries became infected, which required R1 to be hospitalized and have a surgical procedure and antibiotics. Facility failure to assess R1's skin under her brace/ace bandage routinely led to the development of multiple pressure injuries which created a finding of immediate jeopardy that began on 05/15/24. Surveyor notified Nursing Home Administrator of the immediate jeopardy on 07/03/24 at 1:20 p.m. The immediate jeopardy was removed on 07/05/24. However, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan and as evidenced by: The facility did not follow R6's plan of care of placement of a right heel cup to prevent the redevelopment of a pressure injury. This is evidenced by: Example 1: The facility policy entitled, Pressure injury Prevention Guidelines, dated 2022, states in part: Inspect skin underneath medical devices at least twice daily. Keep skin clean and dry underneath. Adjust the device as needed for proper fit. The National Pressure Injury Advisory Panel prevention and treatment of pressure ulcers/injuries quick reference guide 2019 recommendations for device related pressure injuries: Assess the skin under and around medical devices for signs of pressure related injury as part of routine skin assessment. Reduce and/or redistribute pressure at the skin-device interface by regularly rotating or repositioning the medical device and/or the individual. Providing physical support for medical devices in order to minimize pressure and shear. Removing medical devices as soon as medically feasible. Provide high-calorie, high-protein, arginine, zinc and antioxidant oral nutritional supplements or enteral formula for adults with a category/Stage II or greater pressure injury who are malnourished or at risk of malnutrition. R1 was admitted to the facility on [DATE] and has diagnoses that include displaced fracture of the right ulna, fracture right tibia, right tibial plateau fracture repair, falls, subdural hematoma, weakness, atrial fibrillation, and lymphedema. Hospital discharge instructions included tibial plateau fracture repair. Keep cast/splint clean and dry. Weight bearing instructions right lower extremity: toe touch weight bearing. Follow up in 2 weeks for wound check, staple removal. The facility did not clarify discharge instructions for removal of leg brace. 04/18/24 Braden states - bedfast resident is completely immobile does not make even slight changes in body or extremity position without assistance .Braden score 12 High Risk. Additional clinical suggestions: is left blank. Minimum Data Set (MDS) 5 day admission assessment, dated 04/24/24, documented a brief interview of mental status score of 13, cognitively intact. The MDS documents R1 as being dependent on staff for bed mobility and transfers, at risk for pressure injuries and no current pressure injuries. The MDS did not document pressure reducing devices, no turning repositioning program, and no nutritional or hydration interventions were utilized. R1's care plan on admission does not mention skin. No interventions are listed or put into place on the plan of care in relation to skin or prevention of pressure injuries throughout the resident's stay. The initial and final care plans for R1 read the same. Resident has limited physical mobility. Goal: Resident will increase level of mobility through next review, approaches approach resident offer assistance to the bathroom every 2-3 hours around the clock. Per resident please wake up every 2-3 hours to offer bathroom assistance - 2 assist with full body lift. Resident experiences isolation due to being non weight bearing and fear of the hoyer resident will express feelings of around loneliness and isolation when she feels them. Encourage resident to express feelings. R1's treatment administration record (TAR) for April states, Keep cast/splint dry three times a day - this is initialed three times daily, beginning on April 19. Weight bearing instructions: RLE [Right lower extremity], to [should be toe] touch weight bearing, every shift - this is initialed three times a day beginning on April 18. R1's progress notes state in part: 04/18/24 - pain lower Right lower leg: 1 aching, daily Clinical admission details: dated 04/18/24 - right lower leg skin issue: Brace in place . (Surveyor was unable to locate admission skin assessment of the right lower leg.) 04/19/24 - pain in lower legs 7/10 and received scheduled Tylenol - effective 04/21/24 Resident remained in bed all shift complaint of lower legs hurting her a little bit per her usual PM complaint. Pain Continues Low level relieved by Tylenol. 04/21/24 Skin only evaluation -external device removable - yes- External device removed and skin inspected - no. 04/25/24 Progress notes, Resident is bed fast all or most of the time, pain in right lower leg, resident position changed. Non medication interventions provided relief. 04/30/24 Progress notes, Right lower leg brace in place. 05/01/24 Resident seen at [clinic name] Ortho advance to toe touch weight bearing. (This was actually in place on initial admission information.) Nursing progress notes state 05/03/24, Call to Ortho for clarifications for removal of brace. Per Ortho MD brace can be removed while in bed. Brace must be on for all transfers in the unlocked position. 05/10/24 Right lower leg: Brace in place. 05/12/24 Right lower leg: Brace in place. 5/12/24 Resident stayed in bed. Resident refused to have brace removed from right lower extremity. The facility did not document skin assessments for under the right leg brace between 05/03/24 when confirmation to be able to remove brace and 05/14/24. Pressure Injury Tools, dated 05/15/24, read in part: Right inner thigh, 3 areas, this is most superior. Pressure injury 1, length 11.3 cm by width 1.4 cm depth 0 - Deep tissue Pressure injury - skin closed deep purple, almost black necrotic area - plan/treatment - monitor on TAR until healed. Assess for signs and symptoms of infection. Interventions - nutrition or hydration intervention to manage skin problems. Pressure injury 2, Right inner thigh, middle area, length 6.5 cm by width 7.8 cm depth 0 - deep tissue Pressure injury - skin closed, necrotic tissue present 100% deep purple, almost black necrotic tissue noted, almost like blood blister, no open areas. plan/treatment - monitor on TAR until healed. Assess for signs and symptoms of infection. Interventions - nutrition or hydration intervention to manage skin problems. Pressure injury 3, Right inner thigh, most inferior of three areas, length 1.5 cm by width 9 cm depth 0 Deep Tissue Pressure Injury- skin closed necrotic tissue present - dark purple, almost black, appears to be blood blister or necrotic area from improperly applied ace bandage no open areas. plan/treatment - monitor on TAR until healed. Assess for signs and symptoms of infection. Interventions - nutrition or hydration intervention to manage skin problems. Physician notification form dated 05/15/24 notes 3 areas of concern on her inner right thigh. 1. Measures 11.3 cm x 1.4 cm 2. Measures 6.5 cm x 7.8 cm 3. Measures 9 cm x 1.5 cm All areas are dark purple/black, appear to be necrotic areas from ace bandage. Peri-wound area is red, but blanchable. Resident reports burning and pain when touching area. Lotion was applied and ace wrap re-wrapped. MD responded to notification on 05/30/24: Evaluated today will likely need debridement but recommend eval and treat by wound care center and nursing. Keep ace wrap/tubi grips off wound area, Finish ABX last day today. (This antibiotic began on 05/24/24) Continue Tylenol prn for pain. Clinic note, dated 05/16/24, a fax message from the facility to clinic: 3 areas of concern on her inner thigh measuring 11.3 x 1.4 cm, 6.5 cm x 7.8 cm, 9 cm x 1.5 cm. All areas are dark purple/black appear to be necrotic areas from Ace bandage. Physician Assistant (PA) I requested more information about the areas from the facility. 05/16/24 Progress Notes - Right lower leg: Brace in place Clinic note, dated 05/17/24, telephone message from License Practical Nurse (LPN) D to the clinic. Discolored spot update. Right leg looks more like a bruise behind right knee. Area is not open, just bruised, no blisters, not necrotic. Painful to touch .looks like the brace was rubbing causing pressure in this area. Patient wanting to stay in bed due to the hoyer lift straps rub/sit on the sore, bruised area. PA I responded to continue with efforts to offload pressure at the site. Clinic note, dated 05/23/24, message from Medical Doctor (MD) J to facility: Possible cellulitis. She had an abrasion to her right upper leg and developed some surrounding redness, tenderness, induration. Appears to be a cellulitis. Empiric antibiotic recommended. Escalate therapy to clinic or emergency department visit if worsening. MD J ordered to start Cephalexin Capsule 500 mg every 6 hours for 7 days. Physician notification form dated 05/29/24 had no information from the facility only had a physician's response. The response documented to consult wound clinic for medial knee wound and wound care to medial knee with ABD, gauze and bacitracin as needed. Pressure injury tools dated 05/30/24 read in part: Pressure injury 1, Right medial anterior thigh, length 3.5 cm width 8 cm depth .1 cm unstageable pressure injury - necrotic tissue present - 100% black Eschar, summary of findings - worsening - md notified, plan/treatment monitor in TAR until healed, assess for signs and symptoms of infection, heel protectors, float heels off bed, specialty mattress, roho cushion, leg protector, pressure reduction device for chair, pressure reduction device for bed, pad equipment, lie down after meals, maintain wheelchair position, nutrition hydration intervention to manage skin problems. Pressure injury 2, Right medial posterior thigh, length 1.5 cm width 2 cm depth 0 cm - unstageable - necrotic tissue present 100% eschar /black initial documentation was entered as a DTI but is not due to thick layer of eschar with charcoal appearance of skin. Infection suspected, yes, remains on antibiotic for cellulitis unchanged plan/treatment monitor in TAR until healed assess for signs and symptoms of infection, heel protectors, float heels off bed, specialty mattress, roho cushion, leg protector, pressure reduction device for chair, pressure reduction device for bed, pad equipment, lie down after meals, maintain wheelchair position, nutrition hydration intervention to manage skin problems. Pressure injury 3, Right posterior thigh fold, length .7cm width .4 cm depth .1 cm stage 3 pressure injury granulation tissue present slough tissue present 20% slough 80% granulation. Pressure injury 4, Right calf, length .2 cm width 2.5 cm depth 0 Deep tissue pressure injury closed 100% dark purple maroon discoloration non blanchable skin- unchanged - plan/treatment monitor in tar until healed assess for signs and symptoms of infection , heel protectors, float heels off bed, specialty mattress, roho cushion, leg protector, pressure reduction device for chair, pressure reduction device for bed , pad equipment, lie down after meals, maintain wheelchair position, nutrition hydration intervention to manage skin problems (none of these listed interventions were added to the plan of care). Doctor notified. A fax from MD F on 05/31/24 with orders to coordinate surgical consult for right upper leg wound needing a surgical debridement. Physician notification form sent to doctor on 05/31/24, medical device related pressure injuries. 1. Right thigh x 2 - unstageable 1. Medial anterior: 3.5 x 8 cm total area of 100% eschar. Small area where eschar is peeling back had depth of 0.1 cm 2. Medial posterior: 1.5 cm x 2 cm total area black 100% eschar. 2. Right posterior thigh fold - Stage 3 Area measures 0.7 cm x 0.4 cm x 0.1 cm, wound bed 80% granulation / 20% slough. Light serosanguineous drainage noted. 3. Right lower calf - DTI (Deep tissue injury), Area measures 0.2 cm x 2.5 cm. No drainage dark purple/maroon no blanchable. Requested: Can we start Juven oral packet 1 packet po BID (two times a day) for wound healing. Can we get orders for right calf DTI to apply skin prep and cover with bordered foam every Monday/ Wednesday/ Friday. Right thigh unstageable Pressure Injury x 2 cleanse with normal saline pat dry apply bacitracin to any open areas cover with ABD pad and secure with tape BID and PRN until wound clinic appointment? Right posterior thigh fold - cleanse with normal saline, pat dry, calcium alginate ag to wound bed, zinc to surrounding tissue and cover with ABD pad daily and prn. MD F gave orders for referral to general surgery. Agreed with wound care nurse recommendations. The facility's physician notification form, dated 06/03/24, documented PA I gave new order for right lower extremity to cleanse and cover with nonadherent pad daily prn with gauze and bacitracin until seen at wound clinic. Initial wound care consult dated 06/04/24: Right anterior lateral shin: Patient noted to have approximate 3+ lymphedema without active lymphorrhea. Unstable eschar, this was removed revealing an ulceration that is full thickness. No evidence of clinical infection at this time. Wound: Right anterior lateral shin 1.2 cm x 0.5 cm x 0.1 cm - debridement, wound culture obtained. Medial posterior right proximal calf: Full thickness ulceration covered with approximate 40% non-adherent and non-stable eschar with surrounding slough and bioburden. Removed eschar, bioburden and slough exposure of subcutaneous fat, no evidence of muscle, tendon, nor bone exposure. Mild odor. Wound: 7.4 cm x 9.2 cm x 1.2 max depth - varying. Wound culture obtained. The furthest posterior extent there is a satellite ulcer that is separated by a small skin island between the primary ulcer and this satellite ulceration. Covered in 100% eschar. Removed eschar, no evidence of muscle, tendon, nor bone exposure. No evidence of granulation tissue, but the base appears viable. Right proximal medial calf - posterior satellite ulcer wound: 2.5 cm x 3.5 cm x 1.0 cm Mild odor. Visit diagnoses: Primary: Pressure injury of right posterior calf, stage 3. 06/04/24 Juven nutritional supplement was ordered and began 20 days after the pressure injury was first noted. Pressure Injury Tools dated 06/06/24 read in part: Pressure injury 2, Right Medial posterior thigh push tool merged into right medial anterior thigh after debridement at wound care clinic. Both wounds now charted on PUSH tool 1. Length 0 width 0 and depth 0 unstageable pressure injury, obscured full thickness skin and tissue loss, The facility was unable to locate or provide Surveyor with a push tool for pressure injury #1 on this date. Pressure injury 3, Right posterior thigh fold, length .3 width 2 cm depth .1 cm stage 3 pressure injury: Full thickness skin loss. Granulation tissue present, slough tissue present, 10% slough 90 % granulation, moderate, serosanguineous drainage - worsening - antibiotic started- new wound care orders obtained. Peri wound tissue improved but total size larger than last week. Pressure injury 4, Right calf, length .2 width 1.5 depth 0 Deep tissue injury: persistent non-blanchable deep red, maroon or purple discoloration, closed 100% dark purple/maroon. Non blanchable. Improving. Improvement noted with current treatment orders. Will continue to monitor. Physician notification form, dated 06/10/24, MD F responded with a referral made to [Name] wound center follow-up there within the next week. Clinic note, dated 06/11/24, telephone message from facility staff LPN L to the clinic requesting more pain medication. MD F provided orders for tramadol 50 mg every 8 hours prn, 1000 mg Tylenol every 6 hours scheduled. Clinic note, dated 06/12/24, telephone message from facility staff to the clinic requesting pain medication for wound care and scraping. MD K provided orders of Hydrocodone-Acetaminophen 5-325 mg every 6 hours for 5 days. Pressure Injury Tools dated 06/13/24 states in part: Pressure injury number 1, Right medial thigh, length 7.4 cm width 13 cm depth 1 cm - unstageable pressure injury: obscured full thickness skin and tissue loss. Adipose tissue, granulation tissue present, slough tissue present. 10% gran, 90% slough/adipose tissue/eschar. Purulent heavy drainage, odor present- new onset of erythema, induration, warm to touch increased tenderness and odor with purulent drainage. Resident sent out to Hospital due to acute wound decline. MD updated and aware and gave orders to send out. Pressure injury number 3, Right posterior thigh fold, length .3 cm width 1.5 cm depth .1 cm - Stage 3 pressure injury: Full thickness skin loss, granulation slough tissue present. 10% slough, 90% granulation, moderate serosanguinous drainage present, improving. Sent out to hospital d/t acute change in wound with decline. Pressure injury number 4, Right calf, length .2 cm width 1 cm depth 0 cm. Deep tissue injury, closed, faded discoloration noted with improvement. Sent out to hospital d/t acute change in wound with decline. Pressure injury number 5, date acquired 06/13/24 Left medial thigh length 1 cm, width 2 cm, depth 0, unstageable pressure injury: obstructed full thickness skin and tissue loss. Necrotic tissue present 100% obscured due to eschar. First observation, sent out to hospital d/t acute change in wound with decline. 06/13/24 progress note: discharged - to hospital, doctor aware due to wound decline. Right medial thigh wound larger, strong foul odor, increased pain tenderness, increased drainage. Chills and sweating. 06/14/24 clinic communication - Resident admitted to hospital for wound that is not healing. Hospital documentation: 06/13/24 Hospital diagnosis: Infected wound right thigh .right thigh wound culture growing E.coli and Pseudomonas. Patient taken to the Operating Room (OR) on 06/14/24 for wound debridement. History of present illness: .Her wound originated apparently secondary to bracing after treatment to surgically repair a tibial plateau fracture after a fall . Physical exam: There is a large lesion on the right medial thigh approximately 10 x 18 cm, deep down to the subcutaneous fat and some areas in through the subcutaneous fat near the layer of the muscle and other areas. There is eschar present inferiorly and there is odor present. There is a second lesion in the left medial thigh a 1.5 cm diameter eschar with a little surrounding erythema . Medical decision making: The wound appears significantly deeper than was 3 days ago .A culture from 3 days ago revealed that the wound grew polymicrobial flora .a repeat culture was ordered . Assessment/Plan: Patient started on cefepime and vancomycin. 06/14/24 Surgical progress note in part: Resident has a large necrotic wound of the right thigh .the wound was several centimeters deep . I then used a 15 blade to debride black eschar .There was necrosis of the subcutaneous fat which was debrided out with a 15 blade . On 07/02/24 at 4:15 PM, Surveyor interviewed LPN D and Registered Nurse (RN) E. LPN D stated that staff was not looking at skin underneath the brace/ace bandage and did not remove the brace or ace bandage until after receiving an order that the brace could be removed on 05/03/24. LPN D stated that she was not shown or taught how to remove the immobilizer brace. RN E stated that the last two weeks of May the brace was off. LPN D stated the resident would refuse to have the brace removed. Surveyor's review of documentation revealed this was rarely documented. Surveyor asked what interventions were put into place to prevent R1's pressure injuries. RN E indicated R1 had a full pressure reduction bariatric air mattress in place and used pillows for repositioning. LPN D stated at times she used a rolled-up towel between R1's legs. They indicated R1 had a Roho cushion in her wheelchair, but she rarely got out of bed. RN E stated they started the Juven supplement (a nutritional supplement used to aid in healing) on 06/04/24. On 07/02/24 at 6:50 PM, Surveyor interviewed Nursing Home Administrator (NHA) B who stated a skin assessment should have been done on admission, including looking at the skin underneath the brace and ace bandage. When asked if skin under braces and ace bandages should be inspected routinely, NHA B stated, Yes. On 07/03/24 at 12:55 PM, Surveyor interviewed MD F who stated she first saw R1's wounds on 05/30/24, to the best of her recollection. Surveyor asked if she was aware the facility had not been inspecting R1's skin under the brace and ace bandage. MD F stated she was not aware one way or the other. Surveyor asked if R1's wounds would have been preventable if facility staff were removing the ace bandage and brace and assessing R1's skin. MD F stated probably. The failure to put measures in place to prevent the development of a pressure injury and to promote the healing of pressure injuries created a reasonable likelihood of serious harm which led to a finding of immediate jeopardy that began on 05/15/24. The facility removed the immediate jeopardy on 07/05/24 when it had completed the following: 1. Provide education to all nursing staff on skin policies and procedures, including admission [NAME] assessments, and implementing orders to check skin under medical devices daily for signs of pressure related injuries, and timely updates with new skin issues/breakdown with orders obtained and care plans updated. 2. Provide education to the Interdisciplinary Team (IDT) on new admission review to ensure skin assessments are completed and schedule is in place in the treatment administration record (TAR) to check under any medical device daily for signs of pressure related injuries. 3. Provide education to all nursing staff, minimum data set (MDS) coordinator, and IDT on ensuring care plans with specific interventions are implemented for all residents at risk of developing pressure injuries. Education including review of care plans, evaluations of effectiveness of interventions, and addition of new interventions if needed. 4. Perform a facility-wide skin sweep by 07/05/24 to ensure all residents at risk for pressure injuries have care planned interventions, all current skin conditions are documented and on the weekly wound tracking document, and any new skin concerns are identified, and the physician and resident's power of attorney (POA) if applicable are updated with orders obtained and care plan updates are made. 5. Director of Nursing (DON)/designee will conduct new admission audits daily to ensure orders are in place to check under medical devices for those utilizing x 4 weeks, then weekly x 4 weeks. 6. DON designee will conduct weekly audits x 4 weeks, then bi-weekly x 4 weeks, of resident care plans to endure interventions are in place and effective for those at risk for pressure injuries. 7. Medical devices added to IDT daily clinical board to ensure orders in place for skin monitoring. 8. The results of all audits will be brought to monthly quality assurance performance improvement (QAPI) meeting to determine effectiveness and if additional audits or education are needed. Example 2: R6 was admitted to the facility on [DATE] with unspecified dementia, type 2 diabetes, and failure to thrive. R6's care plan dated 01/12/24 states, The resident is at risk for pressure injury r/t (related to) decreased mobility, muscle weakness, and presents of pressure ulcer. On 04/05/24, R6 received an order for R (right) Heel cup to right heel at all times for pressure relief. Check for placement each shift. On 07/05/24, facility updated order to continue R heel cup to right heel at all times for pressure relief. Check placement each shift. On 07/10/24, Surveyor reviewed Treatment Administration Record (TAR) which was signed off each shift during the month of July 2024 of having R heel cup in place. On 07/10/24 at 1:15 PM, Surveyor was unable to visualize R heel cup as resident was wearing shoes. On 07/10/24 at 1:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA) G regarding the R heel cup for R6. CNA G stated not recalling the last time she had seen the heel cup as the area is healed. On 07/10/24 at 1:45 PM, Surveyor interviewed LPN D regarding the R heel cup. LPN D stated R6 has been getting out of bed more lately and has not been wearing the heel cup as he is wearing shoes. LPN D stated would contact hospice to have discontinued. On 07/10/24 at 1:50 PM, Surveyor interviewed RN H, who indicated the order for heel cup has been discontinued. On 07/11/24 at 5:56 AM, Surveyor received further information from RN H, indicating R heel wasn't a true DTI, but a discolored area. The order for the heel cup was put in place, and then three weeks ago R6 started getting up more, going outside more and wearing shoes. The heel cup needed to be taken off when wearing shoes. The facility failed to adjust the order to read wear the heel cup when in bed with his heel boots.

Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for wandering and elopement potential. R1 is severely cognitively impaired and has an Activated Power of Attorney for Health Care (APOAHC). R1 eloped from the facility on 8/31/22. On 9/12/22, R1 eloped again and was found by a member of the community by the road near the facility. The facility did not have a care plan in place for R1 detailing how the facility would keep R1 safe and prevent future elopements. The facility's failure to provide adequate supervision to R1 and ensure all the alarmed doors were armed created a finding of Immediate Jeopardy which began on 9/12/22. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 9/21/22 at 11:00 AM. The Immediate Jeopardy was removed on 9/21/22; however, the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility implements its removal plan. Findings include R1 was admitted to the facility on [DATE] and has diagnoses that include dementia without behavioral disturbance and fracture of T9-T10 vertebra. His most recent MDS (Minimum Data Set), dated 9/5/22, shows a BIMS (Brief Interview for Mental Status) of 3, indicating R1 is severely cognitively impaired. A wander risk review, completed on 8/29/22, shows R1 to have a score of 8. The facility deems any score above 4 to be high risk and in need of a care plan and safety interventions. R1's admission on 8/29/22 came after a hospital stay that was prompted by a fall at home resulting in the multiple vertebra fractures. R1 also experienced a fall at the facility on 9/4/22, without injury. R1 uses a wheelchair to move around the facility but is a contact guard assist of 1 staff when using a four-wheeled walker and gait belt, per Surveyor interview with PTA H (Physical Therapy Assistant) on 9/20/22 at 4:00 PM. The facility sits along a road in a residential area and is across the street from the town's high school, which also holds a football field, soccer field, and baseball fields on its grounds. Additionally, a family playground, park and small waterpark are connected to the high school complex. The facility's main entrance is locked at all times, and does not alarm unless a resident with a wanderguard attempts to exit through that door. Alarms sound when doors at the end of the 100 and 200 halls are opened, regardless of wanderguard. The facility's elopement policy, dated October 2020, states the following: * Missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility or has wandered away from the group during scheduled community outing. The resident shall not be designated missing or eloped if he/she is seen leaving or walking away from the building or is seen by staff as a result of staff responding to an exterior door alarm. *All residents shall be reviewed for safety awareness impairment and elopement concerns upon admission, readmission, quarterly and as needed *Residents identified as a risk for elopement will be given an arm or leg adult monitoring device or placed on a secured unit. *All residents who are at risk for possible elopement shall be accompanied by staff, or responsible party, when leaving the facility grounds. *Residents at risk for elopement shall be identified on the elopement book, This book will have the list of all residents assessed to be at risk for elopement with their name, room number and photo. This book will be located in the receptionist area and one at each nursing station. This book will be updated whenever a new resident is added or taken off the list. On 8/31/22, R1 exited the building. An incident report, as documented by RN F (Registered Nurse), states, Resident exited front entry shortly after family visit. He parked his wheelchair at the inside main entrance doorway and walked out. Writer was able to convince him after a few minutes to come back in the building to visit with me. Resident stated, I'm not staying here, I'm leaving. A facility progress note, dated 9/1/22 at 2:01 PM states, Doctor notified 8/31 that resident was attempting to elope. Doctor states he would like us to continue to deescalate his attempts. On 9/14/22, AC C (Anonymous Citizen) reported to the state that on 9/12/22, while she was driving by the facility, she witnessed another citizen (AC D) trying to assist R1 to sit on a tree stump in the front of the facility near the road. AC C pulled over to assist in getting help from facility staff. In AC C's report, she states her, and AC D could both hear the alarm for the facility going off. AC C attempted to get staff to come out by knocking on the window and ringing the doorbell as the door was locked. AC C stated she rang the doorbell continuously for 15 minutes before staff came out to get R1. The nurse in charge at the time, RN G (Registered Nurse) states in a facility progress note, dated 9/12/22 at 8:18 PM, RN heard two door alarms down the 100 and 200 hall and responded. RN did not see anyone around the outside of either doors. CNA (Certified Nursing Assistant) was observed in front of the nurse's station wheeling the resident in his wheelchair. CNA reported she witnessed seeing resident's empty wheelchair next to the main entrance and went outside to look for him and found him at the end of the driveway sitting on a wooden log. The resident stated he was waiting for the bus. CNA walked resident back to the building and into his chair. RN called resident's son as requested by the resident. No facility evidence or documentation was found that indicates the facility contacted R1's physician. It should be noted that RN G was referring to CNA E. A facility progress note dated 9/15/22 and updated on 9/20/22 at 12:07 PM states, Discussion about a wanderguard for resident. HCPOA (Health Care Power of Attorney) in agreement with resident having a wanderguard as needed. R1's care plan states the following: Focus: The resident is an elopement risk/wanderer. Disoriented to place, impaired safety awareness, resident wanders aimlessly. Date initiated: 9/11/22, revision on 9/20/22 Goal: The resident will have no incidents of injury, date initiated: 9/20/22, The resident will not leave facility unattended through the review date. Date initiated: 9/20/20 Interventions/Tasks: Provide structured activities, redirect/reorient as needed/appropriate, Wander alert-wanderguard as needed. Date initiated 9/20/22 No elopement approaches or interventions were added to R1's CNA Kardex/care plan until 9/20/22. Surveyors interviewed RN G on 9/20/22 at 11:30 AM regarding the elopement on 9/12/22. RN G stated that when R1 was found by facility staff sitting on the log outside, a woman from the community was also there that was apparently worried about R1 because he looked confused. On 9/20/22 at 1:41 PM, Surveyors interviewed AC D, who stated on 9/12/22 at about 7:55 PM she was on her way back from a walk at the park attached to the high school complex, which is approximately 6 minutes walking distance from the facility. AC D stated she could see R1 from the park as she was making her way in the direction of the facility. AC D stated she saw R1 walking on the driveway with an abnormal gate. AC D stated it looked like R1 was having trouble. AC D stated that at first it looked like R1 was exercising and then as she got closer, thought no, he had come from the facility and then as she got even closer, she could hear the alarm. AC D said she crossed the street and helped R1 sit on a stump near the road at the end of the facility driveway and then sat with R1. AC D stated she was going to wait with R1 until someone came out to get him, but then nobody was coming. That is when AC C drove by, got out of her vehicle, and tried to get the staff's attention. AC D stated from the time she sat down with R1 on the stump, it probably took 8-10 minutes for staff to respond. Once staff came out of the building to get R1, AC D stated she felt R1 was safe and then left. On 9/20/22 at 2:26 PM, Surveyors interviewed AC C, who stated that it took around 15 minutes of continuously knocking and ringing the doorbell on the facility's front door until staff responded. Additionally, AC C stated that R1 and AC D were sitting on the stump nearest the road, approximately 10-15 feet from the road. On 9/20/22 at 1:12 PM, Surveyors interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing). NHA A stated there was not an incident report, but rather an IDT (Interdisciplinary Team) review meeting and that the event on 9/12/22 was investigated. NHA A stated R1 only got just outside the doors and the event was not an elopement. DON B stated R1's care plan was completed today (9/20/22). DON B stated that normally the MDS will trigger the assessments quarterly. NHA A stated it would depend on what event happened as to whether another wander risk assessment would need to be completed. DON B then stated wander risk assessments should be done after each event, such as an elopement in order to decide if any changes needed to be made to a plan of care. Both NHA A and DON B stated they were unaware that anybody from the community had been involved in or a part of the event of 9/12/22. DON B was then asked if the interventions placed on R1's care plan for the elopement section of the care plan were done today and, if so, were there any previous interventions in place before today (9/20/22), to which DON B replied, No, I'm only one person and I had not yet gotten to that part of the care plan. On 9/20/22 at 3:22 PM, Surveyors interviewed CNA E, who was the staff who responded to the incident and brought R1 back into the building. CNA E stated that she heard the alarms going off on the night of 9/12/22 and saw R1's chair near the 200 wing exit at the end of the hall. CNA E stated the alarm that was going off was, in fact, the 200-hall alarm and R1 had exited the 200 hall exit and walked around the building to the front of the building. She ran to the front door and saw a staff members husband and some community members knocking on the door. CNA E stated that she then got R1's wheelchair and got the resident, who was sitting near the road, and brought him back into the building. Additionally, CNA E stated that she had not been asked any questions about the elopement of 9/12/22 by anyone and, in fact, speaking with Surveyors is the first time she had talked about the event since initially reporting it to RN D. On 9/20/22 at 2:10 PM, Surveyors interviewed CNA I, who was the only other CNA, in addition to CNA E, working at the time of the 9/12/22 elopement. CNA I stated that she was never asked about the incident from administration or had even talked about the incident since it happened. On 9/20/22 at 3:02 PM, Surveyor interviewed LPN J (Licensed Practical Nurse). While asking LPN J if she was aware of any binder or book that detailed the residents at risk for elopement in the building (there are 5 residents at risk for wandering and elopement according to the facility), Surveyor noticed a yellow binder that said, elopement book. LPN J stated she had not seen that binder before today (9/20/22). RN F, RN D, and CNA E also stated they were not aware of or had seen any binder or book detailing the facility's residents that were at risk for elopement. On 9/21/22 at 8:46 AM, Surveyor interviewed FM K (Family Member) who stated she had had a meeting with the facility on 9/14/22 and the facility had asked if it was OK to use a wanderguard for R1, to which FM K agreed. FM K stated she visits daily and had not seen the wanderguard on R1 until 9/20/22 at approximately 2:30 PM when she visited. The facility conducted a wander risk assessment on R1 on 9/20/22 with a high-risk score of 21. The facility did not reassess R1 after he eloped on 8/31/22 or 9/12/22 and did not have any interventions in place for R1's continued attempts at wandering and elopement. The facility talked with family about R1 wearing a wanderguard on 9/14/22, but did not put it on R1 until 9/20/22, did not have any guidance for staff to determine what as needed meant for his wanderguard, and did not instruct staff where and when to document the status of R1's wandgerguard or that there was a binder providing guidance for staff on who is a wander risk and any approaches or interventions to employ. The facility's failure to ensure R1 had adequate supervision and had interventions in place to address R1's wandering and elopement created a reasonable likelihood of serious harm which led to a finding of Immediate Jeopardy. The Immediate Jeopardy was removed on 9/21/22 when the facility began implementing the following: ~Wander guard signaling device placed on left ankle for affected resident ~Elopement/Elopement risk care plan implemented for R1, including encouraging attendance in structured activities. ~Resident to be checked on frequently throughout each shift to verify whereabouts. If R1 appears to be exit seeking activity staff to do 1:1 activity with him such as walks, chatting about birds, lawn mowing, sunset. ~Frequent reminders to as for assist if he wishes to go outside ~New Wander risk assessment completed ~New Wander risk assessment completed for all current residents. Residents identified to be at risk for elopement had care plans developed with individualized interventions to prevent elopement ~Door alarm testing and Wander guard alarm testing is completed by Maintenance. ~Wander guards placed on appropriate residents based on Wander risk assessment findings. Documentation of signaling device (Wander guard bracelet) function and placement checks entered in PCC for residents utilizing devices ~Elopement drill scheduled monthly on various shifts ~Facility policies and procedures regarding Wander risk and Elopement Management were reviewed/revised ~The DON/designee educated all staff, prior to their next scheduled shift, on the proper use of Wander guard bracelet and alarm system per facility policy, the process of determining proper use of Wander guard system depending on resident's mental and physical status, and the increased risk if not used properly. DON/designee educated all staff regarding the Elopement Management policies and procedures. The need to immediately respond to door alarms, call a code white over the PA, complete a resident head count, residents with elopement attempts or determined at risk for elopement will have care plan updated with new interventions timely. ~IDT educated by CNO and RDO regarding risk management, completing a thorough investigation for incidents, and incident policies and procedures ~The IDT reviewed and assessed all residents determined at risk for elopement, residents added to week at-risk meeting agenda ~The IDT reviewed and revised the care plans of residents with risk for elopement to ensure they had resident specific interventions as well as were entered into Wander/Elopement binder ~The IDT provided education to residents and their responsible parties on elopement risk and the use of Wander guard bracelet and system ~The DON and ED, or designee, will monitor the utilization of Wander guard bracelets and documentation, the completion of Wander risk assessments, and the implementation of care planned interventions, the function of the Wander guard system, the completion of the Wander/Elopement binder, and the results of Elopement drills during rounds that will occur weekly x 4 weeks, monthly x 3 months, and then quarterly. A QAPI PIP was implemented as a means to gather and process information from the monitoring rounds. Findings will be reported at the monthly QAA meeting for a minimum of 3 months.