Every finding on record at Medical Suites at Oak Creek (The)

Based on observation, interview and record review, the facility did not ensure 1 (R1) of 3 residents received the necessary services for acceptable nutrition.*R1 did not have a comprehensive nutritional assessment on admission that included how R1 chews food. Facility staff did not identify that R1 is missing all R1's upper teeth and multiple lower teeth. R1's nutrition care plan did not document interventions related to R1's difficulty in chewing certain foods. R1 had an MD order for weekly weights. Facility staff did not weigh R1 weekly as ordered.Findings include: The facility policy, with a last reviewed date of 4/8/26, and titled, Nutritional Management, documents, in part: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status. Identifying and assessing each resident's nutritional status and risk factors. Evaluating/analyzing the assessment information. Developing and consistently implementing pertinent approaches. Monitoring the effectiveness of interventions and revising them as necessary. Interventions will be individualized to address the specific needs of the resident. Examples include but are not limited to: . Altered-consistency food/liquids after underlying causes of symptoms are addressed (i.e. new dentures, dental consult, dysphagia therapy). Weight-related interventions. Informed consent: the resident/representative has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status. The facility shall discuss the risks and benefits associated with the resident/representative decision and offer alternatives, as appropriate. The comprehensive care plan should describe any interventions offered, but declined by the resident or resident's representative.The facility policy, with a last reviewed date of 12/2/25, and titled, Weight Monitoring, documents, in part: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. A weight monitoring schedule will be developed upon admission for all residents: Weights should be recorded at the time obtained. Newly admitted residents- monitor weight weekly for 4 weeks.R1 was admitted to the facility on [DATE] with diagnosis that include heart failure (a chronic condition where the heart muscle cannot pump blood efficiently to meet the body's need), Local infection of the skin (invasion of the skin and underlying soft tissue by bacteria), Chronic respiratory failure (a long-term condition where the respiratory system cannot properly oxygenate the blood or remove carbon dioxide), abnormalities of gait and mobility (any irregular walking patter, such as limping, shuffling or feeling unsteady), and need for assistance with personal care(a diagnosis used when a patient requires help with daily living activities). R1's admission MDS assessment dated [DATE] documents R1 is cognitively intact. R1 requires staff assist with set up and cleaning for eating. R1 has no complaints of difficulty or pain when swallowing. R1 does not have broken or loosely fitting full or partial denture. On 5/18/26 at 1:15 PM, Surveyor observed R1 trying to eat the facility provided fruit. R1 informed Surveyor that R1 does not typically eat the facility food. R1 prefers food that family brings in or R1 will order food. R1 stated that R1 thought the hot apples would be good to eat but stated that R1 is unable to chew them and they are too hard. R1 stated that R1 had lost R1's dentures a while ago before being admitted to the facility. R1 stated that chewing with no teeth can be difficult. Surveyor asked if facility staff had addressed the fact that R1 does not have R1's dentures. R1 stated no. R1's MD order with a start date of 4/20/26 documents: Regular diet, regular texture, thin consistency.R1's potential for nutritional risk care plan, dated 4/23/26, [related to] obesity, [heart failure], [history left lower extremity] cellulitis and edema. Pertinent interventions include: Administer medications as ordered. Monitor intake of outside food. Monitor/document/report [as needed] any [signs or symptoms] of dysphagia. Provide and serve diet as ordered. Encourage intake of facility meals. [Registered dietician] to evaluate and make diet change recommendations [as needed].Surveyor noted that R1's nutritional care plan does not address R1's dentation and does not address if any other diet texture was offered.R1's admission Head-to-toe evaluation dated 4/17/26 documents, in part: Does the resident wear dentures? No.Surveyor noted facility staff documented that R1 does not wear dentures but does not address the fact that R1 used to have dentures that R1 no longer has. R1's Nutritional note dated 4/22/26 documents, in part: [R1] admits for rehab post hospitalization for [left lower extremity] cellulitis [with] sepsis. Receives regular diet which is appropriate. Reports appetite is good. Eats [independently without] vision concerns interfering [with] meals. No [chewing/swallowing] concerns reported. Surveyor noted that the admission nutritional note documents that R1 did not report any chewing or swallowing concerns, but Surveyor noted facility staff had no other documentation of R1's dentation which has the potential to affect R1's nutritional intake. Surveyor noted that facility staff did not offer a soft texture diet or discuss the risk and benefits of R1's diet related to R1's dentation.R1's Admit Visit Note dated 5/4/26 at 4:03 PM, documents, in part: . Patient unable to chew pills due to lack of teeth.Surveyor noted that R1's provider noted that R1 is unable to chew pills because of R1's dentation. Surveyor noted that this is the only documentation found about R1's dentation.On 5/19/26 at 8:16 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I. Surveyor asked if R1 had ever informed CNA-I of chewing difficulty. CNA-I stated that R1 has stated that it is hard to chew because R1 doesn't have many teeth. Surveyor asked what is done for R1's chewing problems. CNA-I stated that the facility has dentist come occasionally but CNA-I was not sure if R1 has had anything done about R1's teeth.On 5/19/26 at 8:28 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L. Surveyor asked who assesses the resident's dentation status on admission. LPN-L stated the nurse will do the admission assessment and will document things like if the resident has a full or partial dentures. Surveyor asked what is done if a resident does not have their dentures. LPN-L stated that LPN-L would tell the unit manager. LPN-L would also talk to the resident's MD and talk about getting a pureed/soft diet temporary order.On 5/19/26 at 10:02 AM, Surveyor interviewed Unit Manager (UM)-J and Director of Nursing (DON)-B. Surveyor asked who assess residents' dental status related to nutrition. UM-J indicated that CNAs would do oral cares of residents and document if dentures are used. CNAs will also document the consumption of meals. The dietician will do the full assessment and follow up on everything else. Surveyor asked what is done if a resident does not have their dentures. UM-J indicated that the CNA would tell the nurse, the nurse can assess the resident then nurse would tell UM-J. From there, the dietician and therapy could get involved. Facility staff can downgrade their diet but not upgrade. So, the nurse can down grade to a soft diet for safety concerns. Surveyor informed UM-J and DON-B of the concern that R1 has been without R1's dentures since admission. This was not included in R1's nutritional assessment or care plan. In addition, Surveyor observed R1 unable to eat R1's fruit during lunch yesterday. DON-B stated that they would review this.WeightsR1's potential for nutritional risk care plan, dated 4/23/26, documents the following pertinent intervention: Weigh as ordered or per facility protocol.R1's MD order with a start date of 4/18/26 documents: Obtain weight upon admission, then weekly for four weeks, then monthly. Every day shift for baseline weight for 1 Day AND every day shift every [Wednesday] for weight for 4 Weeks .Surveyor reviewed R1's weights: 4/18/26 386 [pounds].5/13/26 388 [pounds].Surveyor noted that facility staff did not weigh R1 weekly as ordered.On 5/19/26 at 8:16 AM, Surveyor interviewed CNA-I. Surveyor asked how weights are completed and documented. CNA-I stated that they are done on admission and then monthly. CNA-I stated that the nurse will let CNAs know if they need to be done more than that. CNA-I stated that weights are documented in the vitals section of the Electronic Health Record.On 5/19/26 at 8:28 AM, Surveyor interviewed LPN-L. Surveyor asked what the facility policy is for residents' weights. LPN-L stated that the resident will have an MD order, and the nurse will have to let the CNA know that a weight is needed. LPN-L stated that it is a cumbersome process and will sometimes take nagging the CNA or asking multiple times to get a weight completed. LPN-L indicated that in the past LPN-L had to get another CNA to get a weight completed because not all CNAs will do them as asked.On 5/19/26 at 10:02 AM, Surveyor interviewed Unit Manager (UM)-J and Director of Nursing (DON)-B. Surveyor asked what the facility weight policy is. UM-J stated that weights are completed on admission, weekly for 4 weeks and then monthly. Surveyor informed UM-J that R1's weight was documented on admission but was not completed weekly as ordered. DON-B indicated that they would review R1's weights. On 5/19/26 at 11:39 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the above concerns related to R1's nutrition assessment and weights. No further information was provided.

Based on interview and record review, the facility did not develop an Activities of Daily Living (ADL) comprehensive plan of care for 1 (R1) of 3 residents reviewed for plans of care. Findings include:The facility policy with a last reviewed date of 5/1/25 and titled, Comprehensive Care Plans, documents, in part: It is the guideline of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive [Minimum Data Set (MDS)] assessment. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.R1 was admitted to the facility on [DATE] with diagnosis that include heart failure (a chronic condition where the heart muscle cannot pump blood efficiently to meet the body's need), Local infection of the skin (invasion of the skin and underlying soft tissue by bacteria), Chronic respiratory failure (a long-term condition where the respiratory system cannot properly oxygenate the blood or remove carbon dioxide), abnormalities of gait and mobility (any irregular walking patter, such as limping, shuffling or feeling unsteady), and need for assistance with personal care(a diagnosis used when a patient requires help with daily living activities). R1's admission MDS assessment dated [DATE] documents R1 is cognitively intact. R1 requires staff assist with set up and cleaning for eating and hygiene. R1 is dependent on staff for dressing. R1 requires substantial/maximal assistance for shower/bathing. R1 is dependent on staff for toileting and transfers. Surveyor reviewed R1's Comprehensive care plan and Certified Nursing Assistant (CNA) Kardex for information on R1's Activity of Daily Living (ADL)'s. Surveyor noted the facility did not have an ADL care plan or information on the CNA Kardex that would inform staff on what assistance R1 would need with: bathing/showering, bed mobility, dressing, eating, toileting, hygiene and transfer. On 5/19/26 at 8:16 AM, Surveyor interviewed CNA-I. Surveyor asked how CNA-I would know what assistance a resident would need with bathing, dressing, eating, toileting and transfers. CNA-I stated that information like that is in the CNA Kardex. On 5/19/26 at 10:02 AM, Surveyor interviewed Unit Manager (UM)-J and Director of Nursing (DON)-B. Surveyor asked how staff would know what assistance a resident would need with bathing, eating, toileting and transfers. UM-J stated that the CNA Kardex and the Care Plan has that information on it. Surveyor informed UM-J and DON-B of the concern that R1 does not have an ADL care plan or any information on the CNA Kardex about R1's ADLs. DON-B stated that they will look at that immediately.On 5/19/26 at 11:39 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the above concerns. No further information was provided.

Based on interview and record review the facility did not provide the necessary Activities of Daily Living (ADL) services for 1 (R1) of 2 residents who were dependent on staff to provide ADL care.R1 is dependent on staff for showering and was admitted to the facility on [DATE]. On 5/18/26, R1 informed Surveyor that R1 has not received a shower since admission. Facility staff have not documented that R1 has received a shower since admission. R1 has not been bathed weekly according to the facility policy. Findings include:The facility policy with a last reviewed date of 6/11/25 and titled, Resident Showers, documents, in part: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided with showers as per request and within reasonable accommodation, or as per facility schedule protocols (at least offered weekly) and based upon resident safety. Partial baths may be given between regular shower schedules as per facility policy.R1 was admitted to the facility on [DATE] with diagnosis that include heart failure (a chronic condition where the heart muscle cannot pump blood efficiently to meet the body's need), Local infection of the skin (invasion of the skin and underlying soft tissue by bacteria), Chronic respiratory failure (a long-term condition where the respiratory system cannot properly oxygenate the blood or remove carbon dioxide), abnormalities of gait and mobility (any irregular walking patter, such as limping, shuffling or feeling unsteady), and need for assistance with personal care(a diagnosis used when a patient requires help with daily living activities). R1's admission MDS assessment dated [DATE] documents R1 is cognitively intact. R1 requires staff assist with set up and cleaning for eating and hygiene. R1 is dependent on staff for dressing. R1 requires substantial/maximal assistance for shower/bathing. R1 is dependent on staff for toileting and transfers. When asked how important is it to you to choose between a tub bath, shower, bed bath or sponge bath, R1 answered Very Important.On 5/18/26 at 8:45 AM, Surveyor interviewed R1. R1 informed Surveyor that R1 has not had a shower since being at the facility. R1 stated R1 had been at the facility for about a month. Surveyor asked why R1 did not receive a shower. R1 stated R1 did not know why. R1 stated that R1 has been asking for a shower but still has not had one. R1 stated that R1 has only been cleaned with wipes. R1 stated that showers relax R1 and R1 sleeps better after showers. Surveyor asked when R1's shower day is. R1 asked Surveyor, how would I know if they didn't tell me. Surveyor asked if R1 refused a shower. R1 stated No.Surveyor reviewed R1's Comprehensive care plan and Certified Nursing Assistant (CNA) Kardex and noted the facility did not have an intervention listed related to R1's shower day or preference.R1's MD order with a start date of 4/22/26 documents: Check vital signs and edema weekly with shower day. Every day shift every Wednesday for monitoring.Surveyor noted Wednesday is listed as R1's shower day.On 5/18/26 at 11:15 AM, Surveyor interviewed CNA-K. Surveyor asked how CNA-K would know when a resident's shower is supposed to take place. CNA-K stated that the information is kept in the binder at the nurse's station. CNA-K showed Surveyor the binder and flipped to the page that has the shower schedule. CNA-K stated that each resident room is listed and has a weekday, and shift associated with them to indicate what day and what shift the resident shower would take place. CNA-K pointed to R1's room number and indicated that R1's shower day is Wednesday on the overnight (noc) shift. Surveyor asked where showers are documented. CNA-K stated that there are shower sheets that are filled out and given to the nurse. The CNA and the nurse sign the sheet after the shower and skin check is completed. The sheets are placed in the file or the binder at the nurse's station.Surveyor reviewed the binder and file at the nurse's station. Surveyor noted multiple shower sheets in the file. The shower sheets go back as far as 4/2/26. Surveyor went through the pile and noted R1 did not have a completed shower sheet in the file. Surveyor reviewed the binder and did not observe a completed shower sheet for R1.On 5/19/26 at 8:16 AM, Surveyor interviewed CNA-I. Surveyor asked how staff know when a resident needs a shower. CNA-I stated they have a schedule that is listed at the nurse's station. CNA-I stated that showers are done once or twice a week and residents are split up between day, evening and night shift. Surveyor asked where showers are documented. CNA-I stated that showers are documented in the electronic health record (EHR) in the CNA task section. CNA-I stated that they document whether the resident gets a shower or bed bath. Surveyor reviewed R1's CNA task section in R1's EHR from the start of R1's admission to the facility. R1's Bathing task documented the following:4/28/26- Bed Bath.5/4/26- Bed Bath.5/6/26-Bed Bath.5/7/26-Bed Bath.Surveyor noted R1 went from 4/17/26 until 4/28/26 (10 days) without documented bathing. Surveyor noted R1 went from 5/7/26 until present time, 5/19/26 (11 days) without documented bathing. Surveyor noted that according to the facility documentation, R1 only received bed baths and did not receive a shower, which is R1's preference, since admission.Surveyor reviewed R1's progress notes and noted facility staff did not document a refusal of shower or bathing since R1's admission to the facility.On 5/19/26 at 8:28 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L. Surveyor asked if nurses have a role in completing resident showers. LPN-L stated that nurses do not give showers but will complete skin checks at the time of shower. LPN-L stated that each resident has a designated shower time and day. Surveyor asked if residents complained about not getting showers. LPN-L stated that some residents will ask for a shower or tell LPN-L that they have not had a shower in a while. LPN-L will inform the CNA but if it is not the residents shower day, it is hard to get the shower completed. LPN-L stated that LPN-L will tell residents that they need to be firm and tell the CNA on their shower day that they want a shower so that is not missed. On 5/19/26 at 10:02 AM, Surveyor interviewed Unit Manager (UM)-J and Director of Nursing (DON)-B. Surveyor asked about the facility shower policy. UM-J stated that showers are given once a week and as needed. Staff can accommodate residents if they ask for a shower. UM-J stated that the CNA will fill out a shower sheet and the nurse will complete the skin check and sign the shower sheet. The shower sheets are kept. Surveyor asked if showers are documented in the EHR. UM-J indicated that CNAs should document that a shower was given in the task section of the EHR. Surveyor informed UM-J and DON-B of the concern that R1 informed Surveyor that R1 had not received a shower, which is R1's preference, since admission. R1 was unaware of R1's shower day, Wednesday night shift. In addition, Surveyor reviewed the task section of R1's EHR and the pile of completed shower sheets. Surveyor found R1 has not had a documented shower since admission and has not been bathed weekly per facility policy. DON-B stated that they will figure out what happened, talk to R1 and offer a shower. DON-B indicated they will also speak with R1 to make sure the time and day of R1's shower schedule will work for R1.On 5/19/26 at 11:39 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the above concerns. No further information was provided.

Based on interview and record review, the facility failed to ensure 5 (R14, R5, R31, R12, and R8) of 5 sampled residents received care and treatment in accordance with assessments and professional standards of practice (including N6, Nurse Practice Act) to ensure their highest practicable physical, mental, and psychosocial well-being. Facility staff did not assess changes in condition, did not ensure orders for labs and treatments were promptly implemented, and did not communicate condition changes to appropriate personnel as necessary to ensure consistency and continuity of care across all disciplines. * R14's Annual Minimum Data Set, dated [DATE] assessed R14 as having declines in her incontinence and mobility during the look back time frame. These declines were not further assessed or addressed in R14's plan of care. On 12/11/25 laboratory results indicated a possible change in condition regarding hydration, kidney function and changing protein levels for R14. The recommendation from Nurse Practitioner (NP)-I was to repeat in 1 week. On 12/22/25 repeat labs were completed on R14. The results of the labs were not reviewed by NP-I until 12/26/25. The results of the labs on 12/22/25 indicated elevated glucose, which was not present on R14's 12/11/25 labs. The labs values noted on 12/11/25 progressively changed. The diagnosis identified on the lab results indicated altered mental status. NP-I did not place any new orders to address R14's progressive change in condition or to monitor R14 for signs and symptoms of dehydration or other possible changes in condition. On 12/23/25 Licensed Practical Nurse (LPN)-EE documented R14 was pocketing food. A diet downgrade slip was submitted to the kitchen changing R14's diet from mechanical soft with regular liquids to pureed with nectar thick liquids. R14 was not assessed for this change in status and an order was not received for this downgrade in consistency for R14. Dietitian-G was not notified that R14 had an infected wound and was having possible diet and nutritional changes to assess. R14's care plan was not revised to ensure R14 received added assistance to ensure safety and adequate intake. On 12/15/25 R15 was noted to have 2 facility acquired pressure injuries (coccyx and right coccyx). R14's pressure injuries were not comprehensively assessed nor were interventions implemented for R14 to prevent further decline in R14's pressure injuries. X-rays on 12/22/25, due to R14's increased expression of pain in her coccyx, indicated R14 could not be ruled out as having osteomyelitis. R14 did not have additional assessments of the possible osteomyelitis and no treatment plan was implemented by NP-I. (Cross-reference F686). On 12/24/26 NP-I documented in her progress notes: She (R14) has a coccyx wound with concerns for osteomyelitis, confirmed on x-ray. Over time, her overall condition has declined further, and she now displays significant difficulty swallowing, as evidenced by her pocketing food . The patient's (POAHC-CCC), who serves as her activated power of attorney, is in agreement with transitioning (R14) to hospice care services to prioritize her comfort moving forward. On 12/25/25 NP-I ordered R14 to receive morphine as needed (PRN) for end of life care. Interview with POAHC-CCC on 4/17/26 at 3:44 PM indicated POAHC-CCC was not made aware of the full extent of R14's changes in condition during the month of December 2025. POAHC-CCC stated at no time did POAHC-CCC agree to or sign documents placing R14 on hospice or agree to end of life care. POAHC-CCC stated the topic was raised by NP-I and a person from a hospice agency but POAHC-CCC had questions whether R14 would even qualify. POAHC-CCC shared she repeatedly asked if R14 had an infection and was told no. On 12/28/25 R14 experienced a change in condition and was sent to the emergency department (ED) where R14 was diagnosed with severe sepsis, acute renal failure and hypovolemic shock; along with notation of having a pressure injury the size of a fist. R14 passed away on 12/29/25. *On 4/5/26, Certified Nursing Assistant (CNA)-X was performing cares alone with R5 in bed, resulting in R5 rolling out of bed. (Cross-reference F689). On 4/6/26 staff indicated awareness of R5 having Bilateral Lower Extremity (BLE) crackling during movement of R5's legs during cares and transfers. This change was not further assessed or communicated with R5's physician. On 4/7/26 R5 was noted to have a left ankle deformity. This was not further assessed, and a consultation was not completed with R5's physician. On 4/9/26, R5 was sent to the Emergency Department (ED) where R5 was diagnosed with bilateral tibia and fibula fractures (bone fractures in the lower legs typically caused by high-energy twisting injuries). R5 was noted to have significant bruises to their body that had not been documented or assessed by facility staff. A forensic assessment was ordered for R5 in the ED due to increased concerns by the hospital R5 had been abused. The facility failed to promptly identify and intervene with acute changes noted on 4/6/26 and 4/7/26. The facility continued to transfer R5 via Hoyer lift and manipulate R5's bilateral lower extremities (BLE) without assessing R5 when it was previously described as staff having to manipulate R5's BLE's due to R5's contractures. The facility failed to perform a Registered Nurse (RN) assessment on 4/6/26, when R5 was noted to have a significant change with staff noting crackling when manipulating R5's BLEs and BLE deformity and increased bruising. * R31 was admitted to the facility on [DATE] for rehabilitation following hospitalization. R31 was receiving diuretics as part of their medication regime. On 4/1/26 the facility received an order from the cardiac clinic to draw labs on R31 on 4/6/26, in preparation for a follow up appointment. On 4/6/26 the cardiac clinic also ordered daily weights to be obtained and recorded for R31 and the implementation of a fluid restriction of 64 fluid ounces. There is no indication the R31 had the lab completed on 4/6/26 as ordered by the cardiac clinic. On 3/30/26 R31 had labs drawn with no corresponding order or detail of who requested the lab draw. There is no indication the facility followed up on any results of the 3/30/26 lab draw that was completed. On 4/8/26 the cardiac clinic contacted the facility asking about the lab results that were to be drawn on 4/6/26. The cardiac clinic was faxed a copy of the 3/30/26 lab results from the facility. The lab results from 3/30/26 indicated R31's potassium level was 2.9 which is an indicator of moderate hypokalemia and requires immediate medical attention. Upon receipt of this lab result, the cardiac clinic contacted the facility and ordered R31 to be emergently transferred to the emergency department (ED). R31 required admission to the hospital for monitoring and stabilization. R31's potassium level was 2.5 upon arrival at the ED. The facility also failed to ensure orders to monitor R31's weight daily and to modify the diuretic R31 was to receive based upon weight was administered as ordered. The facility failed to have a system to ensure labs are ordered, completed, and results of the lab are conveyed and addressed by a physician or practitioner based upon a standard of practice. The facility's failure to provide care to R14, R5, and R31 based upon assessment and professional standards of practices created a finding of immediate jeopardy in the facility starting 12/22/25 based upon example regarding R14. On 4/20/26 at 3:54 PM Surveyors notified Nursing Home Administrator (NHA)-A, Clinical Nurse Specialist (CNS)-B and Director of Operations (DOO)-O of the immediate jeopardy regarding care concerns for R14 and R5. On 5/7/26 at 1:30 PM, Surveyors informed Current NHA-AAA, Former NHA/Director of Nursing (DON)-A, DOO-O and Chief Nursing Officer (CNO)-DDD of the additional immediate jeopardy example regarding R31. The Immediate Jeopardy was not removed at F684 upon exit from the facility on 5/7/26. The facility was also cited for concerns regarding R12 and R8. * R12 had a Foley catheter, and a Urology Consult was ordered on 12/8/25 for continued use. There is no documentation this was implemented. * R8 admitted to the facility with a documented right upper extremity skin alteration that was not treated or assessed by the facility. Findings include: The facility's policy and procedure Notification of Changes revised 3/10/2025 documents The Guidelines: The purpose of this guideline is to ensure the facility promptly informs the resident, consults the resident's physician; And notifies, consistent with his or her authority, the resident representative when there is a change requiring notification. Changes of condition require an evaluation by using the e-interact change in condition evaluation ensures proper documentation and notification has been made. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances Requiring Notification Include: 1. Accidents a. resulting in injury b. potential to require physician intervention 2. Significant change in the resonance physical, mental or psychosocial condition such as deterioration and health, mental or psychosocial status. a. Life threatening conditions, or b. Clinical complications c. Critical lab values 3. Circumstances that require a need to alter treatment. This may include; a. New treatment b. Discontinuation of current treatment due to; i. Adverse consequences ii. Acute condition iii. Exacerbation of a chronic condition. The facility's policy and procedure Providing End of Life Care revised 12/1/2024 indicates: Policy: The facility is committed to providing the needed care and services to those residents at or approaching end of life care in accordance with the resident's preferences, goals, and professional standards of practice in order to promote their highest practicable physical, mental, and psychosocial well-being. Policy Explanation and Compliance Guidelines: 1. The facility utilizes a systematic approach for recognition, assessment, treatment, and monitoring of end-of-life care. 2. Recognition: a. Residents will be evaluated for end-of-life care concerns upon admission, during scheduled assessments, and upon change of condition status. b. The physician will document the residents' prognosis of a life expectancy of less than 6 months, or a terminal illness. c. The facility, in collaboration with the resident's attending physician/practitioner, will inform and educate the resident and/or the resident's family about decisions for end-of-life care. d. Preferences for palliative care, hospice care, and advanced directives will be identified and documented in the medical record. This includes preferences regarding treatment of acute illness, and choices regarding hospitalization. The facility's policy and procedure Consulting Physician/Practitioner Orders revised 10/4/2024indicates: The Policy: The attending physician shall authenticate orders for the care and treatment of assigned residents. Policy Explanation and Compliance Guidelines: Consulting physician practitioner orders are those orders provided to the facility by a physician/ practitioner other than the residents attending physician/ practitioner who is acting on behalf of the attending physician. A consulting physician/ practitioner may include, but is not limited to, the residents: d. Specialist such as Urologist. According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (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 (Licensed Practical Nurse) 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. 1.) R14 was readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, seizures (on anticonvulsants), senile dementia, COPD (chronic obstructive pulmonary disease), asthma, AKI (acute kidney disease), anemia, hypothyroidism, hypertension, hyperlipidemia, hypotension, Type II diabetes mellites, chronic pain, smoker, bipolar type 2, paranoid schizophrenia, anxiety, depression, dehydration and Bacteriuria. R14's Annual Minimum Data Set (MDS) assessment with an assessment reference date of 12/3/25 assessed R14 as understanding others and being able to be understood. Staff completed the cognitive assessment interview for R14 with a summary score of 03 indicating severe cognitive impairment. Staff also competed the summary score for mood and behavior for R14 indicating a severity score of 04 indicating R14 had trouble concentrating on things and moving slowly or being fidgety (not specified). No hallucinations or delusions were noted during the assessment or altered mental status. R14 did not demonstrate behaviors to include rejected of care. R14 was assessed as having no functional limitations in range or motion to upper or lower extremities and R14 utilized a wheelchair. R14 is assessed to need set-up assistance for eating and was dependent upon staff for all other activities of daily living now including oral hygiene. R14 was assessed as now needing substantial/maximal assistance for rolling in bed and was assessed as now being dependent upon staff for all other mobility with the exceptions of transferring to tub/shower and walking 10 feet which were assessed as not attempted due to medical condition or safety concerns. R14 was assessed as having a decline in bladder incontinence with a decline from occasionally incontinent to always incontinent. No toileting program is indicated for R14. R14 was assessed as having occasional pain that rarely interferes with day to day activities with a pain intensity rating of 04. R14 is assessed as having no swallowing disorder and no further weight loss. R14 is assessed as being at risk for pressure injuries and had 1 unhealed, stage 2 pressure injury R14 is assessed as having 3 venous or arterial wounds. R14's assessed treatments included nutrition or hydration program to manage skin problems, pressure injury care, application of nonsurgical dressings other than to feet, and application of ointments/medications other than to feet. R14 is not assessed as needing pressure reducing device for chair or bed and for needing a turning and repositioning program. Section J regarding R14's prognosis documents no – indicating R14 does not have a condition or chronic disease that may result in a life expectancy of less than 6 months. R14's Care Area Assessment (CAA) triggered for nutrition dated 12/4/25. Triggering conditions were R14's BMI (body mass index), R14 receiving a mechanically altered diet and the diet is therapeutic as a nutritional approach and R14 has 1 stage 2 pressure injury or higher that is not healed. The analysis of findings indicates this is an actual problem for R14. Nature of problem/condition is documented as triggered r/t (related to) obesity, hx (history of) weight loss but weight stabilizing over the past couple of months, triggers r/t mech soft (mechanical soft consistency)- ground meats due to dysphagia. Triggers r/t Boost supplement use for nutrition support and weight maintenance. No current eating patterns are identified. Functional problems that affect ability to eat is identified as need for special diet or altered consistency which might not appeal to resident. Cognitive, mental status and behavior problems that can interfere with eating indicated other dementia, disruptive behaviors, throwing food, poor memory, and anxiety problems. No communication problems are identified. Dental/oral problems indicated include broken or fractured teeth. Other diseases and conditions that can affect appetite or nutritional needed indicated anemia, cardiovascular disease, depression, pain, thyroid problem, diabetes, and respiratory disease. The CAA does not indicate any abnormal lab values. Medications identified included antipsychotics and diuretics. No environmental factors are documented. The is no input documented from R14 or POAHC-CCC. Care plan considerations documented maintain current level of functioning. Dietitian-FFF did not document a summary or rationale for care plan for R14. (Cross-reference F636). R14's CAA for pressure injury and ADLs were also triggered. LABORATORY CHANGES/MONITORING: On 12/11/25 laboratory results were obtained indicating R14 had low sodium, elevated blood urea nitrogen (BUN), elevated creatinine, elevated GOT/AST (asparate minotransferase), low albumin, low total protein level, elevated globulin levels, and low albumin to globulin (A/G) ratio. The lab results indicated a possible change in condition regarding hydration, kidney function and changing protein levels for R14. The listed diagnosis on the lab report was hyperprolactinemia (CMD – abnormally high levels of prolactin in the blood). The recommendation and documented note from Nurse Practitioner (NP)-I on 12/12/25 was to repeat in 1 week. This was not completed until 10 days later. On 12/22/25 repeat labs were completed on R14. The results of the labs were not reviewed by NP-I until 12/26/25 with NP-I giving no new orders as a result of the labs. The results of the labs on 12/22/25 indicated elevated glucose, which was not present on R14's 12/11/25 labs. The labs values flagged as high or low on 12/11/25 progressively changed. The diagnosis identified on the lab results indicated altered mental status. NP-I did not place any new orders to address R14's progressive change in condition or to monitor R14 for signs and symptoms of dehydration or other possible changes in R14's status. NP-I did not review R14's use of diuretics at this time despite indicators R14 was dehydrated. On 4/16/26, at 12:06 PM, Surveyor interviewed NP-I regarding R14's lab results from 12/11/25 and 12/22/25. Surveyor asked NP-I about the results from the 12/11/25 lab draw and if the results were concerning or indicators of any changes occurring with R14. NP-I indicated she requested repeat labs in a week. Surveyor asked NP-I about the process to obtain and review lab results, noting the lab results were available on 12/22/25 but were not noted and reviewed by NP-I until 12/26/25. NP-I shared the labs are usually pulled and provided to her when she comes into the facility. Surveyor asked NP-I if NP-I had been in the facility between 12/22/25 and 12/26/25 where NP-I could have reviewed the lab results sooner. NP-I shared she was in the facility on 12/23 and 12/24/25. When asked about the delay in reviewing R14's 12/22/25 labs NP-I did not know why they were not provided to her until 12/26/25. Surveyor asked NP-I about any orders or monitoring recommendations given the lab values on 12/22/25. NP-I stated no, she did not order any treatments or recommendations due to R14 receiving hospice and end of life care. PRESSURE INURY DECLINE/CHANGE IN CONDITION: (Cross-reference F686). R14's Nursing Progress Notes dated 12/15/25, written by RN-H, documented: Notified the POAHC (CCC) regarding new order for wounds. Review of R14's medical record indicated a comprehensive assessment was not completed on 12/15/25 of the (potentially) 2 new, facility acquired unstageable wounds R14 developed. Review of R14's facility wound assessment forms indicated R14 developed two, unstageable, facility acquired pressure injuries; one on the coccyx and a second on the right coccyx. These were not comprehensively assessed until 12/18/25. Review of R14's treatment administration record (TARs) indicated the treatment was not documented as being completed per the physician order. R14's care plan for at risk for further impaired skin integrity related to: age, DM11 (diabetes mellitus), sepsis.This care plan identifies historical wound areas for R14. The goal was to not develop further skin impairments initiated 5/2/25 revised 12/18/25 with a target date of 2/28/26. Interventions updated 12/18/25 included: - 11/27/24 Pressure reduction mattress. Alternating pressure air mattress. Revised 12/18/25. - 11/27/24 The resident needs pressure reducing cushion to protect the skin while up in wheelchair. Specialty cushion – Vicair. Revised 12/18/25. Surveyor noted these intervention were after R14 developed the two facility acquired coccyx pressure injuries on 12/15/25 and despite R14 being at risk for pressure injuries prior to the development of these areas. A nursing progress note dated 12/21/25 at 18:02 (6:02 PM) documented: (R14) stayed in bed throughout the weekend due to increased pain from coccyx wound. She was repositioned from side to side q (every) 2 hours. Resident was given assistance in eating to encourage adequate intake. Surveyor noted that despite documentation of pain and changes in R14's activity and eating there was no assessment of R14's wounds. The weekend included 12/19, 12/20, and 12/21/25. R14's coccyx Wound assessment dated [DATE] at 10:49 AM by Wound Registered Nurse (WRN)-L documented: measurements of 2.80 cm x 2.30 cm x 2.8 cm with the wound bed having 90% loosely adherent slough and 10% bright pink or red (not specified or further detailed) with moderate serous drainage. The peri-wound was documented as having erythema. There is undermining present between 12 o'clock and 1 o' clock 2 cm and between 5 o'clock and 6 o'clock 2 cm. The picture of the coccyx wound has a date and time stamp of 12/22/25 at 10:46 AM. Pain is documented as 3 on the pain scale. The assessment included documentation of probable improvement despite the increased size of the wound and undermining. Surveyor noted there is no assessment of the right coccyx wound dated 12/22/26. On 12/22/25 at 14:41 (2:41 PM), imagining was performed on R14's coccyx due to pain and wound decline. Reason for the study is documented as osteomyelitis, unspecified. Findings: Question subtle bone loss of the dorsal aspect of the sacrum/coccyx. Soft tissues appear swollen with ulceration dorsally. Conclusion: Cannot exclude osteomyelitis, recommend MRI work up. The radiology report included a handwritten note that documented MRI of sacrum coccyx for Dx (diagnosis) osteomyelitis signed as reviewed by NP-I on 12/23/25. Surveyor noted there are no additional orders documented to order and schedule an MRI, potentially obtain a culture and sensitivity of R14's wound, or treatment despite indications R14 had osteomyelitis. Nursing progress notes dated 12/23/25 at 16:32 (4:32 PM) documented: Resident continues to show s/sx (signs/symptoms) of pain r/t coccyx wound, dressing changed d/t soiled with drainage from wound. Surveyor noted that despite documented drainage from R14's pressure injury soiling the dressings R14's pressure is not reassessed and there is no consultation with R14's physician or nurse practitioner despite knowledge R14 has osteomyelitis in their coccyx pressure injury. NP-I's progress note dated 12/23/25 documented: (R14) is seen today due to concerns about the worsening of her wound. An x-ray of her sacral coaxal area was performed, which could not rule out osteomyelitis. (R14) has experienced further decline. She has complex medical history that includes metabolic encephalopathy, COPD, type 2 diabetes, immunodeficiency, peripheral vascular disease, bipolar disorder, dementia and schizophrenia . Assessment: 1. Worsening wound condition: unable to rule out osteomyelitis based on the x-ray, patient experiencing a decline. complex medical history complicates the medical picture. 2. Comprehensive Medical Background: metabolic encephalopathy, COPD, type 2 diabetes; immunodeficiency and peripheral vascular disease, bipolar disorder, dementia, and schizophrenia. Plan: . continue in-house wound care with nursing staff support to monitor (R14's) comfort. NP-I's progress note dated 12/24/25 documented: (R14) was seen today for a follow up regarding her long-term care goals. She has a coccyx wound with concerns for osteomyelitis, confirmed on x-ray. Over time, her overall condition has declined further. Physical exam: Patient is stable and in no acute distress. Diagnostic test results: X-ray findings support concerns for osteomyelitis in the coccyx. Assessment: 1. Coccyx wound with concerns for osteomyelitis, contributing to ongoing wound management challenges. 3. Declining overall condition: The patient continues to experience progressive clinical decline, necessitating a shift in care goals towards comfort and end-of-life services. Plan: 1. Coccyx wound with concerns for osteomyelitis: maintain in-house wound care management, ensure continued attention to wound healing and prevention of further complications. Surveyor noted R14's pressure injury(ies) were avoidable, facility acquired pressure injury (ies) that were not appropriately prevented, assessed, and treated based on standards of practice to prevent further decline and complications. Cross reference F686, Nursing notes dated 12/25/25 at 06:46 AM documented Resident turned q2 hours per protocol in place. Tx to coccyx wound C/D/I (clean/dry/intact). No c/o (complaints of) pain or discomfort noted this shift. All medications taken (sic) and tolerated well. Continue current POC. No revisions were documented on R14's POC to ensure staff consistently followed a repositioning schedule for R14. On 12/26/25 a nurse's progress note documented by NP-I documented lab results reviewed with no new orders. (Reference above section). On 12/26/25 at 10:43 AM NP-I ordered Morphine Sulfate 0.5 ml (milliliter) by mouth every 2 hours as needed for pain, SOB (shortness of breath), elevated heart rate, end of life care. This order triggered drug to drug interaction warnings for R14. A nurse's note dated 12/26/25 at 11:26 AM noted the new order for morphine PRN q 2 hours. R14's Medication Administration Record (MAR) December 2025 documents that R14 received morphine sulfate on12/26/25 due to R14 having pain in their coccyx. On 4/16/26, at 12:06 PM, Surveyor interviewed NP-I. NP-I stated they could not remember if they were notified of R14's pressure injuries on 12/15/25. NP-I shared they were made aware of R14 having increased pain in their coccyx wound and ordered imagining. The x-ray results came back on 12/22/25 showing osteomyelitis. Surveyor asked NP-I if NP-I observed or assessed R14's pressure injury(ies). NP-I stated R14's wounds were being addressed by the facility wound team. Surveyor asked NP-I if NP-I was aware of the delayed assessments of R14's pressure injury(ies) and lack of individualized interventions to prevent and help heal R14's pressure injuries. NP-I indicated she was not aware, that it was handled by the facility wound team. Surveyor asked NP-I about the x-ray results indicating R14 had possible osteomyelitis and recommendations/orders from NP-I to address and treat R14's osteomyelitis. NP-I shared they did not order any treatment for the wound infection. NUTRITION/ POTENTIAL SWALLOWING DECLINE On 12/11/25 and 12/22/25 R14 had results from a Comprehensive Metabolic Panel (CMP). The results for the 12/22/25 lab were not noted or reviewed by NP-I until 12/26/25. The 12/22/25 labs were drawn as follow up/repeat to the labs originally drawn on 12/11/25. Review of R14's medical record indicated R14 was at risk for dehydration and metabolic encephalopathy along having a history of urinary tract infections going back to September 1, 2025 when R14 was readmitted to the facility following hospitalization. Review of R14's care plans indicated: R14's Certified Nursing Assistant (CNA) Kardex (plan of care) does not document any swallowing guidelines or care plan to monitor R14's fluid intake. R14's Dehydration Care Plan documented: The resident has potential fluid deficit r/t (related to) hx (history of) dehydration AEB (as evidenced by) IVF (intravenous fluid) given in the hospital – initiated/created 12/9/24, revised 12/2/25. Goal: the resident will drink/take in a minimum of (not specified) cc's each 24-hour period – initiated/created 12/2/25, revised 12/2/25, Target date: 9/2/25 (sic). Intervention documented: - Educate the resident/family/caregivers on importance of fluid intake – initiated/created 12/9/24, revised 12/2/25 - Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes – initiated 12/9/24, revised 12/2/25 R14's Nutrition Care plan documented: The resident is at risk for nutritional imbalance r/t obesity r/t good intakes, sedentary lifestyle aeb( as evidenced by) Body Mass Index (BMI) > (greater than) 30, need for mech (mechanically) altered diet d/t dysphagia aeb mech (mechanical) soft diet, potential for wt (weight) flux due to fluid shifts, impaired skin – unst (unstageable) PI (pressure injury) – coccyx x (times) 2; vascular – L (left) 1st MTH (metatarsal head), R (right) 1st MTH(right big toe) – initiated 12/2/25, created 12/9/24, revised 12/22/25. Goal: The resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Initiated 5/2/25, created 12/9/24, revised 12/10/25, Target date: 3/10/26. Goal: The resident will maintain adequate nutritional status as evidenced by no sig wt (significant weight) changes or gradual weight loss, no s/sx (signs/symptoms) of malnutrition, and consuming >75% est (estimated) nutritional needs through review date. Initiated 5/2/25, created 12/9/24, revised 12/10/25. Target date 3/10/26. - Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated/created 3/3/25 - Monitor/document/report PRN (as needed) any s/sx of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals – initiated/created 12/9/24 - Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated – initiated/created 3/3/25 - Offer PM (nighttime) snack – yogurt – initiated/created 11/19/25 On 12/22/25 at 16:08 4:08 PM) a nutrition/dietary note was completed by Dietitian-G that documented: F/U (follow up) skin. Per wound assessment 12/22, unstageable PI – coccyx & laceration – vascular. Per wound assessment 12/18, unstageable PI-R (right) coccyx. PIs are new. Has hx (history) of PIs that had healed; however, these are new. Receives regular – mech (mechanical) soft diet which is