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 2 of 15 residents reviewed (R20 and R283) out of a total sample of 15 residents. R20 experienced a change in condition with increased diarrhea which led to fluid volume deficit. The facility did not assess nor implement aggressive interventions to prevent dehydration. R20 was hospitalized requiring intravenous (IV) fluids. R283 was a risk for constipation. The facility was aware R283 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to develop a personalized Care Plan related to bowel movement monitoring and a tracking system that included the consistency of R283's bowel movements. The facility failed to notify R283's Medical Doctor (MD) when R283's bowel medication regime was ineffective; resulting in R283 having to undergo surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Evidenced by: According to N6, Wisconsin Nurse Practice Act, An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. The facility policy, Change in Condition, revised October 2020, states in part, as follows: Purpose: To ensure prompt notification of the resident, the attending Physician, and Durable Power of Attorney/Responsible Party of changes in the resident's physical, psychosocial and/or mental condition and/or status. Procedure: 2. Specific information that requires prompt notification include, but is not limited to: b. Prolonged/unresolved emesis/diarrhea o. A need to transfer the resident to a hospital/treatment center 3. Nurse will complete an assessment and document findings in resident record including but not limited to vital signs, pain, respiratory status as applicable, cardiac status as applicable, etc. Notification of medical professional .will be documented in medical record. Facility policy entitled .Bowel and Bladder Management, dated 7/2020, does not include bowel movement monitoring, care planning, and/or standing orders for constipation relief. Example 1 R20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's Annual Minimum Data Set (MDS) indicated R20's Brief Interview for Mental Status (BIMS) is 15/15 indicating she is cognitively intact. R20 requires extensive 1 staff assist for transferring, toileting and limited assist of 1 for hygiene. R20 is her own person. R20 does not have a care plan for dehydration or fluid monitoring. R20's Physician's Order for Loperamide (initial order date 5/11/20) 2 mg (milligrams) by mouth every 6 hours as needed for diarrhea related to diarrhea, unspecified. After every loose stool max 8 mg in 24 hours and max (maximum) of 3 continuous days in a row. R20's most recent Nutritional Assessment/Screening, dated 2/25/21, documents the following: Estimated fluid needs: 1,636 ml (milliliters) Average fluid intake >1,800 ml Does resident receive nutritional supplements and/or fortified foods: Yes, Banatrol r/t (related to) loose stools Bowel/Bladder/GI (Gastrointestinal) concerns: Yes Explain treatment for constipation, diarrhea, nausea/vomiting: Loose stools Banatrol R20's MAR (Medication Administration Record) indicates Loperamide tablet 2 mg - Give 2 mg by mouth every 6 hours as needed for diarrhea related to diarrhea unspecified. After every loose stool max 8 mg in 24 hours and max of 3 continuous days in a row. Start Date: 6/11/20. R20 received Loperamide 2 mg at the following times in April 2022: 4/10/22: 1:34 PM 4/18/22: 10:47 AM 4/20/22: 5:13 AM R20's fluid intakes are as follows: 4/19/22: 1,440 4/20/22: 1,380 On 4/21/2022 at 10:05 AM, R20's Progress Notes indicate the following: Called the clinic to update Physician about Resident (R20) has had diarrhea for 2 days. Resident has been refusing her banatrel [sic] and the MA (Medication Assistant) stated she will run this by the Physician, waiting for return call as to what to do. Note, there is no documentation of a return phone call, or any follow up with the Physician until 4/27/22 (6 days later). R20's fluid intake on 4/21 was 780 milliliters (mls) R20 received Loperamide 2 mg on: 4/22/22: 11:23 PM 4/23/22: 9:33 AM 4/24/22: 8:36 AM and 8:22 PM R20's fluid intake was documented as: 4/22/22: 1,200 mls 4/23/22: 560 mls 4/24/22: 300 mls 4/25/22: 650 mls 4/26/22: 960 mls Of note, R20 is significantly below her assessed fluid intake needs. The facility did not recognize R20 had increased fluid volume deficit from diarrhea and poor oral intake. The facility failed to monitor R20's fluid intake. On 4/27/22 at 9:41 AM, R20's Progress Notes indicate the following: Resident has had diarrhea and nausea on and off for the last week. On 4/26/22 she did not get out of bed. She did get up this AM and is in her wc (wheelchair) at this time. Writer discussed the possibility of Cranberry supplement causing symptoms as she hasn't had any other medication changes. Resident agrees to discontinue as a trial to see if symptoms improve. Writer contacted Physician office and left voicemail with update on condition. R20 received Loperamide 2 mg on 4/27/22 at 9:35 AM On 4/27/22 at 12:37 PM, R20's Progress Notes indicate the following: Writer received call from the Physician's Medical Assistant and new order received: Discontinue cranberry supplement effective 4/27/22. Resident notified of MD decision. R20's fluid intake on 4/27/22 was documented as 340 mls. R20 received Loperamide 2 mg on 4/28/22 at 8:05 AM. On 4/28/22 at 2:22 PM, R20's Progress Notes indicate the following: Writer contacted the Physician's office to update on continued diarrhea and resident not getting out of bed again today. She did eat breakfast but declined lunch. She is also not drinking her prescribed Banatrol supplement for diarrhea prevention. Writer also updated on the use of Loperamide for 3+ days and inquired if the Physician wants to continue with PRN (as needed) Loperamide. Writer spoke with Medical Assistant; she will speak with the Physician and call the facility back. On 4/28/22 at 5:24 PM, R20's Progress Notes indicate the following: Spoke with Physician regarding resident's current status. MD (Medical Doctor) would like resident to be seen on 4/28/22 to evaluate and determine hydration status. Resident aware, family aware. Will call and schedule with on-call provider in the a.m. on 4/29/22. R20's fluid intake on 4/28/22 was documented as: None On 4/29/22 at 8:47 AM, R20's Progress Notes indicate the following: Resident is to be seen by on-call at 10:15 at clinic. Family member will meet resident at clinic. Wheelchair taxi to pick up at 10:00 AM. R20's fluid intake on 4/29/22 was documented as: 160 mls - R20 was transferred to the clinic then hospitalized on the morning of 4/29/22. On 4/29/22 at 2:41 PM, R20's Progress Notes indicate the following: Resident has been admitted to the hospital per family member On 4/29/22, the Physician did not document a summary of R20's clinic visit. R20 was sent from the clinic to the ED (Emergency Department). On 4/29/22, the hospital documents the following: Date of admission: 4/29/22 Date of discharge: 5/4/22 Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Acute diarrhea 2. AKI (Acute Kidney Injury) related to dehydration 3. [CONDITION(S)] 4. [CONDITION(S)] 5. Acute [CONDITION(S)] (urinary tract infection) R20 is an [AGE] year-old female who resides at (facility name) with past medical history remarkable for [CONDITION(S)] ([CONDITION(S)]) with right [CONDITION(S)], CAD ([CONDITION(S)]), non-oxygen dependent [CONDITION(S)] (Chronic Obstructive Pulmonary Disease), hypertension, [CONDITION(S)] who was admitted to our hospital directly from (clinic name) on 4/29/22 with 3-week duration of non-bloody diarrhea and dehydration. The patient was extremely weak upon admission. She was in acute kidney injury with a creatinine of 1.6, BUN 41. She was hypokalemic with a potassium of 2.5. She had some mild crampy abdominal pain. There was no known recent exposure to ill contacts at the nursing home. Hospital Course: R20 was admitted to the medical floor and started on IV (intravenous) hydration. She continued to have loose diarrheal stools without blood.A urinalysis grew out pan sensitive E. coli and [CONDITION(S)]. She was initially treated with 3 doses of IV [MEDICATION(S)]. This was transitioned to oral [MEDICATION(S)] 500 mg (milligrams) p.o (orally) twice daily on 5/3. She had a small bump in her white blood cell count on 5/2 to 11.0. This normalized on 5/4 to 8.6. When the GIP (Gastrointestinal Pathogen) panel returned negative, she was started on scheduled [MEDICATION(S)]. She did continue to have frequent loose stools through 5/2. Overnight on 5/4 the patient had 2 stools that were more formed. Her kidney function improved with IV fluids and creatinine improved to normal by 5/1. On day of discharge her creatinine was 0.8. Initially her magnesium level was low at 1.6 and she had received magnesium oxide which coincided with increased loose stools on 5/2. This was stopped on 5/3 as this likely contributed to increased loose stools. Dietary was consulted and high-fiber foods were introduced to her diet. She was initially requiring potassium supplementation, however this normalized when her diarrhea improved. Vitals signs remained stable while hospitalized She was tolerating her diet without nausea and vomiting. She was getting into a chair with assistance. By 5/4 patient was stable for discharge back to the facility. On 8/24/22 at 3:46 PM and 4:22 PM, Surveyor spoke with DON B (Director of Nursing) and Regional Nurse Consultant C. Surveyor asked on 4/21/22 when the RN (Registered Nurse) reached out to the Physician was there any documentation that the Physician called back or that staff followed up with the Physician. Regional Nurse Consultant C stated, if it's not in the notes, I don't know. Regional Nurse Consultant C added, If it's not noted then no. DON B stated, no, there was no follow up with the Physician. Surveyor asked DON B, if a resident is having increased diarrhea, what do you expect staff to do. DON B stated, she expects staff to increase fluids and contact the Physician if it's going on for more than 3 days. Surveyor asked DON B, is there documentation that staff pushed fluids and contacted the Physician timely. DON B stated, I don't see anything in R20's Nurses Notes or medical record to substantiate that anybody followed up on her not meeting fluid intakes. Surveyor asked DON B, would you have expected staff to follow up with R20's Physician. DON B stated, Absolutely. Regional Nurse Consultant C stated, There should have been more monitoring, assessments and documentation and I do agree we should have been monitoring the fluids. Surveyor asked DON B, what assessments should the nurses have completed. DON B stated, A GI (gastrointestinal) assessment, intakes, outputs. Surveyor asked DON B should there be an individualized care plan in place for hydration and bowel management. DON B stated, I would hope so. DON B stated, R20 didn't like the Banatrol and would refuse it most of the time. DON B stated, this wasn't just an acute issue, it was chronic. DON B stated, if she had to guess, it's probably some dietary issue. There is no documentation the facility staff notified the Physician of R20's refusals of Banatrol. DON B stated, when R20 has a choice between drinking this stuff (Banatrol) or taking loperamide, she would choose the loperamide. The facility failed to take immediate action to assess, monitor, and evaluate R20's condition and to seek prompt medical intervention to prevent R20's condition from worsening. Staff did not monitor the resident's condition and did not thoroughly assess her, did not develop plans and interventions for caring for her. When staff left a message for the Physician on 4/21/22, staff did not follow up when there was no response. On 4/29/22, R20 was transferred from the facility to a clinic appointment via taxi before being transferred to the ED where she was diagnosed with acute diarrhea, acute kidney injury related to dehydration, [CONDITION(S)], [CONDITION(S)], and acute urinary tract infection. Example 2 R283 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R283's most recent Minimum Data Set (MDS) assessment, with ARD (Assessment Reference Date) of 7/1/2022, indicates R283 requires 1-person physical assist with bed mobility, 2-person physical assist for transfers, and 2-person physical assist for toileting. R283 is always incontinent of bowel movements, is not using a toileting program, and no constipation was present. R283's Brief Interview for Mental Status (BIMS) was a score of 15 out of 15 indicating R283 is cognitively intact. R283's Managed Care Organization (MCO)'s discharge paperwork, dated 4/6/22, includes, in part: . Steps to Support Long Term Care Outcome - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Currently stable. Care overseen by PCP (Personal Care Provider). R283 was hospitalized [DATE] with a bowel obstruction and again on 2/25/22 with a Sigmoid Volvulus. R283 had an open Sigmoidoscopy on 2/28/22. She has scheduled stool softeners and as needed medications for bowel management. R283's Bowel Bladder Evaluation, dated 6/28/22, includes, in part: does resident have a history of fecal impactions: unknown . bowel continence: always incontinent . perception of need to defecate unable to determine . toilet use: total dependence . elimination assistance: stool softeners . usual elimination pattern: no apparent pattern . taking medications that might affect bowel continence: narcotics or alpha-adrenergic agonists . R283's Baseline Care Plan, dated 4/6/2022, does not include interventions or goals related to R283's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R283's Care Plan, initiated 4/6/22, does not include personalized bowel movement monitoring, does not have any goals or interventions for R283's constipation and bowel movements. (It is important to note even after R283 had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . R283's CNA (Certified Nursing Assistant) care card, dated 8/23/2022, does not include any interventions for bowel movement monitoring. (It is important to note even after R283 had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] .) R283's Physician orders include: [MEDICATION(S)] Suppository 10 MG insert 1 suppository rectally every 24 hours as needed for constipation; start date 6/24/22 [MEDICATION(S)] 20 GM/30ML give 15ml by mouth every 8 hours as needed for constipation; start date 6/24/22 Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) give 30ml by mouth as needed for constipation; start date 6/24/22 [MEDICATION(S)] S Tablet 8.6-50 MG (Sennosides-[MEDICATION(S)] Sodium) give 2 tablets by mouth every 12 hours as needed for constipation; start date 6/24/22 [MEDICATION(S)] Tablet 80MG give 1 tablet by mouth every 6 hours as needed for flatulence; start date 6/24/22 [MEDICATION(S)] 20GM/30ML give 15ml by mouth three times a day for bowel movements give until bowel movements are clear, then decrease to three times a day as needed; start date 7/14/22 Acetaminophen Tablet 325MG give 2 tablets by mouth every 4 hours as needed for pain; start date 6/24/22 [MEDICATION(S)] Tablet 10MG give 1 tablet by mouth three times a day for pain management; start date 6/24/22 [MEDICATION(S)] Patch 72-hour 12 MCG/HR apply 1 patch transdermal every 72 hours for chronic pain management and remove per schedule; start date 6/24/22 [MEDICATION(S)] Tablet 5 MG give 1 tablet by mouth three times a day for [CONDITION(S)] bladder; start date 6/24/22 (Please note the following medications have the ability to cause constipation: Acetaminophen, [MEDICATION(S)], [MEDICATION(S)] Patch, and [MEDICATION(S)]. In addition, R283's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) R283's Medical Record, includes the following: 7/26/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation and received as needed dose of [MEDICATION(S)] suppository for constipation PM shift: refused scheduled dose of [MEDICATION(S)] for constipation (It is important to note there is no documentation as to why R283 refused this medication.) HS shift: refused scheduled dose of [MEDICATION(S)] for constipation (It is important to note there is no documentation as to why R283 refused this medication.) 8:30 PM incontinent bowel movement recorded. (It is important to note there is no description as to the consistency or size of R283's bowel movement.) 7/27/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation PM shift: received scheduled dose of [MEDICATION(S)] for constipation HS shift: received scheduled dose of [MEDICATION(S)] for constipation No bowel movements recorded. 7/28/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation PM shift: refused scheduled dose of [MEDICATION(S)] for constipation (It is important to note there is no documentation as to why R283 refused this medication.) HS shift: refused scheduled dose of [MEDICATION(S)] for constipation (It is important to note there is no documentation as to why R283 refused this medication.) No bowel movements recorded. 7/29/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation PM shift: received scheduled dose of [MEDICATION(S)] for constipation HS shift: received scheduled dose of [MEDICATION(S)] for constipation No bowel movements recorded. 7/30/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation PM shift: refused scheduled dose of [MEDICATION(S)] for constipation (It is important to note there is no documentation as to why R283 refused this medication.) HS shift: refused scheduled dose of [MEDICATION(S)] for constipation (It is important to note there is no documentation as to why R283 refused this medication.) 9:05 PM incontinent bowel movement recorded. 7/31/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation PM shift: received scheduled dose of [MEDICATION(S)] for constipation and received as needed dose of [MEDICATION(S)] Suppository HS shift: received scheduled dose of [MEDICATION(S)] for constipation 1:44 PM incontinent bowel movement recorded under Progress Notes. Medium bowel movement . (It is important to note there is no description, size or consistency for R283's bowel movement.) 8/1/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation PM shift: refused scheduled dose of [MEDICATION(S)] for constipation (It is important to note there is no documentation as to why R283 refused this medication.) HS shift: refused scheduled dose of [MEDICATION(S)] for constipation (It is important to note there is no documentation as to why R283 refused this medication.) No BM recorded. 8/2/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation PM shift: received scheduled dose of [MEDICATION(S)] for constipation HS shift: received scheduled dose of [MEDICATION(S)] for constipation No BM recorded 8/3/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation PM shift: received scheduled dose of [MEDICATION(S)] for constipation HS shift: received scheduled dose of [MEDICATION(S)] for constipation and received as needed dose of [MEDICATION(S)] Suppository No BM recorded (It is important to note, R283's MD was not notified of her bowel regime being ineffective. This is day 3 without a BM recorded.) 8/4/22 AM shift: received scheduled dose of [MEDICATION(S)] for constipation Progress Note from 8/4/22 4:51 AM includes, in part: . PRN administration was ineffective and R283 had a small, hard bowel movement . Progress Note from 8/4/22 10:18 AM states, Resident complained of abdominal pain and constipation. Received suppository last evening with no results. Soft bowel movement felt with rectal exam. Abdomen distended. Small emesis of soft brown material after taking her am meds. Medical Doctor (MD) notified, and orders received to send to emergency room for assessment. On 8/4/22 at 11:20 AM, R283 was sent to the emergency room and then admitted to the hospital until 8/16/22. Hospital face sheet states, dated 8/4/22, includes, in part: Chief Complaint: abdominal pain, distention, vomiting, last known BM (bowel movement) was approx. 5 days ago. History of Present Illness: History of MS and chronic wounds who presents from the nursing home by EMS (Emergency Medical Services) with abdominal pain and vomiting. History is somewhat limited from the patient, but nursing home staff note that she has not had a bowel movement in over 5 days. Patient states she usually has bowel movements daily. She notes she has pain all over but pain is worse in the abdomen. Abdomen has been distended. She has not had any fevers. She has been nauseous for the past few days and started vomiting today. Denies urinary symptoms. No chest pain or shortness of breath. She does note a history of bowel obstructions in the past and does note a history of surgeries although is unable to elaborate on which surgery she has had. Emergency Department Note, 8/4/22, includes, in part: . Physician states, High-grade small bowel obstruction with viscus perforation as evidenced by free intraperitoneal air. Transition point identified near level of a small bowel anastomosis in the left lower quadrant and there is some associated for leaking o the mesenteric this level. Emergent surgical consultation suggested as I am concerned there is a component of torsion or internal hernia resulting in the bowel obstruction. Indeterminant 1.9 cm left adrenal nodule. Discharge Summary Notes dated 8/16/22 at 7:26 AM, Principal Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/23/22 at 8:31 AM, during an interview, R283 shared concerns regarding her bowel movements and pressure sores on her bottom. R283 indicated she has been having problems with having regular bowel movements because she no longer can move around, and the facility has not been assisting her as they should. R283 indicated she has a history of bowel issues including an obstruction and worried about it happening again and it did. R283 stated she felt sick prior to the bowel obstruction on 8/4/22 and that previous to admission she would have a bowel movement once a day. R283 indicated she still worries about having another bowel obstruction. On 8/23/22 at 6:40 PM CNA (Certified Nursing Assistant) D indicated she is unaware of what interventions are in place for R283's bowel movements. On 8/23/22 at 6:45 PM RN (Registered Nurse) E indicated R283 has regular bowel movements about every two to three days and standard practice is if a resident doesn't have a bowel movement for three days, then a as needed medication is given. RN E indicated it is the CNA's job to let the Nurse on the unit know if a resident has not had a bowel movement for three days. On 8/24/22 at 9:20 AM RN F indicated charting is completed on the computer and they have a binder at the nurse's station to monitor residents' bowel movements. RN F indicated the binder at the nurse's station is not always filled out and that CNAs often need reminders and that it is a constant work in progress. RN F indicated the facility does not track bowel movement consistency. RN F indicated that the night shift nurse reviews bowel movement tracking for residents and determines if the resident needs any as needed medications to have a bowel movement. RN F indicated she will then double check to ensure as needed medications are provided if a resident did not have a bowel movement. On 8/24/22 at 12:14 PM, DON B (Director of Nursing) indicated she was unaware of the binder at the nurse station used for tracking residents' bowel movements. DON B indicated the facility was not tracking the consistency of R283's bowel movements before the bowel obstruction and they should have been. DON B indicated R283's care plan should include interventions and goals related to R283's history of bowel obstruction, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B and Surveyor reviewed R283's care plan and did not find interventions and goals related to bowel management or her history of constipation/bowel obstruction. DON B indicated there is no facility standing order for bowel movement managing and each resident has their own specific orders. DON B indicated R283's orders do not specify to use on day 2 or day 3 of no movement and it is up to the nurse to decide when R283 needs the as needed medications. DON B indicated nurses should call when R283 when her bowel medication is ineffective but was not sure what ineffective meant. DON B indicated she was unaware R283's bowel movement routine was to have a bowel movement daily. On 8/24/22 at 5:45 PM NHA (Nursing Home Administer) A indicated R283 does have an individualized care plan related to bowel monitoring, including as needed medications specific to R283's constipation. NHA A indicated R283 refuses her medication at times and dictates her own care. NHA A indicated nurses should give R283 her as needed medication when she is in need of them and call R283's MD when her medications are ineffective. NHA A indicated she was unsure if nurses should give as needed medication or call MD on day 2, 3, or 4 of no bowel movement and the facility did not have standing orders. NHA A indicated she was unsure what R283's bowel pattern was prior to admission. It is important to note the facility was aware of R283's history of bowel obstruction upon admission and were not proactive in preventing further occurrences as R283's physician orders did not have specific instructions for as needed medications, R283's MD was not notified when R283's bowel movement medication regime was ineffective, a personalized care plan related to bowel movement monitoring and R283's usual routine was not developed, the consistency of R283's bowel movements were not documented and tracked, the facility failed to document why R283 refused medications for constipation, and no risks and benefits were given to R283 related to refusing medications. This all resulted in R283 having to undergo surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on staff interview and record review the facility did not ensure 1 of 1 residents (R1) reviewed received appropriate care and treatment to prevent the development of a non-pressure related wound, promote healing of the wound, and prevent infection of the non-pressure related wound. R1 was admitted to the facility without non-pressure wounds on R1's left foot. R1 had historical [CONDITION(S)] of the right foot which had resulted in a below the knee amputation. On 7/9/21 R1 developed shearing on the left third toe. The facility did not: ~ Recognize, identify or assess risk factors associated with the development of R1's toe injury; ~ Develop, evaluate, and revise R1's care plan based on R1's risk factors and needs; ~ Recognize, assess timely and accurately document a comprehensive wound assessments as indicated by the change in condition and deterioration of R1's left third toe; ~ Implement treatment modalities timely; ~ Update R1's physician timely and when decline was noted. R1 was subsequently admitted to the hospital on 7/29/21 from a clinic appointment with a gangrenous left third toe with exposed bone requiring amputation. The facility's failure to recognize, identify or assess risk factors associated with the development of R1's toe injury, develop, evaluate, and revise R1's care plan based on R1's risk factors and needs; complete timely assessments and accurately document comprehensive wound assessments; and implement treatment modalities timely created a finding of Immediate Jeopardy beginning 7/9/21. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 8/19/21 at 1:00 PM. The immediate jeopardy was removed on 8/30/21 and continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility implements its action plan. Findings Include: R1 was admitted to the facility on [DATE] after a lengthy hospitalization . Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission MDS (Minimum Data Set) was dated 6/15/21. The MDS indicated R1 ~ Had a BIMS (Brief Interview for Mental Status) score of 4 indicating a severe cognitive impairment; ~ Had disorganized thinking; ~ Had physical, verbal, and other behaviors; ~ Required extensive to total assistance of one to two staff persons with all aspects of care including bathing, dressing, grooming, using the bathroom, and eating; ~ Did not walk; and ~ Had no pressure injuries, open [CONDITION(S)] on the foot, or diabetic foot ulcers. Surveyor reviewed R1's care plan and noted the following: On 6/11/21 the facility implemented a body pillow. This was noted for fall prevention. The following approaches were noted under the care plan problem titled .Potential for pressure injury . dated 6/24/21 and .Potential/actual impairment to skin integrity . dated 6/14/21. ~ 6/14/21, .keep skin clean and dry. Use lotion on dry skin .Meds (medications)/labs/treatments as ordered . ~ 6/24/21, .Administer treatments as ordered and monitor for effectiveness specialty mattress .turn/reposition at least every 2 hours . R1's CNA (Certified Nursing Assistant) care plan was undated. It had the following approaches. ~ .Body pillow while in bed .Keep skin clean and dry. Use lotion on dry skin .Specialty Mattress . R1's most current skin risk assessment was dated 7/1/21. The risk assessment had a cumulative score of 14 indicating R1 was at moderate risk for the development of a wound. Surveyor completed a review of R1's nursing notes, wound documentation, treatment records, hospital records, and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/15/21, R1 was seen by a physician. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Extremities are warm and dry and well-perfused .left foot is without callus or skin breakdown or other lesion . Admission hospital records dated 6/11/21 indicated R1 had [CONDITION(S)] while hospitalized . A review of R1's nursing notes as follows was indicative [CONDITION(S)] may have continued with admission to the facility. ~ 6/11/21, .very restless in bed .kicks legs around a lot .Has some bruising on legs . ~ 6/12/21, .very busy wiggling around in bed . ~ 6/13/21, .continually moving side to side . ~ 6/14/21, .restless today rolling back and forth in bed .body pillow placed on wall side of bed . ~ 6/15/21, .trying to climb out of bed . ~ 6/16/21, .repeated movements in bed . ~ 6/17/21, .restless .constantly moving in bed .has scrapes noted on his lower extremities from rubbing them into the wall . On 6/11/21 the facility was aware of R1's significant restlessness. By 6/14/21 the facility was aware of the significant risk for injury of R1's extremities and left foot. Despite this, there were no new interventions implemented to protect R1's extremities and left foot from injury aside from a body pillow. Additionally, the facility did not identify the location or measurement of the scrapes nor if treatment was indicated on R1's lower extremity. From 6/11/21 to 7/9/21 there were no nursing notes in R1's clinical record indicating R1 had wounds. On 7/9/21 a nursing note indicated, .has skin shearing of one layer of skin on .left foot, third digit that is new as of today. Wound bed intact, no drainage. Skin is red .Dr. (Doctor) office called for further direction . There was no documentation in R1's record of the measurements or wound characteristics of the shearing on R1's left third toe. On 7/9/21 the facility received faxed physician orders. The fax indicated, .left foot 3rd (third) digit, red, maybe hitting it on something? no pain, no drainage, will monitor .any suggestions/recommendations .Action Taken .if this does not dramatically improve over the weekend I would recommend an evaluation next week .family .requesting a boot to protect it .again, would recommend evaluation if the toe is not better. Please arrange podiatry referral. A walking boot can be ordered in the interim, please arrange . The physician had identified the significance of the injury to R1's left foot third toe and indicated the facility needed to comprehensively and closely assess and monitor R1's left third toe. The physician ordered a podiatry referral. Despite that, from 7/9/21 until 7/13/21, a period of 4 days, there was no documentation in R1's clinical record of the status of R1's left third toe. On 7/13/21 a nursing note indicated, .has ulcerated areas to 3rd and 5th (fifth) left toe. Area cleansed with would cleanser and covered with non-adherent dressing .Ensure sock on and instructed CNA's (Certified Nursing Assistants) to leave .left shoe off and use gripper sock .Stat (immediate) consult with Dr. (Doctor) . Surveyor completed a review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Assessments .Foot ulcer left .I am concerned that he has significant [CONDITION(S)] and this third toe it ischemic. I will ask that he be seen by Dr. (Podiatrist) .has previously lost his right lower extremity .now has a sore on .left foot .third toe .dusky with an ulceration on the top of the toe. The fifth toe has an ulceration laterally . Surveyor completed a review of R1's TAR (Treatment Administration Record) dated 7/1/21 to 7/31/21. On 7/15/21 a treatment was order which included cleansing of the wound followed by a non-adherent dressing covered by a gauze wrap and Podus boot. At some point between 7/9/21 and 7/13/21, according to the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . This required immediate action in order to prevent further deterioration of R1's left third toe. There were no new modalities added to R1's plan of care including treatment orders nor protective measures to ensure R1's left foot was protected from further insult and injury until 7/15/21, 6 days later. There was no comprehensive assessment completed of the wound. Additionally, this was the second time a physician indicated the need for a podiatry referral. The podiatry referral was not arranged until 7/13/21 and R1 was scheduled to see the podiatrist on 7/29/21. There was no indication a walking boot ordered on 7/9/21 had ever been ordered. While the facility did place a protective boot this was done at the request of the family. Additionally, the use of the protective boot was not added to R1's care plan nor CNA (Certified Nursing Assistant) care plan. The directive to leave R1's left shoe off and to use a gripper sock as noted in the nursing note date 7/13/21 was not added to R1's plan of care. It was critical to revise R1's plan of care in order to direct staff in the management of R1's left third toe wound and ensure continuity of care. From 7/13/21 to 7/16/21 there were no nursing notes describing R1's left third toe wound. On 7/16/21 a nursing note indicated, .has a scab on .3rd left toe that has been getting progressively worse. This AM the ulcerated area has black wound edges and is dark red, non-blanchable, and swelled .to ER (emergency room ) for evaluation . R1's ER records note the following:, .presents with left, worsening wound on the left third digit (toe) .wife who provides most of the history tells me .the wound on his left foot appeared to be getting more red .concerned that the infection/redness over the dorsal surface of the foot was increasing .wife states the wound looks worse with black eschar (dead tissue) over it and the area of redness over the dorsum (top of the foot) .states .more pain when he tries to weight bear .there is redness over the dorsum of the foot extending halfway up the foot .toe itself has black eschar over it but this is dry at the time .recommend close follow up .put on .clinic call back list to get in to be seen by podiatry as soon as possible . R1 returned to the facility with orders for an antibiotic, treatment orders for wet to dry dressing changes twice a day and orders for R1 to be put on Podiatry call back list in order for R1 to be seen as soon as possible. The physician's note also indicated the facility needed to closely monitor and assess R1's left third toe. The facility by practice utilizes a form titled Weekly Non-Pressure Ulcer Log. All residents with non-pressure wounds are placed on this log. All resident entries onto the log are undated. None of R1's weekly wound documentation was noted in R1's clinical record. Surveyor completed a review of a Weekly Non-Pressure Ulcer Log dated 7/11/21 to 7/17/21. This was the first noted documentation of R1's left third toe ulcer. The log indicated R1 had developed a facility acquired venous wound on R1's left third digit which measured 1.5 cm x 2.0 cm x 0.1 cm (1.5 centimeters by 2.0 centimeters by 0.1 centimeters). The log indicated, .redness, vascular insufficiency, scabbing present . The log also indicated a treatment and antibiotics had been ordered when R1 was evaluated in the emergency roiagnom on [DATE]. With the information obtained from the wound log it is plausible to consider the assessment of R1's left third toe was completed on 7/16/21. This was 7 days after the wound had been identified. Additionally, the assessment did not identify eschar on the toe, redness on the dorsum of the foot .extending half way up ., nor pain as noted in the emergency room report dated 7/16/21. On 7/20/21 R1 was seen by a physician in-house. The physician discontinued the antibiotic ordered by the emergency roiagnom on [DATE] and ordered 2 different antibiotics. On 7/21/21 a Physicians Telephone Order indicated .Continue wet to dry dressing change once a day .Podiatry to see for right [left] 3rd toe . This was the third time a physician indicated the need for R1 to see the Podiatrist. From 7/16/21 to 7/22/21, a period of 6 days, there were no nursing notes nor comprehensive wound assessment describing the status of R1's left third toe ulcer. Physician documentation from 7/13/21, 7/16/21, and 7/20/21 indicated R1's left third toe wound was deteriorating. Physician directives were to monitor and assess closely. Despite that, from the time the wound was identified on 7/9/21 until 7/22/21, a period of 13 days, there was only one assessment completed of R1's left third toe wound. The assessment completed was not comprehensive. On 7/22/21 a nursing note indicated, .Resident had the following infections, Third left toe ulcer is infected. Currently taking antibiotics, dressing change BID (twice a day) . A Weekly Non-Pressure Ulcer Log dated 7/18/21 to 7/24/21 indicated R1 had a venous ulcer of the left third toe. The log indicated the wound was 1.5 cm in length, 1.5 cm in width, and 0.1 cm in depth. The log indicated, .Redness, vascular insufficiency, scabbing present .No drainage .Improved . The accuracy of the above wound assessment would be in question given recent developments of the wound including black eschar, [CONDITION(S)], and infection. The wound was noted as improved. A Weekly Non-Pressure Ulcer Log dated 7/25/21 to 7/31/21 indicated R1 had a venous wound on the left third toe which measured 1.5 cm long by 1.5 cm wide by 0.2 cm deep. The wound log indicated, .Redness, vascular insufficiency .scab removed, 90% slough, 10% beefy red coloration and tissue present .No drainage .Week 2 - Improved . The wound log indicated R1's left third toe had improved. The wound however presented with 90% slough. This was indicative the wound had deteriorated. Slough is devitalized tissue. 90% slough would obscure the wound base making it impossible for the assessor to determine the depth. There were no changes made to R1's plan of care. The physician was not contacted. From 7/22/21 to 7/28/21, a period of 6 day, there were no nursing notes regarding the status of R1's left third toe wound. On 7/28/21 a nursing note indicated, .3rd left toe infection, area is healing . This was the only information regarding the status of R1's left third toe wound. From 7/13/21 to 7/28/21 there were no further nursing notes nor wound notes describing the ulcerated area on R1's left fifth toe. On 7/29/21 R1 was sent to the Podiatrist for R1's scheduled visit. The Podiatrist progress note indicated, .Assessments .Left foot infection .[CONDITION(S)] of third toe of left foot .Gangrene of toe (dead tissue) .demarcated distal left third digit gangrenous toe with bone exposed within the wound bed. There is surrounding [CONDITION(S)] .Daughters believe this started from his toes pressing up against the end of his bed .Toes to the left foot excluding the third digit are warm and well perfused. There is circumferential gangrenous changes to the left third digit with a soupy moist fibrotic base. Bone is exposed dorsally within the wound. There is [CONDITION(S)] surrounding the area to the distal forefoot .Small superficial wound is noted to the dorsal lateral aspect of the fifth digit . R1 was admitted to the hospital from the clinic. On 7/30/21 R1's left third digit was surgically removed. Of notation: None of the facility's nursing notes nor wound notes had identified gangrene nor exposed bone. At the time of the survey R1 had not returned to the facility. On 8/16/21 at 5:25 PM Surveyor spoke with LPN-A (Licensed Practical Nurse) about R1. LPN-A indicated R1 had been a handful. LPN-A stated R1 developed a sore on the left third toe from moving around in bed. LPN-A indicated the wound did not get any better and R1 ended up being hospitalized and the left third was amputated. LPN-A indicated the nurses chart about wounds but the DON (Director of Nursing) was the wound nurse and was the person who documented the comprehensive assessment of all wounds. On 8/17/21 at 10:46 am Surveyor spoke with RN-B (Registered Nurse). RN-B indicated for any new wound she would chart the description and measurements of the wound and notify and physician, DON, and NHA (Nursing Home Administrator). On 8/17/21 at 10:55 am Surveyor spoke with RN-B and RN-C. RN-B indicated she had cared for R1. RN-B stated once R1 was put on an antibiotic the redness went away and the toe looked a lot better. On 8/17/21 at 11:05 am Surveyor spoke with RN-C. RN-C indicated they request the physician to look at R1's left third toe on 7/13/21 as the toe had swelling and redness. RN-C indicated she recalled the area having white slough and scant purulent drainage. RN-C also indicated R1 was seen by another physician on 7/20/21 who changed R1's antibiotics. Surveyor asked RN-C why the physician changed R1 antibiotics. RN-C indicated for better antibiotic coverage due to R1's historical amputation. Surveyor asked RN-C what caused the wound on R1's left third toe. RN-C indicated R1 was very active while in bed and had both controlled and uncontrolled movements while in bed. RN-C indicated they had placed a mat on the wall side of the bed for protection. The wall mat as indicated by RN-C was never added to R1's plan of care. Surveyor could not determine when the wall mat had been placed. On 8/17/21 Surveyor spoke with RN-D. RN-D indicated she was the nurse who found R1's initial left third toe wound. RN-B indicated she thought R1 was rubbing his foot against the wall. RN-D stated the facility placed a mat on the wall side of the bed. RN-D was not sure when this was placed but indicated it was after the development of R1's wound. RN-D indicated R1 would not keep the dressings on his foot however did keep the protective boot on. RN-D stated she was not sure when the protective boot was placed. On 8/18/21 at 8:40 am Surveyor spoke with COTA-G (Certified Occupational Therapy Assistant) and PTA-H (Physical Therapy Assistant). COTA-G indicated the therapy department had never been involved with R1's wound care including obtaining positioning or off-loading devices. PTA-G indicated he was aware R1 had periods of agitation where R1 would roll around in bed and kick either the foot board or wall. On 8/17/21 at 2:10 PM Surveyor spoke with CNA-E (Certified Nursing Assistant). CNA-E. CNA-E indicated she had cared for R1. CNA-E prior to R1's hospitalization R1's left third toe wound was discolored and black. On 8/17/21 at 2:17 PM Surveyor spoke with CNA-F. CNA-F indicated she had cared for R1. CNA-F indicated R1 rolled around in bed and would hit his left foot on the wall. CNA-F indicated the facility had placed a mat on the wall. CNA-F indicated the mat, however, was not effective because R1 would scoot down so far in the bed beyond the end of the wall mat and still hit his foot against the bare wall. CNA-F stated R1's foot started to turn red. CNA-F stated the redness then went up into R1's foot. CNA-F stated R1's left third toe just kept getting worse and worse, The wall mat the facility placed was ineffective as it did not encompass the full length of R1's bed leaving an area at the end of R1's bed open for continued injury to R1's left foot. There was no indication the facility reassessed the wall mat. There were no new modalities implemented to protect R1's left foot and toes from further injury. On 8/18/21 at 1:40 PM Surveyor spoke with CNA-J. CNA-J indicated she had cared for R1. CNA-J indicated R1 developed a black mark on the left toe. CNA-J indicated she informed the nurse. CNA-J indicated the facility placed a protection boot. Surveyor asked CNA-J when the boot was placed. CNA-J indicated she was not sure but she thought it was one to two weeks prior to R1's hospital admission. On 8/17/21 at 8:40 AM Surveyor spoke with the DON (Director of Nursing). The DON indicated she was the wound nurse and was responsible for the documentation of all pressure and non-pressure wounds. The DON indicated she utilized a wound care log and was not at the present time documenting wounds into resident electronic records. The DON indicated she was still in the process of learning the facility's electronic charting system and had not started entering wound notes into R1's electronic record. The DON stated the wound log was a weekly log. The DON indicated her entries onto the log for each specific resident were not dated, therefore she was unsure of when she actually assessed each wound. On 8/18/21 at 8:10 AM Surveyor spoke with the DON regarding R1's podiatry appointment. The DON verified R1's podiatry appointment had been scheduled on 7/13/21. Surveyor asked the DON why the delay in scheduling the appointment. The DON was unsure. The DON indicated she was sure the facility told the podiatry clinic the need for R1 to be seen as soon as possible and to also put R1 on a call-back list in case there was a cancellation. On 8/23/21 at 8:50 AM Surveyor spoke with MAM-K (Medical Assistant Manager) from the Podiatry clinic. MAM-K indicated the clinic did keep a call back list per request for cancellations. Surveyor asked MAM-K if R1 was on the call back list. MAM-K indicated R1 was not. On 8/18/21 at 9:15 AM Surveyor spoke with Podiatrist-I. Podiatrist-I indicated he saw R1 in the clinic on 7/29/21. Podiatrist-I stated by the time he saw R1, R1 had developed [CONDITION(S)] and wet gangrene of the left third toe and there was nothing more he could do but amputate the toe. Podiatrist-I indicated this can occur very fast and he felt in R1's case probable within one to two weeks. Podiatrist-I indicated he could usually see a patient urgently the same day or the next day. Podiatrist-I indicated with deterioration of any wound he would expect to be called. Podiatrist-I stated if he could not see the person within a day or two he would refer the person to the emergency room . Surveyor asked Podiatrist-I if the facility had recognized and identified and put appropriate and effective treatment modalities in place if the outcome would have been the same. Podiatrist-I indicated he was not certain. On 8/18/21 Surveyor requested the facility's wound management policies and procedures. Surveyor received policies regarding how to complete a dressing change, a physician communication tool, and an audit tool. On 8/18/21 at 3:00 PM Surveyor again spoke with the DON. Surveyor again requested the facility's wound management program policies and procedure. The DON indicated what Surveyor received was all they had. The DON indicated the facility did not have a formal wound care program. The facility's failure to recognize, identify or assess risk factors associated with the development of R1's toe injury, develop, evaluate, and revise R1's care plan based on R1's risk factors and needs; complete timely assessments and accurately document comprehensive wound assessments; and implement treatment modalities timely created a finding of Immediate Jeopardy beginning 7/9/21. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 8/19/21 at 1:00 PM. The immediate jeopardy was removed on 8/30/21 when the facility completed the following: ~All active licensed nursing staff to be educated on wound management (diabetic wounds, Venous, Arterial, and other non-pressure wounds), including wound prevention, comprehensive assessment of wounds, wound documentation, wound treatments specifically as it relates to immediate intervention upon identification, diabetic foot care, care planning, and physician notification of change in condition or deterioration of wounds. Date initiated: August 18, 2021, with 100 percent of active licensed nurses working in facility completed on August 19, 2021, no licensed staff will be allowed to work until they have received education. ~ All active licensed nursing staff to be educated on facility policy and procedure for: Management of wounds (Date initiated: August 18, 2021), Comprehensive care planning (Date Initiated: August 19, 2021), Change in condition (Date Initiated: August 19, 2021), Diabetic foot care (Date Initiated: August 19, 2021), Dressings, Dry/Clean (Date Initiated: August 18, 2021). Nurses will complete a competency for wound assessment, applying wound dressing, and wound documentation (dressing changes & assessments) according to standards of practice. Date initiated: August 19, 2021, with 100 percent of active licensed nurses working in facility completed on August 19, 2021, no licensed staff will be allowed to work until they have received education. ~ All active licensed nursing staff to be educated on wound dressing change expectations according to standard of practice and physician orders. Date initiated: August 18, 2021 with 100 percent of active licensed nurses working in facility completed on August 19, 2021, no licensed staff will be allowed to work until they have received education. ~ All active licensed nursing staff to be educated on resident care plans that include approaches for wound treatment and skin management. Licensed nursing staff will be educated on following resident care plan and care plan development for skin management. Date initiated: August 19, 2021 with 100 percent of active licensed nurses working in facility completed on August 19, 2021, no licensed staff will be allowed to work until they have received education. ~ All training noted above to be completed prior to each licensed nurse next working shift. Any nurses who do not complete the competency will not be scheduled until completed. Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to give an education. On August 18, 2021, facility reviewed policy and procedure on Dressings Clean/Dry, Medication & Treatment Orders, and Wound Measurement in coordination with medical director, including wound identification, wound assessment, wound treatment, and wound documentation to ensure policy meets current standards of practice. Policy was deemed to be up to date with current practices for wound and skin care management. ~ On August 18, 2021, all residents in facility received a head-to-toe skin assessment by RN. All wounds were measured, care plans and treatments were reviewed for appropriateness and accuracy. ~On August 30, 2021, all residents with diabetes had monitoring orders entered into their TAR for daily diabetic foot checks. ~ On March 3, 2021, facility procured services with (Name of Company) for wound supplies and staff education. Company does not measure wounds nor provide wound MD. Residents with wound care are followed externally by a wound clinic. ~ On August 19, 2021, QAPI meeting held with resident's MD's covering colleague, (MD Name). ~DON and Nursing Supervisor will conduct audits daily x 2 weeks, weekly x 8 weeks, and monthly x 3 months for residents that have complex non-pressure injuries and residents with pressure injuries to ensure wounds receive weekly comprehensive assessment according to standards of practice, any wounds identified as stalled past 2 weeks or with decline are reported to physician timely with appropriate interventions and care plan changes initiated accordingly. Results of the audits will be reviewed at the QAPI meeting for further recommendations. ~Nursing Management or Administrator will conduct audits daily x 2 weeks, weekly x 8 weeks, and monthly x 3 months for wound documentation completion and infection control practice adherence with treatment changes. Results of the audits will be reviewed at the QAPI meeting for further recommendations. ~Chief Nursing Officer will conduct audits on comprehensive wound assessment and documentation weekly x 1 month then monthly thereafter until deemed otherwise by QAPI committee.

Based on observation, interview, and record review the facility did not ensure one of one residents reviewed with a pressure injury (R2) received the necessary care and treatment to promote healing and prevent infection. R2 was admitted to the facility on [DATE] from the hospital with a Stage II pressure injury requiring an IV (Intravenous) antibiotic due to pseudomonas [CONDITION(S)]. The facility did not; ~ Recognize, identify or assess risk factors related to R2's pressure injury; ~ Develop, evaluate, and revise R1's care plan based on R2's risk factors and needs; ~ Recognize, assess, and timely and accurately document comprehensive wound assessments as indicated by the change in condition and deterioration of R2's pressure injury; ~ Update R1's physician timely and when decline was noted; nor ~ Ensure wound documentation was included in R2's electronic clinical record. R2 was subsequently admitted to the hospital on 8/2/21 and diagnosed with an infected stage III pressure injury due to historical pseudomonas and newly diagnosed [CONDITION(S)] ([CONDITION(S)]-resistant Staphylococcus Aureus) infection. R2 returned to the facility on [DATE] on two IV antibiotics. On readmission to the facility the facility did not ~ Ensure treatment modalities for off-loading were applied correctly; ~ Ensure dressing changes were completed timely and according to current standards of practice; nor ~ Implement infection prevention practices according to current standards of practice. The facility's failure to recognize, identify or assess risk factors related to R2's pressure injury; failure to develop, evaluate, and revise R1's care plan based on R2's risk factors and needs; failure to timely recognize, assess, and accurately document comprehensive pressure injury (PI) assessments as indicated by the change in condition and deterioration of R2's pressure injury; failure to update R1's physician timely when a decline was noted; and ensure wound documentation was included in R2's electronic clinical record created a finding of Immediate Jeopardy beginning 7/14/21. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 8/19/21 at 1:00 PM. The immediate jeopardy was removed on 8/19/21 and continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility implements its action plan. Findings Include: Surveyor completed a review of R2's clinical record and noted the following. R2 was admitted to the facility from the hospital on 7/2/21. R2's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was admitted to the facility with treatment orders which included negative-pressure wound therapy with dressing changes three times a week, and an IV antibiotic. R2's admission MDS (Minimum Data Set) was dated 7/9/21. The MDS indicated R2; ~ Had both short and long-term memory problems; ~ Cognitive skills were severely impaired; ~ Was rarely or never understood; ~ Required extensive assistance of one to two staff persons for all aspects of care including bathing, dressing, grooming, bed mobility, and using the bathroom; ~ Did not walk; ~ Ate independently with supervision; ~ Height 72 inches (6 feet); ~ Weight 125 pounds; ~ Had a ROM (Range of Motion) defect on both the upper and lower extremity on one side; and ~ Had two stage II pressure injuries. R2's current care plan titled .has potential/actual impairment to skin integrity .Stage III pressure injury . was dated 8/11/21. The care plan had the following treatment approaches. The dates noted in parenthesis was the date originally initiated. ~ 8/11/21, .keep skin clean and dry. Use lotion on dry skin as ordered/desired/needed . (7/6/21); ~ 8/11/21, .Meds (medications)/labs/treatments as ordered . (7/6/21); ~ 8/11/21, .Float/Elevate Heels . ~ 8/11/21, .Specialty Mattress . (7/6/21); and ~ 8/11/21, .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations . R2's historical care plan had the following approaches not noted on R2's current plan of care. ~ 7/12/21, .Report abnormalities, failure to heal s/sx (signs and symptoms) of infection, maceration .to MD (Medical Doctor) . and; ~ 7/12/21, .Remind resident to reposition every 2-3 hours and prn (as needed) . R2's CNA (Certified Nursing Assistant) care plan was not dated. The care plan had the following approaches; ~ .Keep skin clean and dry. Use lotion on dry skin .Float/Elevate Heels .Specialty Mattress . Surveyor completed a review of a TAR (Treatment Administration Record) dated 8/1/21-8/31/21. The TAR had the following treatment order. ~ Reposition every 2 hours and prn (as needed) three time a day for Monitor for repositioning .Start Date .7/24/21 .Hold Date-from 8/3/21 to 8/5/21 .D/C (discontinue) date .8/5/21 . There was no indication the facility recognized, assessed, and developed a specific individualized turning and repositioning program based on R2's specific needs to ensure total pressure relief of R2's right outer ankle pressure injury. Turning and positioning programs including the use of positioning and off-loading modalities are a critical part of promoting healing of a pressure injury R2's skin risk assessment dated [DATE] had a cumulative score of 13 indicating R2 was at moderate risk for the development of a pressure injury. Surveyor completed a review of R2's nursing notes and weekly wound documentation and noted the following. The facility by practice documented all pressure injuries on a form titled Weekly Pressure Ulcer Log. This was a cumulative log of all residents in the facility with pressure injuries. None of the entries onto the wound log were dated. None of R2's weekly wound documentation was noted in R2's clinical record. A nursing note dated 7/4/21 indicated .Heel/foot protectors applied . The intervention of heel protectors was implemented 2 days after admission to the facility. The intervention was not added to R2's plan of care. A nursing note dated 7/7/21 indicated, .Wound measures 2.4cm x 3cm x 0.3cm deep (2.4 centimeters long by 3.0 centimeters wide by 0.3 centimeters deep) had scant amount of blood at the edges, center yellow in color, no odor noted . This was the first noted documentation of R2's right outer ankle pressure injury, 5 days after R2's admission. The description of R2's wound was incomplete and did not identify all wound characteristics including type, stage, and location, description of wound base, wound edges, and condition of skin surrounding the wound. Comprehensive wound assessments are critical in order to determine if the wound is healing stagnant or deteriorating, if physician consultation is required, and if treatment modalities need to be changed including care plan interventions for off-loading. A Weekly Pressure Ulcer Log wound log dated 7/4/21 to 7/10/21 indicated R2 had a stage II pressure injury on the right heel which measured 3.5 cm (centimeters) long by 2.6 cm wide by 0.3 cm deep. The note indicated, .50% slough (devitalized tissue), 50% beefy red granulation tissue .odor N/A (non-applicable) .scant dark red drainage .Wound progress: New Wound . The above note did not include all the elements of a comprehensive wound assessment. The accuracy of the wound staged as an II pressure injury would be in question given the amount of slough and inability to fully assess the wound base. Additionally the location of the wound was not accurate. On 8/17/21 at 12:55 PM Surveyor spoke with the DON (Director of Nursing). The DON indicated she was the wound nurse and was the person who completed all documentation on the facility's Weekly Pressure Ulcer Log. The DON indicated the wound location all of R2's documentation as noted on the Weekly Pressure Ulcer Log was an error. The DON indicated the wound was located on R2's right outer ankle. There were no further nursing notes describing R2's right outer ankle pressure injury until 7/10/21. On 7/10/21 a nursing note indicated, .dressing changed to right ankle wound .Peril wound boggy and red, wound bed has large amount slough tissue present in the central wound and beefy red granular tissue on the out edges, scant amount of serosanguineous drainage, no malodor . The above nursing note did not include a comprehensive wound assessment. The nursing note indicated R2's wound had however deteriorated. Boggy, red, and large amount of slough were indicative the wound had deteriorated and become unstagable with the potential of infection. There was no physician notification, there were no changes made to R2's treatment regimen. On 7/12/21 a nursing note indicated, .Wound bed pink with scant white, granulation tissue noted. Small amount of serosanguinous [sic] drainage noted . On 7/14/21 a nursing note indicated, .prior to dressing change resident was up all shift in his w/c (wheel chair) and the wound vac machine was in the Off position and not running .old dressing removed .large amount of slough tissue present over most of the wound bed, edges have beefy red granular tissue, periwound is moist and macerated, red and boggy around the ankle bone, heal and foot protectors placed after new wound vac dressing applied . The above nursing notes did not include a comprehensive wound assessment. The nursing note indicated a deterioration of R2's right outer ankle pressure injury. A wound with slough over most of the wound bed is unstagable as the base of the wound is obscured. Boggy, moist redness is again a sign of infection. There was no physician notification. There were no new interventions added to R2's plan of care. A Weekly Pressure Ulcer Log dated 7/11/21 to 7/17/21 indicated R2 had a stage II pressure injury on the right outer ankle that measured 3.6 cm by 2.5 cm by 0.6 cm. The log indicated, .50% slough tissue, 10% beefy red granular tissue .improved . The above wound log was incomplete and did not include all the elements of a comprehensive wound assessment. The wound itself measured deeper than the previous wound log note dated 7/4/21 to 7/10/21. The wound given the amount of slough was again indicative the wound was unstageable. Despite that, the physician was not contacted. There were no changes made to R2's plan of care. From 7/14/21 to 7/21/21, a period of 7 days, there were no nursing notes describing R2's right outer ankle pressure injury. On 7/21/21 a nursing note indicated, .Wound vac changed no issues noted . The above note did not contain any elements of a comprehensive wound assessment. A Weekly Pressure Ulcer Log dated 7/18/21 to 7/24/21 indicated R2's right outer ankle pressure injury was a stage II pressure injury and measured 3.5 cm by 2.2 cm by 0.5 cm. The wound log indicated, .90% slough tissue, 10% beefy red granular tissue .Moderate serous drainage .improved . The above wound note as compared to the previous wound log note dated 7/11/21 to 7/17/21 again indicated R2's wound had deteriorated and had become unstageable. This was not identified by the facility as the wound note log note dated 7/18/21 to 7/24/21 indicated R2's wound had improved. The wound was noted to have increased drainage. On 7/24/21 the facility faxed R2's physician. Surveyor completed a review of the fax. The fax was noted as a .FYI (For Your Information) . The fax indicated, .Wound 90% slough .May need debridement .Writer will contact ID (Infectious Disease) or wound care . While the facility notified the physician via faxed information the status of R2's right outer ankle wound bed, the faxed information contained no further information regarding the status of the wound. Changes in wounds including bogginess which dated back to 7/14/21, measurements changes, and increased drainage are all indicators of a wound deteriorating and suspect for infection. These types of changes in a wound require immediate action to prevent further deterioration. Despite that, there was no indication the physician was informed of the changes. There were no changes made to R2's treatment regimen. From 7/21/21 to 7/30/21, a period of 9 days, there were no nursing notes regarding the status of R2's right outer ankle pressure injury. On 7/30/21 a nursing note indicated a treatment had been done. The nursing note contained no information regarding the status R2's right outer ankle pressure injury. A Weekly Pressure Ulcer Log dated 7/25/21 to 7/31/21 indicated R2 had a stage II pressure injury on the right outer ankle that measured 3.2 cm by 2.5 cm by 0.2 cm. The wound log indicated, .90% slough tissue 10% beefy red granular tissue . The above wound log note was not accurate. R2's right outer ankle pressure was unstable. The wound note again did not contain all the elements of a comprehensive wound assessment. The wound note indicated for the second week the wound bed was 90% slough. There were no changes made to R2's plan of care. The physician was not consulted. On 8/2/21 at nursing note indicated, .Wound vac changed .wound appears to have very little moisture at the base, area is yellow in color . The nursing note again contained no information regarding the status of R2's right outer ankle pressure injury. On 8/2/21 a nursing note indicated, .Appointment made .for follow up post-surgical evaluation and wound vac on right ankle. Writer described slough presentation of office. Appointment made for 8/4/21 . While the facility identified via fax on 7/24/21 the need for R2 to be seen due to changes in R2's right ankle wound, the appointment was not made until 8/2/21, 9 days later. On 8/2/21 a nursing note indicated R2 had a change in condition including poor appetite, nausea, and low grade temperature. On 8/2/21 the facility scheduled and sent R2 to a clinic appointment. R2 was subsequently transferred from the clinic to the emergency room and admitted to the hospital. R2 returned to the facility on [DATE]. Surveyor completed a review of R2's hospital records dated 8/6/21. The hospital records indicated, .Initially patient was referred for admission due to dehydration, malaise, and decreased appetite. However, after arrival to the medical floor, wound vac was noted to be malfunctioning. Dressing removed and significant amount of purulent foul-smelling exudate was noted .Patient had been on wound vac however due to the deterioration in the wound and high-volume purulent material this was removed on admission .Right lateral malleolus [CONDITION(S)] that grew Pseudomonas at outside hospital and newly diagnosed [CONDITION(S)] infection . Hospital records indicated R2 was to be followed by the wound clinic. There were no treatment orders given for R2's right outer ankle pressure injury on discharge. The facility had not identified the decline and deterioration of R2's right outer ankle pressure injury. Hospital record indicated R2's admission was unrelated to R2's pressure injury. The deterioration of R2's right outer ankle pressure injury was identified during R2's hospitalization . R2 was diagnosed with a new [CONDITION(S)] infection of the right outer ankle. R2 returned to the facility on two different antibiotics. Surveyor completed a review of R2's nursing notes beginning 8/6/21 when R2 returned from the hospital. From 8/6/21 to the date of survey 8/16/21, there were no nursing notes describing R2's right outer ankle wound. Surveyor completed a review or R2's TAR (Treatment Administration Record) dated 8/1/21 to 8/31/21. From 8/6/21 until 8/9/21 there was no record of a treatment being completed on R2's right outer ankle pressure injury. On 8/11/21 a nursing note indicated, .[CONDITION(S)] infection to ankle wound . This was also noted in R2's hospital discharge records dated 8/6/21. There was no indication the facility developed a care plan to drive care for R2's [CONDITION(S)] infection. Surveyor completed a review of a Weekly Pressure Ulcer Log dated 8/1/21 to 8/7/21. There was no documentation of R2's right outer ankle pressure injury. A Weekly Pressure Ulcer Log dated 8/8/21 to 8/14/21 indicated R2 had a stage II pressure injury measuring 3.0 cm by 3.0 cm by 0.4 cm. The wound log indicated, .10% slough tissue, 40% beefy red granular tissue, 50% yellow tissue present .Improved . Of notation. The wound log had not yet been updated noting R2's pressure ulcer was on the right outer ankle. The log still indicated right heel. The stage as noted on the wound log was incorrect. The wound note again did not include all elements of a comprehensive wound assessment. On 8/16/21, during the initial tour of the facility beginning at 12:00 PM, R2 was not noted to be on enhanced precautions. On 8/17/21 at 7:05 am Surveyor noted R2 in bed. There were no protective boots in either of R2's feet. R2 was not noted on enhanced precautions. On 8/17/21 at 8:35 am Surveyor observed R2 in bed. R2's right foot was not completely covered and partially exposed. There was a protective boot on R2's right foot however the boot was on backwards. On 8/17/21 at 8:40 am Surveyor requested to look at R2's lower extremities with the assistance of the DON (Director of Nursing). The DON turned R2's protective boot around. The DON removed and untucked bedding around R2's left leg. Surveyor noted R2's right leg was crossed over R2's left leg. Due to the thin nature of R2's lower extremities this caused R2's right outer ankle while in the protective boot to rest directly on the surface of the mattress. R2's right ankle was not off-loaded. Additionally the toes of R2's right foot were pressed against the bed's foot board. Once the DON straightened R2's lower extremities R2's lower legs were hanging over the end of the foot board at the level of the Achilles tendon. R2's head was noted approximately 1 foot from the top of the mattress. R2's bed was not long enough to support R2's height. This would make it extremely difficult for R2 to be positioned and repositioned appropriately while in bed. On 8/17/21 at 9:22 am Surveyor observed the DON with the assistance of RN (Registered Nurse)-C complete a dressing change in R2's right outer ankle pressure injury. The DON removed a gauze wrap. This revealed a secondary dressing. There was drainage apparent through to the outside of the secondary dressing. The DON removed the secondary dressing. There was a moderate amount of brownish tan colored drainage noted on the old dressing. The DON measured the wound. Wound measurements were noted as 2.6 cm by 3.0 cm by 0.4 cm. Surveyor noted the wound was a full thickness wound or stage III pressure injury. The wound base had scattered yellow slough encompassing approximately 10% of the wound. The wound base was light pink with apparent biofilm. There was a 1-2 mm heavy ring around the wound margin indicating probable epibole. The wound edges were not firmly adhered to the wound base. Surveyor questioned the DON regarding tunneling or undermining of the wound and requested the DON assess for both. The DON obtained a Q-tip and carefully rolled with Q-tip along the base edge of the wound. Surveyor noted skin movement indicating the edges were not securely adhered to the wound base. There was not however enough pressure utilized with the Q-tip to determine if either tunneling or undermining were present. The DON gathered dressing supplies and a wound cleanser. The DON sprayed the wound including the wound base. The DON gathered a gauze and swiped the skin around the opening of the wound. The DON then gathered clean dressing supplies. Surveyor stopped the DON's process and indicated to the DON the need to cleanse the wound base as well as change her contaminated gloves. Both epibole and biofilm are causative factors for non-healing wounds. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had returned from the hospital on 8/6/21 newly diagnosed with [CONDITION(S)] infection and on IV antibiotics. Neither the DON nor RN-C donned a gown prior to R2's dressing change. On 8/18/21 at 8:10 am Surveyor observed R2 in bed. Surveyor noted R2 had protective boots on both feet. Surveyor noted R2 was tilted to the right side. The caused R2's right leg to be rotated outward. The right side of the protective boot was resting on the surface of the mattress. R2's right outer ankle pressure injury was not off-loaded. On 8/17/21 at 10:55 am Surveyor spoke with RN-B and RN-C. RN-B indicated she had cared for R2. RN-B stated she did not measure any wounds as the DON did all the measuring. RN-B stated she felt the R2's wound at the end of July was about the same as when R2 was admitted . RN-B indicated if there was a change in a wound she would notify the DON, physician, administrator, and make an appointment for the resident to be seen in the clinic. On 8/17/21 at 11:45 am Surveyor spoke with RN-D. RN-D indicated she had cared for R2. Surveyor asked RN-D about R2's right ankle pressure injury. RN-D indicated the wound was mostly unchanged. RN-B also indicated she was aware R2 had been diagnosed with [CONDITION(S)] on readmission 8/6/21. On 8/17/21 at 2:10 PM Surveyor spoke with CNA-E (Certified Nursing Assistant). CNA-E indicated she had cared for R2. Surveyor asked CNA-E what R2's skin care plan was. CNA-E stated to lotion R2's dry skin. CNA-E indicated she did nothing with R2's feet. CNA-E indicated R2 could help with cares and turning however he couldn't use his right arm to help himself roll only his left arm. CNA-E indicated R2 spent 95% of his time on his back. Surveyor asked CNA-E if R2 was on a turning and repositioning schedule. CNA-E indicated he was however R2 turned himself. On 8/17/21 at 2:17 PM Surveyor spoke with CNA-F. CNA-F indicated she had cared for R2. CNA-F stated R2 was able to roll to the right independently however needed assistance to roll to the left. CNA-F indicated she felt R2's bed was too short and his foot would get stuck under the foot board. CNA-F indicated she had requested a larger bed however R2 never received one. CNA-F stated R2 laid with his legs crossed all the time. On 8/18/21 at 8:40 am Surveyor spoke with COTA-G (Certified Occupational Therapy Assistant) and PTA-H (Physical Therapy Assistant). Surveyor asked if either COTA-G or PTA-H had been involved with any type of wound treatment modality for R2 including the use of positioning and off-loading devices. Both COTA-G and PTA-H indicated they had not. COTA-G thought R2 had come into the facility with at least one protective boot. On 8/17/21 at 8:40 am Surveyor spoke with the DON (Director of Nursing). The DON indicated she was the wound nurse and was responsible for the documentation of all pressure and non-pressure wounds. The DON indicated she utilized a wound care log and was not at the present time documenting wounds into resident electronic records. The DON indicated she was still in the process of learning the facility's electronic charting system and had not started entering wound notes into R2's electronic record. The DON stated the wound log was a weekly log and all her entries onto the log for each specific resident were not dated, therefore she was unsure of when she actually assessed each wound. On 8/17/21 at 3:10 PM Surveyor spoke with the DON. Surveyor reviewed R2's TAR and lack of treatment orders for R2's right outer ankle pressure injury when R2 was readmitted . The DON indicated she did not know why. The DON also indicated she was from acute care and had never worked in long term care. The DON indicated she had little knowledge of wounds as other clinical staff in the acute care arena drove wound care. On 8/18/21 at 8:35 am Surveyor spoke with the DON. The DON indicated she was not aware R2 had a newly diagnosed [CONDITION(S)] infection when R2 was readmitted from the hospital. The DON subsequently placed R2 in enhanced precautions. On 8/18/21 Surveyor requested the facility's wound management policies and procedures. Surveyor received policies regarding how to complete a dressing change, a physician communication tool, and an audit tool. On 8/18/21 at 3:00 PM Surveyor again spoke with the DON. Surveyor again requested the facility's wound management program policies and procedure. The DON indicated what Surveyor received was all they had. The DON indicated the facility did not have a formal wound care program. The facility's failure to recognize, identify or assess risk factors related to R2's pressure injury; failure to develop, evaluate, and revise R1's care plan based on R2's risk factors and needs; failure to timely recognize, assess, and accurately document comprehensive pressure injury (PI) assessments as indicated by the change in condition and deterioration of R2's pressure injury; failure to update R1's physician timely when a decline was noted; and ensure wound documentation was included in R2's electronic clinical record created a finding of Immediate Jeopardy beginning 7/14/21. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 8/19/21 at 1:00 PM. The immediate jeopardy was removed on 8/19/21 when the facility completed the following: ~ All active licensed nursing staff to be educated on wound management, including wound prevention, comprehensive assessment of wounds including staging of pressure injuries, wound documentation, wound treatments, [CONDITION(S)] Infections specifically as it relates to isolation precautions, care planning, and physician notification of change in condition including but not limited to deterioration in wounds. Date initiated: August 18, 2021 with 100 percent of active licensed nurses working in facility completed on August 19, 2021, no licensed staff will be allowed to work until they have received education. ~ All active licensed nursing staff to be educated on facility policy and procedure for: Management of wounds ( Date initiated: August 18, 2021), Comprehensive care planning (Date Initiated: August 19, 2021), Change in condition (Date Initiated: August 19, 2021), [CONDITION(S)] Isolation Precautions (Date Initiated: August 19, 2021), Dressings, Dry/Clean (Date Initiated: August 18, 2021), and Pressure Ulcer Prevention & Treatment (Date Initiated: August 19, 2021). Nurses will complete a competency for wound assessment, applying wound dressing, and wound documentation (dressing changes & assessments) according to standards of practice. Date initiated: August 19, 2021 with 100 percent of active licensed nurses working in facility completed on August19, 2021, no licensed staff will be allowed to work until they have received education. ~ All active licensed nursing staff to be educated on wound dressing change expectations according to standard of practice and physician orders. Date initiated: August 18, 2021 with 100 percent of active licensed nurses working in facility completed on August 19, 2021, no licensed staff will be allowed to work until they have received education. ~ All active licensed nursing staff to be educated on resident care plans that include approaches for wound treatment and skin management. Licensed nursing staff will be educated on following resident care plan and care plan development for skin management. Date initiated: August 19, 2021 with 100 percent of active licensed nurses working in facility completed on August 19, 2021, no licensed staff will be allowed to work until they have received education. ~ All training noted above to be completed prior to each licensed nurse next working shift. Any nurses who do not complete the competency will not be scheduled until completed. Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to give an education. ~ All active licensed nursing staff to be educated on wound dressing change expectations according to standard of practice and physician orders. Date initiated: August 18, 2021 with 100 percent of active licensed nurses working in facility completed on August 19, 2021, no licensed staff will be allowed to work until they have received education. ~ All active licensed nursing staff to be educated on resident care plans that include approaches for wound treatment and skin management. Licensed nursing staff will be educated on following resident care plan and care plan development for skin management. Date initiated: August 19, 2021 with 100 percent of active licensed nurses working in facility completed on August 19, 2021, no licensed staff will be allowed to work until they have received education. ~ All training noted above to be completed prior to each licensed nurse next working shift. Any nurses who do not complete the competency will not be scheduled until completed. Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to give an education. ~ On August 18, 2021, facility reviewed policy and procedure on Dressings Clean/Dry, Medication & Treatment Orders, and Wound Measurement in coordination with medical director, including wound identification, wound assessment, wound treatment, and wound documentation to ensure policy meets current standards of practice. Policy was deemed to be up to date with current practices for wound and skin care management. ~ On August 18, 2021, all residents in facility received a head-to-toe skin assessment by RN. All wounds were measured, care plans and treatments were reviewed for appropriateness and accuracy. ~On August 18, 2021, resident with [CONDITION(S)] in wound was placed on Contact isolation precautions. ~On March 3, 2021, facility procured services with (Company Name) for wound supplies and staff education. Company does not measure wounds nor provide wound MD. Residents with wound care are followed externally by a wound clinic. ~ On August 19, , QAPI meeting held with resident's MD's covering colleague, Dr. (Name). ~DON and Nursing Supervisor will conduct audits daily x 2 weeks, weekly x 8 weeks, and monthly x 3 months for residents that have complex non-pressure injuries and residents with pressure injuries to ensure wounds receive weekly comprehensive assessment according to standards of practice, any wounds identified as stalled past 2 weeks or with decline are reported to physician timely with appropriate interventions and care plan changes initiated accordingly. Results of the audits will be reviewed at the QAPI [Quality Assurance and Performance Improvement] meeting for further recommendations. ~Nursing Management or Administrator will conduct audits daily x 2 weeks, weekly x 8 weeks, and monthly x 3 months for wound documentation completion and infection control practice adherence with treatment changes. Results of the audits will be reviewed at the QAPI meeting for further recommendations. ~Chief Nursing Officer will conduct audits on comprehensive wound assessment and documentation weekly x 1 month then monthly thereafter until deemed otherwise by QAPI committee.