Based on record review, observation and interview, the facility failed to ensure 3 (R14, R15 and R32) of 3 sampled residents with pressure injuries received care and treatment based upon standards of practice to promote healing, prevent infection, and prevent new pressure injuries from developing. * R14 was assessed to be at risk for pressure injuries and was noted to have a pressure injury that was healed on 12/1/25. 12/3/25 was the assessment reference date for R14's annual minimum data set (MDS). This MDS assessed R14 as requiring greater assistance for turning and repositioning and decline in incontinence of bladder for R14. This MDS also identified R14 to be at risk for pressure injuries but did not assess additional interventions such as pressure relieving devices for R14's wheelchair and bed and a repositioning program for R14 as her mobility had declined. On 12/15/25 R14 was noted to have 2 facility acquired, avoidable unstageable pressure injuries located on R14's coccyx and buttock. These areas were not comprehensively assessed upon discovery. Revisions were not made to R14's plan of care to address R14's changes in status or to prevent further decline in the wounds. During the period of time following the discovery of the wounds to 12/22/25 R14 expressed feeling pain in her coccyx/buttock area. On 12/22/26 an x-ray result indicated the possible presence of osteomyelitis in R14's pressure injury(ies). This determination of possible osteomyelitis was not further assessed or treated by the facility; specifically, by Nurse Practitioner (NP)-I. R14's Power of Attorney for Healthcare (POAHC)-CCC was not provided with timely and accurate information regarding R14's pressure injuries to make an informed decision regarding R14's overall care. On 12/28/25 R14 was transferred to the hospital for a progressive change in condition that included infection. The Hospital Emergency Department (ED) Notes dated 12/28/25 documented a necrotic sacral ulcer the size of a fist. The facility's failure to assess and treat R14's possible osteomyelitis created a situation of immediate jeopardy that began on 12/22/25. Surveyor notified the Nursing Home Administrator (NHA)-A, Clinical Nurse Specialist (CNS)-B and Director of Operations (DOO) -O, of the immediate jeopardy on 4/20/26 at 4:30 PM. The immediate jeopardy was removed on 5/7/26, however, the deficient practice continues at a scope and severity of G (actual harm/pattern) as the facility implements its action plan and related to the following examples regarding R15 and R32: *R15 admitted to the facility at risk for pressure injuries, with no current pressure injuries. R15 was dependent on staff for cares including bed mobility and repositioning. R15 developed an avoidable, unstageable pressure injury to the left elbow on 3/10/26. The facility did have preventative measures in place prior to R15 developing the pressure injury and did not immediately put pressure relieving interventions into place after finding the pressure injury. Interventions were not added to R15's plan of care until 3/18/26. During the survey, R15 was observed to not have pressure relieving interventions in place per their plan of care. * R32 has contractures to both hands. R32 developed an avoidable, facility acquired stage three pressure injury due to R32's fingernails becoming embedded in R32's palm. R32's plan of care was not updated to reflect that facility staff should trim R32's fingernails and R32's pressure injury was not comprehensively assessed when it was first discovered. Findings include: The facility's policy and procedure Pressure Injury Prevention and Management revised 4/17/25 documents: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/ injury, prevent infection and the development of additional pressure ulcer/ injuries. Explanation and Compliance Guidelines:2. The facility shall establish and utilize A systematic approach for pressure injury prevention and management, including prompt assessment and treatment; Intervening to stabilize, reduce or remove underlying risk factors; Monitoring the impact of the interventions; And modifying the interventions as appropriate.4. Assessment of Pressure Injury [NAME]. Licensed nurses will conduct a pressure injury risk assessment, using the Braden Risk Evaluation, and all residents upon admission, weekly times 4 weeks, then quarterly or whenever the residence condition changes significantly.c. Licensed nurses will conduct a full body skin assessment on all residents upon admission readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record.d. Assessments of pressure injuries will be performed by a licensed nurse and documented on the medical record. The staging of pressure injuries will be clearly identified to ensure correct coding on the Minimum Data Set (MDS).4. Interventions for Prevention and Promote Healing.a. After completing A thorough assessment evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment ( e.g. Moisture management, impaired mobility, nutritional deficit, staging, wound characteristics).c. Evidence based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present period basic or routine care interventions could include, you're not limited to; I. Redistribute pressure (such as repositioning, protecting and/or offloading heels; II. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; III. Provide appropriate, pressure redistributing, support services; IV. Provide non-irritating surfaces; and V. Maintain or improve nutrition and hydration status, were feasible. 1.) R14 was readmitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, dysphagia (difficulty swallowing) and metabolic encephalopathy. In November of 2025 R14 was diagnosed with peripheral vascular disease. R14's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/3/25 assessed R14 as understanding others and being able to be understood. Staff completed the cognitive assessment interview for R14 with a summary score of 03 indicating severe cognitive impairment. Staff also completed the summary score for mood and behavior for R14 indicating a severity score of 10 for trouble with sleep, feeling tired or with little energy, trouble concentrating, moving slowly or being fidgety (not specified), and being short tempered or easily annoyed. R14 was not assessed to reject care. R14 was assessed as having no functional limitations in range or motion to upper or lower extremities and R14 utilized a wheelchair. R14 is assessed to need set-up assistance for eating and was dependent upon staff for all other activities of daily living (ADLs) except oral hygiene. R14 was assessed to need partial/moderate assistance to roll left and right and substantial to moderate assistance to go from a sit to lying position. All other mobility assessment areas were indicated as not applicable to R14. R14 was assessed to be occasionally incontinent of bladder and always incontinent of bowel and R14 was not on a toileting program. R14 was assessed as not having a swallowing disorder and had experienced weight loss while not being on a physician prescribed weight loss program. R14 was assessed as not being in pain during the assessment period. R14 was assessed to be at risk for pressure injuries with no pressure injuries at the time of the assessment. R14's treatments identified in the MDS included nutrition or hydration intervention to manage skin problems. Treatments to include pressure reducing device for chair or bed were not assessed nor was a turning or repositioning program. By the time of the next assessment, R14's condition had changed. R14 was assessed as now needing substantial/maximal assistance for rolling in bed and was assessed as now being dependent upon staff for all other mobility with the exceptions of transferring to tub/shower and walking 10 feet which were assessed as not attempted due to medical condition or safety concerns. R14 was assessed as having a decline in bladder incontinence with a decline from occasionally incontinent to always incontinent. No toileting program is indicated for R14. R14 was assessed as having occasional pain that rarely interferes with day to day activities with a pain intensity rating of 04. R14 is assessed as being at risk for pressure injuries and had 1 unhealed, stage 2 pressure injury R14 is assessed as having 3 venous or arterial wounds. R14's assessed treatments included nutrition or hydration program to manage skin problems, pressure injury care, application of nonsurgical dressings other than to feet, and application of ointments/medications other than to feet. R14 is not assessed as needing pressure reducing device for chair or bed and for needing a turning and repositioning program. Review of R14's electronic medical record (EMR) indicated R14 had a stage 2 pressure injury to left medial buttock that started on 11/17/25 and was documented as healed on 12/1/25. R14's Care Area Assessment (CAA) triggered for pressure injury dated 12/4/25 indicates the pressure injury CAA was triggered due to R14 having bowel and bladder incontinence, being at risk for pressure injuries with a stage 2 pressure injury, and R14's assessed need for mobility assistance in bed requiring substantial assistance and being dependent upon staff to lie down and sit up. Analysis of findings identifies this problem as being a potential for problems. The only area checked for existing pressure injury is to assess location, size, stage, presence and type of drainage, presence of odors, condition of surrounding skin. No extrinsic factors were identified to include a problem with pressure, sheering, maceration etc. Intrinsic risk factors identified include altered mental status, cognitive loss, incontinence, and poor nutrition. Medications that increase risk for pressure injuries include antipsychotics, antidepressants, and opioids. Diagnoses that present complications or increase pressure injury risk included diabetes, chronic or end stage renal disease, peripheral vascular disease, other dementia, depression, severe pulmonary disease, and pain. Treatments and other factors that cause complications or increase risk was newly admitted or readmitted . Care plan considerations documented yes, pressure injury/functional status will be addressed in the care plan. The overall objective was improvement and avoid complications. The rationale for care plan decision documented: Resident is a [AGE] year old female with pmhx (primary history) (sic) of metabolic encephalopathy, seizures, senile dementia, COPD (chronic obstructive pulmonary disease), exacerbation of persistent asthma, AKI (acute kidney injury), anemia, hypothyroidism, HTN (hypertension), T2DM (type 2 diabetes mellitus), chronic pain, current smoker, bipolar 2, paranoid schizophrenia, anxiety, depression. CAA triggered d/t (due to) resident needing extensive assistance with ADLs and being at risk. Assistance provided every shift by licensed nursing assistants. Based on the following above (sic), will continue to care plan. R14's Plan of Care (POC) for Impaired skin integrity initiated: 9/2/25; with a created date of 12/18/25 by Wound Registered Nurse (WRN) -L identified the focus as: Left 1st MTH (metatarsal head) arterial ulcer; right 1st MTH arterial ulcer; coccyx unstageable pressure injury; right coccyx unstageable pressure injury;The Goal is to not experience complications from skin condition requiring hospitalization until wounds are resolved. Target Date: 2/28/26. Interventions identified for R14 included: Surveyor noted all identified interventions have a created date of 12/18/25 by WRN-L. - 9/2/25 Address pain prior to treatment to improve resident tolerance acceptance of wound care.- 12/15/25 Assist resident to shift weight while up in chair at least once an hour.- 9/2/25 nursing to monitor dressing integrity with each resident encounter and replaced dressing if soiled/ loose/ missing. Dressing location (sic): right 1st MTH, coccyx. - 9/2/25 Referral to Registered Dietitian for evaluation related to impaired nutrition impacting wound healing period provide supplements per MD /NP (Medical Doctor/Nurse Practitioner) orders.- 9/2/25 Studies/labs to be performed as needed for diagnostics per MD/ NP orders.- 9/2/25 Wound measurement is performed weekly and PRN (as needed) by Wound Care Team. If resident is unavailable, assessment will be completed at earliest availability.9/2/25 Wound care treatment to be performed by Wound Care Team/ nursing as ordered by MD/NP. R14's care plan for ADL self-care performance deficit r/t (related to) metabolic encephalopathy. was initiated 11/27/24, revised 12/5/24. The Goal is to improve current level of functioning through the review date initiated 5/2/25, revised 12/3/25 with a target date of 12/2/25 (prior to the last revised date). Interventions included were: - 4/15/25 (R14) is weight bearing as tolerated. Revised 4/15/25 - 3/16/25 enabler/assistive device placed bilaterally to improve mobility and increase independence and safety. Revised 10/31/25 - 11/27/24 Bed Mobility: requires minimal assist with bed mobility. Revised 4/15/25 - 11/27/24 Toilet use: is dependent/Hoyer/2 assist for toilet use. Revised 5/5/25. -11/27/24 Transfer: requires Hoyer and two assist for transfers. Revised 5/5/25. R14's falls care plan initiated 11/27/24 and revised 10/13/25 included interventions that may have impacted R14's ability to reposition or be repositioned including body pillows on both sides of resident while in bed initiated 10/15/25; bolster mattress on bed initiated 10/17/25; and Dycem in wheelchair initiated 5/12/25. (R14) was to be up in wheelchair after lunch in the common areas initiated 5/19/25. R14's care plan for altered respiratory status. initiated 11/27/24, revised 12/5/24 included an intervention initiated 11/27/24 and revised 12/5/24 to elevate the head of the bed to 30 degrees. R14 also had a care plan for at risk for further impaired skin integrity related to: age, DM11 (diabetes mellitus), sepsis.This care plan identifies historical wound areas for R14. The goal was to not develop further skin impairments initiated 5/2/25 revised 12/18/25 with a target date of 2/28/26. Interventions included: - 11/27/24 assist to turn and/or reposition every 2-3 hours (not individualized). - 11/27/24 Barrier cream with incontinence episode and as needed. - 11/27/24 Braden upon admission, weekly times 4 weeks, quarterly, and as needed. - 11/27/24 Educate resident/family/caregivers of causative factors and measures to prevent skin injury. - 11/27/24 Encourage good nutrition and hydration in order to promote healthier skin. - 11/27/24 Float heels if resident cannot turn and reposition themselves. Utilize pillows for offloading d/t abnormal positioning of feet. Revised 12/18/25. - 11/26/25 Follow facility protocols for treatment of injury. - 11/27/24 Keep skin clean and dry. Lotion skin with cares. Do not apply lotion between toes. Revised 12/6/24 - 11/27/24 – Monitor skin during cares. Report any changes to nurse. - 11/27/24 Obtain blood work such as CBC (complete blood count) with Diff (differential), blood cultures, and C&S (cultures & sensitivity) of any open wounds as ordered by physician. - 11/27/24 Weekly licensed nurse skin evaluation. R14's Nursing Progress Notes dated 12/15/25, written by RN-H, documented: Notified the POAHC regarding new order for wounds. Review of R14's medical record indicated a comprehensive assessment was not completed on 12/15/25 of the (potentially) 2 new, facility acquired unstageable wounds R14 developed. On 12/15/25 a treatment was added to R14's Treatment Administration Record (TARs) that stated: cleanse coccyx wounds with normal saline (NS), skin prep to peri wound, cover with Medihoney mesh (cut to size), followed by border foam dressing. Change 3 times a week and as needed. Every, day shift on Monday, Wednesday and Friday for unstageable times 2. R14's TAR does not indicate this treatment order was documented as being completed on 12/15/25 and 12/17/25. R14's December 2025 TAR documented: APM (alternating pressure mattress) initiated 12/15/25. On 12/15/25 Physiatry Assistant (PA)-J documented at 17:14 (5:14 pm) .Today patient is evaluated as I continue to follow the patent to optimize treatment and facilitate discharge. Patient continues with neuromuscular deconditioning with activities of daily living and/or gait dysfunction. Patient is a poor historian. Denies acute pain today. Reports generalized pain with long periods in w/c (wheelchair). See Pain assessment.Denies change in appetite or sleep. Pain assessment: unable to rate. Acute, generalized, intermittent pain. Worse with ling periods in w/c. Relieved by oxycodone, repositioning/laying down. Plan/recommendation: .Due to OA (open area) with pain and decreased mobility patient is high risk for falls. DM2 (diabetes mellitus type 2) Due to DM2 patient is high risk for poor healing and at high risk for infection that could necessitate the need for IV (intravenous) and readmission to the hospital.Surveyor noted there was no discussion or follow up to assess R14's care plan and time R14 spends up in a wheelchair despite indications it was contributing to pain and increased pressure to R14's bottom/lower back. The facility provided Surveyor with R14's wound assessments. The assessment forms included a picture of the wounds that are dated and time stamped to reflect the date they were created/completed by WRN-L. The 12/18/25 assessment, time stamped at 9:44 AM, documented -R14 had a facility acquired, unstageable pressure injury to the coccyx assessed on 12/18/25 at 9:44 AM. The assessment documentation indicated the coccyx wound was identified on 12/15/25. The wound on 12/18/25 measured 1.2 centimeters (cm) x (by) 1.30 cm x 0.10 (length by width by depth). The wound bed is documented as 100% slough with scant serous drainage. The surrounding skin has erythema (redness) and maceration (breakdown of skin by moisture). Also, on 12/18/25 the assessment for R14 documented R14 had a second facility acquired, unstageable pressure injury with this area noted to be on R14's right coccyx. The first comprehensive assessment of this area was dated 12/18/25 at 9:48 AM. The wound assessment documentation identified this area as originally identified on 12/15/25. The right coccyx wound measured 0.90 cm x 1.30 cm x 0.10. The wound bed is documented as 90% slough and 10% red (not further clarified). Scant serous drainage is documented. The surrounding skin area is documented as having erythema and maceration. R14's care plan for at risk for further impaired skin integrity related to: age, DM11 (diabetes mellitus), sepsis.This care plan identifies historical wound areas for R14. The goal was to not develop further skin impairments initiated 5/2/25 revised 12/18/25 with a target date of 2/28/26. Interventions updated 12/18/25 included: - 11/27/24 Pressure reduction mattress. Alternating pressure air mattress. Revised 12/18/25. - 11/27/24 The resident needs pressure reducing cushion to protect the skin while up in wheelchair. Specialty cushion – Vicair. Revised 12/18/25. Surveyor noted these intervention were after R14 developed the two facility acquired coccyx pressure injuries on 12/15/25 and despite R14 being at risk for pressure injuries prior to the development of these areas. Review of R14's TAR indicated the treatment for R14's coccyx pressure injuries was not documented as completed on 12/19/25. On 12/19/25 a nursing progress note documented: An Interdisciplinary Meeting (staff were not identified) was held. Wounds: coccyx unstageable; initial assessment; alternating pressure mattress (APM); new treatment placed. Coccyx right unstageable; initial assessment; APM; new treatment placed. Dietitian: Boost twice a day (BID), PM (evening) snack, ice cream BID (twice daily). Continue with current care plan. Update Provider weekly. On 12/19/25 at 15:45 (3:45 PM) PA-J assessed R14 and documented .Complains of acute on chronic b/l (bilateral) knee pain today. Denies change in appetite or sleep. Nursing treating unstageable PI (pressure injury) of coccyx. Due to OA (open area) with pain and decreased mobility patient is high risk for falls. DM2 (diabetes mellitus type 2) Due to DM2 patient is high risk for poor healing and at high risk for infection that could necessitate the need for IV (intravenous) and readmission to the hospital. Unstageable PI of coccyx: wound MD following. Encourage repositioning q2hr (every two hours) and PRN to decrease pain and pressure areas. Continue orders per wound team. On alternating pressure air mattress, Boost BID for wound healing. Discharge planning: pending ALF (adult licensed family home) placement. A nursing progress note dated 12/21/25 at 18:02 (6:02 PM) documented: (R14) stayed in bed throughout the weekend due to increased pain from coccyx wound. She was repositioned from side to side q (every) 2 hours. Resident was given assistance in eating to encourage adequate intake. Surveyor noted that despite documentation of pain and changes in R14's activity and eating there was no assessment of R14's wounds. The weekend included 12/19, 12/20, and 12/21/25. R14's coccyx Wound assessment dated [DATE] at 10:49 AM by WRN-L documented: measurements of 2.80 cm x 2.30 cm x 2.8 cm with the wound bed having 90% loosely adherent slough and 10% bright pink or red (not specified or further detailed) with moderate serous drainage. The peri-wound was documented as having erythema. There is undermining present between 12 o'clock and 1 o' clock 2 cm and between 5 o'clock and 6 o'clock 2 cm. The picture of the coccyx wound has a date and time stamp of 12/22/25 at 10:46 AM. Pain is documented as 3 on the pain scale. The assessment included documentation of probable improvement despite the increased size of the wound and undermining. Surveyor noted there is no assessment of the right coccyx wound dated 12/22/26. On 12/22/25 at 14:41 (2:41 PM), imagining was performed on R14's coccyx due to pain and wound decline. Reason for the study is documented as osteomyelitis, unspecified. Findings: Question subtle bone loss of the dorsal aspect of the sacrum/coccyx. Soft tissues appear swollen with ulceration dorsally. Conclusion: Cannot exclude osteomyelitis, recommend MRI work up. The radiology report included a handwritten note that documented MRI of sacrum coccyx for Dx (diagnosis) osteomyelitis signed as reviewed by NP-I on 12/23/25. Surveyor noted there are no additional orders documented to order and schedule an MRI, potentially obtain a culture and sensitivity of R14's wound, or treatment despite indications R14 had osteomyelitis. On 12/22/25 at 16:08 4:08 PM) a nutrition/dietary note was completed by Dietitian-G that documented: F/U (follow up) skin. Per wound assessment 12/22, unstageable PI – coccyx & laceration – vascular. Per wound assessment 12/18, unstageable PI-R (right) coccyx. PIs are new. Has hx (history) of PIs that had healed; however, these are new. Receives regular – mech (mechanical) soft diet which is approp (appropriate). Appetite is fair with po (oral) intake at 50%-100%. Receives Boost BID, ice cream lunch & dinner, and scheduled snack for nutritional support. Suspect current po intake + (plus) supp (supplements) approp to support skin. Cont (continue) POC (plan of care) and monitor at this time. Surveyor noted there is no indication Dietitian-G was made aware of or assessed the documentation by nursing staff that R14 had required greater assistance in eating to ensure intake related to increased pain due to R14's pressure injuries. R14's 12/22/25 at 16:30 (4:30 PM) assessment by PA-G documented. Chief complaint: Mobility and ADL impairment due to alzheimer's disease and charcot arthropathy, now with coccygeal pain. Complains of increased coccygeal pain today. See pain assessment. Denies change in appetite or sleep. Nursing treating unstageable PI of coccyx. Pain assessment: location: coccyx, acute intermittent, intensity of 5 out of 10. Worse with lying in bed. Relieved by repositioning.current pain medications include acetaminophen 650 mg (milligrams) TID (three times daily), and 650 mg q6hr (every 6 hours) PRN, Lidocaine patch 4% qd (each day), oxycodone 5 mg BID, biofreeze gel 4% BID.Plan/recommendations: Discussed plan of care with patient. XR (x-ray) sacrum/coccyx pending per primary care d/t increased pain and new wound; primary team to f/u on results. Patient to continue current medications and rehabilitation services per orders. Due to OA with pain and decreased mobility, patient is at high risk for falls. Dysphagia: on mech (mechanical) soft diet, thin liq (liquids). Due to dysphagia, patient is at high risk for aspiration pneumonia, that could require readmission to the hospital. Patient to maintain upright position with eating and for at least 30 minutes after meals. Encourage small bites (1/2 to 1 teaspoon at a time) alternating with small sips. DM2 (diabetes mellitus type 2) Due to DM2 patient is high risk for poor healing and at high risk for infection that could necessitate the need for IV (intravenous) and readmission to the hospital. Unstageable PI of coccyx: wound MD following. Encourage repositioning q2hr (every two hours) and PRN to decrease pain and pressure areas. Continue orders per wound team. On alternating pressure air mattress, Boost BID for wound healing. Discharge planning: pending ALF (adult licensed family home) placement. On 12/23/25 R14 was accompanied by R14's POAHC-CCC to obtain custom orthopedic shoes and braces in the community in preparation for discharge planning. Nursing progress notes dated 12/23/25 at 16:32 (4:32 PM) documented: Resident continues to show s/sx (signs/symptoms) of pain r/t coccyx wound, dressing changed d/t soiled with drainage from wound. Resident appears to be pocketing food, diet downgraded to puree (sic), nectar thick liquids. Surveyor noted that despite documented drainage from R14's pressure injury soiling the dressings R14's pressure is not reassessed and there is no consultation with R14's physician or nurse practitioner despite knowledge R14 has osteomyelitis in their coccyx pressure injury. Surveyor also noted there is no order for assessment or diet downgrade despite the documented change of condition of R14 pocketing food. (Cross-reference F684). Surveyor located a Diet Change Form dated 12/23/25 for puree and nectar liquids that was presented to the kitchen to implement the diet change despite no orders or assessment for the diet downgrade or change in R14's eating ability. On 4/15/26, at 10:15 AM, Surveyor interviewed Dietitian-G regarding R14. Surveyor asked Dietitian-G about the documented nutritional assessment on 12/22/25 where Dietitian-G documented no nutritional changes for R14 and R14's intake was good. Dietitian-G explained to Surveyor they were not aware that R14's coccyx pressure injury had become infected; they were aware there were unstageable wounds. Surveyor asked Dietitian-G about labs that had been run on R14 twice in December and the results indicating changes in R14's hydration status and kidney functions along with protein and albumin changes. Dietitian-G indicated they were not aware of the lab results for R14. Surveyor asked Dietitian-G about R14's changes in eating, consistency changes, and potential need for greater assistance from staff to ensure intake. Dietitian-G indicated they were not aware of any eating concerns or diet changes. Surveyor asked Dietitian-G if they had been aware of these issues regarding R14 what would they have potentially done. Dietitian-G stated if they were aware of the infection, lab results and diet changes, they would have made nutritional changes for R14. NP-I's progress note dated 12/23/25 documented: (R14) is seen today due to concerns about the worsening of her wound. An x-ray of her sacral coaxal area was performed, which could not rule out osteomyelitis. (R14) has experienced further decline and is now pocketing her food. She has complex medical history that includes metabolic encephalopathy, COPD, type 2 diabetes, immunodeficiency, peripheral vascular disease, bipolar disorder, dementia and schizophrenia. Vitals signs: Blood Pressure 149/86, Temperature: 98.2, Pulse 97 bpm (beats per minute), Weight: 165 lbs. Respirations 18 breaths per minute, pulse oximetry 96%. Physical Exam results: heart rate is regular with normal rhythm, lung sounds are clear throughout, patient is stable and in no acute distress. Assessment: 1. Worsening wound condition: unable to rule out osteomyelitis based on the x-ray, patient experiencing a decline indicated by pocketing food, complex medical history complicates the medical picture. 2. Comprehensive Medical Background: metabolic encephalopathy, COPD, type 2 diabetes; immunodeficiency and peripheral vascular disease, bipolar disorder, dementia, and schizophrenia. Plan: 1. Worsening wound condition: discuss and initiate hospice services under the guidance of (R14's POAHC-CCC), continue in-house wound care with nursing staff support to monitor (R14's) comfort. 2. Comprehensive Medical Background: Coordination and communication with (R14's POAHC-CCC) regarding goals of care; continued support from nursing staff. Signed NP-I. NP-I did not order any diet changes or downgrades to R14's diet or assessment despite noting a potentially significant change that could impact healing of R14's pressure injury(ies). NP-I's progress note dated 12/24/26 documented: (R14) was seen today for a follow up regarding her long-term care goals. She has a coccyx wound with concerns for osteomyelitis, confirmed on x-ray. Over time, her overall condition has declined further, and she now displays significant difficulty swallowing, as evidenced by her pocketing food. Her diet was previously downgraded to mechanical soft foods with nectar thick liquids. The patient's (POAHC-CCC), who serves as her activated power of attorney, is in agreement with transitioning (R14) to hospice care services to prioritize her comfort moving forward. The objective vital signs documented vital signs similar to those documented on 12/23/25 by NP-I, there was a documented change regarding R14's lung sounds which documented diminished in bases. Physical exam: Patient is stable and in no acute distress. Diagnostic test results: X-ray findings support concerns for osteomyelitis in the coccyx. Assessment: 1. Coccyx wound with concerns for osteomyelitis, contributing to ongoing wound management challenges. 2. Difficulty swallowing: Patient exhibits pocketing of food, posing complications with oral intake and requiring modification of diet. 3. Declining overall condition: The patient continues to experience progressive clinical decline, necessitating a shift in care goals towards comfort and end-of-life services. Plan: 1. Coccyx wound with concerns for osteomyelitis: maintain in-house wound care management, ensure continued attention to wound healing and prevention of further complications. 2. Difficulty swallowing: continue the downgraded diet of mechanical soft foods and nectar thick liquids to reduce risk of aspiration, monitor for