Based on observation, interview and record review, the facility did not ensure that a resident who enters the facility without a PI (Pressure Injury) does not develop a PI and a resident with a PI receives appropriate care, treatment, and preventative interventions to promote healing for 2 of 3 residents reviewed (R1 and R3) for PI's. R1 was admitted to the facility without a PI and was identified to be at risk for PI development. R1 was diagnosed , at the hospital, with a PI and the facility failed to identify this area as a PI upon R1's return. The facility did not complete weekly PI measurements and R1 was observed to have multiple layers of linens on his air mattress. R1's plan of care was not updated and directed staff to reposition R1 every 4 hours. R1 was observed to be adhered to the linens on his bed; staff were observed ripping R1's skin when trying to remove the linens. Facility staff did not follow infection control standards of practice when providing wound care. These failures created a finding of Immediate Jeopardy (IJ) that began on 7/10/18. Surveyor notified NHA A (Nursing Home Administrator) of the IJ on 7/31/18 at 3:43 PM. The IJ was removed on 7/31/18, however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan and as evidenced by the following: Surveyor observed R3's pressure relief seat cushion not in place while R3 was seated in her recliner. This is evidenced by: AMDA (American Medical Directors Association) clinical practice guideline entitled 'Pressure Ulcers and Other Wounds,' dated (YEAR), states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear.Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications.Step 2. Examine the patient's skin thoroughly to identify existing pressure ulcers. Examine the patient's skin upon admission or readmission, .Step 3. Assess the patient's overall physical and psychosocial health and characterize the pressure ulcers. A pressure ulcer should be assessed along with the patient's overall clinical, functional, and cognitive status weekly reassessment and documentation of ulcer characteristics is recommended. More frequent assessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment.Step 4. Identify factors that can influence ulcer treatment and healing.functional status. Functional factors, including impaired mobility, a self-care deficit, and incontinence (especially fecal incontinence), may influence the severity, duration, and healing of a pressure ulcer.Step 5.Documentation should cover all pertinent characteristics of existing pressure ulcers, including location; size; depth; maceration; color of the ulcer and surrounding tissues; a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; tissue types covering the wound bed; .and a description of the periwound skin .including type and amount of drainage.Step 6. Identifying priorities in managing the ulcer and the patient .Pain control related to the ulcer and any comorbid conditions.The same factors that increase a patient's susceptibility to developing pressure ulcers .may also impair the healing of an existing pressure ulcer .Table 9 .Pain: unresolved pain may adversely affect healing. Pain may be related to the ulcer, surrounding infection, or other directly or indirectly related factors, alone or in combination .Identify and manage underlying causes of pain. Treat pain with adequate [MEDICATION NAME] . The National Pressure Ulcer Advisory Panel (NPUAP) at www.NPUAP.com defines PI's in the following categories: Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury - depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The NPUAP guidelines dated 6/13/12, recommends use of positioning devices and incontinence pads that are compatible with the support surface and to limit the amount of linen and pads placed on the bed. They also direct clinicians not to leave moving and handling equipment under the individual after use. The facility's Pressure Injuries / Skin Breakdown Protocol with a revision date of 1/18/18 includes; in part, Assessment and Recognition - 2. B. full assessment of PI including location, stage, length, width and depth. C. Pain assessment. E. Resident's mobility status. F current treatments including support surfaces. Treatment /Management - 2. The physician will help identify medical interventions related to wound management, managing pain related to wound or to wound treatment. Monitoring - 2. Licensed staff review and modify the care plan as appropriate when wounds are not healing or new wounds develop despite existing interventions. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's CAA (Care Area Assessment) worksheet for Pressure Ulcer dated 1/31/18 includes, in part, Triggers: bed mobility self- performance problem and Bowel incontinence are indicated, and Extrinsic risk factors: needs special mattress or seat cushion to reduce or relieve pressure, Confined to bed, and requires staff assistance to relieve pressure. Requires regular schedule of turning, maceration, persistently wet from fecal incontinence, wound drainage, or perspiration, moisture associated skin damage. [MEDICATION NAME] Factors: immobility, incontinence and poor nutrition. Analysis of Findings: requires 2 staff assist with positioning, refuses routine assistance. Has alternating air mattress and pressure reduction cushion when up in wheel chair. Is a heavy perspirier. Has large BM incontinence. Has Rosacea, which in combination with refusal of hygiene does result in open area of this rash. Care Plan Consideration: CAA triggered due to being at risk for PI, worsening of chronic skin rash related to foley use, impaired bed mobility, heavy perspiration, BM incontinence, and lack of cooperation with turning and repositioning and refusal of basic hygiene skin care. R1 continues with chronic rash on back and buttocks with open areas at times. R1 has Rosacea as well. Encourage adequate nutrition and fluids. Ensure pain is managed. Monitor skin status and complete treatment as per order. Reapproach for treatments and cares refused. Review of R1's Braden (skin breakdown risk) dated 3/21/18 score of 13 indicating R1 is at moderate risk for skin breakdown. Review of R1's Braden dated 6/24/18 score of 12 indicating R1 is at high risk for skin breakdown. R1's Comprehensive care plan for PI dated 3/2/16 with a revision date 9/21/16 includes, in part, R1 is at risk for PI, worsening of chronic skin rash related to Foley (Catheter) use, impaired mobility, heavy perspiration, BM incontinence, lack of cooperation with turning, repositioning, and refusal of basic hygiene skin care. R1 continues with chronic rash on back and buttocks with open areas at times. R1 has Rosacea as well. Goal - R1 will maintain or develop clean and intact skin dated 3/2/16 with a revision date 7/30/18. Will have healing of buttocks and scapula abrased OA (Open Areas) dated 6/20/18 with a revision date 7/30/18. Interventions - educate residents/family/caregivers of causative factors and measures to prevent skin injury as needed dated 3/2/16, revised 9/21/16. Keep skin clean and dry. Use lotion on dry skin as ordered /desired/ needed dated 3/2/16. Medicate as needed 30 - 60 minutes prior to dressing change dated 3/2/16 revised 7/21/17. Place 2 inch foam between knees and ankles and small pillow roll under ankles to float heels dated 8/9/17, revised 8/11/17. Specialty mattress, alternating air dated 3/2/16. Use draw sheet or lifting device to move resident dated 3/2/16. * It is important to know that the facility did not develop a Comprehensive Care Plan for PI treatment when R1 was re - admitted to the facility from the hospital with the [DIAGNOSES REDACTED]. Skin Observation Tool, dated 5/3/18, includes, in part: the following: Reason: weekly observation. Known skin impairments: yes. Listing of Skin Impairments: Site: Right scapula. Description: excoriated area receives treatment. Physician orders [REDACTED]. Indicate level of pain using scale of 1-10. If pain > (greater than) goal of 5 offer PRN (when needed) 4 times a day for pain. Skin Observation Tool, dated 5/10/18 Reason: weekly observation. Known skin impairments: yes. Listing of Skin Impairments: Site: Right scapula. Description: daily dressing change. Skin Observation Tool, dated 5/10/18 Reason: weekly observation. Known skin impairments: yes. Listing of Skin Impairments: Site: Right scapula. Description: daily dressing change. Skin Observation Tool, dated 5/17/18 Reason: weekly observation. Known skin impairments: yes. Listing of Skin Impairments: Site: left blank Description: left blank. Skin Observation Tool, dated 5/24/18 Reason: weekly observation. Known skin impairments: yes. Listing of Skin Impairments: Site: Right scapula. Description: daily treatment. Skin Observation Tool, dated 6/7/18 Reason: weekly observation. Known skin impairments: yes. Listing of Skin Impairments: Site: Right scapula. Description: excoriated area, daily treatment. Progress notes dated 6/13/18 at 8:00 PM, includes, in part: R1 complained that his back was stuck to the bedding and that he wanted the nurse to douse him in saline. R1's bed was wet as his catheter was leaking. When repositioning R1 it was noted he was incontinent of BM. While rolling R1 over to clean and change bedding, his backside was noted to be raw, red and bleeding. Greenish - blue drainage spots were on the linen. Skin Observation Tool, dated 6/14/18 Reason: weekly observation. Known skin impairments: yes. Listing of Skin Impairments: Site: Right scapula and Left buttock Description: daily dressing change to right scapula and barrier crème applied. Progress notes dated 6/14/18 at 11:01 AM includes, in part: R1 indicates they should just use that stuff they use with my dressing change to unstick me and then I wouldn't hurt. Note: the care plan does not address how to peel the linens from R1's skin. Progress notes dated 6/14/18 at 8:56 PM, includes, in part: R1 allowed staff to spray saline onto buttocks while under pad absorbed fluids keeping bedding dry. R1 then pulled at his skin stuck to pad away{sic}. Progress notes dated 6/15/18 at 3:59 PM, includes, in part: R1's back is starting to breakdown again, area was cleaned and dried and barrier cream was applied along with treatment orders to back. Progress notes dated 6/16/18 at 10:01 PM includes, in part: both wounds are red, raw and bleeding. Painful to R1. Areas sticking to bedding. Progress notes dated 6/17/18 at 10:00 PM includes, in part: R1 would not allow HS (bedtime) cares to be done. R1 c/o (complained of) on the PM (evening) shift that his butt was hurting. Has red, raw bleeding left butt cheek. Right scapula is also red and bleeding. Dressing applied yesterday, but R1 non-compliant today. Progress notes dated 6/19/18 at 11:14 AM, includes, in part: A risk benefits has been completed so R1 can be on a regular diet. Surveyor did not see a risks benefits regarding wound treatment refusal. The facility's Non- Pressure skin Condition form dated 6/20/18 includes, in part: Wound / skin problem acquired - in house. Site -Left buttock Description - moisture related excoriation - 2 areas. Distal open area 2.0 cm (centimeters) x 1.0 cm x 0.0 cm. Serosanguinous drainage size of a dime. Proximal area 1.0 cm x 0.5 cm x 0.0 cm. 1.0 cm serosanguinous drainage. Description of pain- states they stick to the sheets. Pain rating - 4. Skin Observation Tool, dated 6/21/18 Reason: weekly observation. Known skin impairments: - yes. Listing of Skin Impairments: Site: Right scapula, right and left buttock Description: wound receiving treatment is documented for the 3 areas listed about. Of note; there are no measurements of the above areas being treated. Progress notes dated 6/30/18 at 9:37 PM, includes, in part: R1's back was fire engine red from shoulders to back of thighs. R1 hollered in pain during cares. R1 was bleeding from 2 areas on buttocks. The facility's Non- Pressure skin Condition form dated 7/4/18 includes, in part: Wound / skin problem acquired - in house. Site - right scapula and left buttock Description - both areas documented as moisture related excoriation. Right scapula - chronic excoriation, has bright red blood on old dressing. Left buttock - 2.0 cm x 1.0 cm x 0.2 cm. Wound bed has bright red bloody drainage when old dressing is removed. Peri wound is red and excoriated. Description of pain- I feel like my skin is being ripped off. Pain rating - 8. Progress notes dated 7/4/18 at 9:34 PM, includes, in part: upper back continues to bleed freely. R1 complains of burning sensation to back. Progress notes dated 7/6/18 at 11:30 PM, includes, in part: [MEDICATION NAME] given for back pain stuck to the bed {sic}. Progress notes dated 7/7/18 at 3:28 PM, includes, in part: Gray drainage from back wounds with foul odor present. R1 was sent to the ER. Review of R1's hospital notes dated 7/7/18, R1's back had an extensive area of first and second degree decubitus ulceration with an area of 20 cm x 20 cm of macerated and open skin on the right thorax extending to the lumbar vertebra with a 10 cm x 20 cm areas of abrasion and maceration on either buttock and another similar size on the lower lumbar spine and sacrum. R1 has [DIAGNOSES REDACTED] extending out from these and those areas were extremely tender. R1 is known to [MEDICAL CONDITIONS] is a bacterium that is responsible for difficult to treat infections. R1 is kept on contact precautions. Progress notes dated 7/10/18 at 8:41 PM, includes, in part: returned from hospital. Complains of pain to his back is excruciating {sic}. Even though the hospital documentation had called the wounds decubitus ulceration. The facility did not update R1's care plan on his return. Progress notes dated 7/11/18 at 8:05 PM, includes, in part: received order for [MEDICATION NAME] to be given prior to dressings, cares to backside. R1 continues to have excruciating pain. physician's orders [REDACTED]. Of note, the [MEDICATION NAME] did not arrive in the facility until 7/27/18 at 12:43 AM. physician's orders [REDACTED]. Allevyn dressing to buttocks. Change every other day. Pre-medicated prior to dressing changes. Cleanse with saline one time a day every two days for skin breakdown. Progress notes dated 7/14/18 at 9:44 PM, includes, in part: Difficult trying to keep R1 on his side to clean feces as well as unstick his back and buttocks from the sheets. Was unable to apply fresh dressing to back due to R1's behavior and lack of cooperation. Progress notes dated 7/15/18 at 9:19 PM, includes, in part: previous [MEDICATION NAME] soaked and removed after several attempts. [MEDICATION NAME] removed and back bleeding. No new dressing applied. The facility's Non- Pressure skin Condition form dated 7/17/18 includes, in part: Wound / skin problem acquired - in house. Site - left buttock Description - moisture related excoriation. Excoriated area - 2.0 cm x 1.0 cm x 0.0 cm. Has scattered excoriations. Areas bleeding at times. Peri wound pink. Description of pain- Burns, My skin is being ripped off. Pain rating - 9. R1 had a significant change MDS (Minimum Data Set) dated 7/18/18. Section M0150 risk of PI indicates R1 is at risk for PI. Section M0210 unhealed PI indicates R1 does not have a PI. CNA (Certified Nursing Assistant) Kardex updated 7/18/18 includes, in part, Skin Integrity:at risk for skin breakdown. Reposition in bed every 4-6 hours. (This is contrary to standard of practice i.e. repositioning every 2 hours). Reposition when up in chair every 2 hours. Progress notes dated 7/20/18 at 9:05 PM, includes, in part: message left for MD D that R1's [MEDICATION NAME] was not given on 7/11/18. Requesting to discontinue the order. The facility's Non- Pressure skin Condition form dated 7/24/18 includes, in part: Wound / skin problem acquired - in house. Site - left buttock Description - moisture related excoriation. Excoriated area - 1.5cm x 1.0 cm x 0.0 cm. Areas scattered. Minimal bleeding on old dressing. Peri wound pink. Description of pain- left blank. Pain rating - left blank. R1's CAA worksheet for Pressure Ulcer dated 7/26/18 includes, in part, Triggers: bed mobility self-performance problem and Bowel incontinence is indicated, and Extrinsic risk factors: needs special mattress or seat cushion to reduce or relieve pressure, Confined to bed, and requires staff assistance to relieve pressure. [MEDICATION NAME] Factors: immobility, incontinence and poor nutrition. Analysis of Findings: is at risk for PI, worsening of chronic skin rash related to foley use, impaired physical mobility, heavy perspiration, BM (bowel movement) incontinence, lack of cooperation with turning and repositioning. R1 continues with chronic rash on back and buttocks with open areas at times. R1 has Rosacea as well. Care Plan Consideration: CAA triggered due to being at risk for PI, worsening of chronic skin rash, impaired bed mobility, heavy perspiration, BM incontinence, lack of cooperation with turning and repositioning. R1 continues with chronic rash on back and buttocks with open areas at times. R1 has Rosacea as well. Treat skin sites as ordered. Referral to another discipline-no, MD (Medical Doctor) following, has had improvement of skin status since readmission. Progress notes dated 7/30/18 at 1:14 PM, includes, in part: [MEDICATION NAME] given prior to dressing change. Old dressing removed with saline. Other areas of skin stuck to the bed. On 7/31/18 at 10:10 AM, Surveyor observed R1 lying in bed on an alternating air mattress set at 15 while positioned on his back. R1's heels were not floated. The air mattress pump was on the floor near the foot of R1's bed. Surveyor noticed foul odor in R1's room. Surveyor asked R1 if he had any sores on his back. R1 indicated yes. R1 indicated he was recently hospitalized . Surveyor asked R1 if the sores on his back were infected. R1 indicated they were. Surveyor asked R1 if it would be ok to observe his wound treatment. R1 indicated yes. Of note, the facility did not have a sign on R1's door or an isolation cart outside his room. On 8/1/18 at 10:00 AM, Surveyor interviewed DON B regarding R1 [MEDICAL CONDITION]. Surveyor asked DON B if R1 should be in contact isolation. DON B indicated that she was not aware of the need for isolation for R1 as he has a history [MEDICAL CONDITION] in his urine. Surveyor asked DON B if the staff is aware of [MEDICAL CONDITION]. DON B indicated the staff is to use standard precautions and that would be on the care plan. Review of R1's care plan for urinary catheter and CNA kardex does not document [MEDICAL CONDITION] precautions. On 7/31/18 at 10:30 AM, Surveyor interviewed RN C (Registered Nurse) regarding R1's skin condition. Surveyor asked RN C if R1 had any PI's. RN C indicated no. RN C indicated that R1 has Rosacea on his back and it opens up at times. Surveyor asked RN C when she was going to do R1's treatment to his back. RN C indicated that R1 has the treatment every other day. Surveyor asked RN C to describe what the treatment consisted of and what R1's back looked like. RN C indicated that the wounds are cleansed with saline, followed by [MEDICATION NAME] and an ABD pad. RN C indicated they don't tape the dressing in place. Surveyor asked RN C if it would be possible to see what is behind the ABD pad since it is not taped in place. On 7/31/18 at 10:40 AM, Surveyor, RN C, CNA G knocked and entered R1's room with permission as R1 likes his door closed. R1 swore and complained of pain throughout this treatment as staff tried to remove the linens that were adhered to R1's skin. (Cross reference F697.) During a portion of this observation R1 was observed to be incontinent of stool. RN C provided peri care. R1 was yelling out I'm ready to die, I can't take the pain. R1's bilateral buttocks was bleeding. R1 yelled I can't take this, come on, quit it. RN C removed her gloves and donned another pair of gloves without washing her hands or using sanitizer. RN C placed a 4 x4 piece of gauze against R1's bleeding area on his scapula to absorb the blood. R1 yelled out You have to help me, I can't take the pain. RN C then applied the [MEDICATION NAME] and ABD pad to R1's scapula. Surveyor observed blood soaking through the ABD pad which was approximately the size of a tennis ball. R1 yelled I can't take the pain. You got me scared. RN C cleansed R1's left buttocks with saline and applied an Allevyn dressing. No dressing was applied to the open area on R1's thigh. Surveyor observed the back of R1's thighs and noted areas of the skin that were circular and very dark red in color approximately 12 cm in size. R1 was yelling out I can't take it, lay me down. As R1 was being rolled over he yelled Jesus Christ, I can't take this, oh man oh man. Let me die, I can't take this. R1 started to cry. CNA G adjusted the bed control on the footboard, the bed jerked and R1 moaned and continued to cry. R1 indicated that the pain was unbearable during the treatment. On 7/31/18 at 11:18 AM, Surveyor asked DON B for R1's wound measurements. DON B indicated measurements were not done because R1 has Rosacea and you can't measure that as it's all over. On 7/31/18 at 11:25 AM, another Surveyor indicated hearing R1 yelling and swearing while walking down the hallway. On 7/31/18 at 2:05 PM, Surveyor interviewed MD D (Medical Doctor) via phone regarding the [DIAGNOSES REDACTED]. MD D indicated they come and go. Surveyor asked MD D if R1 has rosacea on his back. MD D indicated no. Surveyor asked MD D if she would expect R1 to be pre-medicated with [MEDICATION NAME] prior to his dressing change. MD D indicated yes. On 7/31/18 at 3:30 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) regarding R1 and his wound treatment. LPN F indicated R1 calls out. Surveyor asked LPN F if R1 had the PI before he went to the hospital. LPN F indicated yes. LPN F indicated that R1 should get the [MEDICATION NAME] before his treatments. LPN F indicated R1 would pour water on himself as his backside from his head to his thighs were fire engine red. LPN F indicated R1 would complain he felt like his skin was on fire. On 7/31/18 at 3:40 PM, Surveyor asked R1 to rate his pain level during the wound treatment. R1 indicated it was way above 10. Surveyor asked R1 when he receives the [MEDICATION NAME], what his pain level usually is. R1 indicated he could not put a number on it but it usually helps. Surveyor observed R1 lying on his back with his heels on the mattress. On 7/31/18 at 4:15 PM, Surveyor asked DON B who is WCC at the facility. DON B indicated no one. Surveyor asked DON B who the facility consults with for wounds. DON B indicated the facility does not have a WCC. Surveyor asked DON B what standard of practice the facility follows for wound care. DON B indicated the facility follows the AMDA (American Medical Directors Association) guidelines. The failure to comprehensively assess and treat R1's skin for PI's, obtain weekly measurements, provide pain management, follow infection control standards created a finding of Immediate Jeopardy. The facility removed the IJ on 7/31/18 when it had completed the following: 1. Facility will do a sweep of the center to identify any resident at risk for pressure injury. Any resident identified with an open area will have an assessment to determine if area is a pressure injury. 2. The facility will measure pressure injuries weekly. 3. Facility will assure that proper treatment is completed. 4. Facility will utilize minimal linens used with air mattresses. 5. Facility will make sure all residents at risk have proper interventions in place. 6. Facility will create a Choice Care Plan for the resident providing risk and benefits of and when he is refusing treatment. 7. Facility will consult with the physician or Medical Director to assure proper treatment and dressing are used to prevent skin from sticking to linens and assure appropriate wound care treatments. 8. Facility will have a wound care certified nurse consultant available to assist with consultations as indicated. 9. Facility to educate nurses prior to next shift on pressure injuries, how to identify them, appropriate staging, appropriate interventions, treatments and wound care per standards of practice. 10. Facility will update care plan to reflect pressure injury. 11. Facility will audit wound care treatments every day for 7 days, then weekly for 4 weeks. 12. Facility will educate nurses prior to next shift on proper hand hygiene. Cross reference F697 The deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) as evidenced by: Example 2 R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's significant change Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) was completed, with R3 scoring a 7 indicating she has severe cognitive impairment. Section M0150, of the MDS, indicates R3 is at risk for developing pressure ulcers. Section G0110, Activities of Daily Living (ADL's), indicates R25 requires 2 staff and extensive assist for bed mobility and transfers. R3's Comprehensive Care Plan for pressure injuries includes: At risk for pressure injury, bruises as related to impaired mobility, tubi grips, [MEDICAL CONDITION], ASA use. Date initiated: 1/2/17, Revision on 6/25/18. Goal: The resident will maintain or develop clean and intact skin by the review date. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin as ordered/desired/needed. Float/elevate heels. Heel lift boots when in bed. Pressure reduction alternating air mattress on bed. Pressure reduction seat cushion in recliner. R3's CNA Care Card for Skin Integrity includes the following: At risk for skin breakdown; Reposition in bed q2 (every 2) hours; Alternating air specialty mattress/pressure relief; Pressure relief seat cushion in recliner; Float heels; [MEDICATION NAME] and shoes on when up in recliner. On 7/31/18 at 2:22 PM, Surveyor observed R3 sitting in her recliner with no pressure relief seat cushion in place. On 7/31/18 at Surveyor spoke with Certified Nursing Assistant (CNA) I. Surveyor asked CNA I if R3 has a cushion in her recliner. CNA I checked and stated, No. Surveyor asked CNA I if R3 should have a pressure relieving cushion in her recliner. CNA I replied, Yes.