Based on observation, interview, and record review, the facility did not ensure 3 residents (R) of 4 residents reviewed were provided with adequate supervision and assistance to prevent accidents (R11, R5, and R13.) *R11 had an unwitnessed fall, without injury, on 2/13/2026. The facility did not implement immediate fall interventions, complete a fall investigation, determine a root cause, or review/revise the fall care plan to prevent further falls. R11 experienced another fall on 2/14/2026, which resulted in a laceration to R11's right eye and a Traumatic Brain Injury (TBI) requiring admission to a Neurology Intensive Care Unit. *R5 is documented as being dependent on staff for all cares. On 4/5/26, Certified Nursing Assistant (CNA)-X was performing cares alone with R5 in bed. R5 was facing away from CNA-X and when CNA-X turned away from R5 to grab supplies to perform cares, R5 rolled away from CNA-X and fell out of bed onto the floor. R5 was sent to the emergency room (ER) on 4/9/26 and diagnosed with bilateral tibia and fibula fractures (bone fractures in the lower legs typically caused by high-energy twisting injuries.) The facility failed to utilize standards of practice with bed mobility and cares for a resident who is dependent on staff for cares. The facility continued to transfer R5 via Hoyer lift and manipulate R5's Bilateral Lower Extremities (BLE) without assessing R5 when it was previously described by staff as having to manipulate R5's BLEs due to R5's contractures. The facility's failure to provide adequate supervision and proper assistance to R11 and R5 created a reasonable likelihood for serious harm, thus leading to the finding of immediate jeopardy that began on 2/14/2026. Surveyor notified the facility of the Immediate Jeopardy on 4/20/26, at 3:57 PM. The immediate jeopardy was removed on 4/23/26 when the facility implemented a removal action plan. The following example involving R13 is being cited at a scope/severity of D (potential for more than minimal harm/isolated): *R13 experienced an unwitnessed fall on 3/16/2026, without injury. The facility did not determine a root cause for R13's fall and interventions were not implemented. R13 experienced another unwitnessed fall on 3/24/2026, with no injuries and neurological checks were not completed due to not having a nurse, per the facility's documentation. Findings include: The facility's policy titled Accidents and Supervision, with a last reviewed/revised date of 10/8/2024, documents: 1. Identification of Hazards and Risks . a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying hazards of the environment, while taking into consideration the unique characteristics and abilities of each resident. B. The facility should make a reasonable effort to identify the hazards and risk factors for each resident.2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. A. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazards and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. C. Evaluations also look at trends such as time of day, location, etc. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes: . f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. 1.) R11 was admitted to the facility on [DATE] with diagnoses that include history of Subarachnoid Hemorrhage and aneurysm, (Status post clipping on 12/2025,) chronic foley catheter, intrabdominal drain, hemiplegia (severe or total paralysis on one side of the body caused by brain or spinal cord damage,) hemiparesis (one-sided muscle weakness,) and muscle weakness. R11's admission Minimum Data Set (MDS), dated [DATE], documents that R11 was assessed to have severely impaired cognition, impairment on 1 side of upper and lower extremities, is dependent on staff for all Activities of Daily Living (ADLs,) dependent on staff to roll left to right, and has no history of falls and no care area for falls triggered. R11's admission Fall risk assessment dated [DATE], indicates R11 is a low fall risk. R11's readmission Fall risk assessment dated [DATE], indicates R11 is a moderate fall risk. R11's Fall risk Care plan, initiated 1/16/2026, documents the following interventions: -Be sure R11's call light is within reach and encourage R11 to use it for assistance as needed. R11 needs prompt response to all requests for assistance -Follow facility protocol. The facility provided document titled Visual/Bedside Kardex Report for R11 documents the following: R11 is an assist of 1 staff to turn and reposition, toileting. Ensure call light within reach and a mechanical lift for transfers with 2 staff assistance. Surveyor reviewed R11's Electronic Health Record (EHR) and noted a progress note, dated 2/13/2026, written by Registered Nurse (RN)-II indicating RN-II was alerted to a loud crash, and went to R11's room. R11 was observed lying on R11's right side, on the floor, alongside R11's bed. R11 was sent to the emergency room for evaluation and returned to the facility on 2/14/2026. Surveyor noted R11 did not sustain any injuries due to this fall. Surveyor noted there were no immediate interventions implemented, no fall investigation completed, no review of R11's care plan, and no revision/update to R11's fall interventions. R11's Fall Risk Assessment completed on 2/13/2026, indicates R11 is a high risk for falls. Despite the fall risk assessment dated [DATE], Surveyor noted no update to R11's fall care plan occurred. R11 had another unwitnessed fall on 2/14/2026. Surveyor reviewed R11's EHR and noted a progress note, dated 2/15/2026 at 1:15 AM, written by Licensed Practical Nurse (LPN)-F indicating LPN-F was notified at 11:15 PM on 2/14/2026, that R11 was on the floor in R11's room. LPN-F observed R11 face down on the floor on R11's right side with a laceration to R11's left eye lid, noting a moderate amount of blood. 911 was called and R11 was transported to the emergency room for evaluation. Surveyor was unable to locate an investigation for this fall. R11's care plan was updated and indicates R11 sustained a fall on 2/15/26 with head injury, created on 2/23/2026. R11's Post-Fall Risk Assessment, dated 2/14/2026, indicates R11 is a moderate fall risk. Surveyor noted R11 did not return to the facility and was transferred to another facility after discharging from the hospital. Surveyor reviewed the emergency room after visit summary, dated 2/15/2026, which documents: - CT (computed tomography) of R11's head shows an area of concern for acute hemorrhage compared to previous CT Problems Addressed: Intraparenchymal hemorrhage of brain (a severe traumatic brain injury (TBI) where blood vessels rupture inside the brain tissue) (CMS-HCC): complicated acute illness or Injury and indicates, given new traumatic intracranial hemorrhage, R11 will require admission to neuro Intensive Care Unit (ICU.) On 4/15/2026, at 9:00 AM, Surveyor was informed by Clinical Nurse Specialist (CNS)-B that there was not a process in place for fall investigations prior to CNS-B coming to the facility and CNS-B began implementing a process about 1 week ago which included fall packets and expectations of fall investigations. CNS-B indicated R11's falls on 2/13/2026 and 2/14/2026 were not investigated for root cause. On 4/15/2026, at 1:08 PM, Surveyor interviewed LPN-F. LPN-F indicated on 2/14/25 LPN-F was informed by a CNA that R11 was on the floor in R11's room. LPN-F indicated they did not have a CNA assigned to R11's assignment that evening until 11PM. LPN-F observed R11 on the floor with an injury to R11's right eye. LPN-F called RN/PM Supervisor-D and R11 was ultimately sent to the emergency room for evaluation. LPN-F informed Surveyor that LPN-F did not complete a fall investigation and has not been trained on that. On 4/16/2026, at 9:02 AM, Surveyor interviewed RN/PM Supervisor-D. RN/PM Supervisor-D informed Surveyor an RN will perform the assessment of the resident after a fall and put what happened into a progress note, complete the fall packet, and implement immediate interventions. The unit manager the next day will review the fall packet and ensure immediate interventions are implemented and care plan reviewed/revised. The Intradisciplinary Team (IDT) will review the fall investigation the next day during morning meetings, but indicated RN/PM Supervisor-D is not part of the morning IDT meetings. On 4/20/2026, at 10:15 AM, Surveyor interviewed Unit Manager (UM)-E. UM-E indicated R11 did not have fall investigations completed and that now fall packets are completed by the floor nurse assigned to the resident who also implements an immediate intervention; the unit managers will review the fall packets and bring to morning meetings for IDT review to ensure care plan review and revisions. 2.) R5 was admitted to the facility on [DATE] with diagnoses that include congenital hydrocephalus (water on the brain causing symptoms of cognitive difficulties like memory loss), contracture of bilateral upper extremities (fibrous tissue injury resulting in lack of movement in the arms), contracture of bilateral lower extremities (fibrous tissue injury resulting in lack of movement in the legs), osteoarthritis (OA) (tissue in the joints, break down causing pain, stiffness, swelling and reduced mobility), and history of falls and seizures. R5's Significant Change Minimum Data Set (MDS) completed on 4/2/26, documents that R5 was assessed to be dependent with all cares (including toileting, transfers, eating, and dressing.) R5 is frequently incontinent of bowel and bladder. R5 was documented as having a Brief Interview for Mental Status (BIMS) score of 9, indicating that R5 has moderate cognitive impairment. R5's Care Area Assessments (CAA) document: Cognitive Loss/Dementia CAA: R5 has cognitive decline and needs limited to extensive assistance with Activities of Daily Living, mobility and bowel and bladder management. Falls CAA: R5 receives psychotropic medications and needs extensive assistance with ADLs, mobility and bowel and bladder management. R5 is at risk for falls, with and without injury. The plan is for nursing staff to monitor R5's safety. The goal is for R5 to remain free of falls while residing at the facility. R5's care plan dated 6/22/22, documents: R5 is at risk for falls, accidents and incidents related to unawareness and safety needs. R5 will fall from the bed or chair as a behavior. R5 has been noted to throw themselves on the floor. R5 will be half in bed and half out of bed at times (date initiated 1/23/26, revised on 1/23/26). Interventions include, in part: Be sure R5's call light is within reach and encourage R5 to use it for assistance as needed (PRN). R5 needs prompt response to all requests for assistance (date initiated 2/19/25, revised on 1/23/26). Bed to be kept in lowest position (date initiated 10/11/25). Body pillows to be placed on both sides of R5 while in bed (date initiated 10/11/25). Hourly rounding or placement in common areas for monitoring (date initiated 10/22/25). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes if possible. Educate R5/family/caregivers/Interdisciplinary Team (IDT) as to causes (date initiated 10/22/25). Use bilateral body pillows (date initiated 6/9/25). Use bilateral floor mats (date initiated 5/2/25). Use bolsters on bed (date initiated 10/1/25). Educate R5 to call for assistance (date initiated 8/3/22, revised on 6/2/24). Ensure bed brakes are locked (date initiated 6/22/22). Ensure two staff members are present during cares and interactions with R5 (date initiated 1/18/25, revised 4/9/26). If increased restlessness or anxiety, encourage R5 to be up in the wheelchair in the common area (date initiated 6/8/25). R5 has an ADL self-care performance deficit and limited physical mobility related to right intertrochanteric femur fracture status/post Open Reduction and Internal Fixation (ORIF), fall, acute blood loss anemia, GERD, constipation, insomnia, congenital hydrocephalus with a shunt, seizures and Osteoarthritis (OA) (date initiated 6/22/22, revised on 5/2/25). Interventions include: Personal Hygiene: Physical assist of 1 staff member (created on 6/22/22, revised on 10/5/22). Ensure there is a pillow placed in the broda chair to the right side to assist with arm positioning (date initiated 12/31/24). Bathing: Physical assistance of 1 staff member with reclining shower chair to be utilized when providing a shower (date initiated 6/22/22, revised on 9/3/23). Dressing: Physical assistance of 1 staff member (date initiated 6/22/22, revised on 10/5/22). Toileting: Assistance of 1 staff member with a bedpan and incontinence care (date initiated 6/22/22, revised on 7/14/24). Transfer: R5 requires a Hoyer lift with 2 staff assistance (date initiated 7/8/22, revised on 6/21/24). Surveyor reviewed R5's Kardex which documents the following: Dressing – assistance of 1 staff member Bed Mobility – is not filled out and does not specify the number of staff members needed for R5's bed mobility Transfers – Hoyer lift requiring 2 staff members for assistance Hourly rounding or placement in common areas for monitoring Ensure two staff members are present during cares and interactions with resident Bathing – assistance of one staff member with bathing Surveyor reviewed R5's Fall Risk Assessments which document: 2/21/26 – R5 is high risk for falls 3/3/26 – R5 is high risk for falls 3/22/26 – R5 is high risk for falls 4/5/26 – R5 is a moderate risk for falls Surveyor notes R5 had a fall with injury on 4/5/26 and was documented as being a moderate risk for falls with all other fall risk assessments indicating R5 is high risk for falls. Surveyor reviewed R5's Electronic Medical Record (EMR) which documents R5 having an Unwitnessed Fall (UWF) on 3/22/26, at 11:07 PM. Surveyor reviewed R5's fall investigation dated 3/22/26, which documents the following: On 3/22/26, at 11:07 PM, R5 was found lying on the floor next to the bed. R5 was last seen and toileted at 10:00 PM. Skin Assessment completed which documents R5 having an abrasion/bruise (no location of where abrasion and bruise are located/documented. There is a check mark indicating abrasion and bruising.) Laceration to the left side of R5's nose measuring 0.1 x 0.1 cm. A laceration to R5's right side of the head measuring 0.2 x 0.1 cm. Pain assessment completed documenting R5 denied pain. Neurological checks were completed with one missing entry noted on 3/23/26 at 5:15 PM (4-hour neurological check). Registered Nurse (RN) assessment completed with vital signs documented as within normal limits. The facility notified Hospice, APOA, Medical Director (MD) and R5's community case manager of R5's fall on 3/22/26. Surveyor notes the following concerns with R5's 3/22/26 fall investigation: A thorough root cause was not identified. No indication the care plan was thoroughly reviewed to identify if interventions are appropriate or additional interventions are needed. The Interdisciplinary Team (IDT) met and identified R5 as being a very high fall risk with unavoidable behavioral fall pattern. The unavoidable behaviors are not identified, and the IDT does not indicate the unavoidable conditions that contribute to R5's falls. On 4/16/26, at 7:25 AM, Surveyor interviewed RN/PM Supervisor-D who stated the therapy department determines the number of staff needed for assistance with performing cares. Surveyor asked RN/PM Supervisor-D why R5 has falls and RN/PM Supervisor-D responded that she is not sure why and then stated R5 is supposed to be an assist of two staff members and a buddy system. RN/PM Supervisor-D stated if a resident does not have good body coordination, that resident could roll right off the bed. On 4/15/26, at 12:40 PM, Surveyor interviewed LPN-EE who stated the therapy department usually reviews and updates resident's care plans and Kardexes to determine the number of staff required for assistance with a resident. LPN-EE stated she will contact an RN in the building for an assessment with any change in condition, obtain vitals and notify POA, MD and case manager. LPN-EE stated R5 can be squirrelly in bed and try to move around and get out of bed at times. Staff will try to calm R5 down when R5 is squirrelly. LPN-EE stated R5 is a total assist, requiring assistance of two staff members with a Hoyer lift. LPN-EE then stated R5 requires assistance of one staff member with bed mobility and cares in bed. (Note: This is contrary to the care plan.) Surveyor reviewed R5's Electronic Medical Record (EMR) and facility self-report which documents R5 having a fall on 4/5/26 at 6:00 AM. Surveyor reviewed R5's fall investigation dated 4/5/26, which documents the following: Certified Nursing Assistant (CNA)-X was performing cares alone on R5 with R5 lying in bed. CNA-X had R5 facing away from her at the time of cares and R5 rolled out of bed. CNA-X did not see R5 roll out of bed but heard R5 roll out of bed. All interventions were documented as being in place. Immediate interventions were documented as putting the bed in the lowest position and bilateral body pillows to be placed. The root cause was documented as R5 had a high fall risk requiring 2-person assistance, however, care was performed with 1 staff member. Staff interviews were performed who worked night shift from 4/5/26 – 4/8/26. A statement from Medical Director (MD)-NN documents R5 exhibits impulsive behavior specifically history of forceful self-extraction from beds and chairs. These sudden movements combined with impaired judgement present an increased risk of falls. It is helpful to note that contractures create leverage on the bones. If R5 falls while a limb is contracted, the bone is much more likely to snap than a flexible limb would be. Chronic contractures severely limit R5's Range of Motion (ROM) and postural stability, making independent movement unsafe and increasing the physical stress on long bones during any sudden shift in position. Given R5's overall frailty and the mechanical stress caused by the aforementioned contractures and documented impulsive movements, R5 is a markedly increased risk for pathological, or trauma induced fractures. On 4/15/26, at 10:22 AM, Surveyor interviewed CNA-X who stated R5 is contracted in the fetal position with R5's knees approximately 10 - 15 inches away from R5's chin. CNA-X stated R5 was excited to see CNA-X on 4/5/26, and R5 was attempting to wiggle her way out of bed. CNA-X stated she would go into R5's room and ask if R5 was ok. CNA-X stated R5 could not say if anything was wrong. CNA-X stated she increased her rounding with R5 due to R5 consistently wiggling and attempting to roll out of bed. CNA-X stated she was working with R5 on 4/5/26 at 6:00 AM, performing cares on R5 while R5 was lying in bed. CNA-X turned away from R5 while performing cares and R5 then rolled out of bed. CNA-X did not see R5's actual fall from the bed. CNA-X only heard R5 fall. CNA-X stated she thinks R5 hit R5's head on the bedside table and rolled on to R5's body, on top of R5's legs. CNA-X immediately got two nurses who were at the nursing station. CNA-X stated R5 developed a bump on R5's head with no other noticeable injuries or bruising. Surveyor asked CNA-X to describe how staff utilize the Hoyer lift with R5's severe contractures. CNA-X responded, R5 is supported with R5's back and buttocks, depending on how R5 is adjusted in the Hoyer lift. Staff have to adjust R5's legs when putting R5 into the wheelchair so R5 doesn't sit on R5's legs or get them caught in the wheelchair. CNA-X stated the way R5's body is, R5 could easily sit on R5's legs with the Hoyer lift. When R5 is in bed, CNA-X stated, staff also have to be careful with the wedges for support. On 4/15/26, at 3:00 PM, Surveyor interviewed RN-DD who stated staff refer to the EMR and Kardex to determine the number of staff needed for assistance. RN-DD stated she was the charge nurse on 4/5/26 and was contacted by nursing staff to evaluate R5 post fall. RN-DD stated R5 was lying on the floor on the nightstand with R5's brief half on. R5 was on the floor lying on R5's right side of bed. RN-DD stated CNA-X indicated she was providing cares for R5 alone and reached to the nightstand when R5 rolled out of bed. RN-DD stated she performed neuro checks, pain assessment, skin check, contacted hospice and obtained vitals. RN-DD stated she rubbed R5's legs to see if R5 would wince and grimace. RN-DD stated R5 denied pain and noted no bruising to bilateral lower extremities. RN-DD stated facility staff assisted R5 back into bed using a Hoyer lift. On 4/14/26, at 12:55 PM, Surveyor interviewed Forensic Nurse-CC. R5 arrived at the ER for evaluation on 4/9/26, for left ankle deformity. ER staff noted R5 having extensive bruising on BLEs. Forensic Nurse-CC stated the ER was notified of R5 having a fall from bed on 4/5/26 that did not seem to correlate with the fall. Forensic Nurse-CC stated the hospice nurse arrived at the ER at the same time Forensic Nurse-CC arrived in the ER to evaluate R5. Forensic Nurse-CC asked R5 if anyone harmed R5, and R5 stated no, but then stated yes indicating someone had pushed R5. R5 was unable to state whether it was a resident or staff member who pushed R5. R5 denied pain at the time of evaluation when asked however, R5 would start moaning when ER staff picked up R5's BLEs. Forensic Nurse-CC stated she performed a skin assessment on R5 which documented the following: Round fingerprint bruise under chin, not on bony prominence. Significant intermittent bruising on left forearm and left wrist potentially from being grabbed. 3 to 4 finger like bruising impressions on right clavicle that were more vertical than horizontal. Left leg with significant bruising from just below the left knee. Mid-calf to the foot appeared swollen, ecchymotic and deformed. Right lower leg appearing swollen, ecchymotic and bruised. Forensic Nurse-CC stated, when staff picked up R5's left leg, it was floppy, and the left leg bent in half when being picked up. Forensic Nurse-CC stated x-rays were performed and revealed bilateral proximal and distal tibia and fibula fractures on both legs. Forensic Nurse-CC acknowledged R5 having a history of fractures in the past and then stated the radiologist determined the tibia and fibula fractures were acute fractures. On 4/16/26, at 10:56 AM, Surveyor interviewed Nurse Practitioner (NP)-I who stated R5 is completely dependent on staff and requires two staff members for assistance. Surveyor asked NP-I who reviews and updates R5's care plan to determine how many staff are needed for assistance, and NP-I stated she would assume the therapy department determines the number of staff needed for assistance and cares. NP-I stated she was notified on 4/9/26 of R5's fall that occurred on 4/5/26. NP-I stated she was contacted by nursing staff on 4/9/26 regarding R5's change in condition post fall and having deformity and bruising. NP-I stated R5 had bruising on R5's shins that were purple with yellowing which indicated bruising didn't happen the morning of 4/9/26. NP-I advised staff to send R5 to the ER for evaluation. NP-I stated R5 has experienced multiple falls and is unsure when deformity to R5's left ankle occurred. NP-I stated behaviors often imply they are intentional, so NP-I stated R5 does not have behaviors because they are not intentional. NP-I stated she would describe R5 as being restless which can contribute to R5 falling out of bed. NP-I then stated terminal restlessness can be a cause of falls. On 4/15/26, at 8:58 AM, Surveyor interviewed Clinical Nurse Specialist-B who stated the expectation of every fall is to complete all checks listed below: *Fall Risk Assessment that includes when the resident was last seen, toileted, if interventions were in place and if immediate interventions were initiated. *Neuro checks *Vital signs *Skin assessment *Pain assessment *Notify Hospice, POA, MD and Case Manager *Root Cause *72-hour post fall assessment *Care plan interventions reviewed/evaluated/updated *IDT to meet to discuss fall On 4/16/26, at 3:23 PM, Surveyor interviewed NHA-A, Clinical Nurse Specialist-B, and Director of Operations-O. Director of Operations-O stated there was a delay in the facility's response with R5's change in condition and then notification of change was not properly completed. Clinical Nurse Specialist-B stated R5 is not truly an assist of one and CNA-X should have had another staff member with her. On 4/16/26, at 3: 23 PM Surveyor notified NHA-A, Clinical Nurse Specialist-B, and Director of Operations-O of the following concerns: *CNA-X was performing cares independently on 4/5/26, on R5 who is dependent on staff with all needs. *CNA-X failed to utilize standards of practice with bed mobility and cares for R5 who is dependent on staff for cares. *CNA-X rolled R5 away from her when performing cares. *The facility continued to transfer R5 via Hoyer lift and manipulate R5's BLEs without assessing R5 when it was previously described by staff as having to manipulate R5's BLEs due to R5's contractures. *R5 was evaluated in the emergency room (ER) on 4/9/26 and diagnosed with bilateral tibia and fibula fractures (bone fractures in the lower legs typically caused by high-energy twisting injuries.) *Statement from MD-16 documents R5 having known impulsive behaviors with a history of forceful self-extraction from bed and chairs. This is a known history with R5 having multiple recent falls with no indication R5's care plan was reviewed. *No recent ADL care plan revisions noted with last revisions documented in 2023 and 2024. *Conflicting documentation indicating R5 requires assistance of 1 vs 2 staff members on R5's care plan and Kardex. R5's care plan and Kardex document staff are to use the buddy system with cares, however, bathing, dressing, and toileting document 1 staff member needed. *Documentation and statements from Forensic Nurse-CC identify R5 with having bruises on the chin, clavicle, forearm, forehead, and BLEs. BLEs appeared swollen and ecchymotic with extensive bruising. R5's left leg bent in half when picked up. Acute spiral fractures were identified in both legs. *Incomplete fall investigation for R5's fall on 4/5/26. Surveyor identified no post fall evaluation, vitals, and no review of care plan interventions. *Fall Risk Assessment documented on 4/5/26 indicates R5 is a moderate risk. All other fall risks determined R5 to be high risk for falls. Clinical Nurse Specialist-B stated R5 is truly an assist of 1 staff member, but the facility has the buddy system of 2 staff members. Clinical Nurse Specialist-B stated CNA-X should have had another staff member with her when performing cares on R5 on 4/5/26. Surveyor noted that if this was the case, the R5's care plan should have reflected R5's transfer status as an assist of 2 staff members, not 1. The facility's failure to keep R11 and R5 free from hazards, reduce the risk of all known and foreseeable accident hazards that cannot be eliminated, provide appropriate and sufficient supervision to R11 and R5 to prevent an avoidable fall increased a reasonable likelihood for serious harm, thus creating a finding of Immediate Jeopardy. This Immediate Jeopardy was removed on 4/23/26 when the facility completed the following: A review of current residents who had falls in the last 30 days was completed to ensure the following: Physician notification; Risk management was completed; Care plan interventions are appropriate; Plan of care was followed In-house residents who are at high risk for falls had their plan of care reviewed and/or revised to ensure appropriate interventions in place. A list of sample post fall interventions was placed at the nurse's stations to assist the nurses in implementing new immediate fall interventions. A new fall review checklist was implemented which includes the following: Complete fall packet; Neuro checks; Fall evaluation; Skin evaluation; MD notification; Responsible party notification; IDT progress note including the RCA completed; Review of care plan and revisions as indicated An Ad hoc QAPI was completed to include the medical director Re-education to licensed nurses related to the facilities accident and supervision policy Re-education to the nursing staff related to the Stop and Watch tool which is placed at the nurse's stations. This training will include agency staff. Re-education to certified nursing staff related to Kardex review including buddy system and location of Kardex. Education to nursing staff related to bed mobility best practice of when to utilize assist of 2 for cares, repositioning, and toileting Re-education to licensed nurses related to the facilities notification of change policy initiated This training will include agency staff and new orientation. The Director of Nursing and/or designee will conduct an audit daily x 4 weeks during clinical start up to identify any notifications of change and proper notifications and follow-through made. The Director of Nursing and/or designee will conduct an audit daily x 4 weeks during clinical start up to ensure fall protocol is followed, fall checklist completed. While the immediate jeopardy was removed on 4/23/26 when the facility implemented the above action plan, however deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) for the following example: 3.) R13 was admitted to the facility on [DATE], with diagnoses including Dementia (a progressive, irreversible syndrome causing decline in memory, thinking, and behavior) and muscle weakness. R13's Quarterly MDS, with a reference date of 2/17/2026, documents a Brief Interview for Mental Status score of 12 indicating moderate cognitive impairment, R13 does not exhibit behaviors, requires partial/moderate assistance rolling left to right, sit to standing and transfers, experienced a fall since admission, and uses a manual wheelchair. R13's Fall Risk Assessments document: 2/3/2026- high risk 3/16/2026- moderate risk 3/24/2026- moderate risk 4/8/2026- high risk The facility provided document titled Care Plan Report for R13, indicates R13 is at risk for falls created on 1/20/2025 with the following interventions: -Ensure R13 is wearing leather shoes or non-skid socks when ambulating or mobilizing. Initiated 1/20/2025 -Follow facility protocol. Initiated 8/27/2025 -gripper socks on at all times. Initiate

Based on interview and record review the facility did not ensure that 5 of 5 direct care staff reviewed received the required training regarding compliance and ethics.CNA (Certified Nursing Assistant) TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training.This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.Findings include:The facility's policy dated as last revised 1/1/25 and titled Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training necessary are based on a facility assessment. 3. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles.6. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibilities for caring of residents. c. Elements and goals of the facility's QAPI program. d. Written standards, policies and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency procedures.10. Documentation of required training will be forwarded to the HR ( human resources) Department to be placed into the individual's personnel file, in accordance with facility policy for retention of training records. On 5/4/26, Surveyor chose 5 Certified Nursing Assistants (CNA) from a list of employees provided by the facility. Surveyor chose the following staff to review their annual performance reviews and required training.CNA- TT was hired on 12/4/2024CNA- UU was hired on 10/30/2024CNA- VV was hired on 12/4/2024CNA- WW was hired on 5/7/2024CNA- XX was hired on 10/30/2024.The facility was unable to provide evidence that CNA-TT, CNA-UU, CNA-VV, CNA-WW and CNA-XX had received training regarding compliance and ethics.On 5/5/26 at 9:45 AM, Surveyor interviewed HR (Human Resources) Director-YY who stated that after an employee is hired, HR Director-YY is responsible for all of the new-employee on-boarding and does not have anything to do with any of the annual trainings after the initial hire. HR Director-YY informed Surveyor that annual training should all be kept track of by nursing and that there is currently no Nurse Educator or Staff Development Coordinator.On 5/5/26, Surveyor interviewed Nursing Home Administrator- AAA and Director of Operations- O who both confirmed the facility did not have any evidence of compliance and ethics training being provided to staff. Nursing Home Administrator- AAA stated that all of the training records are in boxes that were kept by the previous Director of Nursing, and they have nothing organized for employee trainings. Nursing Home Administrator- AAA confirmed that there is no Staff Development Coordinator/ Designee who is maintaining a training schedule and or documentation for completed trainings. No additional information was provided.

Based on interview and record review the facility did not ensure that 5 out of 5 Certified Nursing Assistants completed 12 hours of required training annually. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than one year and have not completed the required annual 12 hours of training. This has the potential to affect all 112 residents as the 5 staff members work on various units throughout the facility.Findings include:The facility's policy dated as revised 1/1/25 and titled Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training necessary are based on a facility assessment. 3. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles.7. It is the responsibility of each employee, volunteer, or contract staff to complete required training. a. the facility offers a variety of training methods and times to accommodate individuals. b. An individual's failure to complete required training in a timely manner will result in termination of employment or contractual/volunteer status. 10. Documentation of required training will be forwarded to the HR (human resources) Department to be placed into the individual's personnel file, in accordance with facility policy for retention of training records. On 5/4/26, Surveyor chose 5 Certified Nursing Assistants (CNA) from a list of employees provided by the facility. Surveyor chose the following staff to review their annual performance reviews and required training.CNA- TT was hired on 12/4/2024CNA- UU was hired on 10/30/2024CNA- VV was hired on 12/4/2024CNA- WW was hired on 5/7/2024CNA- XX was hired on 10/30/2024.The facility was unable to provide evidence that CNA-TT, CNA-UU, CNA-VV, CNA-WW and CNA-XX had completed 12 hours of required trainings annually.On 5/5/26 at 9:45 AM, Surveyor interviewed HR (Human Resources) Director-YY who stated that after an employee is hired, HR Director-YY is responsible for all of the new-employee on-boarding and does not have anything to do with any of the annual trainings after the initial hire. HR Director-YY informed Surveyor that annual training should all be kept track of by nursing and that there is currently no Nurse Educator or Staff Development Coordinator.On 5/5/26, Surveyor interviewed Nursing Home Administrator- AAA and Director of Operations- O who both confirmed the facility did not have any evidence of the 12 hours of annual training being completed. Nursing Home Administrator- AAA stated that all of the training records are in boxes that were kept by the previous Director of Nursing, and they have nothing organized for employee trainings. Nursing Home Administrator- AAA confirmed that there is no Staff Development Coordinator/ Designee who is maintaining a training schedule and or documentation for completed trainings. No additional information was provided.

Based on interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.*The facility did not ensure sufficient Certified Nursing Assistant (CNA) and nurse staffing was provided based on the facility's staffing plan and staffing patterns.This deficient practice has the potential to affect 98 of 98 residents in the facility.Findings include:On 04/01/2026, Surveyor reviewed the facility's assessment with an approved date of 08/29/2025. The facility assessment documents under Information About Our Staffing Patterns section: The staffing plan is based on the facility assessment, along with facility-based and community based risk assessments to inform staffing decisions to ensure that there are sufficient number of staff to care for the residents' needs. This document is updated and adjusted as necessary based on changes to the resident populations.On 04/01/2026, at 1:36 PM, Surveyor interviewed Scheduler-QQ regarding the facility's staffing patterns. Per Scheduler-QQ, the facility staffs Certified Nursing Assistants (CNAs) based on census and resident acuity. Scheduler-QQ informed Surveyor that the facility transitioned CNAs from twelve hour shifts to eight hour shifts around the beginning of March 2026. Per Scheduler-QQ, when the facility was utilizing twelve hour shifts for CNAs, there were 10 CNAs needed for the AM shift and 7 CNAs needed for the PM shift. When the facility transitioned to eight hour shifts for CNA staffing, the facility utilized 10 CNAs for first shift, 10 CNAs for second shift, and 7 CNAs for third shift.Surveyor reviewed the facility staffing patterns from 02/01/2026 through 04/14/2026. Surveyor noted the facility was short staffed on the following dates:02/14/2026 - 1 CNA short on PM shift.02/16/2026 - 1 CNA short on PM shift.03/02/2026 - 1 CNA short on PM shift.03/06/2026 - 1 nurse short on PM shift due to a no call/no show and 1 CNA short.03/13/2026 - 1 CNA short on PM shift and 1 CNA short on night shift.03/20/2026 - 2 CNAs short on night shift.On 04/02/2026, at 9:43 AM, Surveyor interviewed Scheduler-QQ and reviewed the above dates. Scheduler-QQ confirmed the facility was short staffed on the above dates. Surveyor asked Scheduler-QQ whom passed medications on the unit on 03/06/2026 when the nurse did not show up for the PM shift. Scheduler-QQ stated she did not know. On 04/16/2026, at 3:15 PM, during the facility exit meeting with Nursing Home Administrator (NHA)-A, Clinical Nurse Specialist (CNS)-B, and Director of Operations (DOO)-O, Surveyor informed the facility of the staffing concerns identified during survey.No additional information was provided.

Based on interview and record review, the facility did not ensure that 5 out of 5 direct care staff reviewed, received the required training regarding abuse, neglect and exploitation. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training.This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.Findings include:The facility's policy dated as last reviewed 1/1/25 and titled Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training necessary are based on a facility assessment. 3. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles.6. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibilities for caring of residents. c. Elements and goals of the facility's QAPI program. d. Written standards, policies and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency procedures.10. Documentation of required training will be forwarded to the HR ( human resources) Department to be placed into the individual's personnel file, in accordance with facility policy for retention of training records. On 5/4/26, Surveyor reviewed 5 Certified Nursing Assistants (CNA) from a list of employees provided by the facility. Surveyor chose the following staff to review their annual performance reviews and required training.CNA- TT was hired on 12/4/2024CNA- UU was hired on 10/30/2024CNA- VV was hired on 12/4/2024CNA- WW was hired on 5/7/2024CNA- XX was hired on 10/30/2024.The facility was unable to provide evidence that CNA-TT, CNA-UU, CNA-VV, CNA-WW and CNA-XX had received training on abuse, neglect and exploitation.On 5/5/26 at 9:45 AM, Surveyor interviewed HR (Human Resources) Director-YY who stated that after an employee is hired, HR Director-YY is responsible for all of the new-employee on-boarding and does not have anything to do with any of the annual trainings after the initial hire. HR Director-YY informed Surveyor that annual training should all be kept track of by nursing and that there is currently no Nurse Educator or Staff Development Coordinator.On 5/5/26, Surveyor interviewed Nursing Home Administrator- AAA and Director of Operations- O who both confirmed the facility did not have any evidence of abuse, neglect and exploitation training being provided to staff. Nursing Home Administrator- AAA stated that all of the training records are in boxes that were kept by the previous Director of Nursing, and they have nothing organized for employee trainings. Nursing Home Administrator- AAA confirmed that there is no Staff Development Coordinator/ Designee, per policy who is maintaining a training schedule and a documentation system for completed trainings.No additional information was provided.

Based on interview and record review, the facility did not ensure that 5 out of 5 direct care staff reviewed, received the required resident rights training. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training.This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.Findings include:The facility's policy dated as last reviewed 1/1/25 and titled, Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training necessary are based on a facility assessment. 3. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles.6. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibilities for caring of residents. c. Elements and goals of the facility's QAPI program. d. Written standards, policies and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency procedures.10. Documentation of required training will be forwarded to the HR ( human resources) Department to be placed into the individual's personnel file, in accordance with facility policy for retention of training records. On 5/4/26, Surveyor reviewed 5 Certified Nursing Assistants (CNA) from a list of employees provided by the facility. Surveyor chose the following staff to review their required resident rights training.CNA- TT was hired on 12/4/2024CNA- UU was hired on 10/30/2024CNA- VV was hired on 12/4/2024CNA- WW was hired on 5/7/2024CNA- XX was hired on 10/30/2024.The facility was unable to provide evidence that CNA-TT, CNA-UU, CNA-VV, CNA-WW and CNA-XX had received the required resident rights training.On 5/5/26 at 9:45 AM, Surveyor interviewed HR (Human Resources) Director-YY who stated that after an employee is hired, HR Director-YY is responsible for all of the new-employee on-boarding and does not have anything to do with any of the annual trainings after the initial hire. HR Director-YY informed Surveyor that annual training should all be kept track of by nursing and that there is currently no Nurse Educator or Staff Development Coordinator.On 5/5/26, Surveyor interviewed Nursing Home Administrator- AAA and Director of Operations- O who both confirmed the facility did not have any evidence of resident rights training being provided to staff. Nursing Home Administrator- AAA stated that all of the training records are in boxes that were kept by the previous Director of Nursing, and they have nothing organized for employee trainings. Nursing Home Administrator- AAA confirmed that there is no Staff Development Coordinator/ Designee, per policy who is maintaining a training schedule and a documentation system for completed trainings.No additional information was provided.

Based on interview and record review, the facility did not ensure that 5 out of 5 direct care staff reviewed received the required communication training. CNA (Certified Nursing Assistant) TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training.This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.Findings include:The facility's policy dated as last revised 1/1/25 and titled Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training necessary are based on a facility assessment. 3. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles.6. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibilities for caring of residents. c. Elements and goals of the facility's QAPI program. d. Written standards, policies and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency procedures.10. Documentation of required training will be forwarded to the HR ( human resources) Department to be placed into the individual's personnel file, in accordance with facility policy for retention of training records. On 5/4/26, Surveyor reviewed 5 Certified Nursing Assistants (CNA) from a list of employees provided by the facility. Surveyor chose the following staff to review their annual performance reviews and required resident right's training.CNA- TT was hired on 12/4/2024CNA- UU was hired on 10/30/2024CNA- VV was hired on 12/4/2024CNA- WW was hired on 5/7/2024CNA- XX was hired on 10/30/2024The facility was unable to provide evidence that CNA-TT, CNA-UU, CNA-VV, CNA-WW and CNA-XX had received the required communication training. On 5/5/26 at 9:45 AM, Surveyor interviewed HR (Human Resources) Director-YY who stated that after an employee is hired, HR Director-YY is responsible for all of the new-employee on-boarding and does not have anything to do with any of the annual trainings after the initial hire. HR Director-YY informed Surveyor that annual training should all be kept track of by nursing and that there is currently no Nurse Educator or Staff Development Coordinator.On 5/5/26, Surveyor interviewed Nursing Home Administrator- AAA and Director of Operations- O who both confirmed the facility did not have any evidence of communication training being provided to staff. Nursing Home Administrator- AAA stated that all of the training records are in boxes that were kept by the previous Director of Nursing, and they have nothing organized for employee trainings. Nursing Home Administrator- AAA confirmed that there is no Staff Development Coordinator/ Designee, per policy who is maintaining a training schedule and a documentation system for completed trainings.No additional information was provided.

Based on observation, interview and record review, the facility did not implement an effective infection control program, including surveillance of infections in the facility, and sanitizing equipment. This had the potential to affect all 105 residents in the facility. The facility did not have documentation of facility infection surveillance for January, February and March of 2026. * R20 received blood glucose sampling through an un-sanitized glucometer machine. Findings include: The facility's policy and procedure Infection Surveillance revised 5/29/2024 documents: Policy: Infection surveillance services. There's a core activity of the Facilities Infection Prevention and Control Program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections.Policy Explanation and Compliance Guidelines:1.The infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and report surveillance findings to the Facilities Quality Assessment and Assurance Committee, in public health authorities when required. The facility's policy and procedure Infection Prevention and Control Program revised 2/5/2025. Policy: This facility established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. As per accepted national standards and guidelines.Explanation and Compliance Guidelines:3. Surveillance:a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards.b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance binding to the Facilities Quality Assessment and Assurance Committee.c. The RN's and LPN'S participate in surveillance through assessment of residents and reporting changes in condition to the resident's physician and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. 1.) On 4/14/26, at 3:20 PM, at the facility exit meeting with Nursing Home Administrator (NHA) -A, Clinical Nurse Specialist (CNS) -B and Director of Operations (DOO)-O, Surveyor asked for the facility Infection Preventionist (IP). The facility has had changes in staff and CNS-B, and DOO-O are covering that role. Surveyor requested for the last 6 months of facility infection surveillance documentation. On 4/15/26, at 2:00 PM, Surveyor interviewed DOO-O. DOO-O provided surveillance documentation for November 2025, December 2025 and April 2026. The Surveillance documentation could not be located for March 2026. The January and February 2026 documentation was not documented into the surveillance form. There was no documentation of infection surveillance for January, February and March 2026. The IP responsible during this period is no longer at the facility. Surveyor noted that the facility did not have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. On 4/16/26, at 3:15 PM, at the facility exit meeting with NHA-A, CNS-B and DOO-O, surveyor shared the concerns with the facility surveillance documentation. No additional documentation was provided. The facility's policy and procedure titled, Glucometer Cleaning & Disinfection date reviewed 10/07/2025, documents: Guideline: The purpose of this procedure is to provide expectations for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Explanation and Compliance Guidelines1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use.3. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus.4. Glucometers will be cleaned and disinfected, stored in clean area, Ziplock or individual/labeled case, after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use.5. Procedure recommendations.i. Retrieve (2) disinfectant wipes from container.j. If visible soiled/dirty, proceed with cleaning step. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer.k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry.l. Discard disinfectant wipes in waste receptacle. 2.) R20 was admitted to the facility on [DATE] with pertinent diagnoses of type 2 diabetes mellitus. R20's Annual Minimum Data Set (MDS) with an assessment reference date of 4/13/2026, documents that a Brief Interview for Mental Status (BIMS) was not completed because the resident is rarely/never understood. The MDS documents R20 was assessed to have no behaviors exhibited during the look back period and is usually understood and usually understands others. The MDS documents that a hypoglycemic (including insulin) was administered to R20 during the assessment period. R20's physician order dated 12/4/2025, documents: Immunodeficiency monitor for any signs/symptoms of: fever, redness, drainage, or swelling around wounds, catheters, or vascular sites, cough, respiratory symptoms, dysuria, hematuria, flank pain, and or foul smelling urine. One time a day for type 2 diabetes mellitus with diabetic/immunodeficiency. R20's physician order dated 1/22/2026, documents: Insulin aspart injection solution, inject as per sliding scale. Surveyor noted the blood glucose is recorded in addition to the amount of insulin given. On 4/15/2026, at 7:57am, Surveyor observed Licensed Practical Nurse (LPN)-U wipe the glucometer with an alcohol wipe pad. LPN-U then proceeded to obtain R20's blood glucose. After this, LPN-U wiped the glucometer with an alcohol wipe pad again and put the glucometer in the cart drawer. On 4/15/2026, at 8:09am, Surveyor interviewed LPN-U and asked if the glucometer was for individual residents or shared and LPN-U informed Surveyor that the glucometer is shared by the residents on the unit. Surveyor asked what the cleaning procedure was. LPN-U informed Surveyor that LPN-U uses an alcohol wipe pad unless there are wipes available, if there is, then LPN-U will use those. On 4/15/2026, at 8:18am, Surveyor interviewed Unit Manager (UM)-T about the glucometers and was told each cart has 2, they are not assigned to individual residents. Surveyor discussed LPN-U wiping with alcohol wipe pad between residents and not cleaning the glucometer with the correct disinfectant. On 4/15/2026, at 3:30pm, during the end of day meeting, Surveyor let Clinical Nurse Specialist-B and Nursing Home Administrator (NHA)-A know of concern that the glucometer on the back area of the Sparkle unit was not cleaned with the proper disinfection process between residents. No additional information was provided regarding the use of an unsanitized glucometer for blood glucose sampling.

Based on interview and record review, the facility did not ensure that 5 out of 5 direct care staff reviewed received the required behavioral health training.*CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required behavioral training.This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.Findings include:The facility's policy dated as implemented 7/10/24 and revised 1/1/25 and titled Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training necessary are based on a facility assessment. 3. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles.6. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibilities for caring of residents. c. Elements and goals of the facility's QAPI program. d. Written standards, policies and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency procedures.10. Documentation of required training will be forwarded to the HR ( human resources) Department to be placed into the individual's personnel file, in accordance with facility policy for retention of training records. On 5/4/26, Surveyor randomly reviewed 5 Certified Nursing Assistants (CNA) from a list of employees provided by the facility. Surveyor review their annual performance reviews and required training.CNA- TT was hired on 12/4/2024CNA- UU was hired on 10/30/2024CNA- VV was hired on 12/4/2024CNA- WW was hired on 5/7/2024CNA- XX was hired on 10/30/2024The facility was unable to provide evidence that CNA-TT, CNA-UU, CNA-VV, CNA-WW and CNA-XX had received the required behavioral health training.On 5/5/26 at 9:45 AM, Surveyor interviewed HR (Human Resources) Director-YY who stated that after an employee is hired, HR Director-YY is responsible for all of the new-employee on-boarding and does not have anything to do with any of the annual trainings after the initial hire. HR Director-YY informed Surveyor that annual training should all be kept track of by nursing and that there is currently no Nurse Educator or Staff Development Coordinator.On 5/5/26, Surveyor interviewed Nursing Home Administrator- AAA and Director of Operations- O who both confirmed the facility did not have any evidence of behavioral health training being provided to staff. Nursing Home Administrator- AAA stated that all of the training records are in boxes that were kept by the previous Director of Nursing, and they have nothing organized for employee trainings. Nursing Home Administrator- AAA confirmed that there is no Staff Development Coordinator/ Designee who is maintaining a training schedule and or documentation for completed trainings. No additional information was provided.

Based on interview and record review the facility did not ensure that 5 out of 5 direct care staff reviewed received the required QAPI (Quality Assurance and Performance Improvement) training. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX all worked at the facility for longer than 1 year and have not received the required training.This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.Findings include:The facility's policy dated as revised 1/1/25 and titled, Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training necessary are based on a facility assessment. 3. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles.6. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibilities for caring of residents. c. Elements and goals of the facility's QAPI program. d. Written standards, policies and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency procedures.10. Documentation of required training will be forwarded to the HR (human resources) Department to be placed into the individual's personnel file, in accordance with facility policy for retention of training records. On 5/4/26, Surveyor reviewed 5 Certified Nursing Assistants (CNA) from a list of employees provided by the facility. Surveyor chose the following staff to review their annual performance reviews and required training.CNA- TT was hired on 12/4/2024CNA- UU was hired on 10/30/2024CNA- VV was hired on 12/4/2024CNA- WW was hired on 5/7/2024CNA- XX was hired on 10/30/2024.The facility was unable to provide evidence that CNA-TT, CNA-UU, CNA-VV, CNA-WW and CNA-XX had received the QAPI training.On 5/5/26 at 9:45 AM, Surveyor interviewed HR (Human Resources) Director-YY who stated that after an employee is hired, HR Director-YY is responsible for all of the new-employee on-boarding and does not have anything to do with any of the annual trainings after the initial hire. HR Director-YY informed Surveyor that annual training should all be kept track of by nursing and that there is currently no Nurse Educator or Staff Development Coordinator.On 5/5/26, Surveyor interviewed Nursing Home Administrator- AAA and Director of Operations- O who both confirmed the facility did not have any evidence of QAPI training being provided to staff. Nursing Home Administrator- AAA stated that all of the training records are in boxes that were kept by the previous Director of Nursing, and they have nothing organized for employee trainings. Nursing Home Administrator- AAA confirmed that there is no Staff Development Coordinator/ Designee, per policy who is maintaining a training schedule and a documentation system for completed trainings.No additional information was provided.

Based on interview and record review the facility did not ensure that 5 out of 5 direct care staff reviewed received the required training regarding infection control practices. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training.This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.Findings include:The facility's policy dated as revised 1/1/25 and titled, Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training necessary are based on a facility assessment. 3. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles.6. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibilities for caring of residents. c. Elements and goals of the facility's QAPI program. d. Written standards, policies and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency procedures.10. Documentation of required training will be forwarded to the HR ( human resources) Department to be placed into the individual's personnel file, in accordance with facility policy for retention of training records. On 5/4/26, Surveyor reviewed 5 Certified Nursing Assistants (CNA) from a list of employees provided by the facility. Surveyor chose the following staff to review their annual performance reviews and required training.CNA- TT was hired on 12/4/2024CNA- UU was hired on 10/30/2024CNA- VV was hired on 12/4/2024CNA- WW was hired on 5/7/2024CNA- XX was hired on 10/30/2024.The facility was unable to provide evidence that CNA-TT, CNA-UU, CNA-VV, CNA-WW and CNA-XX had received infection control training.On 5/5/26 at 9:45 AM, Surveyor interviewed HR (Human Resources) Director-YY who stated that after an employee is hired, HR Director-YY is responsible for all of the new-employee on-boarding and does not have anything to do with any of the annual trainings after the initial hire. HR Director-YY informed Surveyor that annual training should all be kept track of by nursing and that there is currently no Nurse Educator or Staff Development Coordinator.On 5/5/26, Surveyor interviewed Nursing Home Administrator- AAA and Director of Operations- O who both confirmed the facility did not have any evidence of infection control training being provided to staff. Nursing Home Administrator- AAA stated that all of the training records are in boxes that were kept by the previous Director of Nursing, and they have nothing organized for employee trainings. Nursing Home Administrator- AAA confirmed that there is no Staff Development Coordinator/ Designee who is maintaining a training schedule and or documentation for completed trainings. No additional information was provided.

Based on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 1 (R5) of 3 residents reviewed for allegations of abuse.On 4/5/26, Certified Nursing Assistant (CNA)-X performed cares independently with R5, and R5 rolled out of bed. R5 was evaluated in the emergency room (ER) on 4/9/26 with findings that did not correlate to the fall on 4/5/26 and with the bruising identified as potential abuse in the ER.Findings include:The facility's policy titled Abuse, Neglect and Exploitation dated 9/18/23, last reviewed 7/1/25, documents:Guideline:It is the guideline of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property.Definition:Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs.Prevention of Abuse, Neglect and Exploitation:The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur.Identification of Abuse, Neglect and Exploitation:The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.Possible indicators of abuse include, but are not limited to:Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body; Physical injury of a resident, of unknown source; Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and repositioning.Investigation of Alleged Abuse, Neglect and ExploitationAn immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.Written procedures for investigations include:Identifying staff responsible for the investigation; Exercising caution in the handling evidence that could be used in a criminal investigation; Investigating different types of alleged violations; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation.Protection of ResidentThe facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:Responding immediately to protect the alleged victim and integrity of the investigation;This should include staying with the alleged perpetrator to ensure no further contact (verbal or physical) until removal form the facility/environment.Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increased supervision of the alleged victim and residents; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;Protection from retaliation;Providing emotional support and counseling to the resident during and after the investigation, as needed; Revision of the resident's care plan if the residents medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.R5 was admitted to the facility on [DATE] with diagnoses that includes congenital hydrocephalus (water on the brain causing symptoms of cognitive difficulties like memory loss), contracture of bilateral upper extremities (fibrous tissue injury resulting in lack of movement in the arms), contracture of bilateral lower extremities (fibrous tissue injury resulting in lack of movement in the legs), osteoarthritis (OA) (tissue in the joints, break down causing pain, stiffness, swelling and reduced mobility), history of fall and seizures.R5's Significant Change Minimum Data Set (MDS) completed on 4/2/26, documents that R5 was assessed to be dependent with all cares (including toileting, transfers, eating and dressing) and frequently incontinent of bowel and bladder. The MDS documents a Brief Interview for Mental Status (BIMS) score of 9, indicating that R5 has moderate cognitive impairment.R5's Care Area Assessment (CAA) documents:Cognitive Loss/Dementia CAA: R5 has cognitive decline and needs limited to extensive assistance with Activities of Daily Living (ADL)s, mobility and bowel and bladder management. R5 is at risk for behaviors, poor communication and understanding. The plan is for nursing staff to monitor R5's behaviors and R5's ability to communicate with staff. The goal is for R5 to have minimal to no behaviors, optimal communication and understanding with all needs met while residing at the facility.Functional Abilities CAA: R5 needs extensive assistance with ADL's, mobility and bowel and bladder management. R5 is at risk for falls and skin breakdown. The plan is for nursing to monitor R5's safety and skin integrity. The goal is for R5 to remain free of falls and skin breakdown while residing at the facility.Urinary Incontinence CAA: R5 has incontinence and needs extensive assistance with ADL's, mobility and bowel and bladder management. R5 is at risk for urinary complications and skin breakdown. The plan is for nursing staff to monitor R5's urinary status and skin integrity. The goal is for R5 to remain free of urinary complications and skin breakdown while residing at the facility.Falls CAA: R5 receives psychotropic medications and needs extensive assistance with ADL's, mobility and bowel and bladder management. R5 is at risk for falls, with and without injury. The plan is for nursing staff to monitor R5's safety. The goal is for R5 to remain free of falls while residing at the facility.R5's care plan dated 6/22/22, documents: R5 is at risk for falls, accidents and incidents related to unawareness and safety needs. R5 will fall from the bed or chair as a behavior. R5 has been noted to throw themselves on the floor. R5 will be half in bed and half out of bed at times (date initiated 1/23/26, revised on 1/23/26).Interventions include: Bed to be kept in lowest position (date initiated 10/11/25); Body pillows to be placed on both sides of R5 while in bed (date initiated 10/11/25); Hourly rounding or placement in common areas for monitoring (date initiated 10/22/25); Use bilateral body pillows (date initiated 6/9/25); Use bilateral floor mats (date initiated 5/2/25); Use bolsters on bed (date initiated 10/1/25); Ensure bed brakes are locked (date initiated 6/22/22)l Ensure two staff members are present during cares and interactions with R5 (date initiated 1/18/25, revised 4/9/26); True low bed (date initiated 5/21/25, revised on 6/5/25).R5 has an ADL self-care performance deficit and limited physical mobility related to right intertrochanteric femur fracture status/post Open Reduction and Internal Fixation (ORIF), fall, acute blood loss anemia, GERD, constipation, insomnia, congenital hydrocephalus with a shunt, seizures and Osteoarthritis (OA) (date initiated 6/22/22, revised on 5/2/25).Interventions include:Personal Hygiene: Physical assist of 1 staff member (created on 6/22/22, revised on 10/5/22).Toileting: Assistance of 1 staff member with a bedpan and incontinence care (date initiated 6/22/22, revised on 7/14/24).Transfer: R5 requires a Hoyer lift with 2 staff assistance (date initiated 7/8/22, revised on 6/21/24).Surveyor reviewed R5's Electronic Medical Record (EMR) and facility self-report which documents R5 having a fall on 4/5/26, at 6:00 AM.Surveyor reviewed R5's fall investigation dated 4/5/26, which documents: Certified Nursing Assistant (CNA)-X was performing cares alone on R5 with R5 lying in bed. CNA-X had R5 facing away from her at the time of cares and R5 rolled out of bed. CNA-X did not see R5 roll out of bed but heard R5 roll out of bed. All interventions were documented as being in place. Immediate interventions were documented as putting the bed in the lowest position and bilateral body pillows to be placed. The root cause of the fall was documented as R5 had a high fall risk requiring 2-person assistance, however, care was performed with 1 staff member. Staff interviews were collected from facility staff whom worked night shift from 4/5/26 to 4/8/26.A statement from Medical Director (MD)-NN documents: R5 exhibits impulsive behavior specifically history of forceful self-extraction from beds and chairs. These sudden movements combined with impaired judgement present an increased risk of falls. It is helpful to note that contractures create leverage on the bones. If R5 falls while a limb is contracted, the bone is much more likely to snap than a flexible limb would be. Chronic contractures severely limit R5's Range of Motion (ROM) and postural stability, making independent movement unsafe and increasing the physical stress on long bones during any sudden shift in position. Given R5's overall frailty and the mechanical stress caused by the aforementioned contractures and documented impulsive movements, R5 is a markedly increased risk for pathological, or trauma induced fractures.Surveyor noted that the facility's self-report documents staff interviews identified R5 exhibiting/verbalizing pain at the time of the fall on 4/5/26, but did not present with deformity, swelling or bruising.Surveyor noted that Licensed Practical Nurse (LPN)-Y documented R5 was exhibiting left ankle deformity on 4/7/26.Surveyor noted that the facility's skin assessment completed on 4/6/26 for R5 documents R5 having BLE bruising was not identified on the 4/5/26 skin assessment with no further updates to R5's physician.Surveyor noted that the facility documented a failure to escalate incident and failure to complete a 72-hour post fall documentation.On 4/16/26, at 7:25 AM, Surveyor interviewed RN/PM Supervisor-D who stated an RN assessment is required for residents that had a fall, prior to moving the resident and that neurological checks, pain assessment, skin checks and a resident statement are obtained after a fall. RN/PM Supervisor-D stated staff will then use a Hoyer lift to get the resident back in bed if appropriate after an assessment has been completed and that staff will then notify the resident's physician of the fall.RN/PM Supervisor-D stated nursing staff contacted her on 4/9/26 with concerns of R5 having a left ankle deformity. RN/PM Supervisor-D stated RN-Z was caring for R5 and noted left ankle deformity while performing cares. RN/PM Supervisor-D stated that she also noted R5 having +2 to +3 edema to BLE (bilateral lower extremities) with R5's left leg edema greater than right leg. RN/PM Supervisor-D also noted R5 having bruising to both lower extremities from the knees down and described the bruising as patches of bruising that are increased more to the left ankle and left foot. RN/PM Supervisor-D indicated bruising was a reddish-purple bruising with somewhat faded bruising noted on both lower extremities. RN/PM Supervisor-D and RN-Z noted a change in condition with R5's ankles on 4/9/25, and contacted hospice, APOA and the provider.RN/PM Supervisor-D stated the provider ordered STAT x-rays but later determined x-rays would take too long and the on-call provider advised R5 to be sent to the emergency room (ER) for evaluation. RN/PM Supervisor-D stated there wasn't much information in R5's medical record regarding R5's fall that occurred on 4/5/26. Surveyor asked RN/PM Supervisor-D the cause of R5's falls and RN/PM Supervisor-D responded that she is not sure why and then stated R5 is supposed to be an assist of two staff members and a buddy system. RN/PM Supervisor-D stated if a resident does not have good body coordination, that resident could roll right off the bed. RN/PM Supervisor-D also stated R5 will sometimes tell staff that R5 is not in pain when R5 is actually expressing pain by staff observations. RN/PM Supervisor-D stated R5 is not always accurate with responses, and it is hard to rely on R5's responses.On 4/15/26, at 10:22 AM, Surveyor interviewed CNA-X who stated that R5's usual body position is contracted in the fetal position with R5's knees approximately 10 -15 inches away from R5's chin. CNA-X stated R5 was excited to see CNA-X on 4/5/26, and R5 was attempting to wiggle her way out of bed. CNA-X stated she would go into R5's room and ask if R5 was ok. CNA-X stated R5 could not say if anything was wrong. CNA-X stated she increased her rounding with R5 due to R5 consistently wiggling and attempting to roll out of bed. CNA-X stated she was working with R5 on 4/5/26 at 6:00 AM, and CNA-X stated she was performing cares on R5 while R5 was lying in bed. CNA-X turned away from R5 while performing cares and R5 then rolled out of bed. CNA-X did not see R5's actual fall from the bed. CNA-X only heard R5 fall.CNA-X stated she thought that R5 hit R5's head on the bedside table and rolled on to R5's body, on top of R5's legs. CNA-X immediately got two nurses who were at the nursing station. CNA-X stated R5 developed a bump on R5's head with no other noticeable injuries or bruising. CNA-X stated she also worked on 4/6/26 and provided cares to R5 and noted R5's BLE to have significant and noticeable bruising. CNA-X described R5's bruising to be splotchy from R5's knees to ankles which was a change from her previous shift on 4/5/26. CNA-X noted R5's BLE crackling on 4/6/26 when attempting to perform cares and stated she asked the nurse to assess R5 due to this change. CNA-X stated the nurse assessed R5 and noted crackling, and the nurse stated this was documented in R5's medical record and that the nurse directed CNA-X to proceed with dressing R5 and get R5 up for the day which required a Hoyer lift. Surveyor asked CNA-X to describe how staff utilize the Hoyer lift with R5's severe contractures. CNA-X responded that R5 is supported with R5's back and buttocks, depending on how R5 is adjusted in the Hoyer lift and stated that staff have to adjust R5's legs when putting R5 into the wheelchair so R5 doesn't sit on R5's legs or get them caught in the wheelchair. CNA-X stated the way R5's body is, R5 could easily sit on R5's legs with the Hoyer lift. When R5 is in bed, CNA-X stated, staff also have to be careful with the wedges for support.On 4/15/26, at 3:00 PM, Surveyor interviewed RN-DD who stated staff refer to the EMR and Kardex to determine the number of staff needed for assistance. RN-DD stated she was the charge nurse on 4/5/26 and was contacted by nursing staff to evaluate R5 post fall. RN-DD stated R5 was lying on the floor on the nightstand with R5's brief half on. R5 was on the floor lying on R5's right side of bed. RN-DD stated CNA-X indicated she was providing cares for R5 alone and reached to the nightstand when R5 rolled out of bed. RN-DD stated she performed neurological checks, pain assessment, skin check, contacted hospice and obtained vitals. RN-DD stated she rubbed R5's legs to see if R5 would wince and grimace. RN-DD stated R5 denied pain and noted no bruising to bilateral lower extremities. RN-DD stated facility staff assisted R5 back into bed using a Hoyer lift. RN-DD stated she saw R5 a couple of days later on 4/8/26 during the night shift and another nurse reported R5's legs looked broken, and RN-DD went to assess R5. RN-DD stated a CNA reported off to another nurse that R5's legs looked broken, and legs were really bruised up and looked different from when R5 fell on 4/5/26. RN-DD stated that sometimes bruising can take a few days and staff notified RN/PM Supervisor-D who performed an assessment and indicated R5's ankle appeared different.On 4/15/26, at 11:19 AM, Surveyor interviewed LPN-Y. Surveyor asked LPN-Y what the protocol is for a change of condition. LPN-Y responded she will assess the resident to determine if there are immediate needs, obtain a set of vital signs, perform a skin assessment and will notify the unit manager for further assessment. LPN-Y stated the CNA notified her on 4/7/26, that R5's ankle looked deformed. LPN-Y stated she did not observe skin changes or bruising. LPN-Y stated R5 is able to let staff know if R5 is experiencing pain and R5 denied pain at that time. LPN-Y then stated they dropped the ball and should have reported this new change in condition to R5's provider. LPN-Y then stated they were thinking R5's legs normally look like this and stated again, they dropped the ball and should have reported it. LPN-Y stated report that was given at the beginning of the shift reporting no changes for R5. R5 lays on R5's right side and left ankle, with a pillow normally between R5's legs or feet. LPN-Y stated it looked out of place like a joint popped out of place, but she wasn't sure because of R5's contractions. LPN-Y stated no bruising was noted to R5's BLE on 4/7/26. LPN-Y stated she did not report any changes to the next nurse. LPN-Y stated she felt terrible because the facility told her this was something that happened days ago and not reported. LPN-Y stated R5 rolled out of bed and was told someone had R5's bed up super high and she rolled out. LPN-Y stated R5 will swing R5's legs off the Broda chair and R5 leans a lot. LPN-Y stated I felt bad because I was one of the people that dropped the ball with R5.On 4/15/26, at 9:48 AM, Surveyor interviewed RN-Z who stated R5's contractures limits mobility and R5 is in the fetal position. R5 has moderate movement with upper extremities but does not have dexterity in fingers. R5's knees can be up to R5's chin at times depending on how R5 is adjusted in bed. RN-Z stated R5's feet are pointed down and to the center of R5's midline of body similar to drop foot. RN-Z stated he was working on the night shift 4/8/26 into 4/9/26, and it was shared in report that R5 had a fall with bruising on BLE, a knot on R5's head and R5 seemed out of it. Surveyor asked RN-Z if the nurse giving report indicated they contacted R5's provider with R5 being out of it, and RN-Z stated the previous nurse didn't say she contacted anyone regarding R5 is seeming out of it. RN-Z went and administered R5 medications on 4/8/26, at 10:00 PM, and noted R5 to be at baseline. RN-Z then stated the CNA notified him of change. RN-Z then went in R5's room to perform scheduled skin prep on R5's bilateral heels and noticed R5 grimacing and extensive bruising and swelling to both legs. RN-Z stated R5's left leg appeared twisted, and the right leg looked normal per contractures. RN-Z stated he notified the charge nurse with the changes noted to R5's BLE. RN-Z stated the charge nurse indicated this was a change and advised RN-Z to contact hospice and the provider.RN-Z stated the previous skin assessment performed on 4/6/26 had the same information that was assessed on 4/9/26. RN-Z stated there were no notes outside of giving report and everything was being shared by word of mouth. RN-Z stated bruising will develop over time and over several days. RN-Z stated R5 had long bruises to both legs that looked purple and both legs appeared to be swollen with R5's legs appearing to be red, some with purple and increased swelling. RN-Z stated R5's BLE edema increased when R5 got up from the bed with less blood return to the legs which started to be even more alarming. RN-Z stated he did not perform a full skin assessment and stated R5's arms were not exposed. RN-Z was able to view R5's legs due to performing skin prep on bilateral heels. RN-Z stated R5 was sent to the ER for further evaluation.On 4/14/26, at 12:55 PM, Surveyor interviewed Forensic Nurse-CC. R5 arrived at the ER for evaluation on 4/9/26, for left ankle deformity. ER staff noted R5 having extensive bruising underneath the chin, right forehead, right clavicle, left forearm and BLE's. Forensic Nurse-CC stated the ER was notified of R5 having a fall from bed on 4/5/26 that did not seem to correlate with the fall. Forensic Nurse-CC stated the hospice nurse arrived at the ER at the same time Forensic Nurse-CC arrived in the ER to evaluate R5. Forensic Nurse-C stated the hospice aide last saw R5 on 4/7/26 and noted bruising underneath R5's chin and right forehead.Forensic Nurse-CC asked R5 if anyone harmed R5, and R5 stated no, but then stated yes indicating someone had pushed R5. R5 was unable to state whether it was a resident or staff member who pushed R5. R5 denied pain at the time of evaluation when asked however, R5 would start moaning when ER staff picked up R5's BLE's. Forensic Nurse-CC stated she performed a skin assessment on R5 which documents:Round fingerprint bruise under chin, not on bony prominence; Significant intermittent bruising on left forearm and left wrist potentially from being grabbed; 3 to 4 finger like bruising impressions on right clavicle that were more vertical than horizontal; Left leg with significant bruising from just below the left knee. Mid-calf to the foot appeared swollen, echymotic and deformed; Right lower leg appearing swollen, echymotic and bruised.Forensic Nurse-CC stated, when staff picked up R5's left leg, it was floppy, and the left leg bent in half when being picked up. Forensic Nurse-CC stated all bruising was not on bony prominences. Forensic Nurse-CC reiterated that R5's knees, elbows, chin and shoulder bony prominences were free from bruising. Forensic Nurse-CC stated x-rays were performed and revealed bilateral proximal and distal tibia and fibula fractures on both legs. Forensic Nurse-CC stated the ER MD stated verbally to Forensic Nurse-CC that these are spiral fractures that indicate abuse. Forensic Nurse-CC acknowledged R5 having a history of fractures in the past and then stated the radiologist determined these were acute fractures. Forensic Nurse-CC stated police were contacted regarding allegations of abuse.On 4/16/26, at 11:16 AM, Surveyor interviewed NHA-A and Director of Operations-O who stated they were notified of a change in condition with R5 the morning of 4/9/26. NHA-A stated police showed up at the facility on 4/9/26, indicating the ER contacted police with suspicion of abuse. NHA-A stated the facility started an investigation on 4/9/26 and noted R5 with a fall on 4/5/26. The facility's investigation included staff statements from staff that took care of R5 from the time of the fall. NHA-A stated the facility did not suspect abuse. NHA-A stated the facility identified that CNA-X provided cares independently for R5 when cares are to be provided with two staff members. Director of Operations-O stated this wasn't a perfect fall investigation and the facility needed to make some changes.On 4/16/26, at 3:23 PM, Surveyor interviewed NHA-A, Clinical Nurse Specialist-B and Director of Operations-O. Director of Operations-O stated that there was a delay in the facility's response with R5's change in condition and then notification of change was not properly completed. Clinical Nurse Specialist-B stated R5 is truly an assist of one and CNA-X should have had another staff member with her. Surveyor asked how the facility protects residents with abuse allegations. NHA-A stated we should treat it as an injury of unknown origin. NHA-A then stated this was not abuse, it is an injury of unknown origin. Clinical Nurse Specialist-B stated R5 had hospice services and R5 will still get treatment and services even while on hospice care. Surveyor notified NHA-A, Clinical Nurse Specialist-B and Director of Operations-O that police notified the facility of possible allegations of abuse on 4/9/26, that the facility did not complete a thorough abuse investigation as the investigation did not include any resident interviews that were obtained, and staff statements were obtained from night shift only.No additional information was provided.