Based on observation, interview and record reviews the facility staff failed to adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well being for 1 (R1) of 1 residents reviewed for pain. R1 has a physician order [REDACTED]. R1 was not pre-medicated and was observed screaming and swearing in pain during a wound care treatment; R1 was adhered to his bed linens; staff were observed peeling R1's skin away from his body while trying to remove the linens. These failures created a finding of Immediate Jeopardy (IJ) that began on 7/14/18, when the facility failed to ensure R1's pain was managed prior to his wound treatment. Surveyor notified NHA A (Nursing Home Administrator) of the IJ on 7/31/18 at 3:43 PM. The IJ was removed on 7/31/18, however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. This is evidenced by the following: The facility's policy Pain Assessment and Management dated 5/18/18, includes, in part: Pain Management is the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Possible signs of pain: a. verbal expressions such as groaning, crying, screaming. Behaviors such as resisting care. 2. Ask resident if he is experiencing pain. Identifying causes of pain: 2. b. Skin / Wound conditions: 1. Pressure ulcer. 3. Review resident's treatment record or recent nurse's notes to identify any situations or interventions where an increase in resident's pain may be anticipated. b. Treatments such as wound care or dressing changes. 4. Pharmacological interventions: may be prescribed to manage pain. 6. Implement the medication regimen as ordered. R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1's significant change MDS (Minimum Data Set) dated 7/18/18, Section C0500 BIMS (Brief Interview for Mental Status) scored a 15 which indicates R1 is cognitively intact. Section G0110 A. bed mobility indicates R1 requires extensive assistance with 2 or more staff assist and section, B. indicates transfer, R1 is totally dependent and requires 2 or more staff assist. Section J0400 pain frequency indicates R1 has occasional pain, section J0500 indicates R1 is limited in his activities due to pain and J0600 pain rating scale R1 rates his pain a 5. R1's CAA (Care Area Assessment) worksheet for Pain, dated 7/26/18 includes, in part, Triggers: R1 has limited day to day activity because of pain over past 5 days as indicated yes. Analysis of Findings: R1 has chronic pain related to [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION]. R1 is able to verbalize his pain on a 1-10 scale. Disease and conditions that may cause pain: Cancer, Skin/Wound. Other ulcers, wounds, incisions, skin problems. Moisture associated skin damage. Characteristics of pain: R1 complains of back pain and pain all over whenever staff attempt to assist with movement. Hurts Bad. Pain medication routinely and prn given prior to turning or treatment or at least 1 x (one time) shift. Frequency and Intensity of pain: Every day when they move me, not as bad as it was. Other considerations: Improper positioning, Immobility. Declines proper positioning in bed. Care Plan Consideration: CAA triggered due to R1 has complaints of chronic pain related to [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. R1 has history of left hip replacement with failed union as well as history of compression fracture. R1 is able to verbalize his pain on a 1 - 10 scale. Will continue to attempt to manage pain while trying to decrease functional loss. R1's Comprehensive care plan for Pain dated 3/2/16, with a revision date 7/30/18, includes, in part: R1 complains of chronic pain related to [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. R1 has history of left hip replacement with failed union as well as history of compression fracture. R1 is able to verbalize his pain on a 1 - 10 scale. Goal: R1 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Will state pain is less than goal of 5 on a 1 - 10 scale revised on 7/30/18. Interventions: Anticipate R1's need for pain relief and respond to any complaint of pain (dated 3/2/16.) If pain occurs during cares, treatments, procedures, stop immediately and report to nurse. Nurse to assess and treat. Cares, treatments, procedures should not resume until R1 says he is ready to. Pre-medicate to help decrease pain and decrease refusal of care dated 9/21/16. Per R1's ADL (Activities of daily living) care plan dated 3/2/16 with a revision date of 1/31/18, R1 is at risk of ADL needs not being identified or met due to weakness, mood and behaviors, history [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), vascular disease, contractures, choosing to remain in bed, frequently refusing care assist. Chronic pain. Dependent for most all ADL needs to be met. Includes the intervention: Before attempting ADL's, please ensure pain is managed dated 9/21/16. CNA (Certified Nursing Assistant) Kardex updated 7/18/18 includes, in part, Pain - if pain during cares, treatments, or other procedures stop immediately and notify nurse. Do not resume cares until pain resolved. R1's (MONTH) (YEAR) Pain scale record documents that R1's goal is 5 or < (less than). R1 had a total of 11 times the pain score was greater than 5. There was 1 time his pain score was not documented. R1's (MONTH) (YEAR) Pain scale record documents that R1's goal is 5 or <. R1 had a total of 22 times his pain score was greater than 5. There were two times, the pain score was not documented. Physician order [REDACTED]. It is important to know that the facility did not receive R1's [MEDICATION NAME] until 7/27/18 at 12:43 AM. R1 did not receive his first dose of 2 mg of [MEDICATION NAME] until 7/30/18 at 10:45 AM. On 8/2/18 at 11:00 AM, Surveyor spoke with Pharmacy Tech E via phone regarding the date the [MEDICATION NAME] was delivered to the facility. Pharmacy Tech E indicated that the [MEDICATION NAME] was delivered to the facility on [DATE] at 12:43 AM. On 8/3/18 at 11:25 AM, Surveyor spoke with DON B via phone in regard to the delay in the [MEDICATION NAME] delivery for R1. DON B indicated that the pharmacy needed to have a hard prescription before they would dispense it. DON B indicated the facility called the MD (Medical Doctor) D to see if she wanted to discontinue the order. DON B indicated the hospital never sent the prescription to the pharmacy and that was part of the issue. Progress notes dated 6/16/18 at 10:01 PM includes, in part: both wounds are red, raw and bleeding. Painful to R1. Areas sticking to bedding. Progress notes dated 6/17/18 at 10:00 PM includes, in part: R1 would not allow HS (bedtime) cares to be done. R1 c/o (complained of) on the pm (evening) shift that his butt was hurting. Has red, raw bleeding left butt cheek. Right scapula is also red and bleeding. Dressing applied yesterday, but R1 non-compliant today. The facility's Non- Pressure skin Condition form dated 6/20/18 includes, in part: Wound / skin problem acquired - in house. Site -Left buttock Description of pain- states they stick to the sheets. Pain rating - 4. Progress notes dated 6/30/18 at 9:37 PM, includes, in part: R1's back was fire engine red from shoulders to back of thighs. R1 hollered in pain during cares. R1 was bleeding from 2 areas on buttocks. The facility's Non- Pressure skin Condition form dated 7/4/18 includes, in part: Wound / skin problem acquired - in house. Site - right scapula and left buttock Description of pain- I feel like my skin is being ripped off. Pain rating - 8. Progress notes dated 7/4/18 at 9:34 PM, includes, in part: upper back continues to bleed freely. R1 complains of burning sensation to back. Progress notes dated 7/6/18 at 11:30 PM, includes, in part: [MEDICATION NAME] given for back pain stuck to the bed. Progress notes dated 7/10/18 at 8:41 PM, includes, in part: returned from hospital. Complains of pain to his back is excruciating. Progress notes dated 7/11/18 at 8:05 PM, includes, in part: received order for [MEDICATION NAME] to be given prior to dressings, cares to backside. R1 continues to have excruciating pain. The facility's Non- Pressure skin Condition form dated 7/17/18 includes, in part: Wound / skin problem acquired - in house. Site - left buttock Description of pain- Burns, My skin is being ripped off. Pain rating - 9. The facility's Non- Pressure skin Condition form dated 7/24/18 includes, in part: Wound / skin problem acquired - in house. Site - left buttock The description of pain and pain rating were left blank. On 7/31/18 at 10:40 AM, Surveyor, RN C, CNA G knocked and entered R1's room with permission as R1's door was closed. RN C and CNA G washed their hands and donned gloves. R1 was repositioned to his left side. R1's lift sheet (soaker pad) and top sheet was adhered to the back of R1's right thigh and buttocks. RN C poured saline over the adhered linen and attempted to separate R1's skin from the linen. R1 yelled Ow, God damn it, Ow. R1 yelled out to put more saline on it. Surveyor asked RN C if she noticed a foul odor. RN C indicated yes. Surveyor observed the sheet adhered to R1's back. Surveyor asked RN C if R1's back was open. RN C indicated not usually. RN C poured more saline on the back of R1's right thigh as she tried to separate the linen from his skin; an area the size of a quarter opened up on the back of R1's right thigh which immediately began bleeding. R1 screamed out, OW, it's still stuck. RN C asked R1, if she should stop, R1 said no. RN C poured saline on R1's dressing over his right scapula and as she removed the dressing, a circular open area approximately 4-5 cm, immediately began bleeding bright red blood. R1 yelled God damn it, you know it hurts. R1 then yelled Get me some pain pills. R1 stated These hurt me so bad. RN C said to R1 with a strong tone in her voice, we need to get this cleaned up. RN C continued to pour saline along R1's side attempting to free him from the bed linens that were adhered to his skin. Surveyor asked RN C if DON B has seen R1's skin. RN C indicated yes. At 10:55 AM, Surveyor asked CNA G to go get DON B. RN C asked CNA G to get another CNA. Surveyor asked RN C if she was WCC (wound care certified). RN C indicated no. Surveyor asked who at the facility was wound care certified. RN C indicated she thought DON B was. RN C indicated that R1 used to pour his water pitcher down his back. RN C indicated the nurse charted yesterday that R1 did not have any open areas. Surveyor observed yellow drainage on the bed linens. DON B came into R1's room with CNA H. CNA H closed R1's curtains on the window. R1 was repositioned to his right side and yelling out. DON B asked RN C if she gave R1 his [MEDICATION NAME]. RN C indicated no as she gave R1 his [MEDICATION NAME] at 9:00 AM. R1 was observed to be incontinent of stool. RN C provided peri care. R1 was yelling out I'm ready to die, I can't take the pain. R1's bilateral buttock was bleeding. R1 yelled I can't take this, come on, quit it. RN C removed her gloves and donned another pair of gloves without washing her hands or using sanitizer. RN C placed a 4 x4 piece of gauze against R1's bleeding area on his scapula, to absorb the blood. R1 yelled out You have to help me, I can't take the pain. RN C then applied the [MEDICATION NAME] and ABD (abdominal) pad to R1's scapula. Surveyor observed the ABD pad, as blood was soaking through the size of a tennis ball. Surveyor asked DON B if she observed the blood saturating the ABD pad. DON B indicated yes. R1 yelled, I can't take the pain. You got me scared. RN C cleansed R1's left buttocks with saline and applied an Allevyn dressing. No dressing was applied to the back of R1's open area on his thigh. Surveyor observed the back of R1's thighs and noted areas of the skin, that were circular and very dark red in color, approximately 12 cm (centimeters) in size. R1 was yelling out, I can't take it, lay me down. R1's bed linen was then changed. The soiled linen was observed to have bloody, yellow- brown drainage. R1 yelled, God damn it. Surveyor asked DON B if she noticed a foul odor in R1's room. DON B indicated yes, because R1 wants his door kept shut. Surveyor observed that a bottom sheet, a folded in half bath blanket and a soaker pad was placed over the air mattress that R1 was lying on. As R1 was being rolled over he yelled, Jesus Christ, I can't take this, oh man, oh man. Let me die, I can't take this. R1 started to cry. CNA G adjusted the bed control on the footboard, the bed jerked and R1 moaned and continued to cry. R1 indicated that the pain was unbearable during the treatment. On 7/31/18 at 11:25 AM, another Surveyor indicated he could hear R1 yelling and swearing while walking down the hallway. On 7/31/18 at 2:05 PM, Surveyor interviewed MD D via phone regarding R1's pain management. Surveyor asked MD D if she would expect R1 to be pre-medicated with [MEDICATION NAME] prior to his dressing change. MD D indicated yes. On 7/31/18 at 2:13 PM, Surveyor interviewed DON B regarding R1's wound treatment and if RN C should have given R1 the [MEDICATION NAME] prior to R1's treatment. DON B indicated it was too late now. Then DON B indicated, yes. On 7/31/18 at 2:18 PM, Surveyor interviewed RN C regarding R1 and if she should have stopped the treatment. RN C indicated she kept going and probably should have stopped the treatment. On 7/31/18 at 3:30 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) regarding R1's wound treatment. LPN F indicated R1 calls out. Surveyor asked LPN F, if R1 had the PI (Pressure Injury) before he went to the hospital. LPN F indicated yes. LPN F indicated that R1 should get the [MEDICATION NAME] before his treatments. LPN F indicated R1 would pour water on himself and his backside. From his head to his thighs were fire engine red. LPN F indicated R1 would complain he felt like his skin was on fire. The failure to comprehensively assess and treat R1's pain prior to his wound treatment and provide pain management when R1 was experiencing excruciating pain during his wound treatment, created a finding of Immediate Jeopardy. The facility removed the IJ on 7/31/18 when it had completed the following: 1. Identify residents at risk for pain and review and update pain program. 2. Residents will receive appropriate pain regime based on their pain assessment. 3. Facility will educate all licensed staff prior to their next shift to pre - medicate residents prior to treatments and if resident complains of pain, to stop treatment and medicate. 4. Facility will audit residents during treatment for [REDACTED]. 5. Facility will conduct random audits checking on pain relief daily for 7 days, then weekly for 4 weeks. 6. Facility will update care plans to make sure all residents identified as having pain or at risk for pain are on pain management program. Cross reference F686.

Based on interviews, medical record reviews and policy reviews, the facility did not ensure 2 of 11 (Resident #13 and 5) residents reviewed received supervision and interventions to prevent accidents. 1. Resident #13 experienced five falls; the fourth fall resulted in a fractured hip and femur. No new interventions were added until after the fifth fall. 2. Resident #5 cut off her wanderguard bracelet. No investigation was done to determine when this was removed. This is evidenced by: 1. Resident #13's admission Minimum Data Set (MDS), dated [DATE], identifies a Brief Interview for Mental Status (BIMS) score of 10, which indicates moderate impairment. The MDS indicates that Resident #13 is independent with bed mobility and requires assist of one staff member for transfers and toileting. The care plan identifies a problem of falls with a start date of 09/18/14. The care plan states, "(Resident #13's name) is at risk for fall events and injuries associated with fall events related to impaired cognition with impulsiveness and poor safety awareness, weakness, limited ROM (range of motion)..." The interventions on the care plan include: 09/18/14 analyze falls to determine pattern/trend 09/18/14 assure floor is free of glare, liquids, foreign objects 09/18/14 hourly or more frequent safety checks 09/18/14 keep call light in reach 09/18/14 keep personal items and frequently used items in reach 09/18/14 observe frequently and place in supervised area when out of bed 09/18/14 provide an enviroment free of clutter 09/18/14 provide proper, well maintained footwear 09/18/14 provide toileting every two hours Handwritten additional interventions include: 09/12/14 gripper socks in bed 09/16/14 1:1 and redirection 10/02/14 reminder to use call light signs in room The MDS, dated [DATE], identifies a BIMS score of 5 (severe cognitive impairment). It identifies that Resident #13 is independent in bed mobility and requires assist of one staff member for transfers and toileting. Resident #13 has had one fall since admission with no injury. Surveyor reviewed the nurses' notes for Resident #13, dated 11/17/14 to 11/28/14. During this time, Resident #13 had seven falls in seven days. On 11/17/14 at 11:55 a.m., a housekeeper found Resident #13 on the floor. Licensed Pratical Nurse (LPN) C documented in the nurses' notes, "Went in room res was laying on the floor with his head in the bathroom and the rest of his body in the room with the w/c by his feet... he stated he was coming back from the bathroom turned to sit down and he hit the front of the chair and turned and sat on the floor." Surveyor interviewed LPN C on 12/11/14 at 10:15 a.m. LPN C was asked if any new interventions were added after this fall. LPN C stated he continued to monitor the resident that day, but did not add anything new to the care plan. The fall is then looked at by the interdisciplinary team (IDT). The IDT team fall review states the resident was found lying on floor half in room/half in bathroom. The report includes the following information: - "Were reports completed thoroughly?" - no is checked, written statement "No incident report filled out." - Were interventions appropriate?: this is blank - New interventions put into place after staff identified the root cause: this is blank - Review the root cause for accuracy of the conclusions reached: this is blank - Current status: no injury - The need to change and or add interventions to prevent future falls: encourage to go to dining room for meals. (This intervention was not added to the care plan or communicated to staff.) On 11/17/14 at 6:45 p.m., the nurses' notes identify a second fall that day. The nurses' notes state, "Resident found in empty room #114 sitting on floor. Had attempted self transfer from w/c onto bed. Wheels on bed were not locked and bed moved out from under him." The event report has the following information: - Description - "self transferring from w/c to bed" - Event details - location - resident room, fall was unwitnessed, prior to the fall resident was propelling self in w/c in hallway - Interventions - immediate measures taken - "none of the above" is checked - Describe measures - is blank - Outcome of interventions - "interventions ineffective" is checked - Describe - "resident forgetful about using call light for assistance" The weekly IDT fall review states Resident #13 was sitting on floor next to bed in room 114. The report includes the following information: - What interventions were in place at the time: "hourly safety checks, non-slip footwear, 1:1, re-direction" - Were interventions appropriate: yes is checked - New interventions put into place after staff identified the root cause: "redirect back to correct room and hall" (This intervention was already a part of the care plan as of 09/16/14). - Review of root cause for accuracy of conclusion reached: "memory - in wrong room, balance poor" - The need to change and or add interventions to prevent future falls: this area is blank The care plan has hand written "11/18/14 fall x2 no injury monitor." On 11/18/14, the nurses' notes identify a fall at 8:52 p.m. The note states, "Large crash noise heard from room # (room number). Found resident sitting on floor between bedside chair and w/c. When asked what he was doing, resident remarked he was going to bathroom. Had not used call light even tho it was within his reach. Resident self-transfers constantly." No event report or IDT team review was provided to surveyor for this event. The care plan has written, "11/19/14 fall in room stated he was going to BR, monitor." Starting on 11/20/14, the nurses' notes document a change in functional abilities, increased confusion and lethargy. Resident #13 is unable to follow simple commands, diet changed to mechanical soft and now transfers with an EZ stand. The falls care plan identified the change in transfer status but no additional fall prevention interventions. The nurse's note on 11/24/14 at 10:32 a.m. states, "Therapy came to this nurse that resident was on floor. Resident was kneeling on floor with arms over bed." Resident #13 stated he was readjusting himself. The event report indicates resident fell out of bed, no pain, no injury, no rotation or deformity, no immediate measures were taken and no interventions used. No IDT team review was provided to surveyor. The care plan has handwritten, "11/25/14 self transfer - kneeling by bed - no injury. Remind to call for assist." On 11/25/14, nurses' notes identify the left leg to be shorter with rotation, Resident #13 has pain when he tries to straighten it. Power of Attorney (POA) does not want resident sent out. Nurse's note on 11/26/14 states resident's left leg is shorter than right, rotated out, compaint of pain with movement. Doctor was updated and POA does not want sent out. Nurse's note on 11/26/14 at 9:40 p.m. "Resident found on floor at 9:30." A high/low bed was placed and a larger mat on floor. (These were not added to the care plan.) On 11/28/14, POA agreed to send resident out to clinic. Resident was admitted with left hip and left femur fracture. Resident #13 passed away on 12/01/14. On 12/11/14 at 1:00 p.m., Surveyor discussed the falls and lack of root cause analysis and fall interventions with the Director of Nursing (DON) and Regional Director (RDO). No further information was provided. 2. Resident #5 was admitted to the facility on [DATE]. Resident #5 has been identified as an elopement risk and wears a wanderguard bracelet to alert staff of attempts of exiting the building. Resident #5's Certified Nursing Assistant (CNA) care plan read in part: -Elopement risk: Wanderguard right ankle Resident #5's Comprehensive Care Plan read in part: -Problems: Falls... She is at risk for unassisted exits from building. -Approach: Wanderguard on ankle to alert staff of exit attempts from building. Check placement every shift. Ensure function every day. If removes do 15 minute checks -12/04/14. The comprehensive care plan does not include an exit seeking care plan. Review of Resident #5's Resident Progress Notes regarding exit seeking and wanderguard alarm revealed the following: 11/08/14 at 10:38 a.m. read in part: "Res (resident) alerted staff by wander alarm that she went out the employee door. She had her sister's coat on and she was going to (sic) home..." 11/08/14 at 5:30 p.m., read in part: "...Attempted to go out the exit door at 1430 pm (2:30 p.m.)." 11/30/14 at 5:31 p.m. read: "Has been restless all shift, continually wanting to go home. States, "I'm being held here against my will." Tried distraction without success. Went out 100 hall doorway setting off alarms which alerted staff. Was found about 20 feet from door starting to go toward driveway." 11/30/14 at 9:09 p.m. read in part: "Continued to look for doors to get out, had coat and didn't let staff take it off insisting that she was leaving." 12/01/14 at 4:38 p.m. read in part: "Went out front door to end of sidewalk setting off wonder (sic) guard." 12/03/14 at 5:29 p.m., read: "Resident had cut her wanderguard band off within the last few days/was not witnessed, unsure of exact time or circumstances surrounding it. The wanderguard device itself was still in her coat pocket in which she likes to wear every day. Staff trying to determine where resident got the "tool" to cut it off. Writer called residents (sic) guardian (guardian name) and asked permission to search residents (sic) room while she was at church this afternoon. CNAs (names) and writer looked for scissors or the like and did not find anything. New wanderguard and band placed on resident this afternoon. Resident compliant. She remains on 15 minute checks." 12/05/14 at 8:46 p.m., read in part: "Very restless this PM, had three episodes of setting off door alarms. Got to end of sidewalk all three times, was returned to facility by three staff members, was resistive all three times stating "I want to go home and you can't stop me." Review of the Daily Behavior Observation Tool for November shows Resident #5 attempted elopement three times on nights, five times on days and 11 times on evenings. It should be noted November 8 is crossed out for the days and six times were noted for evenings. November 30 shows no elopement. The Daily Observation Tool for December shows Resident #5 with no elopements until December 5 where two on the evening shift were documented. These Daily Behavior Observation Tools do not coincide with the Resident Progress Notes above. On 12/10/14 at 1:05 p.m., Surveyor met with the DON to discuss the above incident. Surveyor stated from the 12/03/14 Resident Progress Note, it appears staff were not aware of the last time Resident #5 had her wanderguard on. The DON stated they found it in her pocket and they were not aware she cut it off. The DON stated it is to be tested every day. Surveyor stated per her care plan, placement is to be checked every shift and it wasn't clear this was done. Surveyor asked if an investigation was done to determine when she cut the wanderguard off. The DON stated, "Yes." The DON went on to say Resident #5's elopements are getting to be two to three times per week. The DON stated she would follow up with an investigation for Surveyor . No investigation was provided. On 12/11/14 at 8:53 a.m., Surveyor met with LPN C to discuss above incident. LPN C stated on 12/02/14 Resident #5 had her wanderguard on when visually checked. LPN C stated he visually checks it every shift and nights checks it with a machine to make sure it is working. LPN C further stated that on 12/03/14 staff brought him the wanderguard and he tried to put one back on and Resident #5 did not allow this, so 15 minute checks were initiated. Surveyor asked LPN C where it is charted that it was checked every shift. LPN C stated, "We chart in the treatment book, I think." LPN C reviewed Resident #5's Treatment Administration Record (TAR) and stated, "It's not in there." LPN C showed Surveyor on a different resident's TAR how it should be noted. On 12/11/14 at 9:05 a.m., LPN C approached Surveyor stating, "It was on the first (of December) that I noticed it wasn't on, and started 15 minute checks at that time; 15 minute checks from 7:00 a.m. on the 1st to PM shift on the 3rd." LPN C further stated, "On the 3rd is when it was put back on, (Registered Nurse V) was on." It should be noted, per the 15 Minute Checklist, 15 minute checks were started on 12/01/14 at 4:15 p.m. Surveyor asked LPN C if anyone ever interviewed him regarding the incident. LPN C stated, "No." Surveyor asked LPN C if he knew the wanderguard was in her pocket or if he found it in her pocket. LPN C stated, "No." No investigation was provided by the end of survey.

Based on interview, observation, policy review and record review, the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being to 1 of 10 sampled residents. Resident #10. Resident #10 has a known history of anxiety and depression. The facility did not adequately address Resident #10s' concerns regarding CNA A, leading to an increase in Resident #10s' depressive symptoms. The facility did not investigate, monitor or train staff to be aware of and help Resident #10 cope with her emotional needs. This is evidenced by: Resident #10 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 12/10/12, at 3:50 p.m., Surveyor conducted an interview with Resident #10, who is alert and oriented. Resident #10 said that she loved her room, and showed Surveyor her birdfeeder and Christmas tree. Resident #10 stated that she enjoys the activities offered at the facility, especially bingo. Surveyor asked Resident #10 about the quality of care she received from the facility staff. Resident #10 stated "I don't want to tattle but I am glad you asked." Resident #10 stated that CNA (Certified Nursing Assistant) A treated her in a disrespectful manner, and had a rushed and rough approach. Resident #10 stated that she has cried "many tears" and "still does" when she sees CNA A. Resident #10 was unable to provide a specific time frame for these allegations or specific incidents, but stated she talked to the SW (Social Worker) and the DON about CNA A's approach and treatment. Resident #10 stated that she also talked to FM M about her concerns. On 12/10/12, at 6:00 p.m., Family Member (FM) M requested to speak with Surveyor . FM M told Surveyor that Resident #10 telephoned her whenever CNA A was assigned to take care of her. FM M stated that Resident #10 told her that CNA A was disrespectful and rough with her, and that Resident #10 called her on the phone "many times" crying and complaining about the "disrespectful treatment" provided to her by CNA A. FM M told Surveyor that she had complained many times to the SW, NHA and DON about CNA A's behavior toward Resident #10, and that she had requested that CNA A not be assigned to care for Resident #10. FM M stated that the SW, DON and NHA did not address Resident #10s' concerns about CNA A. FM M told Surveyor that Resident #10 hated seeing CNA A come to work in the morning, and that she dreaded CNA A being assigned to her. FM M stated that despite her numerous requests to the NHA, SW and DON, CNA A continued to be assigned to care for Resident #10. FM M also stated that she feels Resident #10 has been emotionally abused by this situation. FM M stated that she spoke with Resident #10s' physician about this situation because he wondered why Resident #10's mood was more depressed and why she was having increased incidents of crying. FM M stated to Surveyor "I finally got sick of requesting that CNA A not take care of Resident #10, and told them that unless she stopped taking care of her, I was going to call the State." FM M said that after she threatened to call the State, CNA A was not allowed to care for Resident #10 any longer. A document completed on 06/05/12 and entitled "Resident Grievance/Complaint Form" was reviewed by Surveyor . The complaint form, filled out and signed by the SW, revealed that FM M reported that CNA A has an attitude with Resident #10 and that she treats her with disrespect. Under the section "Corrective Action Plan" the form states "CNA A told that she will not be the aide caring for Resident #10 any more." FM M stated to Surveyor she did not feel the problem was solved, however; because they "Just moved the problem around. Resident #10 still sees CNA A in the building and this intimidates and upsets her." FM M also told Surveyor that the facility changed the type of incontinent product that Resident #10 wore without asking her. FM M stated that Resident #10 told the facility that this product was not absorbent enough to meet her needs. FM M stated that the Resident told the facility that the incontinent product was not working, but the facility did not address the problem until FM M came in and complained to the DON. FM M states that the facility does not listen to Resident #10s' complaints or concerns. FM M also stated that when Resident #10 called for help to the bathroom, CNA A told her that her CNA care card stated she was independent and should not need help to the bathroom. The CNA care card (care plan) states that Resident #10 requires 1 person assistance to the bathroom. FM M also reported that Resident #10 was missing all of her bingo winnings except for 1 quarter, and that $6.00 had been taken from her wallet (see F-225, F-226). FM M also told Surveyor that the NHA told Resident #10, when Resident #10 shook her finger at her when she was upset, that she would not talk to her until she calmed down. FM M told Surveyor that the NHA told Resident #10 that she if she wasn't happy at the facility, the facility would find her another place to live. FM M told Surveyor that after the NHA told Resident #10 this, the resident called her crying. Family Member said that the NHA repeated this to Resident #10 more than once. FM M said that she finally told the NHA to stop saying this to Resident #10 since it was so upsetting to her. FM M stated that "It has been a year of frustration--trying to get the management to address (Resident #10s') concerns." On 12/11/12, Surveyor reviewed Resident #10s' clinical record. The MDS (Minimum Data Set) Section D0300 which outlines the residents extent of possible depression, dated 12/10/12 shows a score of "02". The comparison MDS from 4/2/12 shows a score of "03", indicating minimal symptoms of depression. Documents entitled GDS (Global Depression Scale) reviewed by Surveyor stated that on 04/02/12, Resident #10 showed a score of 3, which indicated "no probable depression." Another GDS conducted on 09/11/12 showed a score of "9" indicating probable depression. These documents were dated and signed by the SW, and a notation in the Residents Progress notes states that SW I reported the increase in depressive symptoms to Resident #10s' primary physician. No other investigation was conducted by SW I as to why Resident #10 was experiencing an increase in depressive symptoms. A document entitled "Krohn Clinic Note" was reviewed by Surveyor . The note, entered by the residents' primary physician, stated that she has had some episodes of frustration at the nursing home. She claimed that the staff accused her of being untruthful. The physician stated that he noted the personal interaction concerns and this was relayed to LPN J. Under the heading "Plan" in the document, the primary physician stated that he recommended that "the patient be able to discuss her concerns with directive nursing (sic) or the SW." On 12/12/12, Surveyor interviewed LPN J. LPN J stated "I am sorry I do not remember recieving this information from the physician to have Resident #10 talk to the SW or the DON." A document dated 9/11/12, entitled "Behavioral Health Note" by the attending psychiatrist, states, in part, "......according to staff she is never happy........she seems worse overall.....she is mean to the staff and will always be disagreeable and unhappy." "She admitted to being frustrated and feeling anger towards a staff member and wondered why staff could not work on other hallways" The note also states that "that person was moved from that hallway a long time ago." The note also stated that the facility staff "Wondered if her noon prn (as needed) dose of lorazepam (an antianxiety) and her antidepressant could be increased." Resident #10s' lorazepam was increased to 0.5 mg. (milligrams) twice a day and her antidepressant (mirtazapine) was increased from 15 mg.(milligrams) every night to 30 mg. every night. Surveyor reviewed a document entitled "Nursing Care Plan" dated 08/29/12, by the SW. Under the "Problem" heading, the Care Plan states that "Resident #10 has verbal behavioral symptoms directed towards others" (e.g. threatening to get staff fired, making fun of others, speaking loud in the dining room about others where residents can overhear)" Interventions include: -SW has discovered role playing certain scenarios works with Resident #10.. -Maintain a calm, slow understandable approach with Resident #10.. -Set expectations and limits for Resident #10. Let her know that disrespect and rudeness towards residents, visitors, or staff is not acceptable. -Avoid power struggles with Resident #10. End the conversation if she becomes verbally asaultive and reapproach at a later time. -Remove Resident #10 from group activities or the dining room when behavior is unacceptable. Surveyor reviewed Resident #10s' Resident Progress Notes. There is no documentary evidence or medical [DIAGNOSES REDACTED]. No behavior monitoring data had been collected. Surveyor reviewed SW I progress and IDT (Interdiciplinary Team) data. Interdiciplinary Team notes stated, at every quarterly review entry from 09/04/12 to 12/11/12, "Care Plan reviewed and remains appropriate for her." A progress note entered by the DON on 10/03/12 says that the resident was asked if she had any concerns with staff members and she said no. The DON asked Resident #10 if she was pleased with the CNAs who care for her and she said yes. On 12/11/10, at 2:20 p.m., Surveyor interviewed CNA A regarding staff treatment of [REDACTED].#10 any longer because of "an incident that happened in the building." When asked by Surveyor for clarification, CNA A stated that she could not remember what the incident was. CNA A stated that "Resident #10 is a very hard person to please and she got frustrated with me and started being mean to me so our intervention was to take me off the wing. I was to stop interacting with her per her family's request." When Surveyor asked if CNA A had received training related to staff treatment of [REDACTED].?" On 12/11/12, Surveyor interviewed SW I. SW I stated that she was aware of Resident #10s' concerns about CNA A. SW I stated that she felt that Resident #10 and CNA A had a personality conflict and that her intervention was to role play with Resident #10 on how to deal with CNA A's personality, as well as other staff personalities. SW I admitted that she did not further investigate Resident #10s' complaints, provide staff teaching on appropriate responses to Resident 10's complaints, or follow up with Resident #10 regarding her feelings about CNA A. She stated that she talks to Resident #10 a lot and wants her to feel at home in the facility. On 12/11/12 at 3:10 p.m., Surveyor interviewed the DON. The DON stated that she talked to Resident #10 in February about CNA A's behavior toward her, and at that time, Resident #10 told the DON that it was "ok for CNA A to take care of her." The DON told Surveyor that she thought that Resident #10's statement was odd since Resident #10 had complained to her in the past about CNA A being disrespectful to her. The DON did not provide documentary evidence of her conversation with Resident #10 in February. The DON stated she felt that Resident #10 and CNA A had a personality conflict. The DON told Surveyor that CNA A she had provided CNA A with verbal education on customer service, and how to use the correct tone of voice to use when addressing the Residents. The DON also stated that she provided education to the staff on 1:1 approaches and that staff were observed on how they interact with the residents by the DON. No disciplinary actions were noted in CNA A's file related to Resident #10. No evidence regarding staff teaching or observations of CNA A's interactions with Resident #10, or observations of cares provided to Resident #10 were provided to Surveyor . The DON stated that in hindsight she thinks that CNA A's behavior toward Resident #10 should have been followed more closely and reported the Office of Care Giver Quality.