Based on interview and record review, the facility did not ensure 13 (R13, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, & R27) of 13 sampled residents with scheduled medication administrations on 3/6/2026 from 7:00pm to 7:00am were free from significant medication errors.Findings include:The Facility Policy and Procedure titled, Medication Error Reporting and Counseling Procedure, last revised 4/9/2025, documents: Explanation and Compliance Guidelines:1. The facility shall ensure medications will be administered as follows:a. According to physician's orders.4. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following:a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to:i. Incorrect dose, route, dosage form, time of administration;ii. Medication omission.8. If a medication error occurs, the following procedure will be initiated:a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible.b. Monitor and document the resident's condition, including response to medical treatment or nursing interventions.c. Document actions taken in the medical record.Detailed Procedure After Medication Error:1. Reporting the Medication Error:a. The person who identifies a medication error should immediately report it to the charge nurse or the designated nursing supervisor and ultimately the Director of Nursing. When a medication error occurs, the licensed nurse/employee needs to be able to report the error, and without fear of penalty, to Nursing Management.b. Provide accurate, factual, and detailed information regarding the error by completing a Risk Management report. There is full transparency around medication errors to develop actions to correct the error and to prevent recurrence.2. Assessing and Documenting the Medication Error:a. A prompt assessment of the resident(s) involved to be completed to determine harm or the potential risks to the resident. Document all relevant details of the medication error in the resident's record and incident report (Risk Management).3. Notifying the Provider(s):a. The facility will inform the primary or prescribing physician(s) of the medication error in a timely manner and document notification in the medical record.5. Medication Error Counseling:a. The staff members involved in the medication error will complete a Medication Error Counseling form with the Director of Nursing or Designee. The error needs to be examined for causative factors including human error and system/procedure issues.7. Continuous Quality Improvement:a. The facility will conduct periodic reviews of medication errors through QAPI (Quality Assurance Performance Improvement) to identify recurring themes or patterns.Findings include:Surveyor was investigating a complaint alleging that residents located in the back part of the Sparkle unit did not receive medications after 7pm on March 6th, 2026. Surveyor reviewed the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for residents residing on the Sparkle unit for that shift. Surveyor noted that 13 residents had medications not marked as administered on their MAR. Surveyor noted that four residents on the unit did not have scheduled medications on the night shift, after 7pm, on 3/6/2026.On 4/15/2026, at 11:03am, Surveyor interviewed Unit Manager (UM)-T regarding the MAR/TAR for 3/6/2026 and medications not administered after 7pm. UM-T had not noticed this and will look into the issue. Surveyor asked if the physicians were called and UM-T stated no, because they did not know about the issue.On 4/15/2026, at 2:17pm, Surveyor discussed concern with Clinical Nurse Specialist-B regarding medications not being administered after 7pm on 3/6/2026. Clinical Nurse Specialist-B stated will look into but won't find anything because it was before Clinical Nurse Specialist-B got here to fix issues.On 4/16/2026, at 8:40am, Surveyor interviewed Agency Nurse-GG who stated their shift started at 7pm, they were on the front part of the Sparkle unit. Agency Nurse-GG remembers that there was not another nurse to cover the back part of the Sparkle unit until 11pm, none of the nurses working would stay late to cover the unit. On 4/16/2026, at 8:53am, Surveyor interviewed Licensed Practical Nurse (LPN)-W who stated they picked up a shift on 3/6/2026 and worked 11pm to 7am. There was another nurse on the front cart. No one was on the back cart when LPN-W started the shift. Surveyor asked if LPN-W gave medications when they arrived that night. LPN-W stated all the medications were red as they were not given and it was past the administration time. Surveyor asked if LPN-W proceeded to give the medications and was told no, due to the time to be given, they should have been given earlier, they were late. Surveyor asked LPN-W if they contacted the physician and was told no, they notified the Assistant Director of Nursing and was told it was ok, so the physician was not notified.A review of the residents MAR on the Sparkle unit for March 6, 2026 after 7 PM noted that the following residents did not receive the following medications per physician orders:*R24 had the following medications scheduled for HS (at bedtime) on 3/6/2026 that were not marked as administered: Amlodipine besylate 10mg for hypertension, ammonium lactate external cream 12% for dry feet, melatonin 3mg for insomnia, and senna-docusate 8.6-50mg for constipation.R24's progress note dated 3/9/2026, written at 6:12pm documents: F/U (follow up) to 3/7 SBP (systolic blood pressure) 191. Nurse Practitioner was notified and no new orders placed. BP (blood pressure) this shift was 145/64. Surveyor noted the 3/7/26 blood pressure was taken in the morning following R24 missing the bedtime dose of amlodipine besylate 10mg. Surveyor noted amlodipine besylate 10mg is for elevated blood pressure which 191 for systolic blood pressure demonstrates.*R23 had the following medications scheduled for HS (at bedtime) on 3/6/2026 that were not marked as administered: Benadryl 25mg for allergies, gabapentin 100mg for neuropathy, Lantus insulin 10 units for diabetes mellitus 2 blood glucose management, metoprolol tartrate 125mg for hypertension, pravastatin 80mg for hyperlipidemia, and trazadone 25mg for insomnia. R23 had the medication amlodipine besylate 5mg scheduled for 5:00am on 3/7/2026 and it was not marked as administered. Surveyor noted LPN-W worked from 11pm to 7am. *R21 had the following medications scheduled for HS (at bedtime) on 3/6/2026 that were not marked as administered: atorvastatin calcium 80mg for hyperlipidemia, Lantus insulin 22 units for diabetes mellitus 2 blood glucose management. Metoprolol succinate 12.5mg for hypertension was scheduled for 9:00pm and gabapentin 200mg for neuropathy was scheduled for 8:00pm and neither were marked as administered. *R22 had the following medications scheduled for HS (at bedtime) on 3/6/2026 that were not marked as administered: Seroquel 50mg for bipolar disorder, acetaminophen 1000mg for pain, benztropine mesylate 1.5mg for Parkinson's, gabapentin 100mg for pain, levetiracetam 750mg for seizures, pramipexole dihydrochloride 0.125mg for restless leg syndrome, and senna plus 8.6-50mg for constipation.*R19 had ramelteon 8mg for insomnia scheduled at 8:00pm on 3/6/2026 that was not marked as administered. R19 had the following medications scheduled for 9:00pm that were not marked as administered: budesonide-formoterol fumarate inhaler for shortness of breath, levetiracetam 1500mg for prevention of seizure, and metoprolol tartrate 150mg (diagnosis not indicated).*R25 had carvedilol 12.5mg for heart health and Eliquis 5mg for blood clot prevention scheduled at 9:00pm on 3/6/2026 that were not marked as administered. R25 had baclofen 5mg for muscle spasms and gabapentin 300mg for pain management scheduled for 8:00pm and neither were marked as administered.*R26 had the following medications scheduled for HS (at bedtime) on 3/6/2026 that were not marked as administered: atorvastatin calcium 40mg for cholesterol, famotidine 20mg for acid indigestion, melatonin 5mg for insomnia, quetiapine fumarate 200mg for sleep/anxiety, dicyclomine HCl 20mg for irritable bowel syndrome, fiber laxative 1250mg for constipation, and pantoprazole sodium 40mg for GERD (Gastroesophageal Reflux Disease).*R20 had atorvastatin calcium 20mg for HDL (high-density lipoprotein cholesterol) and apixaban 2.5mg for nontraumatic subarachnoid hemorrhage scheduled for HS (at bedtime) on 3/6/2026 that were not marked as administered. R20 had mirtazapine 7.5mg for weight loss scheduled at 8:00pm that was not marked as administered. *R13 had melatonin 8mg for sleep deprivation and zyprexa zydis 5mg for schizophrenia scheduled at 8:00pm on 3/6/2026 that were not marked as administered. R13 had senna 8.6mg for constipation scheduled for 9:00pm that was not marked as administered. R13 had gabapentin 200mg for pain, famotidine 20mg for GERD (Gastroesophageal Reflux Disease), preservision areds 2 (supplement for eye health) and Tylenol 500mg for pain/fever scheduled for HS (at bedtime) that were not marked as administered.*R18 had atorvastatin calcium 40mg for cholesterol that was scheduled at 8:00pm on 3/6/2026 that was not marked as administered. R18 had apixaban 5mg for blood thinner and pantoprazole sodium 40mg for GERD (Gastroesophageal Reflux Disease) that were scheduled for HS (at bedtime) that were not marked as administered.*R16 had apixaban 2.5mg for blood thinner that was scheduled at 9:00pm on 3/6/2026 that was not marked as administered.*R17 had the following medications scheduled for 8:00pm on 3/6/2026 that were not marked as administered: atorvastatin calcium 20mg for cholesterol, clonazepam 0.5mg for anxiety, escitalopram oxalate 10mg for anxiety, hydrocortisone 10mg (no diagnosis given), melatonin 9mg for sleep, ropinirole HCl 2mg for restless legs, and tamsulosin HCl 0.4mg (no diagnosis given).* R27 had melatonin 6mg for insomnia scheduled for HS (at bedtime) on 3/6/2026 that was not marked as administered.No additional information was provided as to why the facility did not ensure that above residents received medications on the night shift of 3/6/2026.

Based on interview and record review, the facility did not ensure residents' physician and/or residents' representative were notified of changes including accidents resulting in injury, need to alter treatment for 3 (R1, R5, and R14) of 30 residents reviewed. R1's physician was not made aware of/ consulted with regarding a 20 lb. weight loss between 3/25/2026 – 4/8/2026. R5's case manager was not notified of a fall with injury that occurred on 4/5/2026. R14's power of attorney (POAHC) was not notified on abnormal lab results or changes to R14's wounds. Findings include: The facility policy titled Notification of Changes last reviewed/revised 3/31/2025 documents: The purpose of this guideline is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident' representative when there is a change requiring notification. Changes of condition require an evaluation, by using the eINTERACT Change in Condition Evaluation ensures proper documentation and notifications have been made.Compliance Guideline:The facility must inform the resident, consult with the resident's physician and/ or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notifications include:1. Accidents .2. Significant change in the resident's physical . condition such as deterioration in health .3. Circumstances that require a need to alter treatment. 1.) R1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, dementia, major depressive disorder, anxiety disorder, and chronic obstructive pulmonary disease (COPD). R1's admission Minimum Data Set (MDS) dated [DATE] documents that R1 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. The MDS documents that the facility assessed R1 needing assistance with meal setup and assistance of 1 staff member with activities of daily living (ADL's). The MDS documents that R1 had an order for regular diet with regular fluids. R1 did not have an activated power of attorney and made medical decisions and was discharged from the facility on 4/13/2026. R1's care plan documented nutritional risk related to COPD, chronic kidney disease (CKD) stage 3, obesity, and dementia, initiated on 3/27/2026 had the following interventions:- Administer medications as ordered. Monitor/Document for side effects and effectiveness.- Obtain and monitor lab/diagnostic work as ordered. Report results to medical doctor (MD) and follow up as indicated.- Provide and serve diet as ordered. Monitor intake.- Provide and serve supplements as ordered.- RD (Registered Dietitian) to evaluate and make diet change recommendations as needed.- Weigh as ordered or per facility protocol. Monitor for changes. R1's physician orders document:-Obtain weight upon admission then weekly for four (4) weeks. (Start: 3/26/2026) Surveyor reviewed R1's documented weights and noted R1's only weight documented was 183.8 lbs. on 4/8/2026. Surveyor noted there was no admission weight obtained for R1 on 3/25/2026. Surveyor reviewed R1's medication/treatment administration record (MAR/TAR) for March and April 2026 and noted staff documented weight not obtained for R1 on 3/26/2026 and 4/1/2026. Surveyor reviewed R1's nursing progress notes. Surveyor noted there is no documentation indicating R1 refused to have weights obtained. On 4/15/2026, at 10:06 AM, Surveyor interviewed RD (Registered Dietician)-G who stated an admission weight was not documented for R1 so RD-G reviewed R1's hospital discharge paperwork and noted R1's weight in the hospital was 203.7 lbs. RD-G stated RD-G did a nutritional assessment on R1 and initiated the care plan. RD-G requested a weight be obtained for R1. On 4/8/2026 when RD-G followed-up with R1, RD-G noted R1's documented weight on 4/8/2026 was 183.8 lbs. indicating a 20 lb. weight loss had occurred between 3/25/2026 – 4/8/2026 (14 days). RD-G stated RD-G requested a re-weight for R1 and R1's weight loss was discussed in the morning interdisciplinary team (IDT) review meeting but is not sure what happened after that regarding R1's weight loss. RD-G stated RD-G was never able to follow up because R1 discharged on 4/13/2026. Surveyor asked RD-G when should staff obtain a requested re-weight for a resident. RD-G stated a re-weight should hopefully be obtained within 24-48 hours preferably if not the same day requested. Surveyor asked RD-G if R1 refused to get weights checked. RD-G stated RD-G is unaware if R1 refused to get weights taken. Surveyor asked if RD-G contacted R1's physician regarding the weight loss. RD-G did not contact R1's physician and was waiting to see if the weight obtained on 4/8/2026 was accurate. On 4/15/2026, at 12:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-HH who stated when a resident admits to the facility, staff are to obtain a weight on the resident if able. LPN-HH was not able to recall if LPN-HH obtained a weight on R1 when R1 was admitted to the facility in 3/25/2026. LPN-HH did not recall R2 refusing anything during R1's admission in the facility. LPN-HH stated if a resident refuses treatment, nursing staff is to document in the progress notes what was refused, why, and what interventions were implemented. LPN-HH stated nursing staff would follow up with the certified nursing assistant (CNA) staff to verify if a weight was obtained and why if not obtained. Surveyor asked LPN-HH if a re-weight is requested, how are staff notified and when should the re-weight be obtained. LPN-HH stated a re-weight should be obtained and reported when able to get it and staff are usually notified of a needed weight by looking at the 24 hour board or being told and passed down in end of shift report if it was not completed on the current shift. Surveyor asked who normally would contact the physician regarding weight loss. LPN-HH stated nursing, or management could contact the physician. LPN-HH was not sure if R1's physician had been contacted regarding weights not being obtained or a weight loss having occurred for R1. Surveyor reviewed nursing progress notes and did not find documentation of notification to the physician or an eINTERACT Change in Condition form completed for R1's weight loss. On 4/15/2026, at 2:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, Clinical nurse specialist (CNS)-B, and Director of Operations (DOO)-O. NHA-A stated R1 discharged from the facility before a re-weight could be obtained. Surveyor asked if R1's physician was notified regarding weights not being obtained until 4/8/2026 which identified a 20 lb. weight loss from the hospital admission weight. NHA-A does not recall if the physician was notified and would look into the concern. On 4/15/2026, at 2:39 PM, NHA-A was unable to locate documentation R1's physician was notified of R1's missed weights or a 20 lb. weight difference from R1's hospital discharge weight to R1's current weight obtained on 4/8/2026. No additional information was provided. 2.) R5 was admitted to the facility on [DATE] with diagnoses that include congenital hydrocephalus (water on the brain causing symptoms of cognitive difficulties like memory loss), contracture of bilateral upper extremities (fibrous tissue injury resulting in lack of movement in the arms), contracture of bilateral lower extremities (fibrous tissue injury resulting in lack of movement in the legs), osteoarthritis (OA) (tissue in the joints, break down causing pain, stiffness, swelling and reduced mobility), and history of fall and seizures. R5's Significant Change Minimum Data Set (MDS) completed on 4/2/26, documents R5 is dependent with all cares (including toileting, transfers, eating and dressing). R5 is frequently incontinent of bowel and bladder. R5 was documented as having a Brief Interview for Mental Status (BIMS) score of 9, indicating R5 has moderate cognitive impairment. Surveyor reviewed R5's Electronic Medical Record (EMR) and facility self-report which documents R5 having a fall on 4/5/26, at 6:00 AM. Surveyor reviewed R5's fall investigation dated 4/5/26, which documents the following: Certified Nursing Assistant (CNA)-1 (CNA- X) was performing cares alone on R5 with R5 lying in bed. CNA-1 (CNA-X) had R5 facing away from her at the time of cares and R5 rolled out of bed. CNA-1 (CNA-X) did not see R5 roll out of bed but heard R5 roll out of bed. All interventions were documented as being in place. Immediate interventions were documented as putting the bed in the lowest position and bilateral body pillows to be placed. The root cause was documented as R5 had a high fall risk requiring 2-person assistance, however, care was performed with 1 staff member. On 4/15/26, at 12:40 PM, Surveyor interviewed LPN-EE who stated she contacts a RN in the building for an assessment with a fall or change in condition. On 4/15/26, at 8:58 AM, Surveyor interviewed Clinical Nurse Specialist-B who stated the expectation of every fall is to complete all checks listed below: *Fall Risk Assessment that includes when the resident was last seen, toileted, if interventions were in place and if immediate interventions were initiated. *Neuro checks *Vital signs *Skin assessment *Pain assessment *Notify Hospice, POA, MD and Case Manager *Root Cause *72-hour post fall assessment *Care plan interventions reviewed/evaluated/updated *IDT (Interdisciplinary Team) to meet to discuss fall On 4/14/26, at 1:47 PM, Surveyor interviewed Community RN Case Manager-BB who stated he was notified on 4/10/26 of R5 having a fall with injury on 4/5/26. Community RN Case Manager-BB stated it is an expectation for the facility to notify the community case manager with a significant change or a fall within 24 hours, and this did not happen with R5's 4/5/26 fall. Community RN Case Manager-BB stated R5 currently has bilateral splints to BLE's (Bilateral Lower Extremities) due to fractures. Community RN Case Manager-BB stated he was notified the CNA was changing R5 on 4/5/26, in R5's bed, and left the room to get washcloths and did not witness R5 falling from the bed. Community RN Case Manager-BB stated he thinks R5 can state whether R5 is in pain, but then stated, it is hard to say due to limited communication and cognition. Community RN Case Manager-BB stated he finds it difficult to communicate with R5 and is not sure if R5 understands when you talk with R5. On 4/16/26, at 3: 23 PM Surveyor notified NHA-A, Clinical Nurse Specialist-B and Director of Operations-O of concerns with R5's Community Case Manager was not notified of R5's fall with injury that occurred on 4/5/26 until 4/10/26. 3.) R14 was admitted on [DATE] and has a diagnosis of peripheral vascular disease. R14 has an activated Health Care Power of Attorney (HCPOA) R14 was assessed as having developed 2 unstageable pressure injuries on 12/15/25. On 12/26/25, at 6:13 PM, Wound Registered Nurse (RN)-L documented a change in 1 wound on the right coccyx. A picture of the right coccyx, with a date stamp of 12/18/25 at 6:12 PM, was noted by Surveyor. An accompanied note documents Assessed 12/22/25, at 10:45. The description documents a healed unstageable pressure injury. Surveyor was unable to locate any documentation in R14's medical record that R14's HCPOA was notified of the right coccyx wound being assessed as healed 12/22/25. Surveyor confirmed this through contact with R14's HCPOA. R14's 2nd Wound Assessment for the coccyx documented on 12/22/25, at 10:49 AM, with a picture time stamp dated 12/22/25, at 10:46 AM documents the wound measures 2.80 (centimeters) by 2.30 by 2.8. The wound bed has 90% slough and 10% red with moderate serous drainage. The peri-wound has erythema. There is undermining present between 12 o'clock and 1 o' clock 2 cm (centimeters) and between 5 o'clock and 6 o'clock 2 cm. The December 2025 Treatment Administration Record (TAR) documents: A start date of 12/22/25 to cleanse coccyx wounds with NS, (normal saline) skin prep to periwound, gently pack with silver alginate, and cover with bordered foam dressing. Change daily and as needed for unstageable. On 12/22/25 imagining was performed on the coccyx due to pain and wound decline. The results document they cannot exclude osteomyelitis. The coccyx wound has declined since the last assessment on 12/18/25. There is no documentation in the medical record on 12/22/25 that R14's HCPOA was notified of this decline in the wound with an infection, along with a treatment change. A Nurses Note dated 12/23/25 documents R14 is pocketing food and diet was downgraded to puree with nectar liquids. Surveyor notes there is a Diet Change Form dated 12/23/25 for puree and nectar liquids. There is no documentation R14's HCPOA was notified of this change of pocketing food and the diet change order on 12/23/25. R14's December 2025 TAR documents on 12/27/25 a change to the coccyx wound treatment. The treatment is to cleanse coccyx wounds with Dakins 1/4, pack with blue foam, (cut in spiral for easy packing) skin prep to periwound, and cover with bordered foam dressing. Change daily and as needed. Surveyor was unable to locate any documentation that R14's HCPOA was notified of this treatment change on 12/27/25. On 4/16/26, at 3:15 PM, at the facility exit meeting with Nursing Home Administrator (NHA)-A, Clinical Nurse Specialist (CNS)-B and Director of Operations (DOO)-O, Surveyor shared concerns with R14's infection treatments, wound treatments, and diet changes. On 4/20/25, at 11:55 AM, Nurse Practitioner (NP)-I and Clinical Nurse Specialist (CNS)-B met with Surveyor. NP-I stated there was discussions with R14's HCPOA related to treating the osteomyelitis and R14's HCPOA did not want R14 sent out (to the hospital) to be treated. Surveyor noted that R14's HCPOA informed Surveyor they were not informed there was an infection in the wound, and it was worse. NP-I stated hospice was discussed due to R14's coccyx wound is not being treated and they are pocketing food. There is no documentation R14's HCPOA was notified of the diet change. No additional information was provided.

Based on interview and record review, the facility did not ensure a resident's grievance was thoroughly investigated, pertinent findings or conclusions were documented and communicated to the resident. This was observed with 1 (R12) of 16 record reviews.* R12 voiced a grievance to the facility on 1/7/2026 related to R12 requesting referrals to 2 other Skilled Nursing Facility (SNF). There is no documentation the referrals were completed, or that the grievance findings or conclusion was communicated to R12.Findings include:R12 was admitted to the facility on [DATE] and readmitted on [DATE]. R12 is their own person.On 4/14/26, at 12:54 PM, Surveyor interviewed R12 in their room. R12 stated they voiced to facility staff they wanted a referral to move to another facility. R12 stated R12 provided the facility with the names of 2 skilled nursing facilities (SNF) R12 wanted a referral sent to. R12 stated that the facility has not provided R12 with any documentation these referrals were made. R12 stated this has been going on for months.R12's medical record documents a note dated 11/12/25 written by Social Worker (SW)-PP that documents: There were 2 referrals made.Surveyor noted there is no documentation of results of the referrals.Surveyor noted SW-PP is no longer employed at the facility and was unavailable for an interview.R12's medical record documents a note written on 1/14/26, by SW-K, that documents: 1 SNF had no beds available and the other SNF was still pending. No further documentation of results.SW-K is no longer employed at the facility and was unavailable for an interview.Surveyor reviewed the facility's Grievance Log which documents a Grievance Report on 1/7/26 for R12. The documented summary was from SW-K. The grievance documents the same information as the nursing note on 1/25/26; there is 1 SNF that has no long-term beds and 1 is still pending. SW-K documented that the grievance was resolved on 1/30/26 with R12. There is no documentation identifying who was contacted at the 2 SNF's, or what documents/paperwork was sent to these facilities as part of R12's referral request.Surveyor noted that R12 informed Surveyor that R12 has requested to see the documented referrals and has not seen them and does not know of the outcome of the second referral. On 4/15/26, at 11:56 AM, Surveyor interviewed current Social Worker (SW)-N. SW-N stated they were not aware of R12's SNFs referrals. SW-N stated they are new to the facility. SW-N stated there is a process for referrals and following up of grievances. On 4/16/26, at 3:15 PM, at the facility exit meeting with Nursing Home Administrator (NHA) -A, Clinical Nurse Specialist (CNC) -B and Director of Operations-O, Surveyor shared R12's grievance and follow-up concerns. No additional documentation was provided.

Based on interviews, record review, and facility policy review, the facility failed to ensure two of seven residents (Residents (R) 48 and R158) out of a total sample of 30 received prescribed medications to manage pain. This failure resulted in harm for both residents. Findings include:1. Review of R48's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] following hospitalization for left tibia and femur fractures. She had diagnoses including pain, cramp and spasm, spondylosis (degenerative arthritis of the spine), dorsalgia (back pain), anxiety, and depression. Review of R48's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/25 and located under the MDS tab of the EMR, revealed she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. R48 experienced occasional pain rated at four out of 10, which occasionally made it hard to sleep at night. Review of R48's Care Plan, dated 09/26/25 and located under the Care Plan tab of the EMR, revealed, The resident has acute pain r/t [related to] L [left] oblique tibial fx [fracture], L distal femoral fx. The goal was, The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date The approaches included: Identify and record previous pain history and management of that pain and impact on function. Identify previous responses to analgesia including pain relief, side effects, and impact on function . Monitor/document for side effects of pain medication. Provide the resident with reassurance that pain is time limited. During an interview on 10/01/25 at 9:20 AM, R48 stated when she first arrived to the facility from the hospital, none of her medications were here, and her pain was out of control. R48 stated she was in excruciating pain and had to be sent back to the emergency room for pain management. During the interview, R48 was tearful about the situation and stated that she went through all that pain unnecessarily. Review of R48's hospital Discharge summary, dated [DATE] and located under the Miscellaneous tab of the EMR, revealed, Pain control required multiple adjustments, including the addition of lidocaine [pain medication] patches, scheduled tizanidine [muscle relaxer], tramadol [pain medication], acetaminophen, and topical agents, as well as intermittent use of dilaudid [pain medication] for breakthrough pain and antispasmodics for leg spasms. The summary included orders for diazepam (a benzodiazepine medication used to treat a range of conditions, including anxiety, muscle spasms, and seizures), 5 milligrams (mg) every night and tramadol (pain medication), 100 mg every eight hours as needed and may take an additional 50 mg in between doses if needed for inadequate pain control. Review of R48's EMR under the “Orders” tab revealed admission orders, dated 09/23/25, for tramadol, 100mg three times a day for pain management and order, dated 09/23/25, for diazepam, 5mg at bedtime for anxiety. Review of R48's Clinical Progress Note, dated 09/23/25 at 5:49 PM and located under the Progress Notes tab of the EMR, revealed R48 rated her pain at seven out 10 on admission and was highly anxious and emotional. Review of a Nurses Note, dated 09/23/25 at 11:43 PM and located under the Progress Notes tab of the EMR, written by Unit Manager (UM) 3, revealed, Resident had concerns r/t pain medication. Resident stated she arrived around [1:00 PM] 9/23/25, Writer called pharmacy and faxed medication list. Pharmacy stated the [sic] received med list but have no valid scripts for tramadol and diazepam. Writer updated resident, Tylenol [acetaminophen] given. Resident concerned her pain will be out of control soon and requesting to be sent to [emergency room]. Review of R48's September 2025 Medication Administration Record (MAR), located under the Orders tab of the EMR, revealed an order for diazepam with a start date of 09/24/25. There was no record if this medication was offered on 09/23/25. The MAR also included an order for tramadol with a start date of 09/23/25; however, the box to record administration of the evening dose was blank. Additionally, the MAR documented orders for acetaminophen with a start date of 09/26/25; there was no record of an order for or administration of acetaminophen on 09/23/25. Review of an “eINTERACT SBAR Summary for Providers,” dated 09/24/25 at 12:02 AM and located under the “Progress Notes” tab of the EMR, revealed, the facility used a service called 3rd Eye to contact the on-call physician. The resident was transferred to the hospital ER before receiving a response. Review of R48's ER [Emergency Room] Documentation, dated 09/24/25 and located under the Miscellaneous tab of the EMR, revealed, [R48] . presenting to the emergency department from her subacute rehab for uncontrolled pain to her left knee. Per patient, she was recently admitted to the hospital for a femur fracture. Patient was discharged to a subacute rehab yesterday afternoon. However, the facility told her they do not have any pain medication to give her, so they sent her back to the ED [emergency department] for uncontrolled pain. Patient reports that the pain is primarily located in her knee. Review of a Nurses Note, dated 09/24/25 at 4:08 PM revealed, Resident returned to facility at [4:00 AM] from [emergency room] . Resident was treated in ER for uncontrolled pain. [Two] doses of tizanidine and 1 dose of dilaudid was given with relief. Resident is alert and oriented with no complaints of pain at this time. During an interview on 10/01/25 at 4:10 PM, the Pharmacist in Charge (PIC) at the facility's contracted pharmacy stated prescriptions, including diazepam and tramadol, were received from the discharging hospital on [DATE]; however, were not delivered to the facility until 09/24/25. The PIC was unable to determine the time the medications were delivered to the facility. The PIC stated even though the prescriptions were received from the hospital, they could not be filled until the resident was admitted into the system by the facility. The PIC stated the resident had not been entered into the system until the evening of 09/23/25. During an interview on 10/02/25 at 9:03 AM, Unit Manager (UM) 3 stated the day R48 was admitted , the nurse on duty (Licensed Practical Nurse (LPN) 7) reported to her that the hospital had never sent in her prescriptions to the pharmacy. UM3 stated R48's pain was out of control and the resident wanted to be sent to the ER to manage the pain. UM3 stated she was concerned about R48's pain and agreed she needed to go to the ER for pain management. Since the pharmacy did not have valid prescriptions, the facility could not access the prescriptions in the facility's emergency contingency kit. During an interview on 10/02/25 at 10:22 AM, LPN7 stated her shift 09/23/25 began at 7:00 PM on 09/23/25, and R48 had been admitted to the facility around 11:00 AM. LPN7 stated when she came on shift, R48 was in a lot of pain. LPN7 called the pharmacy but the pharmacy reported there were no valid prescriptions for R48. LPN7 stated at that time, R48 rated her pain at nine or ten out of ten, and added, I was [expletive] because she came in at 11:00 AM and it wasn't addressed. LPN7 added R48 was very upset about the situation and she [LPN7] reported the situation to UM3. She stated R48 was sent to the ER to get her pain under control, since there was no access to pain medication for R48. LPN7 explained that the discharging hospital had not faxed the prescriptions to the pharmacy, and she had to wait for the pharmacy to put the resident into their system. She stated she was unable to use the medication in the facility's emergency contingency kit because the pharmacy did not have a valid prescription and could not provide the authorization code needed to retrieve the medication. LPN7 stated that R48 needed to go back to the ER for adequate pain management and to get valid prescriptions for all ordered medications. During an interview on 10/03/25 at 11:50 AM, the Director of Nursing (DON) stated she was told the pharmacy did not have prescriptions from the hospital, yet the hospital had faxed the prescriptions to the pharmacy and so she was not able to obtain another set of prescriptions. The DON stated R48's pain was severe, and she had to be sent to the ER to get pain medication. The DON stated the facility staff were told they were unable to pull the medications from the emergency contingency kit, as the pharmacy did not have a valid prescription to authorize obtaining the medication. The DON stated the nurse should have contacted the Medical Director in this situation to obtain an emergency prescription. 2. Review of R158's undated Face Sheet located under the Profile tab in the EMR indicated R158 was admitted to the facility on [DATE] with diagnoses of displaced comminuted fracture of shaft of humerus and left arm. Review of R158's Admission/Readmission/Routine Head-to-Toe Evaluation – V7 located under the Evaluations tab in the EMR, dated 09/26/25 indicated R158 was alert. Under Memory/Recall Ability it was documented that R158 could recall the current season, location of own room, staff names, and faces, and where they were.Review of R158's Care Plan located under the Care Plan tab in the EMR dated 09/29/25 indicated, [R158] is on pain/opioid medication therapy r/t RUE [right upper extremity] fx [fracture]. Interventions were, Administer ANALGESIC [sic] [pain] medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [sic] [every shift]. Review of R158's Nursing Progress Notes dated 09/26/25 at 3:04 PM indicated, [AGE] year female with hx [history] of ESRD [end stage renal disease] on hemodialysis, dm [diabetes mellitus] type 2 [sic]… who presented to ED [emergency department] following fall at home. She [R158] was evaluated by ortho [orthopedic] and was recommended for non-operative [sic] management with immobilization/sling and pain control… Review of R158's Admission/Readmission/Routine Head-to-Toe Evaluation – V7 located under the Evaluations tab in the EMR, dated 09/26/25 at 3:04 PM indicated R158's pain was assessed as being a 0 on a pain scale of 1-10. R158's pain goal was documented as being 0. Review of R158's Physician Orders revealed orders dated for 09/26/25 for Roxicodone 5 mg (milligrams) Give 0.5 tablet by mouth every four hours as needed for pain, Tramadol 25 mg give one tablet by mouth every six hours as needed for pain, and Acetaminophen 500 mg give two tablets by mouth every eight hours as needed for pain for seven days. Pain evaluation was also ordered on 09/26/25 to be completed every shift. Review of R158's Medication Administration Record (MAR) dated September 2025 indicated, Acetaminophen 500 mg two tablets were given on 09/27/25 at 10:46 PM, for pain documented as 8, on a zero to 10 scale. There was an E documented below the nurses' initials representing the medication was effective. On 09/28/25 at 10:53 AM, Acetaminophen 500 mg two tablets were administered to R158 for pain documented as 5. There was an E documented below the nurses' initials on the MAR representing the medication was effective in relieving R158's pain. On 09/29/25 at 4:51 PM, Acetaminophen 500 mg two tablets were administered to R158 for pain documented as 4. There was also an E documented below the nurses' initials on the MAR representing the medication was effective in relieving R158's pain. Further review of the nursing progress notes indicated no documentation to reflect an assessment for pain from admission on [DATE] through 09/30/25. Continued review of R158's “MAR” indicated no Roxicodone or Tramadol had been administered to R158 since admission on [DATE]. On 09/30/25 at 11:56 AM Registered Nurse (RN)1 was overheard saying to R158, Your pain medication is not here yet from pharmacy, but I can give you some Tylenol for now. During an interview on 09/30/25 at 12:01 PM, R158 stated her pain was a 10 in her right shoulder. I have not had any pain medication, and I am in severe pain. I went to dialysis this morning and I told them I was in pain, and they gave me two Tylenol too. I don't know what is wrong here. During an interview on 09/30/25 at 12:06 PM, RN1 stated, I will have her [NAME] [Roxicodone] by three o'clock today. The scripts were given to the unit manager and were faxed to the pharmacy an hour and a half ago. The pharmacy says they did not get the fax. As soon as they are faxed to the pharmacy again and they [pharmacy] get them [scripts], it usually takes about two hours for a STAT [immediate] delivery to come. Then I will be able to give her [R158] the [NAME] [Roxicodone]. I gave her [R158] Tylenol for now. During an interview on 09/30/25 at 1:05 PM, R158 rated her pain as a 7 and stated her pain continues to hurt in her right shoulder. They keep telling me the medicine will be here after three today. R158 was noted to be restless in bed at this time. Review of R158's MAR indicated RN1 had not documented the administration of Tylenol to the resident, nor was the pain level documented. During an interview on 09/30/25 at 3:38 PM, Unit Manager (UM)1 stated, If the admission comes from the hospital, the hospital physician can use escribes [electronic system to order medications] and that goes to our pharmacy. Today, we printed a blank script; gave it to the NP [nurse practitioner] and she filled it out for the Roxicodone and Tramadol. I faxed these to the pharmacy three times today because the pharmacy stated they had not received the scripts. We have the contingency machine that after we fax the order for a narcotic to the pharmacy and they receive the script then we can call the pharmacy and get a code to get the narcotic out of the box and give to the resident. I was not aware of the resident was not getting her pain medication. During an interview on 09/30/35 at 4:03 PM, RN1 stated, I did get the NP [nurse practitioner] sign scripts again this morning because I saw when I came in today the narcotics were not in the drawer. I gave them to [UM1] to fax to the pharmacy for me because I was extremely busy today. RN1 confirmed he had not received these narcotics from pharmacy. RN1 stated, No, I did not look in the contingency box. I really don't know what is in there. RN1 confirmed he had administered Tylenol earlier today at 12:06 PM and stated, I should have documented the first Tylenol that I gave today. During an interview on 10/01/25 at 8:47 AM, UM1 confirmed that R158's Roxicodone was delivered yesterday by the pharmacy and confirmed it was in the contingency supply which was also available for use since admission. During an interview on 10/01/25 at 08:55 AM, R158 stated, I am in pain now, but I feel better than I did yesterday after I received my pain medicine that I was supposed to be taking. During an interview on 10/01/25 at 4:10 PM, the Pharmacist in Charge (PIC) stated, The first script that we received for Roxicodone 5 mg and Tramadol 50 mg for [R158] was on 09/30/25 at 10:30 AM. Both scripts were dated 09/29/25 by the facility NP [nurse practitioner]. We did receive hospital discharge orders for this resident, but we did not receive any scripts from the hospital physician. During an interview on 10/03/25 at 7:15 PM, the Director of Nursing (DON) stated, Pain assessments should have been completed on admission for this resident. As soon as the nurses noted that the narcotics did not come from the pharmacy, then they should have called the pharmacy to see if the scripts were there. If they were not there, then the scripts should have been signed by the provider, and the nurse fax the scripts to the pharmacy right then. We have Roxicodone and Tramadol in the emergency supply here. The nurse would have to get an order from the provider, call the pharmacy and the pharmacy will give us a code to get the medication out. Review of the facility's policy Pain Management dated 02/05/25 indicated, The facility must ensure that pain management is provided to residents who require such services. Consistent with professional standards of practice… and the residents' goals and preferences… Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change or status occurs… the facility in collaboration with the attending physician/prescriber… and resident and/or resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual's pain beginning at admission… Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen…

Based on interview and record review, the facility did not ensure 1 (R35) of 23 residents experiencing a change of condition received treatment and care in accordance with professional standards of practice. *R35 went to the emergency roiagnom on [DATE]. R35 was prescribed Prednisone for neck inflammation with no end date. R35 received a high dose of Prednisone from 9/12/23 through 9/29/2023 when the Provider ordered a Prednisone taper. R35 was hospitalized on [DATE]. Hospital documentation indicated R35 might have an element of adrenal insufficiency considering [R35] was on high dose of Prednisone for 2 to 3 weeks. R35 had a history of recurrent Urinary Tract Infections (UTI) and sepsis. On 10/1/2023 and 10/2/2023, R35 experienced low blood pressure readings. No provider was notified of R35's low blood pressures. R35 had an active order for Midodrine (a medication given to help low blood pressures). Midodrine was not given as ordered on 10/1/2023 and 10/2/2023. A provider was not notified of the missing Midodrine administrations. On 10/3/2023, Nurse Practitioner (NP)-HH documented R35 as being unstable and noted that R35 had low blood pressures that NP-HH was not contacted about. NP-HH ordered R35 be sent to the emergency room (ER). On 10/3/2023, R35 was admitted to the Intensive Care Unit (ICU) and was hospitalized with Sepsis and UTI. The facility failure to identify a change in condition and notify a provider timely, created a finding of immediate jeopardy that began on 10/1/2023. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on 7/11/2024 at 12:31 PM. The immediate jeopardy was removed on 7/11/2024, however the deficient practice continues at a scope/severity of D (potential for harm/isolated). Findings include: The facility policy, entitled Notification of Changes, dated 10/24/2023, documents, in part: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . The facility must inform the resident, consult with the resident's physician . when there is a change requiring such notification . Circumstances requiring notification include: . 2. Significant change in the resident's physical .status. This may include: Life threatening conditions or clinical complications. The facility policy, entitled Non-Controlled Medication Orders, dated 1/2023, documents, in part: Medications are administered only upon the receipt of a clear, complete and signed order by a person lawfully authorized to prescribe . Medication orders include the following specifics: Resident's Name. Date. Name of medication. Strength of medication . Dose and dosage form. Time or frequency of administration. Route of administration. Quantity or duration (length) of therapy, when applicable-If not specified by prescriber on a new order, the duration may be limited by automatic stop order policy . Any dose or order that appears inappropriate, considering the resident's age, condition, allergies or diagnosis, is verified by nursing with the prescriber . Written transfer orders (sent from a hospital or other health care facility) .If the order is unsigned or signed by another prescriber . the receiving nurse verifies the order with the current attending prescriber before medications are administered. The nurse documents verification on the admission order record by entering the time, date and signature .The nurse who transcribes the orders to the physician order sheet and/or MAR (Medication Administration Record) documents on the admission form the date, the time and by whom the orders were noted . Orders are transmitted to the pharmacy with any additional information required for new admission . Complete documentation by clarifying orders as necessary. R35 was admitted to the facility on [DATE] and has diagnoses that include Multiple Sclerosis, Hemiplegia/Hemiparesis following a stroke, Hydronephrosis, Neurogenic bladder, Urinary retention, and Hypotension. R35's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents that R35 is usually understood and understands. R35 is cognitively intact. R35's was hospitalized on [DATE] prior to R35's admission to the facility. Hospital Discharge paperwork dated 8/9/2023, documents the following discharge diagnoses: Sepsis, UTI, left nephrolithiasis (kidney stone) with hydronephrosis (excess fluid in a kidney due to back up of urine). R35 was admitted to the hospital on 8/10/2023 due to a new onset of weakness that occurred at the facility. R35 was hospitalized from 8/10/2023 through 8/12/2023. R35's Hospital Discharge paperwork, dated 8/12/2023, documents the following discharge diagnoses: complicated UTI, Suspected sepsis, and transient hypotension. R35 returned to the facility on [DATE]. R35's progress note, dated 8/31/2023 at 10:43 AM, NP-HH documents: review [R35's] bilateral renal ultrasound results. [R35] noted to have mild hydronephrosis . Labs also reviewed showing 25% worsening GFR (a blood test that checks how well your kidneys are working) over the past 7-10 days . [NP-HH] decided to have [R35] sent to [Emergency Department] for [evaluation] and [treatment]. R35 was admitted to the hospital from 8/31/2023 through 9/7/2023. R35's Hospital Discharge paperwork dated 9/7/2023 documents the following discharge diagnoses: Renal Insufficiency, Complicated UTI, and C-diff (a germ that causes diarrhea and inflammation of the colon). R35 returned to the facility on [DATE]. Surveyor notes from 8/2/2023 through 9/7/2023, R35 had 3 admissions with the diagnosis of UTI, 2 admissions with the diagnosis of Sepsis and a documented history of hypotension. Surveyor notes R35 did not have a care plan addressing R35's risk for infection due to recurrent UTI's with Sepsis. Surveyor notes R35 did not have a care plan addressing R35's diagnosis of hypotension. On 7/10/2024 at 10:09 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if DON-B would expect staff to create a care plan with a diagnosis of recurrent UTIs with sepsis. DON-B indicated that a resident should have a care plan addressing the recurrent infections. Surveyor asked if DON-B would expect staff to create a care plan with a diagnosis of Hypotension. DON-B stated Yes. R35's MD order with a start date of 9/7/2023, documents: Midodrine oral tablet 5mg (milligrams). Give one tablet by mouth before meals for hypotension. Midodrine is used to treat low blood pressure. It works by stimulating nerve endings in blood vessels, causing the blood vessels to tighten and, thus, increasing blood pressure. Surveyor notes the Midodrine order did not have any blood pressure parameters documented within the MD order. On 9/12/2023 at 2:45 PM, NP-HH documents in a progress note: [R35] is seen and examined today . [R35] is reporting severe neck pain . [R35] stated [R35] does not feel good and requesting to be transferred to the hospital. R35 was sent to theER on [DATE] and returned to the facility the same day. R35 was treated for neck pain. R35's Hospital After Visit Summary (AVS) dated 9/12/2023, documents R35 should start taking Prednisone 20mg take 2 tablets by mouth daily. R35's MD (Medical Doctor) order with a start date of 9/13/2023, documents Prednisone 20mg. Give 2 tablets by mouth one time a day. Surveyor notes neither the hospital AVS nor the facility's MD orders had a stop date or tapered dosing for Prednisone administration. R35's progress note dated 9/19/2023 at 6:56 PM, NP-HH documents: [R35] has new hematuria (blood in urine). [Urinary analysis] ordered and suggestive of UTI . Plan to wait for culture and sensitivity and treat as appropriate. WBC (white blood cell count) 14. (According to the laboratory report from the facility's laboratory report, a normal WBC count is between 4.8 and 10.8) R35's MD order with a start date of 9/20/2023, documents Cipro (an antibiotic medication used to treat UTI) 500mg. Give 1 tablet by mouth two times a day for a UTI for 5 days. Surveyor notes R35 received Cipro from 9/20/2023 through 9/25/2023. R35's WBC count on 9/25/2023 was 10.5. R35's progress note dated 9/29/2023 at 2:17 PM, documents: New orders received from [MD]-C for Prednisone taper. R35's MD order with a start date of 9/30/2023, documents Prednisone 10mg. Give 3 tablets by mouth one time a day for 5 days. Give 2 tablets by mouth one time a day for 5 days. Give 1 tablet by mouth one time a day for 5 days. Surveyor noted that R35 had received 40mgs of Prednisone daily from 9/12/2023 through 9/29/2023. On 7/10/2024 at 9:20 AM, Surveyor interviewed Medical Doctor (MD)-C. Surveyor asked when R35's Prednisone should have been stopped. MD-C stated that Prednisone dosage is very individualized. MD-C stated it could be 5, 7, 10 days or longer. Surveyor asked if R35 was supposed to receive Prednisone for 17 days. MD-C stated that MD-C did not have an answer. On 7/10/2024 at 10:09 AM, Surveyor interviewed DON-B regarding R35's Prednisone order with no stop date or tapered dosing. Surveyor asked what the process for entering readmission orders. DON-B stated that floor staff would take and enter the orders, a unit manager would audit the admission orders and then the Pharmacist would review the orders. DON-B stated this process was not followed when R35 was readmitted after the 9/12/2023 ER visit. DON-B indicated that the stop date or tapered dosing was missed. R35's Medication Administration Record (MAR) documents a Blood pressure (BP) before each administration of Midodrine. R35's BPs on 9/28/2023 were documented as 106/65, 108/72, and 110/65. R35's BPs on 9/29/2023 were documented as 114/68, 110/64, and 124/62. R35's MD order with a start date of 9/30/2023, documents: STAT [immediately] CBC (complete blood count) on 9/30/2023 (must call [Lab] in the morning to place STAT order) one time only for hematuria. R35's BPs on 9/30/2023 were documented as 111/60, 111/60 and 108/58. On 10/1/2023 at 7:30 AM, R35's BP was documented as 152/90. Midodrine was documented as given on the MAR. On 10/1/2023 at 11:30 AM, R35's BP was not documented. Midodrine was documented as code 9 on the MAR. The code 9 on the MAR indicates, other see notes. An eMAR (Medication administration note) documented at 2:59 PM documents: Too late to give. Surveyor notes R35 did not have a BP reading documented and a provider was not notified when R35 did not receive the afternoon dose of Midodrine. On 10/1/2023 at 4:30 PM, R35's BP was documented as 78/50, Pulse 71. Temperature 97.2. Midodrine was documented as code 11 on the MAR. The code 11 on the MAR indicates, Vitals outside parameters. Surveyor notes the facility did not consult with a physician about R35's low blood pressure and the fact that R35 did not receive the evening dose of Midodrine. On 10/2/2023 at 7:30 AM, R35's BP was not documented. Midodrine was documented as code 2 on the MAR. The code 2 on the MAR indicates, Drug refused. Surveyor notes R35 did not have a BP reading documented and a provider was not notified when R35 refused the morning dose of Midodrine. On 10/2/2023 at 11:22, R35's BP was documented as 88/56, Pulse 98, Temperature 98. Midodrine was documented as code 2 on the MAR. Surveyor notes a provider was not consulted about R35's low blood pressure and the fact tht R35 had refused the afternoon dose of Midodrine. On 10/2/2023 at 4:30 PM, R35's BP was not documented. Midodrine was documented as code 2 on the MAR. Surveyor notes R35 did not have a BP reading documented and a provider was not consulted with when R35 refused the evening dose of Midodrine. R35's progress note dated, 10/2/2023 at 3:55 PM, NP-HH documents: Labs from 9/30/2023 reviewed. Orders placed . Surveyor notes R35's WBC results from 9/30/2023 were 13.2. Surveyor notes R35's WBC count increased from 10.5 on 9/25/2023. R35's MD order with a start date of 10/2/2023 documents, in part: STAT CBC . for recurrent elevated WBC . On 10/3/2023 at 0730, R35's BP was documented as 96/54. Pulse 73. No Temperature was documented R35's progress note, dated 10/3/2023 at 10:36 AM, NP-HH documents: Labs from 10/2/23 reviewed . Surveyor notes R35's WBC results from 10/2/2023 were 16.3. Surveyor notes R35's WBC count increased from 13.2 on 9/30/2023. R35's progress note, dated 10/3/2023 at 11:50 AM, documents, in part: The change in condition reported on this evaluation are: Abnormal vital signs . Resident request to be sent to the ER. R35's progress note, dated 10/3/2023 at 12:32 PM, documents: [R35] is being sent to the [local ER] per resident request for hypotension, elevated WBC's, tachycardia. Orders to send resident to ER [placed by] [NP-HH] . R35's late-entry progress note, dated 10/3/2023 at 9:10 PM, NP-HH documents, in part: [R35] is seen and examined today in [R35's] room. [R35] is diaphoretic, stating, 'I do not feel good,' unable to give any specific symptoms. With assessment tachycardia noted, soft BP's. After review vitals from weekend noted [R35] has been hypotensive with low [systolic] BPs to 70-80s, no provider was notified. Also noted that [R35] was continued on prednisone which was ordered only for short term at theER on ,d+[DATE]; noted on 9/30 and addressed with MD who [ordered] titration dose Labs reviewed, noted elevated WBCs again but [R35] is on prednisone Due to [R35's] presentation and being unstable, concerns of possibility of sepsis and some degree of adrenal insufficiency patient is sent to ER for evaluation. R35's Hospital History and Physical dated 10/3/2023 documents, in part: [R35] presented to the ED on 10/3/2023 with complaints of hypotension and tachycardia which has been ongoing for the past 3 days associated with intermittent fevers . On arrival to the emergency department, [R35] had a temperature of 100.1 . [R35] was hypotensive with [systolic] BP in the 70's to 80's . [R35] was started on sepsis protocol . WBC result from 10/3/2023 at 12:55 PM was 20.1 .[R35] was admitted to the ICU for further management . Assessment/Plan: Septic shock secondary to [UTI] . There might be element of adrenal insufficiency also considering she was on high dose of prednisone for 2 to 3 weeks . Chronic hypotension: continue Midodrine . R35 was admitted to the ICU on 10/3/2023 and was hospitalized until 10/11/2023 when R35 returned to the facility. On 7/9/2024 at 11:15 AM, DON-B informed surveyor that NP-HH is no longer with the same medical group and does not come to the facility. DON-B provided Surveyor with MD-C's phone number and stated MD-C could answer questions regarding R35. On 7/10/24 at 9:20 AM. Surveyor interviewed MD-C regarding R35's change in condition and hospitalization on [DATE]. Surveyor asked when MD-C would expect to be notified of a low blood pressure reading. MD-C stated if a systolic blood pressure was less than 90, MD-C would expect a notification. Surveyor informed MD-C of the low blood pressure readings (78/50 and 88/56) R35 experienced days prior to being admitted to the hospital with sepsis. MD-C stated he would absolutely expect a call with R35's documented low blood pressures. Surveyor asked if MD-C would expect a notification alerting MD-C that R35 did not take multiple doses of Midodrine. MD-C stated, knowing the BPs (78/50 and 88/56), staff should have called with the missing doses of Midodrine. On 7/10/2024 at 10:09 AM, Surveyor interviewed DON-B. Surveyor asked what the expectation is for staff to notify a Provider if a resident is experiencing low blood pressures. DON-B stated that staff should notify the provider immediately based on the severity of symptoms. Surveyor reviewed R35's low blood pressures (78/50 and 88/56) with DON-B. DON-B stated staff should have notified the provider. Surveyor asked if staff should have notified the provider after R35 was not given multiple doses of Midodrine on 10/1/2023 and 10/2/2023. DON-B stated that DON-B would expect staff to call for the missed doses of Midodrine. The failure to identify a change of condition and to consult with a provider timely created a finding of Immediate Jeopardy. The facility removed the jeopardy on 7/11/2024 when it had completed the following: RESIDENT DIRECTLY INVOLVED: 1) [R35] was evaluated for any noted change in condition to include evaluation of vital signs on 7/11/2024. 2) [R35] had [R35's] medications reviewed to ensure provider call parameters are in place on 7/11/2024. ACTIONS FOR POTENTIALLY AFFECTED RESIDENTS: 1) Residents residing in the facility were evaluated for any noted change in condition to include evaluation of vital signs on 7/11/2024. EDUCATION: 1) Nursing staff will be educated on the facility notification of change policy to include provider notification and RN assessment and will complete a test to validate competency. 2) All staff will be educated on proper reporting of any noted changes in condition. 3) Licensed nursing staff will be educated on appropriate documentation for changes in condition. 4) Licensed nursing staff will be educated on the facility policy regarding medication reconciliation and administration. Licensed nursing staff and CNAs; including agency will receive the above re-education by 7/15/2024 or prior to next scheduled shift. MONITORING: 1) A daily audit during clinical standup will be conducted to monitor for any changes in condition to include vital signs. This audit will be conducted for one month. Results of audits/monitoring will be provided to QAPI, which may further modify audit expectations based on results of initial audits. 1) AD HOC QAPI meeting - The QAPI Committee (composed of but not limited to; Administrator, Director or Nursing, Assisted Director of Nursing, and Medical Director) to be held by 5/15/2024 to review the alleged deficiency, discuss above action items and planned audits related to findings.

Based on observation, interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R11) of 8 residents reviewed for pressure injuries. * R11 developed a stage 4 pressure injury to the sacrum and a stage 3 to the left buttock. The left buttock was deemed heeled [DATE]. The Facility knew the risk for pressure ulcers was present due to R11 having a femur fracture and other related comorbidities. The Facility failed to take immediate action by creating a plan of care to include comprehensive interventions for prevention of pressure ulcers. The resident did not receive an air mattress until 12 days after admission and 7 days after development of pressure ulcer. A Braden Scale Evaluation was not completed until ,d+[DATE] when the pressure ulcer was discovered, and the score was 11 indicating high risk. These actions created the findings of the IJ starting [DATE]. The facility was notified of the IJ on [DATE], at 12:27 PM. The IJ was removed on [DATE] when the facility completed the following: Related to R11: -A comprehensive wound evaluation completed on 6/ ,d+[DATE] -Braden completed on [DATE] -New treatment orders obtained [DATE] -Foley initiated to aid in healing on [DATE] -Care plan initiated on [DATE] including LAL mattress -COC completed [DATE] with MD notification -Clinical leadership and RD met, reviewed and revised CP on [DATE] Facility wide: -A full house skin sweep was completed on [DATE]. -Braden's re-evaluated. -A full-time wound nurse has been hired and started on [DATE]. -Licensed nursing staff education on skin and wound policy to include what to do when a new wound is found, weekly skin check, what to do if there is a change in a wound and validated with a test initiated on [DATE]. -Certified nursing assistants' education on skin and wound policy to include what to do when a new wound is found, how to communicate changes in conditions and validated with a test initiated on [DATE]. -Risk meetings were initiated on [DATE]. Quality monitor introduction on [DATE]. -CMS Meta Star training is scheduled for [DATE]. -An audit of weekly skin will be completed during clinical stand up. * R64's bed was observed to not at the correct setting. R64 had a stage III pressure injury. * R217 obtained a pressure injury that were not documented or measured until [DATE] and [DATE]. Findings include: The Facility Policy titled Pressure Injury Prevention and Management implemented [DATE], documents (in part) . Policy Explanation and Compliance Guidelines: .3. Evaluation of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk evaluation, using the Braden, on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. b. The tool will be used in conjunction with other risk factors not captured by the risk evaluation tool. Examples of risk factors include, but are not limited to: i. Impaired/deceased mobility and deceased functional ability; . vii. Exposure of skin to urinary and fecal incontinence; . 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment . c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; . e. The goals and preferences of the resident and/or authorized representative will be included in the plan of care. f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting . 1.) R11 was admitted to the facility on [DATE]. R11 has diagnoses which include multiple sclerosis, fracture of unspecified part of neck of right femur, muscle weakness, unspecified dementia, neuromuscular dysfunction of bladder, and legal blindness. R11's 5 Day Minimum Data Set (MDS) with an assessment reference date of [DATE] indicated R11 had a Brief Interview for Mental Status score of 06 (severe cognitive impairment). R11 is responsible for self, however, has a Power of Attorney for Healthcare set up. The MDS reads that for vision R11 is highly impaired. For rejection of care, the behavior was not exhibited. R11's MDS showed that upper extremities have no impairment and lower extremities have impairment on one side. The MDS has no unhealed pressure ulcers/injuries noted, however, is coded as a risk for pressure ulcer/injury. R11 is dependent for toileting, needs substantial/maximal assistance for shower/bathe, is partial/moderate assist for upper body dressing and is dependent for lower body dressing. R11's MDS is coded as frequently in pain and pain interferes with therapy and day to day activities occasionally. Braden Scale Evaluations were completed first on [DATE] with a score of 11 indicating high risk for pressure ulcer development and again on [DATE] with a score of 13 indicating moderate risk of pressure ulcer development. Surveyor notes the first was done 5 days after admission and the same day the pressure ulcers were identified. R11 has a Focus on plan of care at admission which reads, The resident is at risk for alteration in skin integrity. The Goal is The resident will remain free of new skin impairment through the review date with a target date of [DATE]. Interventions at admission include: o Apply barrier cream per facility protocol to help protect skin from excess moisture. Created on: [DATE] o Encourage/assist with turning and repositioning every ,d+[DATE] hours Created on: [DATE] o Provide skin/wound treatments as ordered Created on: [DATE] R11 had a Focus on plan of care added when the pressure injury was discovered which reads: o The resident has potential/actual impairment to skin integrity of the: Sacrum - Unstageable pressure ulcer L buttock - Unstageable pressure ulcer Bridge of nose - Biopsy surgical site Created on: [DATE] Revision on: [DATE] Interventions include (in part): o Air Mattress, Setting:290 Created on: [DATE] Revision on: [DATE] o Braden upon admission, weekly x 4 weeks, quarterly, and as needed. Created on: [DATE] o Cushion to wheelchair Created on: [DATE] o Encourage good nutrition and hydration in order to promote healthier skin. Created on: [DATE] o Low air loss mattress Created on: [DATE] o Turn/Reposition approx. every ,d+[DATE] hours Created on: [DATE] o Use a draw sheet or lifting device to move resident. Created on: [DATE] The admission Skin Integrity Assessment done on [DATE] shows the only skin impairment is a post biopsy on bridge of R11's nose. New Initial Wound Assessments were completed by Registered Nurse (RN)-K on [DATE] and two pressure ulcers were identified. One on the sacrum, unstageable, and one on the left buttock, stage 3, the left buttock was deemed healed on [DATE]. Surveyor notes these were identified five days after R11 admitted to the Facility. The first charting of the pressure ulcers on [DATE] measured: left buttock: 4.0cm, 5.0cm, 0.1cm depth deemed stage 3 with 100% granulation sacrum: 6.0cm, 2.5cm, n/a depth deemed unstageable with 25% granulation and 75% slough Surveyor notes a SBAR Communication Form and Progress Note form was completed on [DATE] for R11's physician. It was identified that things that make this condition worse are impaired mobility, urinary incontinence and refusal of repositioning/getting out of bed. RN-K added an observation of the resident revealing unstageable pressure ulcer to sacrum and stage 3 pressure ulcer to L buttocks with surrounding purple DTI to peri wound. Patient has impaired mobility r/t hip fx. Patient is reluctant to reposition d/t pain. Pre-medication with oxycodone required for wound evaluation. Patient incontinent of bowel and bladder, hx including neurogenic bladder. Increased amount of fluid intake resulting in heavy urination and multiple linen changes today. Patient refusing to get out of bed and repositioning d/t pain with hip fx. Surveyor notes no plan of care interventions were put in place for refusals before or after wounds discovered. Assessment by Tissue Analytics wound doctor on [DATE]: left buttock: 2.03cm, 1.58cm, 0.10cm depth deemed unstageable with slough ,d+[DATE]% sacrum: 3.31cm, 2.69cm, 0.10cm depth deemed unstageable with slough ,d+[DATE]% and eschar ,d+[DATE]% The sacrum was debrided at this time and post debridement measured: 3.21cm, 3.69cm, 2.6cm depth deemed unstageable with slough ,d+[DATE]% Physician Orders post assessment: -Encourage repositioning Q 2hrs: Document refusal every 2 hours for Wound to Sacrum Start Date: [DATE] -Complete bed rest d/t sacral wound induration. Encourage/assist with aggressive side-to-side offloading q ,d+[DATE] hours. Float heels on ,d+[DATE] pillows (unable to use Prevalon boots d/t abduction wedge). Document resistance/refusals of repositioning in progress note(s) every shift for wound care Start Date: [DATE], discontinue date: [DATE] Surveyor notes no orders for abduction wedge usage found. The wound doctor recommended a pressure redistribution mattress and wheelchair cushion for R11 and to offload heels. On [DATE] an intervention was added to the plan of care for the mattress. It had been added [DATE] for the wheelchair pressure redistribution devices. A Physician Order was entered [DATE] that addressed floating of heels. Surveyor notes all of these were put in place after the discovery of the wound and 2 of them not until after the wound doctor saw R11. Assessment by Tissue Analytics wound doctor on [DATE]: left buttock: 0.16cm, 0.42cm, 0.10cm depth deemed stage 3 with granulation ,d+[DATE]% and slough ,d+[DATE]% sacrum: 3.88cm. 2.54cm, 2.2cm depth deemed unstageable with slough ,d+[DATE]% and eschar ,d+[DATE]% The sacrum was debrided at this time and post debridement measured: 3.21cm, 3.69cm, 2.6cm depth deemed unstageable with slough ,d+[DATE]% Surveyor notes that on [DATE] a Risk/Benefit Record Tool form was completed by the Facility related to R11 refusing repositioning. This documents that R11 was verbally educated that it is important for you to allow staff to reposition you. It will help with wound healing. Updates are notated to have been made to the physician and care plan. Surveyor notes no plan of care was developed for refusals of care. Surveyor notes this was done 20 days after admission and 15 days after R11 was discovered to have a pressure injury Assessment by Tissue Analytics wound doctor on [DATE]: no left buttock assessment sacrum: 4.51cm, 2.55cm, 2.5cm depth deemed stage 4 with granulation of ,d+[DATE]% and slough ,d+[DATE]% negative pressure wound therapy started The [DATE] Facility Wound Assessment details report for L Buttock shows healed and 100% intact skin. Assessment by Tissue Analytics wound doctor on [DATE]: sacrum: 4.33cm, 2.23cm, 1.0cm depth deemed stage 4 with granulation of ,d+[DATE]% and slough ,d+[DATE]% On [DATE], at 10:34am, Surveyor observed wound care with Registered Wound Care Nurse (RWCN)-G. The sacrum wound measured 3.8cm, 1.7cm, 1.1cm deep with undermining from 7 to 12o'clock and 1.4cm at 9o'clock. The wound was 10% slough and 90% granulation per RWCN-G. 0n [DATE], during wound care, Surveyor asked RWCN-G why this wound developed, and the response was that noncompliance started the wound before RWCN-G started with the facility. On [DATE], at 08:22 AM, Surveyor spoke with RWCN-G and asked again about the wounds starting and was told that the buttock was small and superficial. For the sacrum the nurse was not here but would attribute wound to pressure, incontinence, and pain with movement. RWCN-G's expectation for someone who is bed bound would be to reposition and off load and have incontinence measures to prevent skin breakdown. Have pain management in place and have an alternating pressure mattress. On [DATE], at 01:52 PM, Surveyor spoke with the Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who stated they cannot speak of the incident prior to taking over. R11's admission on [DATE] was a transition time. The Facility has since completed education and skin sweeps. R11 wounds were identified on ,d+[DATE], the last skin sweep on [DATE] was a full house where they identified issues and moved forward to correct. The morning meeting process was revamped for more skin issue regulation. They allege compliance for skin issues was reached [DATE]. Surveyor notes that the Facility knew the risk for pressure ulcers was present due to R11 having a femur fracture. The Facility failed to take immediate action by creating a plan of care to include comprehensive interventions for prevention of pressure ulcers. The resident did not receive an air mattress until 12 days after admission and 7 days after development of pressure ulcers. A Braden Scale evaluation was not completed until ,d+[DATE] when the pressure ulcer was discovered, and the score was 11 indicating high risk. These actions created the findings of the IJ starting [DATE]. 22692 2.) R64 was admitted to the facility on [DATE] with diagnosis that included Peripheral Vascular Disease and Traumatic Brain Injury. R64's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and documented that R64 is not understood and his cognition is severely impaired. R64's MDs also indicated he had 3 stage 3 pressure injuries at the time of the MDS On [DATE] at 11:17 AM, R64 was observed in bed with his air mattress set at 660 pounds. On [DATE] at 2:15 PM, R64 was observed in bed with his air mattress set at 660 pounds. On [DATE] at 8:49 AM, R64 was observed in bed with his air mattress set at 660 pounds. On [DATE] at 12:45 PM, R64 was observed in bed with his air mattress set at 660 pounds. Wound Registered Nurse (WRN)-G completed treatment to both of R64's Stage 3 pressure injuries on his right wrist and left arm. After WRN-G completed the treatment she was interviewed as to why R64's bed was set to 660 pounds when his last weight was 123.8 pounds. WRN-G indicated the Certified Nursing Assistant's (CNA's) probably forgot to turn it to the correct setting after doing cares. The Surveyor indicated it had been consistently at that setting for 2 days of observations. WRN-G then changed the air mattress setting to 150 pounds. On [DATE] at 12:45, R64 was observed to have 2 stage 3 pressure injuries to his left inner forearm measuring 2 centimeters (CM) long by 1.4 CM wide by 0.1 CM deep and to his right wrist measuring 0.8 CM long by 1.1 CM wide by 0.1 CM deep. This remained essentially unchanged from previous weeks measurements. On [DATE], R64's weights were reviewed and documented his last weight on [DATE] was 123.8 pounds. On [DATE], R64's current care plan for potential for impairment of skin integrity dated [DATE] was reviewed and documented: Air mattress check function daily. Settings 180 pounds. On [DATE] at 3:00 PM, Administrator-A and Director of Nurses-B were made aware of the above findings. Additional information was requested if available. None was provided as to why R64's bed was not at the correct setting. 38146 3.) R217 admitted to the facility on [DATE] following a fall at home. Diagnoses include lymphedema, Acute Kidney Failure, Urinary Tract Infection, Contusion of left lower leg, Type 2 Diabetes Mellitus, Viral Hepatitis, Heart Failure, Hypotension and Osteoarthritis. R217's Admission Minimum Data Set (MDS) with an Annual Reference Date (ARD) of [DATE] documents: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage: Number of Stage 2 pressure ulcers - 0 Number of Stage 3 pressure ulcers - 1 Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - 1 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - 0 Number of unstageable pressure ulcers with suspected deep tissue injury (DTI) in evolution - 2 Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - 2 Enter the total number of venous and arterial ulcers present - 5 On [DATE] at 11:02 AM, Surveyor observed R217 lying in bed on back with his head resting on his left hand. Prevalon boots were on both feet and and air mattress was on his bed. R217 reported he has wounds on his legs and feet from a fall in the shower at home. R217 reported he was not sure how long he was down, but didn't think it was too long because his son was home at the time. On [DATE] at 11:53 AM, Surveyor asked Director of Nursing (DON)-B what was the expectation when a nurse finds a wound. DON-B reported the nurse should document measurements and what the would looks like. Then, if we have a wound nurse, she'll come in an do an assessment and tweak it. We recently got a wound nurse hired, we didn't have one before, but I pushed for that after I was hired. Surveyor asked for all of R217's wound documentation. R217's Admission/Readmission/Routine Head-to toe Evaluation dated [DATE] documents: Braden score 15. Does the resident have any skin alterations? Yes. Description: L (left) back of knee hematoma. L lat (lateral) foot calluses. R (right) heel pressure injury. Skin tear L elbow. Surveyor noted there was not a comprehensive assessment, measurements or staging of the right heel pressure injury documented. In addition, R217's admission MDS documents 1 stage 3 pressure injury, 2 unstageable/deep tissue injuries and 5 venous and arterial ulcers as present on admission none of which were on the admission assessment. R217's Weekly Skin Check dated [DATE] documents: BLE- dry skin L calf back- unstageable 3.0 cm (centimeters) x 2.0 cm x 0.1cm (not on admission assessment) L heel- DTI 3.0 cm x 3.0 cm x 0.0 cm- wound bed dark purple in color (not on admission assessment) L lateral foot- unstageable 2.0 cm x 0.2 cm (admission assessment documents callous) L lateral great toe- callous 0.5 cm x 0.5 cm (not on admission assessment) L lateral heel- unstageable 5.0 cm x 2.0 cm x 0.0 cm (not on admission assessment) R buttocks- stage 2- 3.0 cm x 1.0 cm x 0.1cm (not on admission assessment) R heel- DTI 2.0 cm x 3.0 cm (admission assessment documents only pressure injury - no stage) R lateral calf- scabbed area 3.0 cm x 0.5 cm (not on admission assessment) R medial heel-unstageable 6.0 cm x 4.0 cm x 0.1cm (not on admission assessment) The facility Wound Assessment Details Report dated [DATE] documents wounds measured in cm: (No documentation of L calf back unstageable) Left heel DTI 5 x 3 x unknown. Deep Maroon 100%. Left lateral foot pressure unstageable 1.5 x 1.5 x 0.4 - bright pink/red 25% necrotic 75% Left lateral heel pressure unstageable 3.5 x 2.0 Purple ecchymosis 25%, necrotic 75% Right buttock DTI 1.0 x 1.0 deep maroon 100% (documentation day prior on ,d+[DATE] documents stage 2) Right heel DTI 4.0 x 3.0 Deep Maroon 100% Left medial foot vascular Diabetic/Callous 4.5 x 3.0 x unknown. Intact skin 50% deep maroon 50% (not on previous assessments). Right medial heel pressure unstageable 2 x 2.4 x unknown. 25% slough, 75% necrotic. Right lateral leg vascular 3.5 x 2.9 x 0.1. Bright beefy red 25%, necrotic 75%. Surveyor noted all wounds document Date Identified as [DATE], however the admission assessment completed on [DATE] listed only the left lateral foot calluses and right heel pressure injury (neither of which had an assessment, measurements or staging documented). R217's wounds are followed by Tissue Analytics Nurse Practitioner. [DATE] Tissue Analytic notes document: Wound #1: Left lateral foot evaluation: Diabetic Ulcer 1.28 cm Width: 1.69 cm Depth: 0.10 cm Wound bed Assessment Slough ,d+[DATE]% Eschar ,d+[DATE]% Wound #2: Left heel Evaluation: Pressure Ulcer - Suspected DTI. Length: 4.42 cm Width: 3.72 cm Depth: 0.10 cm Wound bed Assessment Purple. Wound #3: Right heel Evaluation: Pressure Ulcer - Suspected DTI Length: 3.49 cm Width: 5.10 cm Depth: 0.00 cm . Wound bed Assessment Purple. Wound #4: Right buttock Evaluation: Pressure Ulcer - Stage 3. Length: 1.57 cm Width: 0.55 cm Depth: 0.10 cm Wound bed Assessment Fully granulated. On [DATE] at 11:26 AM, Surveyor spoke with MDS LPN (Licensed Practical Nurse)-Z. Surveyor asked where she obtained the information regarding pressure injuries for R217's admission MDS. MDS LPN-Z reported she went to the wound rounds tab in PCC (Point Click Care) and listed all the wounds that were dated [DATE] as present on admission. Surveyor reviewed documentation of R217's admission skin assessment on [DATE] which listed only 1 pressure injury (which was not staged). Surveyor advised the facility wound notes on [DATE] then documented 3 DTI's, 3 Unstageable pressure injuries and 1 diabetic/vascular wound. MDS LPN-Z reported she was not sure, I just went by the date in the PCC wound notes, by the date entered as date identified. I know he came in with a lot of wounds, and a lot of them healed pretty quickly. On [DATE] at 12:25 PM, Surveyor observed wound care with Registered Nurse (RN) Wounds-G. Surveyor was advised R217 currently has only 2 wounds: Left heel necrotic area and left lateral foot vascular wound, all other wounds have healed. Surveyor observations of R217's wounds: Left heel: Necrotic area, no separation of edges, no drainage or odor. Left lateral foot: Vascular wound clean with red tissue wound base. No drainage, odor or redness to surrounding skin. [DATE] facility wound notes document: Left heel DTI 4.1 x 3.8 x Unknown. Deep Maroon=75%, Necrotic Hard, Firm, Adherent =25%. L lateral foot Vascular Diabetic/Ulcer 1.0 x 1.1 x 0.2 Bright Pink or Red=25%, Slough [NAME] Fibrinous=75%. Surveyor identified no concern with treatment application or infection control. No signs or symptoms of infection was noted. Surveyor advised RN Wounds-G of concern there was no assessment or measurements of R217's wounds upon admission to the facility. The facility doumentation indicates all wounds were present on admission, however the admission assessment documents only 1 pressure injury, which was not staged. It wasn't until [DATE] and [DATE] when multiple additional pressure injuries were documented and measured. RN Wounds-D stated I know we've had issues. When I started I could see right away there were issues with pressure injuries, like assessments and measurements. We had Metastar do training 2 weeks ago on assessments and measurements. They're going to come back an do another training [DATE] & 18th. On [DATE] at 2:15 PM, Nursing Home Administrator (NHA)-A was advised of the above concerns. NHA-A reported she understood, adding We have identified a lot of areas we need to work on to improve going forward. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure 5 (R167, R83, R35, R11, and R99) of 5 residents reviewed were provided adequate supervision and interventions to prevent accidents. R167 was admitted to the facility on [DATE] and discharged from the facility on [DATE] after an unwitnessed fall occurred on [DATE], at 10:50 PM. R167 had a Fall Risk Assessment completed on [DATE], which put R167 at high risk for falls. There were no further fall risk assessments completed after [DATE]. Despite being at high risk for falls and despite staff indicating R167 would scoot at times to the edge of the bed, there were no individualized care plan interventions addressing the high risk for falling (e.g., bed in lowest position, floor mat next to bed). On [DATE], at 10:50 PM, R167 had an unwitnessed fall from bed. The bed was not in the lowest position and there was not a floor mat next to the bed. This fall resulted in surgical intervention on [DATE] at 2:18 PM to repair a left femoral neck fracture. On [DATE], R167 developed post-surgical complications with elevated white blood cells (WBC), decreased oxygen saturations, and decreased urine output. R167 was transferred to inpatient hospice care on [DATE] at 2:41 PM and expired on [DATE]. The facility's failure to identify R167's risk factors for falls, its failure to comprehensively assess R167 by completing quarterly Fall Risk Assessments and developing an individualized fall risk care plan with revisions, and to provide care, treatment, and supervision necessary to prevent accidents, created a finding of Immediate Jeopardy (IJ), which began on [DATE]. Nursing Home Administrator (NHA)- A and Director of Nursing (DON)- B were notified of the immediate jeopardy on [DATE], at 12:29 PM. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a severity/scope of G (actual harm that is not immediate) as the facility continues to implement its removal plan and as evidenced by the following examples: * R83 was transferred without a mechanical lift and fractured her right ankle, and the Certified Nursing Assistant's (CNA's) knew they should use the mechanical lift and decided to transfer her with 2 assist and a gait belt. When R83 fell during the transfer the CNA's got her off the floor and into her wheelchair this was not reported to the nurse on duty till several hours later. During the transfer the CNA was heard to say to R83. This resulted in actual harm to R83. * R35 was assessed to be at high risk for falls. R35 had a fall on [DATE]. The facility did not conduct a fall investigation to provide a thorough root cause analysis and to ensure that fall interventions were in place and remained appropriate. * R11 has grab bars attached to their bed frame with not documentation of an assessment being completed or risks being explained to R11 and/or their representative. * R99 has grab bars attached to their bed frame with not documentation of an assessment being completed or risks being explained to R11 and/or their representative. Findings include: The facility's policy Accidents and Supervision dated [DATE] documents: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions: Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident. Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he/she had caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidenced suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Hazards refers to elements of the resident environment that have the potential to cause injury or illness. Risk refers to any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of all resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources provide information about hazards and risks in the resident environment. d. These sources may include, but are not limited to: i. Quality assessment and assurance (QAA) activities ii. Environmental rounds iii. MDS/CAA data iv. Medical history v. Physical exam vi. Facility assessment vii. Individual observation e. This information is to be documented and communicated across all disciplines. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends, such as time of day, location, etc. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions (e.g, plans of action developed through the QAA Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully h. Facility-based interventions may include, but are not limited to: i. Educating staff ii. Repairing the device/equipment iii. Developing or revising policies and procedures i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new interventions 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. defined by type and frequency b. Based on the individual resident's assessed needs and identified hazards in the resident environment Through Quality Assurance and Performance Improvement (QAPI) and daily rounds continue to establish and utilize the systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1.) R167 was admitted to the facility on [DATE]. R167's diagnoses include dementia, palliative care, malnutrition, pleural effusion, gastritis, anxiety, orthostatic hypotension, disorientation, history of right femur fracture, fall, anemia, aortic valve insufficiency, lymphedema, and osteoarthritis. R167's Annual MDS (Minimum Data Set) completed on [DATE] documents that R167 is dependent with transferring, bathing and toileting requiring a two-person assistance with a hoyer. R167 was documented as having a BIMS (Brief Interview for Mental Status) score of 6, indicating that R167 has severe cognitive impairment. R167's care plan, dated [DATE], documents: R167 is at risk for falls related to impaired mobility, weakness, and dementia. Created on [DATE]. Interventions include: ~ Anticipate and meet R167's needs. Date initiated [DATE]. ~ Educate R167, family, and visitors on need to call for assistance when transferring in and out of the chair. Date initiated [DATE]. ~ Ensure bed brakes are locked. Date initiated [DATE]. ~ Ensure footwear fits properly. Date initiated [DATE]. ~ Ensure R167's call light is within reach and encourage the resident to use it for assistance as needed. R167 requires prompt response to all requests for assistance. Date initiated [DATE]. .~ Follow facility fall protocol. Date initiated [DATE]. ~ R167 requires non-skid socks and footwear gripper socks on at all times. Date initiated [DATE]. After the fall on [DATE], the facility added: ~ Bed in lowest position and call light within reach. Date initiated [DATE]. ~ R167 requires a fall mat. Created on [DATE] Surveyor notes R167's care plan does not include individualized care plan interventions. Surveyor reviewed R167's medical records which includes a Fall Risk Assessment performed on [DATE] and [DATE]. R167 scored high risk for falls on [DATE] and [DATE]. Surveyor notes there are no changes to R167's care plan after scoring high risk for falls on [DATE]. On [DATE], at 9:36 AM, Surveyor interviewed NHA- A and Assistant NHA- BB who indicated a Fall Risk Assessment is to be performed quarterly and as needed (PRN) for each resident within the facility. NHA- A and Assistant NHA- BB indicated if a resident is determined to be high risk for falls, the facility would investigate resident specific interventions and take a deeper dive into environmental factors. NHA- A indicates DON- B completes the Fall Risk Assessments and includes interventions on resident's care plans based on Fall Risk Assessment results. Surveyor notified NHA- A and Assistant NHA- BB of R167 having Fall Risk Assessments completed on [DATE] and [DATE]. Surveyor requested additional Fall Risk Assessments and additional information if available. NHA- A indicated what is in the system is what is available and provided no additional Fall Risk Assessments for R167. On [DATE], at 9:51 AM, Surveyor interviewed DON- B who indicates Fall Risk Assessments are to be completed quarterly and PRN. DON- B indicates the standards of care for a resident at high risk for falls would include a fall mat, bed in the lowest position and individualized care plan interventions. DON- B indicates a fall mat and low bed would be expected if a resident was high risk based on their Fall Risk Assessment. Surveyor notified DON- B of no fall mat intervention noted on R167's care plan along with no individualized care plan interventions after R167 was determined to be high risk for falls on [DATE]. Surveyor notified DON- B of R167 having a Fall Risk Assessment completed on [DATE] and [DATE]. Surveyor asked for additional information and if there were additional Fall Risk Assessments completed for R167. DON- B indicated the facility did not have additional Fall Risk Assessments completed for R167 and indicated if she were working at the facility at the time of the missing quarterly Fall Risk Assessments for R167, they would have been completed. The facility incident report dated [DATE], for incident description, documents the nurse and CNA heard R167 yelling for help. The nurse and CNA went into R167's room and found R167 on the floor lying face down. R167 had complaints of pain in her arm, neck and back and indicated her arm may be broken. R167 declined a blood pressure attempt due to pain. The nursing supervisor was contacted and assessed R167. The nurse called 911 and R167 was transported to the hospital for evaluation. The facility incident report included a Fall Scene Investigation Report indicating R167 stated she rolled out of bed. The facility incident report included a nursing progress note from the nursing supervisor dated [DATE] at 11:11 PM, indicating the nurse supervisor was notified of R167 having an unwitnessed fall in her room. The nursing supervisor observed R167 lying face down on the floor next her bed. R167 had c/o pain in her head, neck, back and right arm. The nursing supervisor instructed staff to call 911 and to not move R167. The nursing supervisor observed R167 to be continent at the time of her fall, not having footwear on and the bed was not in the lowest position. The facility incident report included a statement from CNA- W dated [DATE]. CNA- W performed cares on R167 on [DATE], at 9:00 PM. CNA- W overheard R167 yell out for help 3 times. CNA- W went into R167's room and found R167 lying face down on the floor complaining of pain. CNA- W notified the nurse. On [DATE], at 1:48 PM, Surveyor interviewed CNA- W who indicates R167 is very confused, anxious and yells out when she is confused. CNA- W indicates she was doing rounds on the unit when she heard R167 screaming for help. CNA- W went into R167's room and found R167 on the floor, face down next to her bed. CNA- W reports R167 rolled off the right side of her bed. CNA- W got the nurse after finding R167 face down on the floor. CNA- W reports R167 having a habit of trying to get up out of bed and being confused. CNA- W indicates R167 would frequently say she wants to get up which means she's probably going to do it sooner or later. CNA- W indicates R167 did not have a fall mat in place. CNA- W reports the facility called 911 and stated, I hope she's ok because we haven't seen her since. On [DATE], at 2:20 PM, Surveyor interviewed Licensed Practical Nurse (LPN)- R who reports R167 being confused at times and will scream out at times. LPN- R stated R167 did not transfer on her own and would mostly stay in bed. LPN- R stated the CNAs told LPN- R that R167 would scoot to the edge of the bed at times and the CNAs would help her get back to the middle of the bed. LPN- R indicates he never witnessed R167 scooting to the edge of her bed. LPN- R states R167 had her call light next to her, floor mats in place, and signs in her room indicating call don't fall. LPN- R indicated on [DATE], at 10:50 PM, he was at the nursing desk charting after completing his rounds when he overheard R167 scream out for help. LPN- R stated he went to R167's room and on the way overheard CNA- W say R167 was laying on the floor face down complaining of pain. LPN- R contacted the RN supervisor who completed an assessment and advised staff to not move R167 and call 911. LPN- R reports R167 on the floor, on the right side of her bed, if lying in bed. LPN- R states he was new to the facility and was not aware of R167 having previous falls. The facility incident report included interviews with facility staff. Question number 3 on the facility staff interviews asked, Have you ever witnessed R167 reaching for any items around her in the past?. There were 45 facility staff members interviewed, and 9 of those staff members indicated yes, they had witnessed R167 reaching for items around her in the past. The facility incident report included an Assigned CNA Fall Investigations dated [DATE]. On the CNA Fall Investigation, CNA- W indicates last cares performed and last interaction with R167 prior to her fall was on [DATE], at 9:00 PM. Question 15 on the Assigned CNA Fall Investigation asks, What could have been done differently to prevent this fall?. CNA- W answered question 15 indicating hourly checking because she's so confused and maybe think she can get up and walk. Question 13 on the Assigned CNA Fall Investigation asks, Have there been any changes in the resident's condition or routine in the last week? CNA- W and CNA- GG both answered question 13, indicating R167 is more confused. R167's hospital records dated [DATE], documents R167 was evaluated in the emergency room (ER) on [DATE] and sustained a left femoral neck fracture. Surgical intervention was advised by hospital staff and R167's family was hesitant for surgical intervention to repair the left femoral neck fracture. R167's family and hospital staff met several times and agreed to proceed with a left hip hemiarthroplasty which was completed on [DATE], at 2:18 PM. On [DATE], R167 developed complications with elevated white blood cells (WBC), decreased oxygen saturations, and decreased urine output post-surgical intervention. On [DATE], at 11:30 PM, R167 was noted to have very low urine output in her foley catheter and hospital staff started IV fluids. On [DATE], at 5:31 AM, hospital staff notes R167 having very low urine output of only 50 CC of urine from [DATE] at 1:45 PM to [DATE] at 5:31 AM, while receiving continuous Intravenous (IV) fluids for 5 hours. On [DATE], at 5:36 AM, R167 was receiving oxygen (O2) post left hip hemiarthroplasty and hospital staff attempted to remove O2 therapy two different times without success. R167's O2 levels would decrease to 86% after these two attempts to remove O2 therapy. Hospital records report R167 having normal WBCs of 10.5 on [DATE] prior to her left hip hemiarthroplasty. R167's WBCs increased to 22.7 on [DATE], at 4:52 AM, which is likely stress-induced post-surgical intervention per hospital records. Family and hospital staff decided to transfer R167's care to hospice due to surgical complications. R167 was transferred to inpatient hospice care on [DATE] at 2:41 PM. On [DATE], at 10:32 AM, Surveyor spoke with R167's Power of Attorney (POA) who indicated R167 passed on [DATE]. These actions created the findings of the IJ. The facility was notified of the immediate jeopardy on [DATE], at 12:29 PM. The IJ was removed on [DATE] when the facility completed the following: ~ Reviewed residents fall risk care plan starting [DATE] to ensure individualized interventions in place as needed by [DATE]. ~ Reviewed with therapy resident transfer status with care plan revisions as needed. Initiated on [DATE]. ~ Care plans reviewed for mechanical sling lifts to include sling size. Initiated on [DATE]. ~ Review of post fall meeting and new process put into place to include review of chart and full IDT review on [DATE]. ~ A weekly risk meeting will be initiated and completed weekly ongoing starting on [DATE]. ~ Quality monitor introduction on [DATE]. ~ Fall education for licensed nurses and CNAs. Initiated on [DATE]. ~ Review of trending fall report on [DATE]. Staffing allocation reviewed for the facility. ~ Transfer competencies. Initiated on [DATE]. ~ Additional lifts rented for the facility on [DATE]. ~ An audit will be completed daily during clinical stand up to complete Interdisciplinary Team (IDT) review. ~ A member of the governing body will review the plan on a weekly and as needed basis until substantial compliance has been achieved. 49435 2.) R35 was assessed to be at high risk for falls. R35 had a fall without injury on [DATE]. The facility did not conduct a fall investigation to provide a thorough root cause analysis and to ensure that fall interventions were in place and remained appropriate. Findings include: R35 was admitted to the facility on [DATE] and has diagnoses that include: Multiple sclerosis, Hemiplegia/hemiparesis following a stroke and affecting the left side, Hypotension, and Weakness. R35's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], documents R35 is cognitively intact. R35's Admission MDS, dated [DATE], documents the following: Did the resident have a fall any time in the last month prior to admission? Unable to determine. Did the resident have a fall any time in the last ,d+[DATE] months prior to admission? Unable to determine. Admission performance for picking up object. 09-Not applicable. R35 requires partial moderate assistance to roll left and right and to move from sitting on the side of the bed to lying flat on the bed. R35's ADL (Activities of Daily Living) Care plan dated [DATE], documents R35 requires a physical assist of 2 with Hoyer mechanical lift. R35's At risk for falls Care plan dated [DATE], documents interventions that include: Anticipate and meet the resident's needs. Ensure bed brakes are locked. Ensure footwear fits properly. Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. R35's Fall risk evaluation dated [DATE], documents that R35 is at high risk for falls. On [DATE] at 2:52 PM, R35's change in condition progress note documents, in part: Fall. [Blood pressure] ,d+[DATE], [Pulse] 111, [Respiratory Rate] 18 . Mental status evaluation: No changes observed. Functional Status Evaluation: Fall. Neurological Status Evaluation: No changes observed . On [DATE] at 3:32 PM, R35's progress notes document, [R35] sent to [emergency room (ER)] for further evaluation due to fall. [R35] reports that [R35] was attempting to grab a paper off the floor and leaned forward and fell . [R35] states [R35] did hit the back of [R35's] head. Nurse of Duty updated [Nurse Practitioner], order obtained to send to ER for further evaluation. [R35] agreeable. On [DATE] at 9:10 AM, R35's progress notes document, [Follow up] ER visit . [due to] fall [DATE]. [R35] is under an observation stay at this time. CT scan and x-rays all negative . R35 did not experience an injury from the fall. Surveyor noted a fall investigation was not located in R35's medical record. On [DATE] at 8:25 AM, Surveyor interviewed Medication Technician (Med Tech)-P. Med Tech-P stated that if a resident falls, Med Tech-P would notify the nurse. A Registered Nurse (RN) needs to do an assessment. The facility has a fall packet that should be completed. The nurse fills out the fall packet, but Certified Nursing Assistance (CNA)s will give statements as part of the investigation. On [DATE] at 8:16 AM, Surveyor interviewed Licensed Practical Nurse, Unit Manager (LPN UM)-J. LPN UM-J stated that if a resident has a fall, the staff are to notify a nurse so that a RN assessment can be completed. The Medical Doctor (MD) and family are notified of the fall and a fall packet is completed. Surveyor asked what was in a fall packet. LPN UM-J stated a fall packet has a list of everything that needs to be done and is located at the nurse's station. The nurse is to complete the fall packet as soon as possible after a fall. Surveyor noted R35's fall packet with a RN assessment, statements from CNAs, a thorough route cause analysis and an assessment if fall interventions were in place at the time of the fall was not located within R35's medical record. On [DATE] at 11:50 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked for R35's fall investigation from R35's fall on [DATE]. DON-B stated that DON-B was not working at the facility at the time of R35's fall. DON-B stated that DON-B would expect a fall investigation to be completed with every fall, but DON-B could not locate a fall investigation for R35's fall on [DATE]. On [DATE] at the daily exit meeting, Nursing Home Administrator (NHA)-A and DON-B were notified of the concern that no fall investigation was completed on R35's [DATE] fall. No further information was provided. 22692 3.) R83 was admitted to the facility on [DATE] with diagnoses that included weakness and falls which resulted in a right femur fracture. R83's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief interview for Mental Status score of 10, indicating that R83 is moderately impaired. The MDS also documents R83 is dependent for transfers from her bed to the wheelchair. The facility reported incident investigation submitted by the facility on [DATE] documented: On [DATE] R83 had a staff assisted fall. R83 complained of pain and her right ankle appeared discolored. Nurse Practitioner was contacted and R83 was sent to the emergency room for further evaluation. On [DATE], the facility was informed R83 had a closed displaced bimalleolar fracture of the right ankle. On [DATE] at approximately 2:30 PM CNA-JJ and CNA-KK went to R83's room to assist her in her wheelchair so she could attend bingo. CNA-JJ and CNA-KK were unable to locate a Hoyer (full mechanical lift) sling per R83's plan of care and attempted to transfer R83 with a gait belt into her wheelchair. During the transfer, R83 was lowered to the floor by CNA-KK. CNA-JJ and CNA-KK stated they were not aware that they needed to get a nurse after a staff assisted fall so both CNA-JJ and CNA-KK assisted R83 into her wheelchair and R83 went to bingo. After R83 returned from bingo CNA-JJ told LPN-LL about the assisted fall that happened with R83 earlier. The Investigation conclusion section documented: The allegation of neglect of R83 was substantiated for the following reasons: Both CNA-JJ and CNA-KK were aware of R83 being a two-person mechanical sling lift, but transferred her using a gait belt. Neither CNA-JJ or CNA-KK updated Licensed Practical Nurse (LPN)-LL of the assisted fall until after R83 returned from bingo approximately 2 hours later. R83 has been tearful, but her mood changes when not speaking about the incident that occurred. A statement from LPN-LL (who no longer works at the facility) was included in the investigation and documented: at approximately 5:30 PM (3 hours after the fall) I was informed by CNA-JJ that R83 was in pain. CNA-JJ told me that R83 was lowered to the ground evaluated R83 and the Nurse Supervisor was updated. During the evaluation R83 was teary eyed, which is her base line. R83 did verbalize being upset regarding the transfer that occurred. R83's nursing note written by LPN-LL on [DATE] at 6:19 PM documented: Staff informed writer that R83 was lowered to ground. Staff were able to get R83 back up her wheelchair. This was not immediately reported to this writer. Upon being notified, went to R83's room finding her in high back wheelchair. R83 was upset and informed me that her right ankle is always pronated inwards and this is baseline. She has trace pedal edema but no localized swelling. Acetaminophen and cold compress applied. Updated Manager on duty and Nurse Practitioner who will see her tomorrow. No redness or bruising noted at this moment. No acute distress or abnormal findings noted. Continuing to monitor per protocol. On [DATE] at 10:49 AM, LPN-LL was interviewed and indicated he wad not been notified of R83's fall until several hours after. LPN-LL indicated he told the LPN-II, who was the house supervisor) of the fall and assumed she would take over the investigation. LPN-LL indicated he did not call the Administrator or suspend CNA-JJ and CNA-KK pending investigation and both completed their shifts. On [DATE] at 10:28 AM, Nursing Home Administrator (NHA)-A was interviewed and indicated she was not notified of the incident with R83 until [DATE] about 9:30 AM and after that she proceeded to get statements and start an investigation. NHA-A indicated the nursing supervisor who was LPN-II should have informed her right away. NHA-A indicated CNA-JJ and CNA-KK were not suspended until [DATE] and should have been suspended immediately after the allegation. The nursing schedule for [DATE] was reviewed and indicated CNA-JJ was scheduled till 3:00 PM ( LPN-LL documented she reported R83's fall to him at 3:30 PM and CNA-KK worked till 7:00 PM. On [DATE] at 1:39 PM, LPN-II was interviewed and indicated she doesn't remember much about R83's fall because that was too long ago. LPN-II indicated she was not sure if she documented anything on the incident or if she completed any investigation. (No documentation was found regarding LPN-II's involvement in the investigation and LPN-II is not mentioned in the facility investigation even though Administrator-A indicated LPN-II should have called her as she was the house supervisor). On [DATE], R83 was interviewed and indicated that about a month ago 2 CNA's transferred her and dropped her because they didn't use the lift like she told them too. R83 also indicated that one of the CNA's swore at her and it greatly upset her. R83 did not know the CNA's name and did not see either CNA after the day of the fall. R83's nursing note written by LPN-NN dated [DATE] documented: R83 is complaining of increased pain to right ankle. Ankle is swollen and bruising purple in color. Third eye (virtual doctor) updated about R83 wanting to go to the hospital for evaluation. Third eye physician gave orders to send to emergency room for evaluation ambulance called. R83's emergency room report dated [DATE] documented: a diagnosis of a closed displaced bimalleolar fracture of the right ankle. A short leg splint was applied to R83's right leg and a consultation with orthopedic surgery was ordered in one week. R83 was ordered oxycodone 10 milligrams (MG) every 6 hours as needed. R83's medication administration record (MAR) was reviewed for her oxycodone use from [DATE] to [DATE] and she received it per request approximately ,d+[DATE] times a day. R83's orthopedic consult notes dated [DATE] which indicated R83 underwent an outpatient closed reduction and casting of the right leg for the right ankle fracture. R83's current care plan for activities of daily living dated [DATE] was reviewed and documented: Intervention: Transfers, resident requires Hoyer lift with 2 assist started [DATE]. R83's CNA care sheet dated [DATE] was reviewed and documented: Transfers R83 requires Hoyer lift with 2 assist. The above findings were shared with the NHA-A and Director of Nurses-B on [DATE]. Additional information was requested if available, none was provided as to why CNA-JJ and CNA-KK did not follow R83's care plan for transfers and an investigation into the fall was not started immediately. 49011 The Facility Policy titled, Proper Use of Bed Rails Date Implemented: [DATE], Date Reviewed/Revised: [DATE], documents in part: Policy Explanation and Compliance Guidelines: Resident Assessment 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditi [TRUNCATED]