Based on observation, interview and record review, the facility did not ensure 2 of 4 residents at risk for falls, were provided appropriate supervision and assistance devices to prevent accidents. Resident #1 had a history of [REDACTED]. Facility staff did not: ~Assess consistently whether the resident was at moderate or at high risk for falls; ~Update the resident's care plan accurately to include all appropriate interventions implemented following previous falls; ~Implement detailed 15-minute checks as recommended after the video surveillance was discontinued on 11/14/11; ~Update the nursing and certified nursing assistant (CNA) care plans following the fall on 11/28/11 to include placement of the wheelchair when the resident was in bed; ~Communicate consistently to all staff the definition of "frequent" checks; ~Initiate appropriate supervision and/or devices to prevent a fall with serious injury after the 15-minute checks were discontinued on 12/08/11; ~Ensure the resident's auto-lock brakes were in proper working order. On 12/16/11, Resident #1 was up in her wheelchair, unsupervised, after her usual bedtime. The resident was found at approximately 8:00 p.m. lying on the floor in a "family room" which was located on a nonresident hallway, with complaints of right hip pain. The resident was transported to the hospital and admitted with a right hip fracture. Resident #2 was assessed to be at high risk for falls and had a recent history of falls when her knees buckled. The resident was readmitted to the facility on [DATE] following hospitalization related to confusion and decreased sodium. The resident wore bilateral protective boots in bed. On 11/08/11, Resident #2 was last observed in bed and found two hours later on the floor in front of her recliner without injury. A mat was initiated on the floor in front of the resident's bed. Facility staff did not assess the resident's ability to stand at the bedside and evaluate if the mat was a tripping hazard. This is evidenced by the following: The facility's policy/procedure related to falls was provided to Surveyor on 01/04/12, titled Heyde Health System Fall Prevention Manual, dated 08/01/2010, and was confirmed by the interim nursing home administrator (NHA) as well as CRN PP as the current fall policy/procedure in place at the time Resident #1 fell and sustained serious injury on 12/16/11. The policy/procedure included the following, "We must avoid the pitfalls of over-utilization of alarms or implementation of other inappropriate interventions that do not address the root cause of the fall...nothing takes the place of monitoring and supervision...we are obligated to know the whereabouts of our residents at all times, especially those who are prone to accidents...The resident or representative's goals must also be considered in determining appropriate interventions...in certain circumstances an alarm may be an appropriate intervention, but it should never be the first intervention that is put in place. Unless an emergency situation exists, you must have approval of the DON (Director of Nursing) before initiating an alarm...Interventions should be as resident-specific as possible." Some post fall interventions included hip protectors, 15-minute or 30-minute checks, keep within view, and one-to-one (1:1) monitoring. 1. On various dates, from 01/03/12 to 01/11/12, Surveyor reviewed Resident #1's medical record including computerized nurses' notes (with incidents and events detailing falls and investigations related to the falls), social service notes, assessments, care plans, behavior monitoring, 15-minute checklists, physical therapy (PT) notes, physician orders, and physician and hospital reports. Resident #1 is a [AGE] year-old female who was admitted to the facility on [DATE]. It was identified the resident's Power of Attorney for Health Care (POA-HC) was activated at that time with Family Member (FM) UU listed first as the POA-HC and FM VV listed second. Resident #1's [DIAGNOSES REDACTED]. ~02/11/11 - found lying on the floor next to the bathroom door in her room at 6:45 p.m. after attempting to self-transfer out of the wheelchair and ambulate to the bathroom. This fall resulted in an overnight emergency room visit (per hospital records) that noted left hip pain and a bump to the head. Nurses' notes reported the resident's x-rays were negative for fracture as a result of the fall, a torn ligament was identified, and 15-minute checks as well as a floor mat next to the bed would be initiated. The facility investigation, written on 02/16/11 by the DON, identified that even with her call light nearby, the resident did not remember to use it, 15-minute checks would be initiated (floor mat not addressed), the resident was at high risk for falls, and the care plan was updated. A video surveillance camera (monitored at the nurses' station) was added at the request of the family. ~06/12/11 - found sitting on the floor next to the bathroom door in her room at 9:56 p.m. after attempting to self-transfer out of bed and ambulate to the bathroom resulting in a skin tear to the right elbow. The facility investigation, dated 06/13/11, identified the action taken following the fall was to turn the monitor/video surveillance camera to view the resident's bathroom when she was out of bed, the resident was at moderate risk for further falls, and the care plan was updated. ~07/11/11- found sitting on the floor in front of the recliner in her room at 10:20 p.m. after attempting to self-transfer out of the wheelchair with no reported injury. The facility investigation, dated 07/11/11, identified the action taken following the fall was to take the resident to supervised areas for activities when up and about, the resident was at moderate risk for falls, and the care plan was updated. The monitor/video surveillance camera was not addressed in the documentation regarding the incident. Resident #1's Minimum Data Set (MDS), with an assessment reference date of 08/08/11, identified she had severe cognitive impairment, required limited assistance of one staff for transfers, required extensive assistance of two staff for personal hygiene and toileting, required supervision with wheelchair locomotion, had bilateral range of motion (ROM) limitations in both upper and lower extremities, utilized both a wheelchair and a walker for mobility, and was frequently incontinent of both bowel and bladder. The MDS also identified Resident #1 had fallen in the last quarter with minor injury. ~10/24/11 - was found lying on the floor in front of the exit door of the hallway at 6:15 p.m. after attempting to self-transfer out of the wheelchair with no reported injury. The facility investigation, written on 10/24/11 by the DON, identified she recognized the resident had previous falls at approximately the same time of the day. The action taken following the fall was, "when resident is going up and down the halls and in lobby will have staff do frequent checks during that time of hallways to make sure all items are off the floor." The investigation stated the resident was at high risk for falls and the care plan was updated. Surveyor reviewed Resident #1's Care Area Assessment, dated 11/01/11, which included, "Resident scored a 4/15 on the Brief interview of mental status...can be confused and forgetful...some short and long-term memory problems...wanders around the facility...has hearing and vision impairments...occasional incontinence of urine...attempts (to toilet) on own at times...now in review to set up an effective toileting plan to both decrease incontinence and help avoid self-transfer attempts...not always aware of need to go to toilet...recent fall, and need for assist with transfers and ambulation...often seen picking up bits from floor...reaching down from her w/c (wheelchair). This action was not witnessed (with most recent fall), but is thought to be the root cause as identified by both staff and family...unsteady standing and requires 1 staff for balance, ambulation, and transfer...bed at knee high and has a transfer pole in place for safety if self-transfers...auto lock brakes on her w/c ...confused and disoriented...poor safety awareness...at risk for falls and injury related to poor cognition, with no forthought (sic) of safety...at risk related to balance deficits... Will continue to monitor for any additional saety (sic (safety)) measures needed or remove them that may be unnecessary after thorough review with family and staff...Does have limited ROM in upper and lower extremities..." On 11/06/11, Resident #1's nurses' notes included the following. "Resident requires 1 aide assist to transfer to provide balance and support during transfers without bearing weight...Needs to be supervised frequently in order to prevent falls. D/T (due to) dementia she is not aware of the safety risks of transferring without assist from staff...requires 1 aide assist...some weight bearing when walking in room...propells (sic) own w/c..." Resident #1's current nursing (comprehensive) care plan, dated 11/08/11, identified the resident was at risk for falls related to the desire to pick up tiny items off the floor when she was in her wheelchair. Interventions included keeping the resident's room and halls free of obstructions and tiny items, keeping personal items within easy reach, having auto-lock brakes on the wheelchair, and having a transfer pole "next to bed to facilitate safer transfer if self-transfer occurs." The current care plan, dated 11/08/11, identified the resident had the behavior of wandering and had urinary incontinence. Interventions included the use of a wanderguard, "Staff to attempt to keep (Resident #1) in view of staff at all times while awake to the extent possible," and toilet before meals/after meals/at bedtime/every two hours as needed/at 10:00 p.m. Staff did not include on the current care plan the intervention the resident was to be taken to supervised areas for activities when up and about which had been initiated following the fall on 07/10/11, but did state activities should be provided that minimized "the potential for falls while providing diversion and distraction." On 11/11/11, social service notes written by SW J identified there was a meeting held with POA-HC UU, NHA TT (the previous administrator) and SW J, with Regional Ombudsman (RO) SS also present via telephone. At this meeting the removal of the surveillance camera was discussed. It was identified POA-HC UU "expressed concern regarding taking the camera out...in fear that she would fall." The notes stated POA-HC UU agreed to the removal of the monitor/camera if 15-minute checks were initiated at night. SW J stated in the notes, "This writer also stated Resident (#1) has been keeping busy during the day and hasn't been wanting to stay in her room as much as she used to." Surveyor interviewed RO SS on 01/04/12 at 8:20 a.m. At the above meeting, RO SS stated she expressed the importance to the facility of identifying and documenting what Resident #1 was doing during the 15-minute checks in order to be proactive and initiate other interventions that might be necessary to prevent serious injury if a fall occurred. RO SS stated only staff initials or checkmarks during 15-minute checks for Resident #1 would have been meaningless. On 11/14/11, a nurse's note written by the DON stated she removed the camera from the resident's room and the visual monitor from the nurse's station with 15-minute checks initiated during nighttime hours and when the resident was in the bed during the day. Staff did not put a plan in place to adequately monitor Resident #1 when she was not in bed. On 11/22/11, Resident #1's nurses' notes identified, "Needs supervision will attempt to transfer self if not monitored. She is very forgetful...propells (sic) own w/c ...Staff attempt to keep (Resident #1) in view of staff at all times while awake to the extent possivle (sic)." ~ 11/28/11- fall out of bed without injury with a new intervention of a 10:00 p.m. snack and toileting implemented. The facility staff did not update the nursing and CNA care plans following this fall to include placement of the wheelchair when the resident was in bed. The 15-minute checks were discontinued on 12/08/11 with "frequent" checks initiated however it was not determined just what "frequent" would mean so all staff were aware. On 11/28/11, nurses' notes identified Resident #1 made poor decisions and required cues and supervision. On 11/28/11, nurses' notes identified the resident was found sitting on the floor holding onto the transfer pole next to the bed in her room at 10:30 p.m. (last toileted at 10:00 p.m. and last observed at 10:20 p.m. and incontinent at the time found) with no reported injury. The facility investigation, written on 11/29/11 by the DON, identified the resident had been observed in bed at 10:15 p.m. with a soft-touch call light placed behind her that would turn on if she rolled over and the wheelchair and the commode were positioned next to the bed. The investigation stated that according to where the wheelchair was found after the fall, it was assumed the resident moved the soft-touch call light, self-transferred out of bed, got into her wheelchair and propelled across the room, went to her bedside stand where she took some bites out of crackers, stood up from the wheelchair and ambulated back to the bed, and then fell while attempting to get back into bed. The action taken following the fall was, "When resident is woken at 10:00 PM for toileting she will be asked if she would like a snack or drink at that time." The investigation stated the resident was at high risk for falls and the care plan was updated by LPN EE (MDS nurse). Fifteen-minute checklists from 11/14/11 to 11/28/11 identified Resident #1 was monitored by staff when in bed and when she was out of bed, and the monitoring stated only "up" when she was out of bed. The checklists identified the resident went into bed on the evening shift, most of the time, between 6:15 p.m. and 7:15 p.m. (one evening she went into bed at 7:30 p.m. and one evening she went into bed at 8:45 p.m.). The 15-minute checks were incomplete for 11/20/11, 11/24/11, 11/25/11, 11/26/11 and 11/27/11. There were only staff initials for monitoring when the resident was in bed and there were no dates that identified the resident got back up out of bed on the evening shift once she was in bed, or that she was up out of bed on the night shift. Staff did not implement detailed 15-minute checks as recommended by RO SS after the video surveillance was discontinued on 11/14/11. Resident #1's nursing care plan was updated on 11/30/11 by LPN EE and included: toilet the resident at 10:00 p.m. at which time to give a drink and offer a snack; keep the commode at the bedside at night; and continue routine toileting and "frequent (checks)." Staff did not update the care plan to include whether the wheelchair should be left at bedside when Resident #1 was in bed or whether it should be placed out of the resident's view when she was in bed to deter her from self-transferring. Surveyor interviewed the DON on 01/04/12 at 11:00 a.m. The DON could not identify any environmental changes made following Resident #1's fall on 11/28/11 involving the placement of the wheelchair or commode nor the presence of the transfer pole. The DON stated the transfer pole was left in place, "to be there in case she got up." Fifteen-minute checklists from 11/29/11 to 12/07/11 identified Resident #1 was monitored by staff when in bed and when she was out of bed, and the monitoring stated only "up" when she was out of bed. The checklists identified the resident went into bed on the evening shift, most of the time, between 7:00 p.m. and 7:15 p.m. (one evening she went into bed at 2:15 p.m.). The 15-minute checks were incomplete for 12/06/11. There were only staff initials for monitoring when the resident was in bed and there were no dates that identified the resident got back up out of bed on the evening shift once she was in bed, or that she was up out of bed on the night shift. Staff did not implement detailed 15-minute checks as recommended by RO SS after the video surveillance was discontinued on 11/14/11. On 12/08/11, a nurse's note written by the DON stated, "At this time DON spook (sic) with nursing staff that 15-minute checks will stop at this time." On 12/08/11, social service notes written by SW J stated she spoke with POA-HC UU who "was informed that the 15-minute checks for resident during the night will be discontinued as of today. Resident's (POA-HC) asked if it were possible to meet with the team tomorrow to discuss this and other possible interventions..." On 12/09/11, social service notes written by SW J identified a meeting was held with participants including POA-HC UU, the DON, regional MDS Nurse Consultant (NC) WW and SW J. The notes included, "DON stated the fifteen minute checks that were being done for the resident during the night were discontinued due to this not being an effective intervention for falls. (POA-HC UU) stated concern about what the facility was going to do to prevent (Resident #1) from falling due to her history for falls. It was explained to (POA-HC UU) that staff monitor resident's routines to find interventions that can help prevent a fall. Resident's care plan was discussed, including the current interventions that are in place. (POA-HC UU) stated she was reassured by the interventions that were discussed. She agreed to the discontinuation of the fifteen-minute checks..." The facility provided no 15-minute checklists for dates after 12/09/11. There were no new changes made to the nursing care plan. The intervention of "frequent (checks)" that had been placed on the care plan on 11/30/11 along with the intervention to toilet and offer a drink/snack at 10:00 p.m. remained on both the nursing and the CNA care plans. Staff did not define what was meant by frequent checks versus the 15-minute checks that had been discontinued. Staff did not identify when the frequent checks should be done such as during a certain time of the day or night or when the resident was in bed or when she was in the wheelchair. Staff did not initiate appropriate supervision and/or devices to prevent a fall with serious injury after the 15-minute checks were discontinued. Surveyor interviewed the DON, the interim NHA and SW J on 01/04/12 at 1:35 p.m. The DON was unable to provide evidence any new interventions were put in place for Resident #1 when the 15-minute checks were discontinued on 12/08/11 and confirmed there was no recent therapy involvement. The interim NHA stated alarms were not an option (per corporate policy). The interim NHA also stated 15-minute checks were almost a 1:1 supervision and the corporate office could not provide the staff necessary for that. SW J stated that on 12/09/11, POA-HC UU was "ok" with the current interventions in place for Resident #1. On 12/13/11, nurses' notes for Resident #1 stated, "moves with no purpose throughout halls...appears lonely spends most of time alone...long-term memory (impaired) short-term memory (impaired)...knows location of room...makes decisions which are poor, requires cues and supervision when making decisions, d/t cognitive deficits..." Resident #1's behavior monitoring for December 2011, identified the resident was being monitored only for loss of appetite and sleeplessness. Staff did not initiate appropriate supervision and/or devices to prevent a fall with serious injury. On 01/04/12, the facility provided to Surveyor Resident #1's CNA care plan, in place on 12/16/11, which identified the resident was at risk for fall events and had auto-lock brakes on her wheelchair and required "frequent (checks)." It was identified the resident's usual bedtime was 7:00 p.m. On 12/16/11, nurses' notes identified Resident #1 was found lying (on the floor) on her left side near an end table/loveseat with her wheelchair parked near the doorway of the room and she was transported to the hospital by ambulance due to complaints of right hip pain. The facility investigation included staff statements that identified the fall occurred in the family room (located near the end of a nonresident hallway next to the residents' dining room) at approximately 8:00 p.m. after she self-transferred out of the wheelchair and ambulated several feet into the room. According to CNA QQ's statement (according to the facility investigation the staff who was assigned to Resident #1 on the evening of 12/16/11), the resident was last toileted at 5:00 or 6:00 p.m. (documentation was changed making it unclear which time the resident was last toileted) and was last observed at 7:30 p.m. "wheeling herself around the facility." Surveyor was unable to contact CNA QQ on 01/03/12 or 01/04/12 for an interview. The facility's "Event Investigation" regarding Resident #1's fall on 12/16/11, written by the interim NHA on 12/20/11, identified the resident sustained [REDACTED]. The report stated the wheelchair brakes were not locked, but "was found to be in good working order" (the resident was supposed to have auto-lock brakes). The report stated CNA QQ had monitored Resident #1 after supper asking the resident three times after supper if she was ready to go to bed (the resident declined), the last time at 7:30 p.m. following an evening snack. It was concluded that in the future, it would be best to state to Resident #1, "It's time to go to bed," instead of an open ended question as the resident would probably not realize when she was tired. Surveyor interviewed CNA HH on 01/03/12 at 4:00 p.m. CNA HH identified he cared for Resident #1 in December 2011 and recalled the resident usually went to bed at approximately 7:30 p.m. CNA HH stated he usually asked Resident #1 if she was tired and wanted to go to bed and if the resident was tired, she would usually respond, "yes," she wanted to go to bed. CNA HH stated he always checked Resident #1 every 15 minutes, even after the 15-minute checks were officially discontinued because the resident had a history of [REDACTED]. CNA HH stated Resident #1 could take "a couple steps" independently. CNA HH stated Resident #1's use of the call light was not always purposeful and if she put it on, could not remember what she wanted. CNA HH confirmed staff had to anticipate the resident's needs.

Based on staff and family interviews, resident record review and review of facility policies, the facility did not provide the necessary care and services to each resident to attain or maintain their highest practicable well-being for 3 of 12 sample residents (#2, #3 and #4). Facility nursing staff did not recognize that an abrupt onset of large amounts of serosanguineous drainage from Resident #2's healing surgical incision represented a significant clinical complication and significant change in condition and did not report this clinical complication to the physician in a timely manner. Facility nursing staff did not thoroughly assess and monitor Resident #2's condition and did not take appropriate action when a significant change in condition occurred. The failure of nursing staff to recognize a significant clinical complication, assess and monitor the resident's condition and take appropriate action when indicated according to current standards of practice, resulted in Resident #2 being hospitalized for [REDACTED]. This created a finding of immediate jeopardy beginning 8/18/11. The Nursing Home Administrator and Director of Nursing were informed of the Immediate Jeopardy on 10/14/11 at 11:15 a.m. The Immediate Jeopardy was removed on 10/31/11. However, the deficient practice continued at a scope and severity of G, (actual harm/isolated) as evidenced by the following; Facility staff did not provide appropriate pain management services to 2 of 12 sample residents (#2 and #3). The facility pain assessment policy is not consistent with current standards of practice. Resident #4 was admitted to the facility with a C2 (cervical - neck) fracture and [DIAGNOSES REDACTED].#4's status of being high risk for issues with the skin integrity of her legs and feet. The facility did not put appropriate preventive measures in place to prevent a painful blister from forming on Resident #4's inner heel. Findings include; 1. The resource titled Wound Care: A Collaborative Practice Manual for Health Professionals, 2007 by Carrie Sussman and Barbara M. Bates - Jensen notes "Evaluation of surgical incisional wound exudate requires knowledge of the expected characteristics of wound exudate during the course of healing. The character and amount of exudate changes as wound healing progresses. The wound exudate immediately after surgery is bloody. Within 48 hours, the wound drainage becomes serosanguineous in nature and, finally, the exudate is serous. The amount of wound exudate should gradually decrease throughout the healing period. An increase in wound exudate usually indicates compromised wound healing caused by infection. New drainage from a previously healed incision heralds wound dehiscence, infection and in some cases, fistula formation." Resident #2's record was reviewed by Surveyor from 10/12/-10/14/11. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital Discharge orders dated 8/3/11 included "change (incision) dressing daily and prn." The Resident Data Collection Form dated 8/6/11 notes "[MEDICATION NAME] to buttocks, dressing to spine, cyberteck brace around midsection." The August Treatment record dated 8/1/11 to 8/31/11 notes the following; 8/5/11 - Monitor for s/s of infection at incision site NOC, AM, PM. 8/6/11 - Change dressing daily AM. Nursing Notes noted the following; 8/6/11 - 1:36 pm - to mid spine, dressing dry and intact 8/7/11 - 9:55 a.m. - dressing dry and intact to spine 8/8/11 - 11:51 a.m. - "Wound review: Lower mid-spine, measures 5.5 inches length, 1 mm width COLOR: pink DRAINAGE: scant amount of serous-sang healing well steri strips intact. No s/s of infection." 8/9/11 - 9:36 a.m. - "Incision to back cleansed and 4 x 4's to cover area. No drainage or s/s of infection noted." 8/9/11 physician progress notes [REDACTED]. Otherwise the incision is healing well and was given three thumbs up by Physician CC (surgeon)." 8/12/11 - 10:40 a.m. - "... Incision site clear. No redness /inflammation or drainage noted. No s/s of infection. Incision well approximated. Steri strips intact, dressing changed and replaced with ABD." 8/13/11 - 10:58 a.m. - "Incision on lumbar back is well approximated, steri strips intact, area cleansed and 4 x 4 gauze dressing applied. Small puncture incision above wound is well approximated no redness, inflammation or drainage to any of the wounds." 8/14/11 - 10:18 a.m. - "...Incision cleansed with normal saline, well approximated, no redness, inflammation or drainage noted. No s/s of infection. Incision covered with 4 x 4." 8/15/11 - 10:45 a.m. - "Mid spine steri-strips have fallen off, large amount of serosanguineous drainage noted. Some blood present. Area cleansed and gauze applied. No oder (odor) or s/s of infection noted. Resident tolerated well and was tender to the touch." On 10/13/11 at 3:15 pm, Surveyor and Surveyor interviewed RN F who recorded this entry in the record. RN F reported he didn't think the increased drainage was anything to worry about because the drainage was normal and was not purulent. 8/15/11 - 10:24 p.m. - "Dressing is saturated with non-odorous sero-sanguineous drainage. Dressing is removed. Constant trickle of sanguineous drainage is observed to pinpoint open area at distal aspect of incision. No drainage observed to any other portion of incision. [DIAGNOSES REDACTED] is observed to site. No warmth, denies pain to site. ABD folded in half applied to distal portion of incision followed by ABD to length of incision secured with [MEDICATION NAME] tape. Resident is placed in side lying position with HOB no greater than 15 degrees to offload pressure to site. Procedure well tolerated." On 10/13/11 at 3:00 pm, Surveyor and Surveyor interviewed RN V who recorded this entry in the record. RN V reported she didn't call anybody about this resident's condition as she didn't see the increased drainage as a problem. 8/16/11 - 1:13 p.m. - "To mid-spine draining serosanguineous large amount. Area cleansed steri-strips applied to bottom inch of incision. Area then covered with sterile gauze." On 10/13/11 at 3:15 pm, Surveyor and Surveyor interviewed RN F who recorded this entry in the record. Surveyor asked RN F why he applied steri strips to Resident 2's incision. RN F reported he "put steri strips on to help - drainage from there - that area not coming apart." 8/16/11 - 10:25 p.m. - "Note: dressing replaced, noted serosanguineous drainage on old dressing. 3 steri-strips replaced on lower incision area, denies any pain or discomfort." 8/17/11 - 3:31 a.m. - "T 100.7 ... 3:32 a.m. - has not needed dressing change as no drainage thus far this shift, will continue to monitor." It should be noted that this temperature is 2.2 degrees above Resident #2's highest baseline temperature and 2.6 degrees above the previous temperature of 98.1 taken on 8/17/11 at 10:31 am. The American Medical Directors Association Clinical Practice Guideline titled Common Infections in the Long-Term Care Setting, 2011 notes the following for Criteria for Defining Fever in the LTC Setting; Increase in temperature of equal or greater than 2 degrees F (1.1 degrees C) from baseline Two or more measurements of oral temperatures equal to or greater than 99 degrees F or rectal temperature equal to or greater than 99.5 degrees F Single measurement of temperature equal or greater than 100 degrees F Late Entry: 8-17-11 (entered 8/18/11 - 10:15 p.m.) - Dressing is saturated with non-odorous sero-sanguineous drainage. Dressing is removed. [DIAGNOSES REDACTED] is observed to site. No warmth, no [MEDICAL CONDITION], resident denies pain to site. Site is cleansed with NSS and sterile gauze. ... 3 - 4 x 4 gauze pads folder lengthwise applied to distal aspect of incision followed by 2 - ABD folded in half secured with [MEDICATION NAME] tape. Resident is placed in side lying position with HOB no greater than 15 degrees to offload site. 8/17/11 - 10:51 a.m. - "Physician CC - Surgeon updated on vitals, large amount of serrous opaque drainage from lower 1/3 in back incision. Incision being warm to touch and reddened 2 cm around incision. Appointment with Physician CC today." It should be noted that the appointment to see Physician CC was not kept due to van service not receiving paperwork. However, the resident was seen by Physician BB - Medical Director on 8/17/11. On 10/13/11 at 3:38 p.m., Surveyor and Surveyor interviewed RN H who recorded this entry in the resident's chart. RN H reported she worked on 8/14/11 and resident was content and fine. RN H reported she "was concerned on 8/17/11 and saw red flags, knew something had to be done." 8/17/11 physician progress notes [REDACTED]. She has not had fevers or chill. She has not had nausea or vomiting ... Her incision shows that there are two open areas. There is one at the very inferior edge of the incision in the lower lumbar spine, it measures approximately ? cm in length and then approximately 1 ? cm above that there is another opening that measures about 1 cm in length. They are each draining serosanguineous fluid. There is no tenderness to palpation, no foul odor, no particular warmth. A: Draining from incision site from recent lumbar decompression laminectomies. P: I did contact Physician CC (surgeon) by phone ... We will start her on Bactrim DS 1 p.o. bid times ten days. ..." The note indicates that this resident is scheduled to see the surgeon on 8/18/11 at 1:00 p.m. 8/17/11 - 10:50 (Late entry written on 8/18/11 at 3:30 p.m.) - Night nurse assessed resident at 22:50 and found her to be hypotensive called ER and received orders from Physician BB to hold dilitiazem and [MEDICATION NAME] d/t low BP until she was to be seen by Physician CC - Surgeon. Nurse was to continue to monitor and send to ER if any further changes. Resident continued to have low B/P throughout night. 8/17/11 - 11:59 p.m. - Physician BB called on resident's condition when this nurse went to assess after being given b/p reading of 80/50 and that resident cool / clammy, this nurse found resident leaning over bed and large amount of clear green bile emesis on floor, also large amount of serosanguineous noted on bed linens, recheck in opposite arm L of b/p 92/40, denies allergy to sulfa as new medication started this p.m. shift for surgical incision infection. Bactrim given on pm shift, res(ident) denies any ill effects or need for hospitalization states "I have an appointment with Physician CC tomorrow and "I should be fine till then." Actions: Orders received hold dilitezem and [MEDICATION NAME] until assessed via Physician CC. Continue to observe and send to hospital if resident changes her mind and needs to go, push fluids. 8/18/11 - 3:12 a.m. - Resident Complaints: sent CNA up to tell this nurse to call an ambulance, assessment made, B/P 80/40 but asymptomatic. Condition Noted: no pain, no new symptoms since first assessment and resident refused to go to hospital then, encouraged to drink fluids as ordered per Physician BB and rest and let staff know if any symptoms arise, acknowledged and seemed satisfied with this suggestion. 8/18/11 - 4:44 a.m. - Resident Complaints: monitoring for low b/p at 0400 78/42, no c/o voiced at this time, incision continues to drain and dressing saturated, changed at this time and when resident raised to sitting position, drainage gushed out when incision expressed, copious amounts of serosanguineous from both sites on incision that are draining, denies dizziness, pain or any other symptoms at this time, encouraged to drink and notify staff if any new symptoms arise, resident alert and oriented and able to make needs known, continues to deny any ill effects. 8/18/11 - 8:38 a.m. - Resident appears more confused this am and states she "just doesn't feel right." Resident to be evaluated at ER. Left by ambulance at 8:40 a.m. The Black River Falls EMS Report dated 8/18/11 noted the following "911 Dispatched for pt (patient) transfer from Family Heritage to BRMH (Black River Memorial Hospital) ER upon arrival on scene pt found lying in bed had low back surgery 2 weeks ago and has had loss of appetite, low blood pressure and excess pain and drainage from the incision site the last 2 days, pt was sheet lifted to our cot, pt BP low pulse elevated and O2 sats normal, pt rested enroute rating her pain a 3/10, incision site appeared to have lite pink fluid and the dressing covering it was full and leaking out, pt care transferred to BRMH ER Staff." 8/18/11 - 3:12 p.m. - Resident was admitted on [DATE] after having laminectomy for rehabilitation and strengthening. Resident was alert and oriented x 3. ...All skin intact with exception to surgical wounds. Wounds were healing nicely until Monday August 15th when drainage was noted on PM shift. The Mayo Clinic Discharge Summary dated 9/2/11 noted "Patient was admitted inpatient with septic shock secondary to wound infection to the intensive care unit ... Discharge [DIAGNOSES REDACTED]." On 10/13/11 at 3:54 p.m., Surveyor interviewed CNA W who was the CNA who alerted RN U on 8/18/11 that Resident #2 wanted to go to the hospital. CNA W reported she went and checked on Resident #2 early in the shift. "I did vitals and her blood pressure was 'really low'." CNA W told RN U who checked Resident #2's vitals and got similar readings. While RN U was in the Resident #2's room she pulled the bathroom call light which is the system the facility uses at night for emergency alert instead of hollering down the hall. When CNA W returned to the room she observed that the resident had a huge/large amount of emesis on floor yellow/brown in color. CNA W stated resident was not good-sick-lethargic, not conversational like she usually is but she initially refused to go to hospital. CNA W stated they had to do a bed change as there was emesis on the bed and her back was draining, "oozing bad" and the dressing on the resident's back looked bloody to her. CNA W said that RN U pushed on it while she was there and stuff gushed out. Around 4:00 a.m., Resident #2 told CNA W that she wanted to go to the hospital. CNA W told RN U who went in and talked with the resident and told her she was stable and they were monitoring her vitals. On 10/13/11 at 3:26 p.m., Surveyor and Surveyor interviewed the DON who indicated that she didn't consider the large amount of drainage a s/s of infection because it was not purulent. On 10/13/11 at 4:40 p.m., the DON gave Surveyor a document titled Infection Control Resident Care Wound Culture Collection. The DON pointed to the text in the document that noted "Infection is evidenced by purulent drainage, swelling, redness or warmth at the site and often the resident will have a fever" as the rationale for not considering the drainage a potential sign of infection. On 10/13/11 at 4:18 p.m., Surveyor and Surveyor interviewed CNA X. CNA X reported she assisted CNA W after Resident #2 had her large emesis which CNA X stated "smelled bad" and I'm one that can't smell but could smell that (emesis). CNA X reported she did lots of vitals that night, wrote them down and gave them to the nurse. CNA X also reported that the nurse had her elevate the resident's feet. On 10/14/11 at 6:10 a.m., Surveyor and interviewed RN U with DON present. RN U worked nights on 8/18/11. She stated she got report on Resident #2 and had seen the doctors order earlier in the day, was aware of Resident #2's condition and start of new medication. RN U reported when CNA reported resident wanted an ambulance she went down to the resident's room to speak with her and to see if it was her desire. Surveyor asked her why she wouldn't think the resident wanted to go to the hospital if she sent the nurse aide to tell her she wanted to go. RN U stated the resident had been a CNA for years and she was more knowledgeable than most. RN U stated she told the resident what the doctor had said. RN U reported that the dressing was dry when she saw it at 4:44 a.m. and she expressed drainage by pushing on an area of her back just above where the dressing was. RN U reported she didn't think the copious amount of drainage was a change as we knew there was drainage. RN U stated she took her BP and a full set of vitals and she would have documented the vitals signs in the computer. At this time, the DON stated "looks like you missed them (vital signs)." RN U reported that the only thing abnormal was the blood pressure. The DON also reported that the CNAs were in there frequently taking vital signs but they are nowhere to be found. The AMDA Clinical Practice Guideline titled Acute Change of Condition in the Long-Term Care Setting, notes "When assessing the patient with signs and symptoms that may indicate an ACOC (acute change of condition), caregiving staff should, at a minimum, do the following; Regardless of the patient's cognitive level, ask the patient how he or she is feeling or how the symptoms developed. Absence of a response should be documented, Take vital signs..." The facility policy titled Change in Condition directs licensed nursing staff to obtain a complete set of vital signs (temperature, pulse, respirations, blood pressure O2 sats and BS (blood sugar) if applicable) at the onset of the change, each shift and/or more often as appropriate/ordered. Facility nursing staff did not follow their own policy and staff did not obtain complete sets of vitals. Vital signs taken by nurse aides were not recorded. The failure of staff to obtain and record complete sets of vital signs prevented staff from thoroughly and accurately assessing Resident #2 and determining the significance of the vital signs in relation to her condition. (Cross reference F157 and F281) These failures created a finding of immediate jeopardy, that was removed on 10/31/11, by which time the facility had completed the following; ~The facility reviewed and revised current policies and procedures related to acute change of condition based on current standards of practice; ~Related assessment and communication tools for identification, documentation and notification in acute changes in resident conditions were reviewed and revised to ensure current standards of practice were in place; ~The care plans for residents currently experiencing alterations in skin integrity were reviewed and revised; ~Physician orders [REDACTED]. ~CNA Care Cards were implemented as an extension of each resident's care plan to replace former CNA care plans and were placed at resident bedsides; ~Education and training of charge nurses on recognizing changes in condition and specific interventions for resident care and services per the care plan including how to monitor for the implementation of the care plan; ~Education and training of direct care staff on recognizing and reporting changes in resident conditions. Noncompliance at F309 continues to exist, at a scope/severity of G (actual harm/isolated) as evidenced by the following examples. PAIN Surveyor reviewed the facility's "Pain Assessment" policy in its entirety on 10/13/11. The policy noted "A pain assessment will be completed on each resident who presents with acute, chronic, and/or suspected pain. The pain assessment will then be utilized in formation of the multidisciplinary care plan to address pain management." The Procedure noted "1. The Pain Assessment Form will be completed on; a. every resident on admission. If pain is not an issue, this will be documented in the nurse's notes. b. Every resident returning from a hospital stay. c. Every resident with a significant change. d. Quarterly on each resident who remains on [MEDICATION NAME]. e. Any resident at the discretion of MD or Clinical Manager. 2. The Pain Assessment Flow Sheet can be used as a follow-up to the Pain Assessment Form until the pain is under control. 3. Use either the vertical pain intensity scale or the pain intensity "faces" to evaluate the effectiveness of pain intervention. 4. Pain management will be addressed by the interdisciplinary team on the care plan. 5. Pain management will be addressed weekly in the weekly summary. The resource titled American Geriatrics Society Pharmacological Management of Persistent Pain in Older Persons, 2009 notes "An effective pharmacological approach to the treatment of [REDACTED]. Routine screening and careful assessment of all older patients is crucial, because pain that is causing severe impairment may not be spontaneously revealed for a variety of personal, cultural or psychological reasons...The current best indicator of the pain experience is the patient's own report which must include an assessment of the pain intensity and an evaluation of the effect of the pain on daily function." 2. Resident #2's record was reviewed by Surveyor from 10/12/-10/14/11. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The August 2011 Treatment Record noted "8/5/11 Monitor for pain every shift NOC AM PM." The standard of practice is to assess a Resident's pain intensity level before and after any pharmacological or non-pharmacological approach. The initial pain assessment dated [DATE] at 10:27 a.m. noted the following; Diagnosis: [REDACTED]. Non-Medication Interventions for Pain: position changes Quality of Pain: aching Describe Pain: intermittent Origin of Pain: Musculo-skeletal secondary to surgery Exacerbating Factors: Exercise, Therapy, Ambulation, transfers, ADLs (activities of daily living) Alleviating Factors: Rest, Distraction, [MEDICATION NAME], Position Changes Manner of Expressing Pain: Verbal Observation: grimacing Summary/Plan: Utilize Non-med interventions as well as ordered [MEDICATION NAME]. Pain Goal: 0-3 out of 10 on the pain scale The Occupational Therapy Initial assessment dated [DATE] noted Resident #2's pain to be 2/10 after pain meds, up to 4/10 with ADLs (activities of daily living). Typically 5-6/10 pain in low back. Also gets muscle spasms in L (left) lower extremity. The Physical Therapy Initial Evaluation dated 8/7/11 noted "Patient presents with impairments in the following areas: Ambulation endurance/safety/pain. One of the short-term goals included "reduce pain rating from 6/10 to 2/10." The care plan dated 8/11/11 completed 6 days after admission identified the problem "I need to regain my strength to return home safely and with help managing my pain related to L2-3, L3-4, L5-6 stenosis requiring surgical intervention, pain,[MEDICAL CONDITION](Hypertension),[MEDICAL CONDITION]([MEDICAL CONDITION] Reflux Disease) manifested by decreased ADL participation." Approaches included but not limited to; monitor for pain, treat with po (oral) and non-med interventions such as ice and repositioning and update MD with unmet pain needs. The pain relief goal was "will have no greater than 3 pain level ungoing (ongoing)." Even though the pain assessment identified exercise, therapy, ambulation, transfers and ADLs exacerbated Resident #2's pain, the care plan does not address premedicating Resident #2 prior to any of these activities. The care plan does not include an approach consistent with current standards of practice to include specifically asking Resident #2 to self-report her pain at rest and during movement. On 10/20/11 at 12:27 p.m., the DON faxed Surveyor documents that included a statement that noted "I do not have any other care plans to send you besides what you have already." The August 2011 Treatment Record noted that nursing staff recorded Resident #2's pain intensity score each shift and her pain intensity score was between 0-4/10 for dates 8/6-8/12/11 with one exception on 8/7/11. The 8/7/11 AM treatment (tx) box lists initials, the PM tx box notes a pain score of 5 and the NOC tx box notes initials. The PRN (as needed) Pain Medication Notes provided via fax by the DON on 10/21/11 at 4:18 p.m. noted the following; 8/7/11 - 8:22 a.m. - [MEDICATION NAME] 5 mg given for hip pain rated at 5/10. 8/7/11 -1:29 p.m. - [MEDICATION NAME] 5 mg given for left hip pain rated at 7/10. 8/7/11 - 1:36 p.m. - Tylenol ES (Extra Strength) 500 mg given for left hip pain 4/10. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The MAR, Nurses' notes, PRN (as needed) Pain Medication Notes and Tx Record for 8/7/11 did not identify Resident #2's pain intensity score after receiving pain medication to determine its effectiveness in reducing her pain intensity score to an acceptable level. Facility staff did not administer pain medication at regular intervals to prevent reoccurrence of Resident #2's pain intensity above her pain relief goal. There is inconsistency between the PRN Pain Medication Notes and the MAR indicated [REDACTED]. On 8/8/11, the facility obtained orders to administer [MEDICATION NAME] 5 mg 1-2 tabs every 4 - 6 hours for pain. The PRN Pain Medication Notes noted the following; 8/8/11 - 6:55 a.m. - [MEDICATION NAME] 5 mg given for all over pain rated a 3/10 8/8/11 - 8:41 a.m. - Pain is worse. 2nd [MEDICATION NAME] given for pain "all over" rated a 6/10 8/8/11 - 1:20 p.m. - [MEDICATION NAME] 5 mg given for "all over" pain rated a 5/10. 8/9/11 - 6:54 a.m. - [MEDICATION NAME] 5 mg given for hip pain rated a 5/10 8/9/11 - 9:27 a.m. - [MEDICATION NAME] 5 mg given for pain during therapy rated a 5/10 8/9/11 - 2:18 p.m. - [MEDICATION NAME] 5 mg given for pain rated a 7/10 8/9/11 - 5:20 p.m. - Med effective. The facility did not administer pain medications at an appropriate frequency and dose to achieve Resident #2's pain relief goal and prevent her from experiencing severe reoccurring pain. Facility staff did not routinely assess Resident #2's pain intensity score after receiving pain medication to determine the effectiveness of the pain medication in meeting her pain relief goal. The facility completed a 5 day MDS with an assessment reference date of 8/12/11 that noted Resident #2 self reported that she frequently experienced pain rated a 6 on a 0-10 scale and the pain limits her sleep and activities of daily living. The document titled Sleep Monitoring Form dated 8/13/11 notes "Still awake when noc (night) shift arrives. Resident #2 wakes more than 3 times during the night due to leg spasms and she has trouble falling back to sleep. "Pain medicine effectiveness" helps the resident fall back to sleep." On 8/18/11, Resident #2 was hospitalized in septic shock due to infection in her surgical wound. Resident #2 was readmitted to the facility on [DATE]. On 10/20/11 at 12:27 p.m., the DON reported that the facility does not complete the facility's admission assessment form titled Resident Data Collection for readmissions. Physician orders [REDACTED]. On 9/6/11, the pain medication was changed to [MEDICATION NAME] 1-2 tabs every 6 hours prn and [MEDICATION NAME] 5 mg 1 tab every 6 hours prn. The September 2011 Treatment Record notes "9/2/2011 Monitor for pain every shift NOC, AM, PM." The 9/7/11 PRN Pain Medication note noted that Resident #2 was medicated as follows; 5:34 a.m. - [MEDICATION NAME] 1 tab for back pain s/p (status [REDACTED]. 8:58 a.m. - [MEDICATION NAME] 1 tab for back pain rated at 4/10 - 11:42 a.m. - med effective 11:42 a.m. - [MEDICATION NAME] 1 tab for back pain rated at 4/10 - 12:44 - med effective 8:56 p.m. - [MEDICATION NAME] 2 tabs for "all over" pain rated at 7/10 - 9/8/11-5:39 a.m. - med effective. Facility staff did not assess Resident #2's pain intensity level after she received pain medication to determine if the pain medication reduced her pain to her pain relief goal. A Physical Therapy Assistant (PTA) treatment note dated 9/7/11 noted " ...Pt (patient) requires rest breaks, she c/o (complains of) pain, cramping going down her R (right) LE (lower extremity)..." The 9/9/11 PRN Pain Medication note noted that Resident #2 was medicated as follows; 8:05 a.m. - [MEDICATION NAME] 1 tab given for back pain rated at 5/10 9:59 a.m. - [MEDICATION NAME] 1 tab given for back pain rated at 7/10 4:00 p.m. - [MEDICATION NAME] 1 tab given for back pain rated a 3/10. 7:34 p.m. - pain reduced 7:39 p.m. - [MEDICATION NAME] 1 tab given for back pain rated at 5/10. 9/10/11 - 6:35 a.m. - med effective. The 9/9/11 PTA treatment note noted "...Pt states she has 10/10 pain in P.T. (physical therapy). Pt required frequent rest break she fatigues easily..." There is no documentation in the PTA note or Nurses' notes that the PTA notified nursing of Resident #2's severe pain. Facility staff did not medicate Resident #2 at an appropriate frequency and dosage to achieve her pain relief goal and prevent her from experiencing severe reoccurring pain. The facility completed an annual MDS dated [DATE] that noted Resident #2 self reported that she frequently experienced pain rated a 6 on a 0-10 scale and the pain limits her sleep and activities of daily living. The MDS triggered the Pain Care Area Assessment which noted "Pain Effect on Function: disturbs sleep at times, decreases appetite at times, adversely effects mood at times, limits daily activities, limits independence, Description of Problem: Need to assist in managing pain, Will develop care plan. [MEDICATION NAME] in use for [MEDICAL CONDITION]. [MEDICATION NAME] for [MEDICAL CONDITION] Arthritis. [MEDICATION NAME] and [MEDICATION NAME] for GI complaints and GERD. [MEDICATION NAME] in use for pain. Attempts to administer pain medication prior to therapy whenever possible. Repositioning and back rubs are helpful at times. Rest is helpful at times as well." A PTA treatment note dated 9/12/11 noted "...pain at 7-8/10. Nursing notified stated she had pain pill 2 ? ago...Pt required frequent rest breaks..." The PRN Pain Medication Notes for 9/12/11 noted that Resident #2 was medicated at 11:00 a.m. with 1 tab of [MEDICATION NAME] for back pain at a 6/10 and medicated again at 1:30 p.m. with 1 tab of [MEDICATION NAME] for back pain at a 5/10. Regardless of the time of the physical therapy tx session, Resident #2 would have been eligible for additional pain medication as the physician ordered 1-2 tabs of [MEDICATION NAME] every 6 hours and Resident #2 only received 1 tablet. The care plan dated 9/14/11 (12 days after admission and 5 days after the MDS)) noted the problem "I have a self care edficit (deficit) related to neck fracture, pain/discomfort manifested by my inability to do my own ADLs." It should be noted that Resident #2 never had a neck fracture. Care plan approaches related to pain include; administer medications, observe for side effects and effectiveness and report adverse effects to my doctor. The care plan was not based on the assessment as it did not incorporate medicating Resident #2 prior to therapy or activities that caused her pain. PTA treatment notes dated 9/19/11 notes "Pt states she has a lot of pain. Pt rates pain 9/10. The PTA treatment note does not indicate that nursing was made aware of Resident #2's severe pain. Nursing Notes dated 9/19/11 do not identify Resident #2's had severe pain during therapy. The PRN Pain Medication Record noted that Resident #2 was medicated with [MEDICATION NAME] 1 tab at 10:10 a.m. for pain rated at 4/10 and [MEDICATION NAME] 1 tab 4:48 p.m. for back pain rated at 5/10. Regardless of the time of the therapy session, Resident #2 was eligible to receive pain medication. The PRN Pain Medication Notes continued to indicate that Resident #2 experienced moderate pain (4-6/10) 2 or more times a day on 9/20, 9/21, 9/22, 9/23, 9/26 and 9/27. Facility staff did not routinely assess Resident #2's pain intensity level after receiving pain medication to determine if the medication was effective in reducing her pain to a level acceptable to the resident. Physical Therapy (PT) Progress Noted dated 9/26/11 noted "Pt has made progress with rehab but is slowed by coccyx skin issues... Also limited by pain..." On 10/11/11 at 7:24 am,

Based on observations, interviews, review of facility and resident records and a facility self report, the facility did not ensure 1 of 2 residents (Resident #2) who entered the facility with a pressure ulcer received necessary treatment to prevent the ulcer from worsening, out of an initial sample of 12. Resident #2 - The facility did not reassess the resident upon readmission on 9/2/11. Despite having an existing pressure ulcer and having been identified as being at moderate risk for developing pressure ulcers, the facility did not develop an initial care plan for Resident #2 when she was readmitted on [DATE]. Nursing and nurse aide care plans did not follow the facility policy and did not include interventions related to turning and repositioning. Nursing and nurse aide documentation is inconsistent and contradictory regarding Resident #2's bed mobility. On 9/15/11, Resident #2 was seen by the wound care nurse at the Spine Clinic and her pressure ulcer had deteriorated in appearance and size. Despite these findings, the facility did not update the resident's care plan to include interventions for an individualized turning and repositioning program. Facility staff did not consult with the physician when Resident #2's pressure ulcer was identified to have deteriorated on 10/9/11. The resident was hospitalized [DATE] with an infected Stage 3 pressure ulcer. Resident #2 returned to the facility on [DATE] with a pressure ulcer that had been diagnosed as a Stage IV sacral pressure ulcer. Following the resident's return, the facility delayed by one week before putting interventions in place to promote healing of the Stage IV pressure ulcer. The facility did not: ~Obtain a pressure relief mattress as ordered by the physician; ~Assess for and obtain an appropriate chair cushion; ~Assess for and provide an individualized repositioning program for the resident; ~Assess nutritional status upon readmission; ~Develop a complete and accurate care plan with specific directions for repositioning in bed and chair consistent with current standards of practice as well as a plan for minimal time up in the chair during visits out to the wound clinic; The facility's failure to care plan and to implement timely interventions to prevent and heal pressure ulcers created a finding of immediate jeopardy that began 10/17/11. Surveyors notified the Nursing Home Administrator of the immediate jeopardy on 10/26/11 at approximately 1:00 p.m. The facility removed the immediate jeopardy on 11/02/11. The deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by the following: The facility did not ensure 4 of 5 residents (#4, #5, #3 and #8) having pressure ulcers out of an initial sample of 12 received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident #4 was admitted to the facility with a neck fracture and with no pressure ulcers. Resident #4 developed avoidable pressure ulcers on the back of her head from pressure from her neck-stabilizing collar. There is no documentation to prove that the physician was immediately consulted. The facility did not prevent the ulcers from worsening. Resident #4 was also admitted with the skin on her buttocks intact and was assessed to be at high risk for developing pressure ulcers. She developed avoidable stage 2 and stage 3 pressure ulcers on her inner buttocks. These pressure ulcers were not mentioned on Resident #4's care plan. The facility did not prevent the ulcers from worsening, although the areas eventually healed. The nurses did not adequately implement aseptic technique when providing care and treatment for [REDACTED]. Resident #5's Comprehensive Minimum Data Set (MDS), 1/21/2011 and Quarterly MDS, 9/21/2011, Sections M-Skin Conditions identify Resident #5 to be at risk for pressure ulcer development and both MDS's indicate no pressure ulcer present. Resident #5 is to have a pressure reducing device for chair, pressure reducing device for bed, a turning/repositioning program and application of ointments/medications. Resident #5 developed a facility-acquired pressure ulcer. Resident #5 was not provided with a pressure reducing device for Resident #5's personal recliner chair which Resident #5 sits in throughout the day. Resident #3's nurse aide care plan did not address turning and repositioning and the use of assistive devices and did not incorporate physician orders to keep pressure off the residents pressure ulcer by whatever means possible. Facility staff did not turn and reposition Resident #3 and did not follow physician orders to place a pillow under the resident's leg to suspend his foot when in bed. Nursing staff did not follow aseptic technique when performing wound care to Resident #3's left foot. Nursing staff did not follow physician orders for wound care and dressing change every three days. Resident #8 who had a stage II pressure ulcer on his coccyx was not provided with appropriate treatment to promote healing when facility staff turned off the pump to his pressure redistribution air mattress causing him to lay on a deflated air mattress on 6/3/11 from 12:15 a.m. to 5:30 p.m. This is evidenced by: The facility's policy/procedure for the "Treatment and Prevention of Skin Breakdown," from Pathway Health Services, dated 2005, included the following: "Establish and care plan an individualized turning and repositioning schedule if the resident is immobile. While in bed not to exceed 2 hours and while in a sitting position and/or if the HOB (head of bed) is greater then (than) 30 degrees not to exceed 1 hour, unless medically indicated. If the resident is capable they should perform push-ups every 15 minutes while in a sitting position. Bony prominences susceptible to pressure will be protected. (Note: Do Not Massage)...Elevate heels off bed as indicated (e.g., place pillows under calf to raise heels off the bed...Occupational therapy to evaluate for wheelchair positioning as needed...Obtain order for nutritional supplements and use of protein supplements as indicated..." 1. Resident #2 was readmitted to the facility on [DATE] status [REDACTED]. She returned to the facility with a stage 2 pressure ulcer on her coccyx. On 9/3/11, the facility completed a Norton Plus Pressure Ulcer risk assessment that determined that Resident #2 was at moderate risk for skin breakdown. Despite this risk and the fact that she already had a pressure ulcer, the facility did not develop an initial care plan with approaches to promote healing and prevent new pressure ulcers from developing. The Admission MDS with an assessment reference date of 9/9/11 notes that Resident #2's self performance for bed mobility is extensive assistance and she requires two staff to assist with bed mobility. Section M - Skin Conditions notes that Resident #2 is at risk of developing pressure ulcers and the resident has a Stage 2 pressure ulcer that was present on admission. The Pressure Ulcer Care Area Assessment noted, "Pressure ulcer present: location: coccyx, size: 2.1 x 0.8 x 0.1 cm, stage: 2, color: pink, drainage: none, odor: none, appearance of surrounding skin: pale, has had previous pressure ulcers(s), none at present, Extrinsic Risk Factors: Requires 2 staff to turn and reposition, requires regular schedule of turning, bed and chair activity only in nursing, Has pressure reduction seat cushion and mattress in use. ...Will develop care plan. Has had decubitus ulcer since May of this year. This is improved. Has suture line mid spine with 7 sutures. Cleansed and gauze dressing applied to this daily and prn. No drainage from this site. Approximating well. PICC care as per information sheet located on resident's chart. PCC (PICC) line in right arm. [MEDICATION NAME] on coccyx, change q (every) 3 days and prn. Is on fluid restriction of 1600 ml/24 hr. Taking fluids. Appetite has been 25-75%. Skin lotioned well with cares." The care plan dated 9/14/11 (12 days after admission) identifies the Problem: "Ulcer to coccyx. [MEDICATION NAME] AG Cover with dressing 10/10/11." The Care plan also includes the problem " I have a self care edficit (deficit) " dated 9/14/11 (12 days after admission) includes the intervention " Nurse Aide --- Assist with ADLs, oral hygiene, grooming, bathing, toileting, transferring, repositioning." The facility did not follow the standard of practice and did not follow their own policy when the care plan did not identify a specific individualized schedule for turning and turning. The C.N.A. care plan is not dated and is blank under the category titled Skin Care and Protective Devices. It notes that Resident #2 requires 1 person assist with transfers which is in conflict with the Care Area Assessment documentation that states Resident #2 requires 2 staff to turn and reposition. The nursing and nurse aide care plans do not identify an individualized turning and repositioning schedule as outlined in the facility's own policy titled, "Policy and Procedure for the Treatment and Prevention of Skin Breakdown." On 10/19/11 at 12:50 p.m., Surveyor spoke with the DON via telephone. Surveyor told the DON that surveyor had copies of care plans dated 8/11/11 from the resident's first admission and copies of care plans dated 9/14/11 from readmission. Surveyor asked the DON if the facility had any other care plans for Resident #2. On 10/20/11 at 12:38 p.m., the DON replied by fax and noted, "I do not have any other care plans to send to you besides what you have already." Despite having an existing pressure ulcer and having been identified as being at moderate risk for developing one, the facility did not develop an initial care plan for Resident #2 when she was readmitted on [DATE]. There was no care plan in place until 9/14/11, 12 days after admission. Nurse aide charting from 9/4/11 through 10/11/11 notes that Resident #2's self performance for bed mobility is extensive assistance and Resident #2 requires one person assist. Nursing documentation is very inconsistent and even contradictory regarding Resident #2's abilities. Nurses' notes on 9/5/11 (2:51 am and 10:33 am), 9/7/11 (4:02 am), 9/10/11 (4:31 am), 9/12/11 (2:10 pm) and 9/15/11 (2:31 pm) indicate that staff thought the resident required no help with bed mobility or the assist of one; Resident #2's condition began changing on 9/14/11. Nursing notes indicate the following: 10:06 am - MD UPDATED: Physician CC updated on lower aspect of incision being reddened with scant amount tan drainage on dressing ...Ulcer below wound is reddened with an odor. ...Moderate amount of serous drainage noted from this area... 10:46 am - SKIN PROBLEMS: ...Ulcer on coccyx has a fowl (foul) odor moderate amount of serrous (serous) drainage. Physician CC updated. On 9/15/11, Resident #2 went to the Spine and Neurological Surg(ery) Clinic for removal of stitches and staples. The Clinic Progress Note noted, "She is here today for 2 reasons. 1. Removal of stitches and staples. 2. Nursing home staff called saying that her wound, the decubitus in the coccyx area/sacral area was becoming odorous with their dressing changes and we needed to take a look at it with our wound care nurse. Today's look at the decubitus shows it is not only unchanged and not healed but even looks a little worse again. There was no odor however. We did get culture and sensitivity even though she is on [MEDICATION NAME] IV PICC line for [MEDICAL CONDITION]. ... She does admit that she finally took 2-3 steps for the first time yesterday. ... She does admit that if she sits too long, she gets pain in legs and hips bilaterally. I did call the nursing home. The nurses do give her periodic pain medication and she did have a pain pill prior to coming here. She can only sit in a wheelchair for 45 minutes before it is too to painful ... As for her coccyx our wound care nurse did cleanse it. We did send cultures. It was nonodorous, not reddened although it has gotten larger and there are 2 other reddened areas above it. Will change the dressings used for that." Despite this alert, the facility did not update the resident's care plan. Nurses' notes dated 10/9/11 noted the following; 9:53 a.m. noted " C/O (complains of) increased pain at ulcer on coccyx today. Weak ... Dressing changed to coccyx. Moderate amount of grey serrous (serous) drainage noted. No odor. Area around ulcer is pink, eschar (indicating it was now a stage 3) over ulcer attempted to debride small amount came off. Edges of ulcer have granulation over given prn pain medication before activity. Will have day shift tomorrow call the wound clinic for a possible evaluation of wound this week. 1:55 pm - Daughter in law updated on Resident having an increase in pain, drainage and weakness and that we will follow up with Dr. It should be noted that the facility did not have orders to debride Resident #2's wound. Staff did not consult with the physician even though the facility policy is to notify the physician of any deterioration. The facility's "Policy and Procedure for the Treatment and Prevention of Skin Breakdown" notes "Signs of healing (i.e., decreased size and depth of the ulcer, decreased drainage) should be evident after 2 to 4 weeks of treatment. Notify physician if any evidence of deterioration is noted. " 6:27 pm noted "RESIDENT COMPLAINTS: resident has an elevated temperature of: 100.8 axillary @ 1630 pm. (This would be equivalent to a temperature of 101.8 oral.) Resident was given 1 [MEDICATION NAME] for pain and fever @ 1700. Resident has generalized malaise, some confusion at times, poor appetite and weakness. Will continue to monitor. RN on day shift will be calling Skemp (clinic) to ask for an eval(uation) ASAP at the wound clinic for resident per RN H. RNs request based on her assessments today. 6:36 pm Note: Residents current temp after [MEDICATION NAME] is 100.0." Staff did not consult with the physician even though Resident #2's pressure ulcer had deteriorated and she was now running a fever. On 10/20/11 at 3:00 p.m., Surveyors spoke with the NHA and DON via telephone and asked them if the facility would expect the nurse to contact the physician on 10/9/11 regarding the information contained in the Nurses' notes at 9:53 am and 6:27 pm. On 10/21/11 at 4:18 p.m., the DON replied via fax and noted, "For the standards on temperatures I found our resource binder at the nurses' station and titled Acute Changes of Conditions ... On page 12 of the guideline it states under vital signs that to report oral temperature immediately if it is >101 F ..." Nurses' notes dated 10/10/11 noted the following; 1:15 pm - PRESSURE ULCER: To coccyx measures 3 cm length x 2 cm width x 9 mm depth. Wound bed white tissue surrounded by beefy red tissue, peri-wound skin is red. Area has an oder (odor) with no drainage present. Area cleansed and [MEDICATION NAME] applied to wound bed and covered with dressing. Will update wound clinic and see if she can be seen sooner than previously arranged appt. Will have MD assess on rounds tomorrow in the am. 1:19 pm - COMMENTS: writer encouraged resident to reposition side to side only while in bed and to utilize gel cushion when out of bed. Resident does state some discomfort to the area. On 10/10/11 at 8:56 a.m., Surveyor toured the 200 unit with Resident Care Coordinator EE who reported that Resident #2 was moderate care, required one person assist and her skin was good. On 10/11/11 at 5:57 am, Surveyor observed Resident #2 lying in bed on her back. On 10/11/11 at 7:24 am, Surveyor observed Occupational Therapist (OT) Y enter resident's room to assist with cares. Resident #2 was lying on her back in bed with bare feet and her feet resting directly on the mattress. Per OT Y, resident slept in her bra and was wearing her dentures which was unusual for her. OT Y put socks and shoes on Resident #2. OT Y asked her if she was in pain and she reported, "I'm always in pain." Resident #2 struggled to get up from a lying to sitting position in bed. She slowly ambulated to the bathroom with OT Y holding onto a gait belt around her upper back. When the resident was seated on the toilet, OT Y stated, "So is your back hurting or is it your bottom and Resident #2 replied, "Bottom." Surveyor observed Resident #2's back and incision which were red. It appeared the redness was from lying on her back in bed. Resident #2 reported she has pain all the time and at times the pain was "bad pain." `At this time Surveyor left the room and tracked down RN H who reported Resident #2 was given [MEDICATION NAME] one tab at 6:45 a.m. RN H reported resident could have 1-2 tabs of [MEDICATION NAME] so she could have another one if needed. At 7:50 a.m., Resident #2 slowly ambulated with assist of OT Y from the bathroom to her recliner chair in her room. Resident #2 reported she has pain when sitting up - "bottom hurts" and lying down when she gets relief. Resident #2 was then seated in her recliner chair with a gel pad underneath her. On 10/11/11, Resident #2 was seen in the Wound Clinic and then hospitalized . The Spine and Neurological Surg(ery) Progress Note dated 10/11/11 noted the following; "...She is here today because of her decubitus in the coccyx region. It has become enlarged, increase in circumferential [DIAGNOSES REDACTED], darkening at the superior border with some necrotic area, increase in depth and she has even had some episodes of confusion at the nursing home recently. Physician DD saw her today and felt she should be seen. We had her come in this afternoon ...EXAM: ...VITAL SIGNS ... Her pain scale is a 7/10 and it is in the coccyx area. SKIN: The coccyx is actually quite inflamed and circumferential [DIAGNOSES REDACTED] around it. There is some darkening at the superior border with increasing depth to it from the last time it was seen a couple weeks ago. It has had an odor. There is increased tenderness. One is unable to see any sacral bone but it may be right underneath. According to the nursing home notes, she needs 1 assist for transfers. The assistant with her says she does not transfer at all, she pivots. We transferred her with 2 assist today. Her lower extremity weakness remains, although she was able to bear weight, but not by herself ...PLAN: 1 ...She does have a stage III ulcer with necrotic tissue. 2. Recommend admitting her, seeing the wound care nurse on a regular basis, First Step mattress, keeping her off her back ...4. Physician CC is suggesting that she need to have plastics over at Gundersen see her as well ..." The General Surgery Consultation *Preliminary Report* dated 10/11/11 and titled noted the following; CHIEF COMPLAINT - Infected sacral decubitus ulcer SKIN - There is a sacral decubitus ulcer, which is unable to be staged at the present time. There is dry eschar and [MEDICATION NAME] sloughing present. [DIAGNOSES REDACTED] surrounding the wound measures 11 x 7.5 cm. The ulcer itself measures 4.2 x 1.0 x 0.9 cm. There is no healthy tissue visualized. There is no visualized purulent drainage and no fluctuance. ASSESSMENT AND PLAN - "...Our recommendation is to reculture the area, start intravenous antibiotics and institute wound care. Need to begin pressure relieving measures with a First Step mattress and a ROHO or other type of cushion when she is up in a wheelchair. Would also recommend Ensure or Boost nutritional supplement to promote wound healing. She may need surgical debridement at some point and will continue to follow. Would not recommend surgical intervention at this time. Given her multiple medical issues, she is a high-risk surgical candidate. The pressure ulcer is currently unable to be staged, but do suspect that it likely extends down to the bone. Further workup including blood culture is still pending. Will continue to follow." Following the above consultation, Resident #2 was hospitalized from [DATE] to 10/17/11 with acute [MEDICAL CONDITION] resolved with hydration, [MEDICAL CONDITION] secondary to stage IV sacral "decubitus" ulcer with [MEDICAL CONDITION] (wound culture grew Pseudomonas and Proteus) and [DIAGNOSES REDACTED] "probably related to stress." The resident received sharp debridement of the pressure ulcer, which was staged as a stage IV, on 10/17/11. She was readmitted back to the facility on that date with physician orders that included [MEDICATION NAME] 10 milligrams (mg) every 12 hours, [MEDICATION NAME] every 4 hours as needed for pain, dressing changes on Monday/Wednesday/Friday, up in the chair no more than 2 hours at a time with a cushion to the chair and "provide pressure relief mattress at the NH (nursing home)." Surveyor interviewed Clinic Nurse (CN) MM on 10/26/11 at 9:40 a.m. who identified she was a Certified Wound Ostomy Nurse (CWON). CN MM stated she thought Resident #2 was on a 2 hour positioning schedule at the nursing home. CN MM stated she wrote the order on 10/17/11 for the resident to be up in the chair for no more than 2 hours at a time because she did not want the resident to be up in the chair and left there for a longer period of time. CN MM stated she was unaware of a standard of practice (SOP) that would limit the time up in the chair to 1 hour. CN MM stated the physical therapy (PT) provided would be important and that she would have expected therapy to evaluate the type of cushion needed for the chair. CN MM stated she wrote the order to include a pressure "relief" mattress because Resident #2 had a Stage IV sacral pressure ulcer which meant it was "to the bone." Resident #2's nursing care plan, dated 10/17/11, included the following interventions related to the sacral pressure ulcer: pressure "reduction" mattress; water cushion in the recliner and in the wheelchair; reposition every 2 hours; encourage to eat while up in the chair; and, Registered Dietician (RD) consult. Staff did not provide specific instructions for repositioning in the chair according to their policy/procedure and current standards of practice. On 10/18/11, a nurse's note identified Resident #2 had a Stage IV sacral pressure ulcer, a "Full thickness of skin and subcutaneous tissue lost, exposing muscle and/or bone..." and included a hospital wound nurse description of the resident's pressure ulcer at the time of readmission back to the facility. It was identified the pressure ulcer was debrided with sharp instruments, measured 4.0 centimeters (cm) by 1.8 cm with a depth of 1.4 cm, had undermining present and a moderate amount of serosanguinous drainage and had redness to the surrounding tissue. The note also stated, "Has pressure relieving device for chair. Has pressure relieving device for bed. Receives turning/repositioning program." Staff did not consistently identify if pressure "relief" or pressure "reduction" was used for the resident. Staff did not assess for and obtain an appropriate cushion for the recliner and the wheelchair. BED MATTRESS On 10/25/11 at 4:00 p.m., Surveyor observed Resident #2's mattress. The mattress was a foam-type mattress with a cleanable cover and an edged perimeter on both sides at the top and bottom with no edge at the center on either side. The DON provided the manufacturer information regarding the mattress on 10/26/11. The information identified the mattress was a Panacea R Original Plus mattress which provided pressure "reduction," and "May be appropriate through Stage II wounds." Despite the order for a pressure "relief" mattress, staff did not provide a pressure relief mattress from 10/17/11 to 10/25/11 as ordered by the physician. Surveyor interviewed Office Manager (OM) NN on 10/26/11 at 8:50 a.m. who stated she received direction from the DON on 10/21/11 to order an air overlay mattress for Resident #2. OM NN stated she submitted the order that same day to the corporate office. Surveyor interviewed the DON on 10/25/11 at 4:15 p.m. who stated she just received approval from the corporate office (on 10/25/11) to purchase a pressure "relief" mattress for Resident #2. Based on surveyor concerns, on 10/25/11, at the end of the day, the DON pointed out to Surveyor that she had obtained an air overlay mattress for Resident #2 from the local hospital. The DON provided the manufacturer's information for the mattress which identified it as a "GAYMAR" bed cushion that provided pressure "relief." On 10/26/11 at 6:50 a.m., Surveyor observed Resident #2's mattress. On top of the mattress had been placed the GAYMAR air overlay mattress. Surveyor interviewed the DON on 10/26/11 at 8:20 a.m. The DON stated she thought she recalled that one of the nurses, "possibly Registered Nurse (RN) H," talked to someone at the hospital who said the mattress in use at the nursing home was "good enough" if the resident was repositioned from side to side. Surveyor interviewed RN H on 10/26/11 at 9:10 a.m., who stated she did not talk to anyone at the hospital regarding Resident #2's mattress. Surveyor interviewed CN MM (Certified Wound Ostomy Nurse) on 10/26/11 at 9:40 a.m. who confirmed she wrote the order, under the direction of the physician on 10/17/11, for Resident #2 to have a pressure relief mattress and stated she did not talk to anyone at the facility to retract the order. CN MM stated the pressure ulcer worsened at the facility and emphasized the need for a pressure relief mattress. Staff did not provide a pressure relief mattress in a timely manner as ordered by the physician. CHAIR CUSHIONS The 2009 National Pressure Ulcer Advisory Panel, Quick Reference Guide for Pressure Ulcer Treatment states, "If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the ulcer." On 10/25/11 at 12:45 p.m., Surveyor observed the CNA care plan hanging in Resident #2's closet. Interventions included to utilize a "water" cushion in the wheelchair or in the recliner. Unit Clerk (UC) G entered the resident's room at that time and exchanged the