Based upon interview and record review, the facility did not ensure the rights of 8 (R1, R15, R16, R17, R18, R19, R20, and R21) of 15 residents to formulate their advanced directive preferences to receive cardiopulmonary resuscitation (CPR) (full code) or do not resuscitate (DNR) if found pulseless and not breathing. *R1 was admitted to the facility on [DATE]. During the admission process, R1 was given a facility Code Status Election form to complete. This document has both Resuscitation and Do Not Resuscitate checked. On the form, the box next to Resuscitation has an X in it and is circled and the box next to No Resuscitation has an X in it and the words are boxed off (bracketed). The document is signed by R1 but does not clearly indicate R1's wishes at the time of signature. There are no other signatures on the form to indicate who may have witnessed the signature of R1 and there is no signature of R1's physician. The electronic medical record (EMR) indicates on [DATE] R1 has a DNR (Do Not Resuscitate) status. The Code Status Election form indicates if a resident elects a DNR status the State of Wisconsin approved DNR form is to be completed. This was not completed at any point in time by R1 or her representative. On [DATE], R1 completed a Power of Attorney for Health Care (POAHC) form designating her son as the primary agent. On [DATE], R1's POAHC was activated. At this time R1's code status election was not reviewed or reestablished with the activation of the POAHC. This made the document signed on [DATE], which has both Resuscitation and No Resuscitation selected, the only existing code status election form. On [DATE], R1 was found unresponsive and absent of vital signs at approximately 8:00 am. The facility staff activated the facility emergency system for R1's room as they would for a resident who is a full code. While Registered Nurse (RN)-E went to check R1's code status, staff responded but no one initiated CPR or other life saving measures for R1. RN-E returned to R1's room stating R1 was a DNR. When emergency medical services (EMS) and the local police department arrived, the facility staff informed them R1 was a DNR and 911 was called on accident. When asked to produce required documents to confirm R1's code status, the facility staff could not produce documents to clearly convey what R1's code status was. EMS initiated CPR and other lifesaving measures on R1 until a physician associated with EMS allowed EMS to stop. R1 was pronounced deceased at 8:25 am. The facility staff implemented procedures for both code designations without really knowing what the accurate wishes of R1 were. R1 did not receive the right to formulate an advanced directive regarding code status that was clear as to her wishes were. *R15 admitted to the facility with an activated POAHC and a physician order documenting DNR. Verbal consents were obtained from the POAHC for 2 DNR forms, but neither form contained a signature. *R16's EMR documented resident was DNR without having a State DNR form signed per facility procedure. *R17's EMR documented R17 is a DNR without having the State DNR form signed and documented per facility procedure. *R18 elected to be DNR. The State DNR form was not signed by the physician until [DATE], 13 days after R18 indicated their code status wishes. *R19 elected to be DNR. R19 does not have a State DNR form per facility procedure. *R20 elected to be a DNR. R20 does not have a State DNR form per facility procedure. *R21 admitted with a State DNR form signed by the physician but not R21. R21 elected to be Full Code on [DATE] and [DATE]. The electronic charting system showed R21 to be a DNR on the dashboard when R21 desired to be a Full Code. The facility's failure to ensure R1's advance directive was accurately completed, and included all necessary signatures, and the failure of the facility to have a system in place to execute advance directives and to honor residents' wishes for residents including R15, R16, R17, R18, R19, R20, and R21 created a finding of immediate jeopardy at a scope and severity of a K (immediate jeopardy/pattern) that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA-A) and Director of Nursing (DON-B) of the finding of immediate jeopardy on [DATE] at 10:01 AM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement their action plan. Findings Include: The facility's Cardiac Pulmonary Resuscitation (CPR) policy, last reviewed ,d+[DATE] indicates: .Policy: This facility is committed to the preservation of life and alleviation of suffering. Therefore, every Resident admitted to this facility will receive total life support, including resuscitation, unless a decision not to resuscitate has been previously made. Social Services and Nursing in collaboration with facility administration are responsible for honoring Healthcare Advance Directives. A licensed social worker, certified social service designee or licensed nurse is available to assist all Residents and representatives to prepare Advance Directives. Questions and concerns will be answered competently and confidentially. Staff are trained and prepared to assist with advance care planning. It is the policy of this facility to recognize the right of Residents and/or representatives to make informed decisions about medical care including the right to accept or refuse medical treatment, including life-sustaining care, even if the refusal could hasten death, and the right to formulate Advance Directives. Further, it is the policy of this facility to comply with applicable law and to promote the right of self-determination by encouraging the use of Advance Directives and honoring treatment preferences expressed by the Resident and/or representative and their advance directives as long as those preferences are allowed by law. Procedure: -Facility staff is responsible for determining the Advance Directive information on admission and reviewed at least quarterly and with any significant change and during each care plan conference. -All discussion will be documented in the Resident's clinical record. -Any Resident designating a desire for full code resuscitation will have a Full Code order entered in the electronic medical record. -Any Resident designating a desire for no resuscitation will have a Do Not Resuscitate (DNR) order entered in the electronic medical record in accordance with all state and federal requirements. -CPR will be initiated until DNR status can be confirmed. -If the Resident has not executed a DNR Advance Directive, CPR will be initiated. An unnamed facility policy and procedure revised/reviewed ,d+[DATE] provided to Surveyor indicates the following: .-Advance Care Planning (ACP): An on-going process of discussing and clarifying the current state of a person's goals, values, and preferences for future medical care. -Advance Directive: A document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decision. -DNR Directive: In writing. signed by the person making the declaration, or by another person in the declarant's presence and by the declarant's expressed direction; dated and witnessed. -Durable Power of Attorney for Health Care (POAHC): A signed, witnessed or notarized document in which the signer designates an agent to make health care decision if the signer is temporarily or permanently unable to make such decisions. The signer should discuss his/her values, wishes and instructions with the agent before and at the time the document is signed and discussion should continue after the document is signed. The agent must be willing to exercise his/her power and authority to make certain that the signer's values, wishes and instructions are respected. Procedure -The facility will immediately seek the physician's order. -The facility will document in the electronic medical record with Resident/representative, including, as appropriate, a Resident's wish to refuse CPR. -A valid DNR order may be electronically signed in the electronic medical record (EMR). -If the Resident has advance directives, the Resident will be asked to provide a copy which will become a part of the Resident's record. The actual Code Status Election Form provided to Residents or their representative on admission documents the following . I, or my legal representative, have been fully informed by my physician or his/her designee, as to the anticipated results of initiating or withholding CPR and/or Automatic External Defibrillator (AED) if I stop breathing and my heart stops while a Resident of this facility. The Resident or representative are asked to choose 1 of the following 3 choices on the Code Status Election Form: -Resuscitation-I am expressing a desire to have CPR and/or external defibrillation performed in the event of cardiac arrest. I understand that in the event of an observed or unobserved cardiac arrest, nursing staff will initiate CPR and the use of AED device and emergency medical personnel will be called. -No Resuscitation-Refer to State approved DNR form if applicable. -I do not wish to make a choice at this time. I understand that if I have not made a choice, the facility's guidelines for performing CPR and utilizing the AED device will be followed. 1.) R1 was admitted to the facility from the hospital on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, Viral Pneumonia, Morbid Obesity, Pulmonary Hypertension, Type 2 Diabetes, and dependence on oxygen (O2). R1 had been admitted to the hospital for community acquired pneumonia of left lower lobe, sepsis, and bacteremia. R1's hospital paperwork dated [DATE] documents throughout the paperwork R1 had elected to be full code. The hospital paperwork also documents POAHC documents are on file as of [DATE]. R1 was discharged to the facility on [DATE]. R1's Admission Minimum Data Set (MDS) dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) score to be a 15 indicating R1's cognitive skills for daily decision making were intact. R1's MDS also documents R1 had a discharge goal to return to the community. Review of R1's medical record does not include any documentation or records of the referenced POAHC documents referenced in the hospital documents dated [DATE]. At the time of admission ([DATE]), R1 was provided with a facility Code Status Election Form to complete. On the form, the box next to Resuscitation has an X in it and is circled and the box next to No Resuscitation has an X in it and the words are boxed off (bracketed). The document is signed by R1 but does not clearly indicate R1's wishes at the time of signature. There are no other signatures on the form to indicate who may have witnessed the signature of R1 and there is no signature of R1's physician. Review of R1's progress notes located in R1's EMR indicates there is no documentation of anyone having a discussion with R1 regarding her code status/clarifying the code status or advance directives. The EMR indicates on [DATE], R1 has a DNR status entered into the orders by Registered Nurse (RN-E). The visible audit trail in the EMR from [DATE] through the time of survey does not show an electronically signed physician order for the DNR that is visible to staff, surveyors, or EMS. On [DATE] at 12:01 PM, Surveyor interviewed RN-E who obtained R1's code status information upon admission. RN-E stated R1 was confused about what full code was and what DNR was. RN-E stated R1's son was in the room and told R1 that it was R1's decision and R1 needed to make it. RN-E stated R1 wanted to be a full code, but then R1 didn't know what to do, and decided to be DNR. RN-E stated that R1 and her son were arguing about what the code status should be. R1's code status form was scanned in under the miscellaneous tab in R1's EMR (referring to the unclear form from [DATE]). RN-E stated that the facility uses the State DNR form but does not use the bracelet system. RN-E had no answer as to why RN-E did not have R1 complete a new Code Status Election form which clarified what R1's wishes were. Surveyor interviewed RN-H on [DATE] at 12:25 PM regarding the facility admission process and documenting a resident's code status. RN-H stated the facility policy is for the State DNR form to be filled out and stated there are 2 forms in the admission packet that need to be completed. Surveyor interviewed LPN-I on [DATE] at 12:35 PM. LPN-I informed Surveyor a State DNR form needs to be completed with a physician signature to make it valid. Review of the facility admission packet indicates the Code Status Election form is followed by the State of Wisconsin Emergency Care Do Not Resuscitate Order (DNR) form (f-44763) to be completed. The facility Code Status Election form indicates this form is to be completed if a resident is a DNR. There is no indication this form was completed or signed by a physician for R1 on [DATE] or anytime during R1's admission to the facility. Review of the progress notes and documentation by the nurse practitioner (NP) and physician indicate there is no documentation that R1's code status or advance directives were discussed with R1 by either individual. On [DATE], the facility initiated a DNR care plan for R1 with an intervention to review advance directives with R1 and/or family/responsible party quarterly and as needed. It is noted this was completed despite R1's Code Status Election form not being clear on R1's requested code status. On [DATE], Care Transitions Assistant (CTA-F) documented CTA-F met with R1 who has an elevated mood score, declined psych, R1 educated on counseling and encouraged to consider benefit of R1 to work through emotions. R1 is tearful, expressing sadness, uncertainty surrounding discharge plan. There is no documentation R1's code status/advanced directives were discussed. On [DATE] in a Care Conference note, CTA-F documents R1 and son are present. Psych is discussed and R1 decides to accept psych and a referral is made. On [DATE] at 8:41 AM, Surveyor interviewed CTA-F regarding R1's care conference on [DATE]. CTA-F informed Surveyor R1's code status and advance directives were discussed with the son at the care conference. There is no care meeting documentation to show the details of the discussion and topics discussed. On [DATE], the facility completed a POAHC document with R1 naming her son as the agent. Review of the POAHC document indicates the witness to the form was a primary nurse provider for R1. Per 155.10 (2)(d) of Chapter 155 of the State of Wisconsin state statutes, the primary nurse provider cannot serve as the witness to this document. Surveyor noted this document is also not signed by R1's agent (son) acknowledging R1's wishes. Review of R1's record following the [DATE] care conference meeting indicates CTA-F met with R1's son and shared psychiatry would be in to see R1 on [DATE]. CTA-F indicates the visit is urgent in nature as R1 cries often, has low/no motivation, is having trouble coping and adjusting, and is expressing high levels of anxiety. R1 has a history of depression. The record indicates R1's son shared no one provides updates on R1. It is documented CTA-F informed R1's son, R1 is their own person so the facility will expect R1 to keep her son updated and explain what is going on with her. It is documented R1's son shared with CTA-F they are aware of R1's POAHC documents and have been educated on the documents and that activation as of [DATE] has not occurred. On [DATE], the POAHC is activated by a psychologist and the NP, who does not date the document. The actual evaluation to determine capacity lasted 20 minutes. The evaluation states R1 has no orientation deficits, recent memory deficits, judgment is impaired, affect and mood is appropriate, thoughts and content are coherent and appropriate. It is documented R1 had trouble evaluating information with judgement questions, challenging, and making consistent decisions on her own behalf; is impaired. Surveyor interviewed CTA-F on [DATE] at 8:41 AM, about the activation of R1's POAHC documents. CTA-F informed Surveyor the reason for activating the POAHC was because R1 wasn't making decisions. Review of R1's record indicated with the activation of R1's POAHC the facility did not initiate a new Code Status Election Form with the agent to confirm R1's wishes regarding CPR and DNR and steps to take should R1 be found unresponsive without a pulse. On [DATE], R1 started to have signs and symptoms of a possible change in condition, including shortness of breath. On [DATE], it is documented by LPN-G at 7:00 AM that R1 is awake and alert, responding to simple commands, talking, able to make needs known, nasal CPAP (continuous positive airway pressure) with O2 in place, repositioned times two, pulled up in bed, head of bed elevated, (R1) requested extra pillows for under arms. On [DATE] at 8:00 AM, R1 was found by shift nurse unresponsive and without vitals. (Cross-Reference F678). On [DATE] at 1:45 PM, Surveyor interviewed RN-E. RN-E informed Surveyor she found R1 unresponsive about 8:00 AM. RN-E stated R1 preferred to get their medications early so RN-E would go to R1's room first. RN-E stated they hit the code button and called for help. RN-E stated everyone came running and does not remember who went to get the crash cart. RN-E stated CPR was not initiated by any facility staff. RN-E stated, At first we thought (R1) was a full code. RN-E did instruct someone to call 911 but does not remember who. RN-E went to the nurse's station and pulled up R1's Code Status Election form under the miscellaneous tab in R1's EMR. On [DATE] at 7:18 AM, Surveyor interviewed LPN-G who confirmed they were present on [DATE] when R1 was found unresponsive. Surveyor showed LPN-G R1's Code Status Election Form and asked what R1's code status would be upon review of this document. LPN-G stated resuscitation is checked and circled and LPN-G would say R1 is a full code and CPR should be initiated. When asked about the incident on [DATE], LPN-G confirmed CPR was not performed by any facility staff when R1 was found unresponsive but that code was called including calling 911. LPN-G stated R1's form is very confusing and LPN-G would not know what to do. LPN-G confirmed that the State DNR form needs to be completed if a resident does not want resuscitation and a physician needs to sign and date the State DNR form. LPN-G confirmed to Surveyor that they activated the emergency call light button from inside R1's room. LPN-G stated they kept asking what R1's code status was while in R1's room, but RN-E had left the room to locate the code status. On [DATE] at 11:21 AM, Surveyor interviewed RN-E again regarding R1's code status and the confusion at the time R1 was found unresponsive. RN-E stated, It was my mistake not getting the State DNR form signed by (R1). RN-E stated she knew it is part of the process of the facility to get both forms signed. RN-E shared R1 was confused about full code and DNR status and R1 didn't know what to do but then decided to be DNR. Surveyor noted this discussion was not documented to have occurred on [DATE] when R1 signed the Code Election Form. It is also noted there is no indication R1's physician or nurse practitioner were consulted with or requested to speak to R1 to help discuss and clarify R1's questions and confusion regarding her code status. On [DATE] at 1:18 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R1. DON-B was present on [DATE]. DON-B confirmed that no facility staff initiated CPR. DON-B stated that staff did not know what the code status was at first because it was confusing for R1 and that is why the alarm was initiated. DON-B stated that the State DNR form should be completed if someone has chosen to have a DNR status. DON-B confirmed that it is the facility procedure to obtain code status on the Code Status Election form and if no resuscitation is the wish, the State DNR form is initiated and needs to be signed by the physician. On [DATE] at 1:36 PM, Surveyor interviewed DON-B again regarding R1. DON-B stated that EMS follows the State DNR form. DON-B stated the facility would follow the other form (Code Status Election form) and if no resuscitation is checked they would consider the resident to be DNR even without the state DNR form. Surveyor showed DON-B R1's Code Status Election form and DON-B stated at first glance it is confusing about what R1's code status is and would have needed to be clarified. Surveyor reviewed the initial police report dated [DATE] and the following is documented by Police Officer (PO-V).Due to several issues while responding to the emergency and noting several concerns, such as inability to locate DNR paperwork. No life saving measures conducted, without DNR paperwork and no facility emergency called or knowledge that emergency responders were responding to the facility . Review of the police report and review of facility video footage indicates EMS provided CPR and other lifesaving measures to R1 until their physician determined CPR could be stopped. The facility's failure to have a clear system in place and an established policy and procedure that is understood and implemented by all staff within the facility created a situation of immediate jeopardy. This failure included R1 admitting to the facility and expressing confusion regarding establishing her code status and the facility not involving either the nurse practitioner or the physician to speak with R1 and inform her of her options. R1's Code Election Form was not completed correctly and clearly to allow facility staff to know R1's code status election when R1 was found unresponsive and not breathing. The facility did not have established systems in place to ensure the activation of a POAHC was completed correctly and the agent was given the opportunity to review and establish directives and code status elections based upon R1's expressed wishes. 20483 On [DATE] at 3:30 PM, Surveyors conducted an audit of all residents currently with DNR status in the facility. Surveyors found 7 additional residents with issues with the facility forms, physician orders, etc. 2.) On [DATE] at 3:04 p.m. Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] & R15's POAHC was activated on [DATE]. R15's diagnoses include malignant neoplasm, adult failure to thrive, COPD (chronic obstructive pulmonary disease,) hypertension, anxiety disorder, and depressive disorder. Review of R15's physician orders revealed an order dated [DATE] which documents Do Not Resuscitate (DNR). The resuscitation form is checked for no resuscitation. On the line for Resident Signature documents verbal: POA [first name] X. Date is [DATE]. The State DNR form has a handwritten notation above the patient or legal guardian or health care agent of an incapacitated patient line which documents verbal: [First name of POA] [DATE] 13:00 (1:00 p.m.). R15's physician signed this form on [DATE]. Surveyor noted neither form includes documentation of who witnessed the verbal consent. The nurses note dated [DATE] at 12:18 p.m. written by LPN/ACNO (Licensed Practical Nurse/Assistant Chief Nursing Officer)-N documents: Writer spoke with POA [first name] regarding code status, verbal consent received for DNR. Code status sent to MD (medical doctor) for signature. POA [first name] states she will be at facility Thursday [DATE] for a meeting and able to provide physical signature at that time. Surveyor noted as of [DATE], the facility does not have a fully signed code status document as the facility did not follow up on getting signatures from R15's POA. 48391 3.) R16 was admitted to the facility on [DATE] with diagnoses of idiopathic hypotension, chronic diastolic heart failure, chronic respiratory failure with hypoxia, cognitive communication deficit, ischemic cardiomyopathy, chronic kidney disease stage 3, major depressive disorder, Bell's palsy, and peripheral vascular disease. R16 signed the Code Status Election Form indicating no resuscitation (DNR) dated [DATE]. R16's DNR order was placed on [DATE] at 7:46 pm. Surveyor reviewed R16's Advanced Directives on the computer dashboard which indicates R16 is a DNR. Surveyor notes there is no updated State of Wisconsin Do Not Resuscitate Order Form after R16's admission on [DATE]. 4.) R17 was admitted on [DATE] with diagnoses of disorder of circulatory system, chest pain, peripheral vascular disease, malnutrition, history of embolism, mild cognitive impairment, syncope, heart failure, chronic kidney disease stage 3, mitral insufficiency, weakness, anxiety disorder, altered mental status, repeated falls, hyperlipidemia, and atrial fibrillation. Surveyor noted R17's DNR order was placed on [DATE] at 7:03 pm. Surveyor reviewed R17's Advanced Directives on the computer dashboard which indicates R17 is a DNR. R17 has a Code Status Election Form signed by the resident indicating no resuscitation (DNR) dated [DATE]. Surveyor notes there is no State of Wisconsin Do Not Resuscitate Order Form in R17's medical record. 38253 5.) R18 was admitted to the facility on [DATE]. R18 did not have an activated Power of Attorney. R18 signed the Code Status Election Form on [DATE] indicating no resuscitation (DNR). A DNR order was entered into the computer charting system on [DATE] and DNR appeared on R18's chart dashboard. The State of Wisconsin Emergency Care Do Not Resuscitate Order form was not signed by R18 but was signed by the physician on [DATE]. R18 did not have the appropriate DNR paperwork in place for 13 days after R18 indicated their code status wishes. 6.) R19 was admitted to the facility on [DATE]. R19 did not have an activated Power of Attorney. R19 signed the Code Status Election Form on [DATE] indicating no resuscitation (DNR). A DNR order was entered into the computer charting system on [DATE] and DNR appeared on R19's chart dashboard. The State of Wisconsin Emergency Care Do Not Resuscitate Order form was not completed or entered into R19's medical record on [DATE]. The facility provided a copy of the State of Wisconsin Emergency Care Do Not Resuscitate Order form on [DATE] to Surveyor. The form had R19's signature and date of [DATE]. The form had the signature of a Nurse Practitioner but was not dated. R19 did not have the appropriate DNR paperwork in place for 3 days after R19 indicated their code status wishes. 7.) R20 was admitted to the facility on [DATE]. R20 did not have an activated Power of Attorney. R20 signed the Code Status Election Form on [DATE] indicating no resuscitation (DNR). A DNR order was entered into the computer charting system on [DATE] and DNR appeared on R20's chart dashboard 13 days before R20 indicated their code status wishes. R20 did not have the State of Wisconsin Emergency Care Do Not Resuscitate Order form in their chart. R20 did not have the appropriate DNR paperwork in place to carry out their DNR wishes. 8.) R21 was admitted to the facility on [DATE]. R21 did not have an activated Power of Attorney (POA). R21 had the State of Wisconsin Emergency Care Do Not Resuscitate Order form in their medical record that was dated [DATE]. The patient signature line had a signature, but it was not that of the patient. The physician signature line had a signature, but no printed name to coincide with the signature. A Full Code order was entered into the computer charting system on [DATE]; R21 did not complete a Code Status Election Form at that time. A DNR order was entered into the computer charting system on [DATE] and DNR appeared on R21's chart dashboard. On [DATE], a Code Status Election Form was completed indicating R21's wish to be a Full Code. R21's spouse signed the form as the POA. R21 did not have an activated POA. A Full Code order was entered into the computer charting system and Full Code appeared on R21's chart dashboard. On [DATE], a Code Status Election Form was completed indicating R21's wish to be a Full Code. R21's spouse signed the form as the POA. R21 did not have an activated POA. A Full Code order was entered into the computer charting system and Full Code appeared on R21's chart dashboard. On [DATE], a DNR order was entered into the computer charting system and DNR appeared on R21's chart dashboard. No Code Status Election Form accompanied this order. On [DATE], Surveyor noted R21 had DNR on the chart dashboard. At 3:42 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that charts were audited, and concerns were found with current residents that had DNR as their dashboard code status that did not have the appropriate paperwork to go with that status. On [DATE], Surveyor received a copy of a Code Status Election form that had been completed and signed by R21 on [DATE] indicating R21 wished to be resuscitated in the event of a cardiac arrest. Surveyor reviewed R21's chart dashboard and Full Code was listed as the code status. Surveyor noted R21 had the wrong status listed on the chart dashboard since [DATE], four months ago. The facility's failure to ensure residents have the right to formulate their wishes regarding advanced directives, including establishing code status created a reasonable likelihood for serious harm, thus creating a situation of immediate jeopardy that started on [DATE] when R1 was admitted to the facility and the facility did not clearly establish R1's wishes regarding CPR or Do Not Resuscitate. The immediate jeopardy was removed on [DATE] and continues at a scope and severity of an E (potential for harm/pattern) when the facility implemented the following: ~ All nursing staff are being re-educated across all shifts on the facility's advanced directive policy and procedure. ~ Social services and admissions staff are being re-educated on the facility's advanced directive policy and procedure ~ On [DATE] all nursing staff began re-education across all shifts on the facility's policy and procedure related to Advanced Directives, education also includes admission and social services personnel. ~ Facility policies were reviewed with the Medical Director (MD), and after review the MD finds all facility policies acceptable in their current form. ~ Current residents have been reviewed to ensure their advanced directive is completed and documented in accordance with the facility policy and procedure related to advanced directives by the Director of Nursing and/or designee. ~ Daily audits will occur for any new or re-admissions by the Director of Nursing and/or designee beginning [DATE] to ensure the facility's advance directive policy and procedure is followed. ~ Results of the audits will be reviewed and discussed in weekly QAPI by the inter-disciplinary team on [DATE] and weekly thereafter. ~ Daily audits will occur x 2 weeks, then weekly x 8 weeks, and monthly x 3 months to ensure substantial compliance.