current CNA care plan with a new one. The new CNA care plan included the additional interventions to assist to turn and reposition and to use a "gel" cushion in the wheelchair or in the recliner instead of the water cushion. On 10/25/11 at 4:45 p.m., Surveyor noted the cushions in the wheelchair and in the recliner appeared as thin and soft to touch (felt like gel or water-filled), covered with a gray vinyl material. The cushion in the recliner was covered with a folded, quilted pad and Resident #2 stated, when she was up in the recliner she sat on the quilted pad that was placed on top of the cushion. On 10/25/11 at 5:25 p.m., Surveyor again observed the cushions in the wheelchair and in the recliner. The cushion in the wheelchair still appeared to be of a gel or water-type cushion. Resident #2 was sitting in the recliner, thus only the corner of the cushion was observed which, at that time, appeared that it could have been gel or water-filled. On 10/25/11, the DON provided manufacturer's information for an "Aquatherm Tenderflo" wheelchair water cushion which she stated was the type used for Resident #2. The information identified the cushion was designed to "reduce" pressure. On 10/26/11 at 6:50 a.m., Surveyor observed Resident #2 as she sat up in the wheelchair in the front lobby, waiting for transportation to take her to the wound clinic which was approximately 50 to 60 miles from the facility. Resident #2 sat on a light blue covered cushion that appeared to be a water-filled cushion. On 10/26/11, the DON provided manufacturer's information for a "LUMEX...TENDERFLO" water cushion which she stated was the type that Resident #2 had brought with her from the hospital. The information identified the intended use of the cushion was as a "support and pressure reduction surface." On 11/01/11 at 1:30 p.m., Surveyor interviewed Occupational Therapist (OT). OT Y stated she mainly works with residents related to their upper body needs and identified chair positioning as part of her role. OT Y stated if a resident needed an upper body device, she would make the recommendation but would leave it up to the facility to obtain the device. OT Y stated following Resident #2's return from the hospital on [DATE] she talked with the DON on 10/18/11 who told her the wound clinic recommended the water cushion and sent it with the resident. OT Y stated she was not very familiar with the water cushion. On 11/01/11 at 2:08 p.m., Surveyor interviewed PTA FF who identified she generally works with the lower body and did not assess wheelchair devices such as cushions. Despite the expectations from the Wound Clinic Nurse (CN MM) that PT staff at the nursing home would evaluate the type of cushion needed for the chair, this did not occur. It was not until 11/01/11 at 10:20 a.m., (after concerns had been expressed by the surveyor) that Surveyor observed that Resident #2 had a Roho (pressure relief) cushion in her wheelchair which was covered with a pillowcase. Staff did not assess for and obtain an appropriate chair cushion in a timely manner. REPOSITIONING The Wound Ostomy and Continence Nurses Society Guideline for Prevention and Management of Pressure Ulcers, 2010 states to assess and inspect skin regularly...A head-to-toe skin inspection should occur upon admission to care setting and at least daily or per specific setting regulation 2008; focusing on high risk areas areas such as bony prominences...Blanching [DIAGNOSES REDACTED] is an early indication to redistribute pressure. Non-blanching [DIAGNOSES REDACTED] suggests that tissue damage has already occurred. All skin changes should be documented including any actions taken...Assess the intensity and duration of pressure on all bony prominences of at-risk individuals at least daily. On 10/21/11, nurses' notes identified Resident #2 required 1 staff assist for bed mobility and "little resident self performance." Resident #2's Certified Nursing Assistant (CNA) care plan observed in the resident's room by Surveyor on 10/25/11 at 12:45 p.m. did not include any direction related to bed mobility or repositioning. Resident #2's CNA charting from 10/17/11 to 11/25/11 identified the resident required extensive staff assistance from 1 staff person for bed mobility. Staff did not individualize the resident's care plan related to her need for assistance with bed mobility and repositioning. On 10/25/11 at 12:45 p.m., Surveyor observed the CNA care plan hanging in Resident #2's closet. The care plan did not address repositioning. Unit Clerk (UC) G entered the resident's room at that time and exchanged the current CNA care plan with a new one. The new CNA care plan included the additional interventions to assist to turn and reposition but it did not identify how often the resident should be repositioned. Surveyor interviewed Resident #2 on 10/25/11 at 12:35 p.m. Resident #2 stated most staff were "good" about helping her to reposition, but added she thought the open area on her bottom might be getting infected again. Surveyor interviewed Resident #2 on 10/25/11 at 4:45 p.m. Resident #2 stated she was up in the chair for breakfast and for lunch for approximately 1 hour each time and added she would ask staff to get her up again for supper. Resident #2 stated the night aides were good about repositioning her every 2 hours, but the day aides were "not so good." Resident #2 stated the day aides positioned her when she asked them to and added that no one so far on this day had come in to reposition her in bed other than when she asked them to assist her up for breakfast and lunch and when she had therapy. Surveyor observed Resident #2 on 10/25/11 at 10:50 a.m., 12:35 p.m., 4:00 p.m. and 4:45 p.m., all times positioned on her left side or slightly onto her left side with a pillow behind her back. CNA HH came in at approximately 4:50 p.m. on 10/25/11 with Resident #2's supper tray. He set the tray down and was starting to leave when Resident #2 asked him if he would assist her up in the recliner for supper which he did. Staff did not develop a complete and accurate care plan with specifi

Based on record reviews, staff interviews and review of facility policy, the facility did not ensure staff immediately consulted with the resident's physician when 1 of 12 sample residents, for 2 separate incidents, experienced a significant change in condition. Resident #2 was admitted to the facility on [DATE] for rehabilitation after having back surgery. Resident #2's record indicates her surgical incision was healing well from admission through 8/14/11. On 8/15/11, Resident #2's surgical incision began draining a large amount of serosanguineous drainage and charting later that evening indicated a constant trickle of sanguineous drainage. Facility staff did not consult with Resident #2's physician regarding the new onset of serosanguineous drainage from her surgical incision until 8/17/11. Resident #2's physician orders [REDACTED]. The resident was identified with an increase in weight of more than 2 pounds in 1 day on 5 individual days and more than 5 pounds in 1 week. Resident #2 experienced weakness with a change in mental status requiring transportation to the emergency room and was diagnosed with [REDACTED]. Facility staff did not immediately consult with the physician each time Resident #2's weight increased according to the parameters stated in the physician orders. This is evidenced by: 1) The resource titled Wound Care: A Collaborative Practice Manual for Health Professionals, 2007 by Carrie Sussman and Barbara M. Bates - Jensen notes "Evaluation of surgical incisional wound exudate requires knowledge of the expected characteristics of wound exudate during the course of healing. The character and amount of exudate changes as wound healing progresses. The wound exudate immediately after surgery is bloody. Within 48 hours, the wound drainage becomes serosanguineous in nature and, finally, the exudate is serous. The amount of wound exudate should gradually decrease throughout the healing period. An increase in wound exudate usually indicates compromised wound healing caused by infection. New drainage from a previously healed incision heralds wound dehiscence, infection and in some cases, fistula formation." Resident #2's record was reviewed by Surveyor from 10/12/-10/14/11. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital Discharge orders dated 8/3/11 included, "change (incision) dressing daily and prn." The Resident Data Collection Form dated 8/6/11 notes, "[MEDICATION NAME] to buttocks, dressing to spine, cyberteck brace around midsection." The August Treatment record dated 8/1/11 to 8/31/11 notes the following; 8/5/11 - Monitor for s/s of infection at incision site NOC, AM, PM. 8/6/11 - Change dressing daily AM. Nursing Notes noted the following; 8/6/11 - 1:36 pm - to mid spine, dressing dry and intact 8/7/11 - 9:55 a.m. - dressing dry and intact to spine 8/8/11 - 11:51 a.m. - "Wound review: Lower mid-spine, measures 5.5 inches length, 1 mm width COLOR: pink DRAINAGE: scant amount of serous-sang healing well steri strips intact. No s/s of infection." 8/9/11 - 9:36 a.m. - "Incision to back cleansed and 4 x 4's to cover area. No drainage or s/s of infection noted." 8/9/11 physician progress notes [REDACTED]. Otherwise the incision is healing well and was given three thumbs up by Physician CC (surgeon)." 8/12/11 - 10:40 a.m. - "... Incision site clear. No redness /inflammation or drainage noted. No s/s of infection. Incision well approximated. Steri strips intact, dressing changed and replaced with ABD." 8/13/11 - 10:58 a.m. - "Incision on lumbar back is well approximated, steri strips intact, area cleansed and 4 x 4 gauze dressing applied. Small puncture incision above wound is well approximated no redness, inflammation or drainage to any of the wounds." 8/14/11 - 10:18 a.m. - "...Incision cleansed with normal saline, well approximated, no redness, inflammation or drainage noted. No s/s of infection. Incision covered with 4 x 4." 8/15/11 - 10:45 a.m. - "Mid spine steri-strips have fallen off, large amount of serosanguineous drainage noted. Some blood present. Area cleansed and gauze applied. No oder (sic (odor)) or s/s of infection noted. Resident tolerated well and was tender to the touch." On 10/13/11 at 3:15 pm, Surveyor and Surveyor interviewed RN F who recorded this entry in the record. RN F reported he didn't think the increased drainage was anything to worry about because the drainage was normal and was not purulent. 8/15/11 - 10:24 p.m. - "Dressing is saturated with non-odorous sero-sanguineous drainage. Dressing is removed. Constant trickle of sanguineous drainage is observed to pinpoint open area at distal aspect of incision. No drainage observed to any other portion of incision. [DIAGNOSES REDACTED] is observed to site. No warmth, denies pain to site. ABD folded in half applied to distal portion of incision followed by ABD to length of incision secured with [MEDICATION NAME] tape. Resident is placed in side lying position with HOB no greater than 15 degrees to offload pressure to site. Procedure well tolerated." On 10/13/11 at 3:00 pm, Surveyor and Surveyor interviewed RN V who recorded this entry in the record. RN V reported she didn't call anybody about this resident's condition as she didn't see the increased drainage as a problem. 8/16/11 - 1:13 p.m. - "To mid- spine draining serosanguineous large amount. Area cleansed steri-strips applied to bottom inch of incision. Area then covered with sterile gauze." On 10/13/11 at 3:15 pm, Surveyor and Surveyor interviewed RN F who recorded this entry in the record. Surveyor asked RN F why he applied steri strips to Resident 2's incision. RN F reported he "put steri strips on to help - drainage from there - that area not coming apart." 8/16/11 - 10:25 p.m. - "Note: dressing replaced, noted serosanguineous drainage on old dressing. 3 steri-strips replaced on lower incision area, denies any pain or discomfort." 8/17/11 - 3:31 a.m. - "T 100.7 ... 3:32 a.m. - has not needed dressing change as no drainage thus far this shift, will continue to monitor." It should be noted that this temperature is 2.2 degrees above Resident #2's highest baseline temperature and 2.6 degrees above the previous temperature of 98.1 taken on 8/17/11 at 10:31 am. According to the AMDA Acute Change of Condition Guideline (ACOC), one temperature reading above 100 degrees F, two readings above 99 degrees F or an increase of 2 degrees F above the upper end of the patient's normal range may indicate an ACOC. 8/17/11 - 10:51 a.m. - Physician CC - Surgeon updated on vitals, large amount of serrous opaque drainage from lower 1/3 in back incision. Incision being warm to touch and reddened 2 cm around incision. Appointment with Physician CC today. It should be noted that the appointment to see Physician CC was not kept due to van service not receiving paperwork. However, the resident was seen by Physician BB - Medical Director on 8/17/11. On 10/13/11 at 3:38 p.m., Surveyor and Surveyor interviewed RN H who recorded this entry in the resident's chart. RN H reported she worked on 8/14/11 and resident was content and fine. RN H reported she "was concerned on 8/17/11 and saw red flags, knew something had to be done." 8/17/11 physician progress notes [REDACTED]. She has not had fevers or chill. She has not had nausea or vomiting ... Her incision shows that there are two open areas. There is one at the very inferior edge of the incision in the lower lumbar spine, it measures approximately ? cm in length and then approximately 1 ? cm above that there is another opening that measures about 1 cm in length. They are each draining serosanguineous fluid. There is no tenderness to palpation, no foul odor, no particular warmth. A: Draining from incision site from recent lumbar decompression laminectomies. P: I did contact Physician CC (surgeon) by phone ... We will start her on Bactrim DS 1 p.o. bid times ten days. ..." The note indicates that this resident is scheduled to see the surgeon on 8/18/11 at 1:00 p.m. On 10/14/11, Surveyor received the facility's undated policy for Change in Condition which notes "Except in a medical emergency or when a resident is incompetent, the facility (i.e. licensed nursing staff) must consult with the resident immediately and notify the resident's physician and if known, the residents legal representative or interested family member. A. A significant change in the resident's physical, mental or psychosocial status B. A need to alter treatment significantly. C. A decision to transfer or discharge the resident from the facility A significant change means deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications." (Cross reference F281 and F309) 2) Resident #2 was admitted to the facility on [DATE] following surgery for [REDACTED]. The resident was treated with an intravenous antibiotic from 08/19/11 through 10/05/11 for [MEDICAL CONDITION] (MRSA) infection in the surgical wound and bacteremia. Resident #2 was hospitalized from [DATE] to 10/17/11 with [DIAGNOSES REDACTED]. The diuretic, [MEDICATION NAME], had been administered during the hospitalization , then put on hold on 10/16/11 and was not ordered to be continued upon readmission to the nursing home on 10/17/11. Readmission orders [REDACTED]. Resident #2's Treatment Administration Record (TAR) for the month of October 2011 identified the resident was on a fluid restriction of 1600 cc until 10/17/11 at which time facility staff discontinued the fluid restriction. The TAR identified the resident was to be weighed daily in the a.m. and with a weight gain of greater than 2 pounds in 1 day or 5 pounds in 1 week, "contact PMB" (the original order stated to contact PMD or primary medical doctor). Staff did not include the 1800 cc fluid restriction on the TAR. Resident #2's significant change Minimum Data Set (MDS) assessment, with an assessment reference date of 10/24/11, identified the resident had no cognitive impairment, but required extensive staff assistance with most activities of daily living (ADLs) except was able to eat and drink independently with setup. The associated Care Area Assessment (CAA) summary for Dehydration/Fluid Maintenance did not include there was a current fluid restriction, daily weights and monitoring for weight increase. Staff did not provide an accurate and complete assessment related to the resident's [DIAGNOSES REDACTED]. Resident #2's nursing care plan related to [MEDICAL CONDITION], dated 10/17/11 and another dated 10/25/11, identified, "weights per order" and did not include a reference to fluid restriction or physician consultation with weight gain. Surveyor reviewed Resident #2's weights on 11/02/11 following the resident's readmission to the facility on [DATE]. The following weights were all measured in pounds. Resident #2 maintained a weight from 115.2 to 116.8 from 10/18/11 through 10/20/11. A weight taken on the p.m. shift on 10/21/11 was 122.6, a weight taken on the a.m. shift on 10/22/11 was 118.4 and a weight taken on the a.m. shift on 10/24/11 was 120.6. There were no weights taken and documented on 10/26/11 and 10/28/11. Resident #2 had persistent weight gains with a weight of 122.2 on the a.m. shift on 10/29/11, a weight of 124.2 on the a.m. shift on 10/30/11 and a weight of 123 on the p.m. shift on 10/31/11. Staff did not weigh the resident on 10/26/11 or on 10/28/11 and did not consistently obtain the weights on the a.m. shift as ordered. Staff consistently initialed the TAR regarding physician contact for a weight gain but did not contact the physician on 10/21/11, 10/22/11, 10/24/11, 10/29/11 or 10/30/11. Surveyor and reviewed the facility's undated policy and procedure related to change in condition/physician notification on 10/14/11, which noted, "Except in a medical emergency or when a resident is incompetent, the facility (i.e. licensed nursing staff) must consult with the resident immediately and notify the resident's physician and if known, the residents legal representative or interested family member. A. A significant change in the resident's physical, mental or psychosocial status B. A need to alter treatment significantly. C. A decision to transfer or discharge the resident from the facility A significant change means deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications." On 10/31/11, Resident #2's nurses' notes on the day shift identified the physician was updated regarding the resident's weight, fluid and sodium restriction and weakness. It was also identified the physician was again updated the resident was more weak during therapy and, "wasn't tracking as usual." Nurses' notes on 11/01/11 identified on the evening of 10/31/11, the resident was transported to the emergency room related to, "change in mental status." Surveyor reviewed the emergency room note on 11/02/11 related to the visit there on the evening of 10/31/11. The resident was noted to have, "a very low sodium at 122" (normal sodium, 137-145) and was diagnosed with [REDACTED]. Surveyor interviewed the Director of Nursing (DON) on 11/02/11 at approximately 4:30 p.m. who stated she would have expected the nurses to contact the physician when Resident #2's weights had increased according to the parameters ordered.

Based on staff interviews, record reviews and review of facility policies, the facility did not provide services that met professional standards of quality for 2 of 12 sample residents (#2, #3). Facility nursing staff did not recognize that an abrupt onset of large amounts of serosanguineous drainage from Resident #2's healing surgical incision represented a significant clinical complication and significant change in condition and did not report this clinical complication to the physician in a timely manner. Facility nursing staff did not thoroughly assess Resident #2's condition and did not take appropriate action when a significant change in condition occurred. The failure of nursing staff to recognize a significant clinical complication, assess and monitor the resident's condition and take appropriate action when indicated, failed to meet professional standards of quality. The facility policy for defining fever is not consistent with current standards of practice. Facility staff did not provide appropriate pain management services to 2 of 12 sample residents (#2 and #3). The facility pain assessment policy is not consistent with current standards of practice. Findings include: 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Hospital discharge orders dated 8/3/11 directed staff to change the dressing to Resident #2's surgical incision daily and prn (as needed). The August Treatment Record dated 8/1/11 to 8/31/11 directs staff to monitor the incision site for s/s of infection each shift. Nursing documentation dated 8/6/11 - 8/14/11 indicates that Resident #2's incision site is clean dry and intact without s/s of infection. A physician progress notes [REDACTED]." Nursing Notes dated 8/15/11 at 10:45 a.m. identified the incision was now draining large amounts of serosanguineous drainage and was tender to the touch. On 10/13/11 at 3:15 pm, Surveyor and Surveyor interviewed RN F who recorded this entry in the record. RN F reported he didn't think the increased drainage was anything to worry about because the drainage was normal and was not purulent. Nursing Notes dated 8/15/11 at 10:24 p.m. identified the dressing is saturated with non-odorous serosanguineous drainage and there is a constant trickle of serosanguineous drainage coming from a reddened pinpoint open area at the distal aspect of the incision. On 10/13/11 at 3:00 pm, Surveyor and Surveyor interviewed RN V who recorded this entry in the record. RN V reported she didn't call anybody about this resident's condition as she didn't see the increased drainage as a problem. Nursing Notes dated 8/16/11 at 1:13 p.m. and 10:25 p.m. continues to identify the presence of serosanguineous drainage from the incision area. Nursing Notes dated 8/17/11 at 3:31 a.m. recorded the resident's temperature as 100.7. On 10/21/11 at 4:18 p.m., the DON reported via fax that the facility used the AMDA Acute Change of Condition (ACOC) Clinical Practice Guideline for temperatures. The DON provided Surveyor with a copy of page 12 of the guideline that noted an oral temperature of > (greater than) 101 degrees F should be reported immediately to the physician. The information submitted is incomplete. The most current AMDA ACOC Guideline notes the following in Table 10. Categories of Symptoms That May Help to Define ACOCs, Temperature; A sudden or rapid change from normal temperature may suggest an ACOC. One temperature reading above 100 degrees F, two readings above 99 degrees F or an increase of 2 degrees F above the upper end of the patient's normal range may indicate an ACOC. 8-17-11 (Late entry dated 8/18/11 - 10:15 p.m. - Dressing is saturated with non-odorous sero-sanguineous drainage. Dressing is removed. [DIAGNOSES REDACTED] is observed to site. No warmth, no [MEDICAL CONDITION], resident denies pain to site. Site is cleansed with NSS and sterile gauze. ... 3 - 4 x 4 gauze pads folder lengthwise applied to distal aspect of incision followed by 2 - ABD folded in half secured with [MEDICATION NAME] tape. Resident is placed in side lying position with HOB no greater than 15 degrees to offload site. Nursing Notes dated 8/17/11 at 10:51 a.m., noted that Physician CC - Surgeon was notified regarded Resident #2's vitals, large amount of serous opaque drainage from lower 1/3 of back incision and incision being warm to touch and reddened 2 cm around the incision. Resident #2 was supposed to see the surgeon on 8/17/11 but didn't due to transportation issues. Resident #2 was seen by Physician BB. 8/17/11 physician progress notes [REDACTED]. She has not had fevers or chill. She has not had nausea or vomiting ... Her incision shows that there are two open areas. There is one at the very inferior edge of the incision in the lower lumbar spine, it measures approximately ? cm in length and then approximately 1 ? cm above that there is another opening that measures about 1 cm in length. They are each draining serosanguineous fluid. There is no tenderness to palpation, no foul odor, no particular warmth. A: Draining from incision site from recent lumbar decompression laminectomies. P: I did contact Physician CC (surgeon) by phone ... We will start her on Bactrim DS 1 p.o. bid times ten days. ..." The note indicates that this resident is scheduled to see the surgeon on 8/18/11 at 1:00 p.m. 8/17/11 - 10:50 (Late entry written on 8/18/11 at 3:30 p.m.) - Night nurse assessed resident at 22:50 and found her to be hypotensive called ER and received orders from Physician BB to hold dilitiazem and [MEDICATION NAME] d/t low BP until she was to be seen by Physician CC - Surgeon. Nurse was to continue to monitor and send to ER if any further changes. Resident continued to have low B/P throughout night. 8/17/11 - 11:59 p.m. - Physician BB called on resident's condition when this nurse went to assess after being given b/p reading of 80/50 and that resident cool / clammy, this nurse found resident leaning over bed and large amount of clear green bile emesis on floor, also large amount of serosanguineous noted on bed linens, recheck in opposite arm L of b/p 92/40, denies allergy to sulfa as new medication started this p.m. shift for surgical incision infection. Bactrim given on pm shift, res(ident) denies any ill effects or need for hospitalization states, "I have an appointment with Physician CC tomorrow and "I should be fine till then." Actions: Orders received hold dilitezem and [MEDICATION NAME] until assessed via Physician CC. Continue to observe and send to hospital if resident changes her mind and needs to go, push fluids. 8/18/11 - 3:12 a.m. - Resident Complaints: sent CNA up to tell this nurse to call an ambulance, assessment made, B/P 80/40 but asymptomatic. Condition Noted: no pain, no new symptoms since first assessment and resident refused to go to hospital then, encouraged to drink fluids as ordered per Physician BB and rest and let staff know if any symptoms arise, acknowledged and seemed satisfied with this suggestion. 8/18/11 - 4:44 a.m. - Resident Complaints: monitoring for low b/p at 0400 78/42, no c/o voiced at this time, incision continues to drain and dressing saturated, changed at this time and when resident raised to sitting position, drainage gushed out when incision expressed, copious amounts of serosanguineous from both sites on incision that are draining, denies dizziness, pain or any other symptoms at this time, encouraged to drink and notify staff if any new symptoms arise, resident alert and oriented and able to make needs known, continues to deny any ill effects. 8/18/11 - 8:38 a.m. - Resident appears more confused this am and states she "just doesn't feel right." Resident to be evaluated at ER. Left by ambulance at 8:40 a.m. The Black River Falls EMS Report dated 8/18/11 noted the following "911 Dispatched for pt (patient) transfer from Family Heritage to BRMH (Black River Memorial Hospital) ER upon arrival on scene pt found lying in bed had low back surgery 2 weeks ago and has had loss of appetite, low blood pressure and excess pain and drainage from the incision site the last 2 days, pt was sheet lifted to our cot, pt BP low pulse elevated and O2 sats normal, pt rested enroute rating her pain a 3/10, incision site appeared to have lite pink fluid and the dressing covering it was full and leaking out, pt care transferred to BRMH ER Staff." 8/18/11 - 3:12 p.m. - Resident was admitted on [DATE] after having laminectomy for rehabilitation and strengthening. Resident was alert and oriented x 3. ...All skin intact with exception to surgical wounds. Wounds were healing nicely until Monday August 15th when drainage was noted on PM shift. The Mayo Clinic Discharge Summary dated 9/2/11 noted, "Patient was admitted inpatient with septic shock secondary to wound infection to the intensive care unit ... Discharge [DIAGNOSES REDACTED]." On 10/13/11 at 3:26 p.m., Surveyor and Surveyor interviewed the DON who indicated that she didn't consider the large amount of drainage a s/s of infection because it was not purulent. On 10/13/11 at 4:40 p.m., the DON gave Surveyor a document titled Infection Control Resident Care Wound Culture Collection. The DON pointed to the text in the document that noted "Infection is evidenced by purulent drainage, swelling, redness or warmth at the site and often the resident will have a fever" as the rationale for not considering the drainage a potential sign of infection. The resource titled Wound Care: A Collaborative Practice Manual for Health Professionals, 2007 by Carrie Sussman and Barbara M. Bates - Jensen notes "Evaluation of surgical incisional wound exudate requires knowledge of the expected characteristics of wound exudate during the course of healing. The character and amount of exudate changes as wound healing progresses. The wound exudate immediately after surgery is bloody. Within 48 hours, the wound drainage becomes serosanguineous in nature and, finally, the exudate is serous. The amount of wound exudate should gradually decrease throughout the healing period. An increase in wound exudate usually indicates compromised wound healing caused by infection. New drainage from a previously healed incision heralds wound dehiscence, infection and in some cases, fistula formation." (Cross reference F309) PAIN Surveyor reviewed the facility's "Pain Assessment" policy in its entirety on 10/13/11. The policy noted "A pain assessment will be completed on each resident who presents with acute, chronic, and/or suspected pain. The pain assessment will then be utilized in formation of the multidisciplinary care plan to address pain management." The Procedure noted "1. The Pain Assessment Form will be completed on; a. every resident on admission. If pain is not an issue, this will be documented in the nurse's notes. b. Every resident returning from a hospital stay. c. Every resident with a significant change. d. Quarterly on each resident who remains on [MEDICATION NAME]. e. Any resident at the discretion of MD or Clinical Manager. 2. The Pain Assessment Flow Sheet can be used as a follow-up to the Pain Assessment Form until the pain is under control. 3. Use either the vertical pain intensity scale or the pain intensity "faces" to evaluate the effectiveness of pain intervention. 4. Pain management will be addressed by the interdisciplinary team on the care plan. 5. Pain management will be addressed weekly in the weekly summary. The resource titled American Geriatrics Society Pharmacological Management of Persistent Pain in Older Persons, 2009 notes "An effective pharmacological approach to the treatment of [REDACTED]. Routine screening and careful assessment of all older patients is crucial, because pain that is causing severe impairment may not be spontaneously revealed for a variety of personal, cultural or psychological reasons...The current best indicator of the pain experience is the patient's own report which must include an assessment of the pain intensity and an evaluation of the effect of the pain on daily function." 2. Resident #2's record was reviewed by Surveyor from 10/12/-10/14/11. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The August 2011 Treatment Record noted "8/5/11 Monitor for pain every shift NOC AM PM." The standard of practice is to assess a Resident's pain intensity level before and after any pharmacological or non-pharmacological approach. The initial pain assessment dated [DATE] at 10:27 a.m. noted the following; Diagnosis: [REDACTED]. Non-Medication Interventions for Pain: position changes Quality of Pain: aching Describe Pain: intermittent Origin of Pain: Musculo-skeletal secondary to surgery Exacerbating Factors: Exercise, Therapy, Ambulation, transfers, ADLs (activities of daily living) Alleviating Factors: Rest, Distraction, [MEDICATION NAME], Position Changes Manner of Expressing Pain: Verbal Observation: grimacing Summary/Plan: Utilize Non-med interventions as well as ordered [MEDICATION NAME]. Pain Goal: 0-3 out of 10 on the pain scale The Occupational Therapy Initial assessment dated [DATE] noted Resident #2's pain to be 2/10 after pain meds, up to 4/10 with ADLs (activities of daily living). Typically 5-6/10 pain in low back. Also gets muscle spasms in L (left) lower extremity. The Physical Therapy Initial Evaluation dated 8/7/11 noted "Patient presents with impairments in the following areas: Ambulation endurance/safety/pain. One of the short-term goals included "reduce pain rating from 6/10 to 2/10." The care plan dated 8/11/11 completed 6 days after admission identified the problem "I need to regain my strength to return home safely and with help managing my pain related to L2-3, L3-4, L5-6 stenosis requiring surgical intervention, pain,[MEDICAL CONDITION](Hypertension),[MEDICAL CONDITION]([MEDICAL CONDITION] Reflux Disease) manifested by decreased ADL participation." Approaches included but not limited to; monitor for pain, treat with po (oral) and non-med interventions such as ice and repositioning and update MD with unmet pain needs. The pain relief goal was "will have no greater than 3 pain level ungoing (sic (ongoing))." Even though the pain assessment identified exercise, therapy, ambulation, transfers and ADLs exacerbated Resident #2's pain, the care plan does not address premedicating Resident #2 prior to any of these activities. The care plan does not include an approach consistent with current standards of practice to include specifically asking Resident #2 to self-report her pain at rest and during movement. On 10/20/11 at 12:27 p.m., the DON faxed Surveyor documents that included a statement that noted "I do not have any other care plans to send you besides what you have already." The August 2011 Treatment Record noted that nursing staff recorded Resident #2's pain intensity score each shift and her pain intensity score was between 0-4/10 for dates 8/6-8/12/11 with one exception on 8/7/11. The 8/7/11 AM treatment (tx) box lists initials, the PM tx box notes a pain score of 5 and the NOC tx box notes initials. The PRN (as needed) Pain Medication Notes provided via fax by the DON on 10/21/11 at 4:18 p.m. noted the following; 8/7/11 - 8:22 a.m. - [MEDICATION NAME] 5 mg given for hip pain rated at 5/10. 8/7/11 -1:29 p.m. - [MEDICATION NAME] 5 mg given for left hip pain rated at 7/10. 8/7/11 - 1:36 p.m. - Tylenol ES (Extra Strength) 500 mg given for left hip pain 4/10. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The MAR, Nurses' notes, PRN (as needed) Pain Medication Notes and Tx Record for 8/7/11 did not identify Resident #2's pain intensity score after receiving pain medication to determine its effectiveness in reducing her pain intensity score to an acceptable level. Facility staff did not administer pain medication at regular intervals to prevent reoccurrence of Resident #2's pain intensity above her pain relief goal. There is inconsistency between the PRN Pain Medication Notes and the MAR indicated [REDACTED]. The facility did not administer pain medications at an appropriate frequency and dose to achieve Resident #2's pain relief goal and prevent her from experiencing severe reoccurring pain. Facility staff did not routinely assess Resident #2's pain intensity score after receiving pain medication to determine the effectiveness of the pain medication in meeting her pain relief goal. On 10/14/11 at 7:45 a.m., Surveyor spoke with the DON about concerns related to Resident #2's pain management. Surveyor informed the DON that staffs were not consistently asking residents to self report their pain intensity level before and after pain medication and not assessing pain intensity at rest and with movement. Staffs were not premedicating residents prior to activities that caused pain. No additional information was provided. During the Exit Meeting on 10/14/11 at 3:50 p.m., Surveyor requested that the facility provide any additional information regarding pain management. (Cross reference F309) 3. Resident #3's most current quarterly MDS dated [DATE] notes that he is usually able to make himself understood and sometimes understands others due to his moderately impaired hearing. The MDS identifies he has short-term memory problems but his long-term memory is OK and he is able to recall the current season, location of his room, staff names and faces and that he is in a nursing home. The MDS indicates that Resident #3 has [DIAGNOSES REDACTED]. The most current care plan identifies the problem "I need my pain to be managed" reviewed on 8/19/11 by Resident Care Coordinator EE. The care plan goal notes "I will have pain level no greater that (than) 3. I will express feeling of comfort or of pain relief within reasonable time after pain med administration x 90 days." Care plan approaches include; administer my medication, monitor and record med effectiveness, med side effects, notify my doctor if any adverse reactions, assess my physical symproms (sic (symptoms)), notify my doctor as needed, Utilize 0-10 pain scale unless unable to verbalize than (then) facial scoring, encourage me to take rest periods, position me for comfort, report any pain I may have to my nurse, assist me with repositioning and provide me with a dark quiet environment. The care plan does not direct staff to ask Resident #3 if he has pain. Signed physician orders [REDACTED]. physician progress notes [REDACTED].#3 is feeling well, only complaint is left knee pain. He has [MEDICAL CONDITION] arthritis, we offered injections and he really wasn't interested. ...Assessment/Plan: 1. Advanced Arthritis; we have offered injections in the past and he is not interested in any treatments at all. Will continue to monitor. No other changes made today. On 10/11/11 at 6:16 a.m., RN F and Surveyor entered resident's room for RN F to perform wound care to resident's left foot. Resident #3 was lying in bed on his left side in a semi-fetal position. Resident #3 who was wearing slacks told RN F "No, I don't want to get up. My knees are all worn out, it hurts them so." RN F reported that resident says the wound on his foot is tender to touch but he usually doesn't complain of pain in his knees. RN F did not ask Resident #3 to rate his pain. At 6:29 a.m., RN H entered the room to give Resident 2 tabs of Tylenol 325 mg for pain. Surveyor did not observe RN H ask Resident #3 to rate his pain before administering Tylenol. On 10/12/11 at 2:49 p.m., Surveyor observed Resident #3 lying in bed on his left side with knees slightly flexed. Resident #3's wife was sitting in a wheelchair close to Resident #3's bed. Resident #3's wife told surveyor that her husband won't be able to hear surveyor when surveyor attempted to speak into his right ear. She reported he wasn't wearing his hearing aides and his "good" ear is the one he was laying on. She reported that Resident #3 told her he gets a pain pill but it doesn't help as it wears off. She said he told her again today that he had a lot of pain. Surveyor used the small whiteboard in Resident #3's room to ask him about his pain. Resident #3 verbalized that his left knee hurts all the time. Surveyor tried to ask him to rate his pain using the 0-10 pain scale and Resident #3 raised his voice and said "IT HURTS BAD." On 10/12/11 at 3:12 p.m., Surveyor interviewed CNA S who reported she was assigned to Resident #3. CNA S reported that Resident #3 refuses cares twice a week and that he doesn't like the E-Z stand lift and he has never said he has pain. On 10/14/11 at 7:45 a.m., Surveyor interviewed the DON regarding the facility pain policy and facility pain management practices. Surveyor informed the DON of observations of staff not asking residents