Based on interview and record review, the facility failed to ensure 1 (R1) of 1 resident reviewed who became unresponsive and pulseless received basic life support and emergency care based upon physician orders and the resident's advanced directives; including their code status. On [DATE], R1 was found unresponsive by staff. R1 had a Code Status Election document on file which had both Resuscitation and Do Not Resuscitate marked. The only signature on the form was that of R1 and the form did not clearly indicate R1's wishes nor have the correct signatures. Facility staff did not initiate CPR or other lifesaving measures for R1 upon discovery of her being unresponsive although a code was called as was 911. After an RN checked R1's electronic medical record (EMR), she informed staff responding to the facility's code system that resident was a DNR. 911 responded. Staff could not produce a document to clearly convey resident's code status, leading to emergency medical personnel initiating CPR and other lifesaving measures until a physician associated with the EMTs allowed them to cease lifesaving measures. Resident was pronounced deceased at the facility. The facility's failure to ensure R1's record accurately identified R1's wishes/advance directives and the failure to provide emergency care and basic life support to R1 in accordance with her advanced directives and wishes created a finding of immediate jeopardy at a scope and severity of a J (immediate jeopardy/isolated) which began on [DATE]. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on [DATE] at 10:01 am. The immediate jeopardy was removed on [DATE] and continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their action plan. Findings include: The facility policy and procedure titled Cardiac Pulmonary Resuscitation (CPR)-Last reviewed ,d+[DATE] indicates: .Policy: This facility is committed to the preservation of life and alleviation of suffering. Therefore, every Resident admitted to this facility will receive total life support, including resuscitation, unless a decision not to resuscitate has been previously made. Social Services and Nursing in collaboration with facility administration are responsible for honoring Healthcare Advance Directives. A licensed social worker, certified social service designee or licensed nurse is available to assist all Residents and representatives to prepare Advance Directives. Questions and concerns will be answered competently and confidentially. Staff are trained and prepared to assist with advance care planning. It is the policy of this facility to recognize the right of Residents and/or representatives to make informed decisions about medical care including the right to accept or refuse medical treatment, including life-sustaining care, even if the refusal could hasten death, and the right to formulate Advance Directives. Further, it is the policy of this facility to comply with applicable law and to promote the right of self-determination by encouraging the use of Advance Directives and honoring treatment preferences expressed by the Resident and/or representative and their advance directives as long as those preferences are allowed by law. Procedure: -Facility staff is responsible for determining the Advance Directive information on admission and reviewed at least quarterly and with any significant change and during each care plan conference. -All discussion will be documented in the Resident's clinical record. -Any Resident designating a desire for full code resuscitation will have a Full Code order entered in the electronic medical record. -Any Resident designating a desire for no resuscitation will have a Do Not Resuscitate (DNR) order entered in the electronic medical record in accordance with all state and federal requirements. -CPR will be initiated until DNR status can be confirmed. -If the Resident has no executed a DNR Advance Directive, CPR will be initiated. Unnamed policy and procedure revised/reviewed ,d+[DATE] provided to Surveyor indicates the following: .-Advance Care Planning (ACP): An on-going process of discussing and clarifying the current state of a person's goals, values, and preferences for future medical care. -Advance Directive: A document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decision. -DNR Directive: In writing. signed by the person making the declaration, or by another person in the declarant's presence and by the declarant's expressed direction; dated and witnessed. -Durable Power of Attorney for Health Care (POAHC): A signed, witnessed or notarized document in which the signer designates an agent to make health care decision if the signer is temporarily or permanently unable to make such decisions. The signer should discuss his/her values, wishes and instructions with the agent before and at the time the document is signed and discussion should continue after the document is signed. The agent must be willing to exercise his/her power and authority to make certain that the signer's values, wishes and instructions are respected. Procedure -The facility will immediately seek the physician's order. -The facility will document in the electronic medical record with Resident/representative, including, as appropriate, a Resident's wish to refuse CPR. -A valid DNR order may be electronically signed in the electronic medical record (EMR). -If the Resident has advance directives, the Resident will be asked to provide a copy which will become a part of the Resident's record. The actual Code Status Election Form provided to Residents or their representative on admission documents the following: .I, or my legal representative, have been fully informed by my physician or his/her designee, as to the anticipated results of initiating or withholding CPR and/or Automatic External Defibrillator (AED) if I stop breathing and my heart stops while a Resident of this facility. The Resident or representative are asked to choose 1 of the following 3 choices on the Code Status Election Form: -Resuscitation-I am expressing a desire to have CPR and/or external defibrillation performed in the event of cardiac arrest. I understand that in the event of an observed or unobserved cardiac arrest, nursing staff will initiate CPR and the use of AED device and emergency medical personnel will be called. -No Resuscitation-Refer to State approved DNR form if applicable. -I do not wish to make a choice at this time. I understand that if I have not made a choice, the facility's guidelines for performing CPR and utilizing the AED (automated external defibrillator) device will be followed. The form does not have details on it to include signature of a witness(s) to the form or a physician signature. R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, Viral Pneumonia, Morbid Obesity, Pulmonary Hypertension, Type 2 Diabetes, and dependence on oxygen (O2). R1's Admission Minimum Data Set (MDS) dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) score to be a 15 indicating R1's cognitive skills for daily decision making were intact. R1's MDS also documents that R1 had a discharge goal to return to the community. R1 had been admitted to the hospital for community acquired pneumonia of left lower lobe, sepsis, and bacteremia. R1's hospital paperwork dated [DATE] documents throughout the paperwork R1 had elected to be full code. The hospital paperwork also documents POAHC documents are on file as of [DATE]. R1 was discharged to the facility on [DATE]. At the time of admission ([DATE]), R1 was provided with a facility Code Status Election Form to complete. This document has both Resuscitation and Do Not Resuscitate checked. On the form, the box next to Resuscitation has an X in it and is circled and the box next to No Resuscitation has an X in it and the words are boxed off (bracketed). The document is signed by R1 but does not clearly indicate R1's wishes at the time of signature. There are no other signatures on the form to indicate who may have witnessed the signature of R1 and there is no signature of R1's physician. The Code Status Election form indicates if a resident elects a DNR status, the State of Wisconsin approved DNR form is to be completed. This form was not completed at any point in time by R1 or her representative. (Cross reference F578.) Review of R1's progress notes located in R1's EMR indicates there is no documentation of anyone having a discussion with R1 regarding her code status or clarifying the code status or advance directives. The EMR indicates on [DATE], Registered Nurse E (RN-E) entered DNR status into R1's orders. The visible audit trail in the EMR from [DATE] through the time of survey does not show an electronically signed physician order for the DNR that is visible to staff, surveyors, or EMS. On [DATE], R1's POAHC was activated by a psychologist and the Nurse Practitioner (NP). The evaluation states R1 has no orientation deficits, recent memory deficits, judgment is impaired, affect and mood is appropriate, thoughts and content are coherent and appropriate. It is documented R1 had trouble evaluating information with judgement questions, challenging, and making consistent decisions on her own behalf; is impaired. Surveyor interviewed Care Transitions Assistant F (CTA-F) on [DATE] at 8:41 AM, regarding the activation of R1's POAHC. CTA-F informed Surveyor the reason for activating the POAHC was because R1 wasn't making decisions. Review of R1's record indicates with the activation of R1's POAHC the facility did not initiate a new Code Status Election Form with the agent to confirm R1's wishes regarding CPR and DNR and steps to take should R1 be found unresponsive without a pulse. (Cross-reference F578). On [DATE], R1 started to have signs and symptoms of a possible change in condition, including shortness of breath. On [DATE], it is documented by LPN-G at 7:00 AM that R1 is awake and alert, responding to simple commands, talking, able to make needs known, nasal CPAP (continuous positive airway pressure) with O2 in place, repositioned times two, pulled up in bed, head of bed elevated, (R1) requested extra pillows for under arms. On [DATE] at approximately 8:00 AM, a shift nurse found R1 unresponsive and pulseless. Certified Nursing Assistant K (CNA-K) was told by RN-E to activate the facility's code system. RN-E went to look up R1's code status in the EMR. During this time, facility staff did not initiate CPR or other lifesaving measures. RN-E instructed CNA-K to call 911. Staff responded to the code within the facility by coming to the room and bringing a crash cart, however no staff initiated CPR for R1 despite R1's code status not being clearly designated on the facility Code Election Form and there being no State of Wisconsin DNR form for R1 as indicated on the facility policies/documents. After calling code and calling 911, facility staff did not notify the front lobby, including the Lead Director of First Impressions (LDI)-I, 911 had been called, and where the emergency was located in the facility to direct emergency medical staff (EMS) and the police department. This caused a delay in emergency personnel reaching R1 to provide basic life support. Surveyor reviewed the EMS report dated [DATE] which documents: At 8:07.49 AM per EMS report, dispatch is notified. Enroute at 8:08.49 AM. At scene at 8:13.58 AM. At patient at 8:15.37 AM. CPR is started at 8:16.22 AM. The report also documents staff reported R1 is not breathing with no pulse and is DNR. R1 is laying supine with no pulse and not breathing. Manual compressions were started (by EMS) with OPA (Oropharyngeal airway) and breaths given with O2 (oxygen) connected to BVM (bag valve mask). IO (intraosseous administration) was started in right leg with 1 epinephrine. EMS notified facility staff that paperwork is needed for DNR. Paperwork obtained by EMS is signed by R1 but not by a medical professional for DNR status. The report indicates the EMS physician (DOC 200) stated DNR paperwork can be granted and R1 was declared deceased at 8:25 AM. Surveyor reviewed the initial police report dated [DATE] and the following is documented by Police Officer (PO-V).Due to several issues while responding to the emergency and noting several concerns, such as inability to locate DNR paperwork. No life saving measures conducted, without DNR paperwork and no facility emergency called or knowledge that emergency responders were responding to the facility. Review of the police report and review of facility video footage indicates R1 was provided with CPR and other lifesaving measure by EMS until their physician determined CPR could stopped. On [DATE], Surveyor was provided the final police report dated [DATE] written by PO-V. PO-V documents that when PO-V arrived at approximately 8:09 AM, PO-V made contact with staff in the front office who were initially confused and were not aware that anybody had called for emergency responders. After ,d+[DATE] minutes, PO-V was led to the room. At 8:25 AM, EMS was able to locate the DNR paperwork that was not signed by a physician. On [DATE] at 1:45 PM, RN-E was interviewed by Surveyor. RN-E found R1 unresponsive about 8:00 AM. RN-E stated R1 preferred to get R1's medications early so RN-E would go to R1's room first. RN-E stated they hit the code button and called for help. RN-E stated everyone came running and does not remember who went to get the crash cart. RN-E stated CPR was not initiated. RN-E stated, At first we thought (R1) was a full code. RN-E did instruct someone to call 911 but does not remember who. RN-E went to the nurse's station and pulled up R1's Code Status Election form under the miscellaneous tab in R1's EMR. Surveyor noted RN-E was the nurse who processed R1's Code Election form on [DATE]. On [DATE] at 1:35 PM, Surveyor interviewed CNA-K, who was present during R1's code. CNA-K stated that RN-E instructed CNA-K to call 911 and CNA-K did. CNA-K stated that someone took the phone from CNA-K but does not remember who. CNA-K stated the blue light was going off indicating a code and someone went to get a crash cart. CNA-K stated there was a lot of commotion and CNA-K just does what I am told. On [DATE] at 1:23 PM, Surveyor interviewed CNA-J who said there was a lot of commotion when R1 was found unresponsive. CNA-J stated no one was performing CPR and people were just standing around. CNA-J stated they went to the lobby and directed the emergency responders of where to go (sic). On [DATE] at 7:18 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G. LPN-G confirmed they were present during the time R1 was found unresponsive on [DATE]. Surveyor showed LPN-G R1's Code Status Election form and asked what R1's code status would be looking at this form. LPN-G stated that resuscitation is checked and circled and LPN-G would say that R1 is a full code and CPR should be initiated. LPN-G confirmed that CPR was not performed by any facility staff on R1 when R1 was found unresponsive. LPN-G stated R1's form is very confusing and LPN-G would not know what to do. LPN-G confirmed that the State DNR form needs to be completed if a resident does not want resuscitation and a physician needs to sign and date the State DNR form. Surveyor asked LPN-G about the code process. LPN-G explained that for a code, the emergency button on the call light system is pushed. LPN-G stated it goes out to the rest of the building. LPN-G stated staff have to look at the monitor at each nurse's station to determine where the code is. LPN-G shared on the date R1 was found unresponsive, RN-E came to the nurse's station and informed LPN-G that R1 was unresponsive. LPN-G and RN-E both went back to R1's room. LPN-G was saying, What happened, I just repositioned her, and kept repeating, what's her code status? LPN-G stated someone went to go get the crash cart. RN-E left the room to determine R1's code status. LPN-G confirmed that EMS initiated CPR. On [DATE] at 11:21 AM, Surveyor interviewed RN-E regarding R1's code status due to the confusion at the time R1 was found unresponsive. RN-E stated, It was my mistake not getting the State DNR form signed by (R1). I know it is part of the process of the facility to get both forms signed. (R1) was confused about full code and DNR status and (R1) didn't know what to do, but then decided to be DNR. Surveyor reviewed the 911 call audio, which is logged at 8:06 AM and indicates there is confusion on the 911 call from facility staff regarding what R1's code status is. Specifically, someone says, Thought patient was a full code, oh wait (R1) is a DNR. Surveyor noted facility staff did not initiate CPR or other lifesaving measures for R1 per RN-E and LPN-G from the 8:06 AM 911 call to when EMS arrived at R1's bedside at 8:15.37 AM. On [DATE] at 10:42 AM, Surveyor spoke with Lead Director of First Impression (LDI-L) who confirmed that LDI-L was present in the lobby when the police and EMS responded to the facility on [DATE]. LDI-L confirmed they did not know where the code was. LDI-L stated they are usually notified by phone and then a staff member comes to the lobby to escort the emergency responders, however, on [DATE], LDI-L confirmed that LDI-L was not notified. LDI-L confirmed that there was a delay of about 5 minutes where the emergency responders were waiting in the lobby until the code location was confirmed. On [DATE] at 7:06 AM, Surveyor interviewed Maintenance Director (MD-GG) regarding the facility code alert system. MD-GG stated an alarm goes off when the emergency button is pushed. MD-GG stated it is not an overhead alarm like a fire alarm. MD-GG stated that everyone should be able to hear it. MD-GG stated it signifies what room to go to and this is gone over at orientation. MD-GG did not know why people would be running around the facility trying to figure out where the code is. MD-GG informed Surveyor that MD-GG does not test the system to see if the emergency button is working. MD-GG then showed Surveyor how it works at the nurse's station, showing the code comes over the white phone monitor system at each nurse's station and reads across the phone the room number. MD-GG stated it will show up at each nurse's station if there is a code. On [DATE] at 12:33 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the code event involving R1. NHA-A stated a CNA had answered R1's call light and R1 was okay at about 7:56 AM before the event. Surveyor had reviewed the facility video footage of the hallway at the time of the code event and noted the footage did not include that time frame for Surveyor to review. When discussing the event further NHA-A stated R1 was a DNR status and no one would admit to calling 911 when looking into the event. Surveyor asked NHA-A if the facility had reviewed or investigated the event. NHA-A confirmed no statements were obtained from staff and no investigation was completed. On [DATE] at 1:18 PM, Surveyor interviewed Director of Nursing (DON-B) regarding R1. DON-B shared they were present on [DATE]. DON-B confirmed that no facility staff initiated CPR or other lifesaving measures for R1. DON-B stated that staff did not know what the code status was at first because it (code status) was confusing for R1 and that is why the alarm was initiated. DON-B confirmed that there was no investigation completed or review of the incident. On [DATE] at 1:36 PM, Surveyor asked about the confusion and if the facility knew what forms the local EMS requires to show DNR status for a resident. DON-B states that EMS follow the State DNR form. DON-B stated the facility would follow the other form (the Code Status Election form) if no resuscitation is checked and would consider the resident DNR. Surveyor showed DON-B R1's Code Status Election form and DON-B stated at first glance it is confusing about what R1's code status is and would have needed it to be clarified. On [DATE] at 7:44 AM, Surveyor shared the serious concern of R1's code status not clearly documented with the appropriate forms and signatures to ensure staff responded to the emergency and provided emergency care and the facility was unable to provide EMS the completed DNR forms for R1. Surveyor shared there was confusion as to what R1's code status was and consequently there was a delay in CPR being initiated for R1 if the code status was not clearly determined. Alternatively, if R1's wishes were to receive no resuscitation and have a DNR status, facility staff could not convey the correct information to prevent EMS from initiating CPR on R1. During this discussion the facility indicated it would carry out a mock code drill while surveyors were in the facility. NHA-A stated, It's a good idea so I can see how the system works. On [DATE] at 8:00 AM, Surveyor observed the mock code drill from Unit 2. Surveyor observed that the room number for a code shows up on the white phone system that is also used for the regular call light system. The regular call light system has a beep, pause, beep, pause. The code blue alarm goes beep, beep, beep. One CNA was overheard to say, Why do we have to tell the nurses to respond? Another Surveyor observed on another unit that not all staff responded, and one nurse was in a room and stated they did not hear the alarm. As part of the mock code staff are supposed to bring the crash carts to the emergency. On [DATE] at 8:09 AM, Surveyor interviewed LPN-HH in regards to the crash carts. LPN-HH stated there is a crash cart on each unit. LPN-HH stated every night the nurse is supposed to be checking that all supplies are stocked and the cart is ready to go. LPN-HH indicated there is an audit sheet in a binder located in the crash carts that should be filled out every night. Surveyors observed the crash carts on each unit and the following is what was observed: Unit 100-done at least weekly but found many days not completed Unit 200-only April is in the binder but only the 10th is completed Unit 300 and 400 share 1 crash cart and there were multiple blanks for March and April. The facility's failure to ensure R1's wishes were accurately and consistently identified in the medical record and the failure of facility staff to provide basic life support in an emergency situation in respect of a resident's advanced directives including the designated code status created a reasonable likelihood that serious harm could occur, thus creating a finding of immediate jeopardy starting on [DATE]. According to a 2016 Division of Appeals Board hearing decision, It is important to not lose sight of the fact than an error in deciding whether or not to resuscitate a resident has dire implications: either someone who had a desire to live faces death without any chance for survival, or a person who desired a natural death is forced to undergo significant interventions, such as chest compressions and defibrillation, in an attempt to extend a life that he or she did not want to be unnaturally extended .If staff members are required to reconcile conflicting orders involving the question of resuscitation during a medical emergency, the resulting inconsistent action is likely to cause serious harm, injury, impairment, or death. https://www.hhs.gov/sites/default/files/static/dab/decisions/alj-decisions/2016/cr4545.pdf The immediate jeopardy was removed on [DATE] when the facility initiated the following: ~ All nursing staff have begun reeducation regarding the facility's policy and procedure related to CPR, advanced directives, identification of code status, and responding to residents who are unresponsive, pulseless, and/or breathless. ~ The Medical Director reviewed all current facility policies related to the alleged deficient practice, and after review found all policies acceptable in their current form. ~ Daily audits have been initiated by the Director of Nursing and/or designee to ensure nursing staff adherence to the facility policy and procedure for CPR, advanced directives, identification of code status, and responding to residents who are unresponsive, pulseless, and/or breathless have begun on [DATE]. ~ Daily audits will occur x 2 weeks, weekly x 8 weeks, and monthly x 3 months to ensure staff adherence with facility policy and procedure. ~ Mock code blue drills have been conducted on [DATE] and will be conducted across all shifts twice weekly on various nursing units by the Director of Nursing and/or designee. ~ Results of all audits have been reviewed during weekly QAPI and will continue to be reviewed weekly by the inter-disciplinary team to ensure compliance with facility policy and procedure.

Based on record review and staff and family interview, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 (R7) of 3 sampled residents. R7 had a history of falls, spastic movements and contractures of bilateral upper extremities. R7 was left alone seated on a mechanical lift sling on a shower chair in his room. The Certified Nursing Assistant (CNA) left R1 unattended and left the room to retrieve a bath blanket. Upon the CNA's return to R7's room, R7 was observed on the floor with bleeding from the head. R7 was transferred to the hospital and diagnosed with a laceration to the head that required 15 sutures and a fractured neck at the 1st cervical vertebrae. The failure to supervise R7 while seated on a shower chair which resulted in a fall created a finding of immediate jeopardy that began on 8/27/23. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 8/31/23 at 11:25 AM. The immediate jeopardy was removed on 9/1/23. However the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan regarding supervision. Findings include: According to the electronic face sheet, R7 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, muscle wasting with atrophy, contractures of the right and left shoulder, left hand, and the right and left elbows. R1 had repeated falls. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/10/23 indicated R7 had moderate cognitive impairment, had impairment of bilateral upper extremities and a history of falls. The Falls Care Area assessment dated [DATE], indicated R7 had difficulty maintaining sitting balance and had cognitive impairment. The facility completed a Falls Risk assessment dated [DATE], which indicated R7 was at high risk for falls. According to a falls care plan which was initiated on 01/11/22 indicated the following: The Resident is at risk for falls related to (r/t) immobility, history of falls, weakness, arthritis, bilateral upper extremities contractures. Interventions included: ~ Anticipate and meet the resident's needs ~ Ensure bed brakes are locked ~ Ensure footwear fits properly ~ Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed ~ Follow facility fall protocol ~ Ensure guest has appropriate footwear (added 03/07/22) ~ Re-educate on use of call light and wait for staff assistance (added 03/08/22) ~ Do not leave resident unattended while in the shower chair (added 08/27/23) The care plan initiated on 01/11/22 indicated, The resident has an alteration in neurological status r/t Parkinson's features. Intervention as followed: ~ Monitor/document/report as needed signs/symptoms of tremors, rigidity, dizziness, changes in level of consciousness and slurred speech (01/11/22) The facility did not complete an assessment to ensure safety while seated in a chair due to jerking movements, contractures and kyphosis. The facility also did not address safety concerns due to the jerking movements, contractures and kyphosis in the plan of care. The electronic Physician Orders indicated R7 received Baclofen 10 milligrams four times daily. (Medication is given to relieve spasms, cramping and tightness of muscles caused by medical problems). A Physician's Assistant note dated 08/25/23 indicated R7 had bilateral elbow flexion contractures with spastic tone to the bilateral upper extremities. Swan neck deformity to bilateral digits (left greater than right) with decreased range of motion in bilateral digit extension. Kyphotic (refers to an abnormally curved spine) posture. The nurses notes dated 08/27/23 documented at 10:45 AM indicated, Resident had an unwitnessed fall this morning at approximately 0948 (9:48 AM) after being left alone on the shower chair while CNA went to get a shower blanket. Resident was found on the floor with a laceration to his scalp. Supervisor began evaluation. Registered Nurse (RN) assessed. Vital signs all stable. Bleeding controlled by gauze and kerlix (a type of gauze). Cold compress applied. 911 called for transport The nurses notes dated 08/27/23 documented at 4:52 PM indicated, Report from hospital (verbal/phone)--Computerized tomography (CT scan) clear. Received 15 stitches on the scalp, hematoma (bad bruise) went down. Head wrapped in gauze and kerlix. Diagnoses--probable acute nondisplaced fracture of posterior/anterior arches of the cervical (C) 1 vertebrae. Resident will need to be in a C collar for 4 weeks. Sutures need to come out in 7-10 days. Follow up with doctor (neurosurgery) in 4 weeks. New orders for hydrocodone/acetaminophen and ibuprofen. Resident returned back to the facility at approximately 1530 (3:30 PM). Family concerned about the injury .Spoke with family---Updated cousin and son about the plan of care and education in place for the Nurse Aides. Resident is comfortable in bed. The nurses notes dated 08/28/23 documented at 5:29 PM indicated R7 weighed 105.2 pounds The emergency room After Summary Report, dated 08/27/23, indicated that R7 was diagnosed with a laceration of scalp without foreign body and a closed nondisplaced fracture of the first cervical vertebrae. On 08/28/23 at 3:00 PM, the Surveyor interviewed CNA D. CNA D indicated R7 was total care and always stays in bed. CNA D stated she had never given R7 a shower as R7 usually takes a bed bath. CNA D indicated it has always been the expectation that staff remain with a resident when on a shower chair. CNA D verified that education was implemented after R7's fall to staff that directed staff to stay with all residents when on a shower chair. On 08/28/23 at 3:05 PM, the Surveyor interviewed CMT E (Certified Medication Technician). CMT E stated that R7 had intermittent jerking movements of the bilateral upper extremities and was a fall risk. CMT E indicated she would have never left R7 alone on a shower chair because of the jerking movements and he could easily fall out of the chair. On 08/28/23 at 3:12 PM, the Surveyor interviewed LPN F (Licensed Practical Nurse). LPN F stated she was the third nurse that responded to R7's fall. LPN F stated R7 had frequent spastic movements of the bilateral upper extremities. LPN F indicated that R7 was seated on a shower chair in his room waiting to be transported to the shower room. LPN F stated the CNA left R7 unattended seated on the shower chair. LPN F indicated she assumed R7 slid off the shower chair and was observed lying on his back on the right side of the bed. LPN F stated that R7 sustained a 1-2 inch laceration to the head which was bleeding. LPN F indicated the RN was doing an assessment and LPN F left the area to get ready to transport R7 to the hospital. LPN F stated the facility initiated education to staff to not leave any residents alone while seated on a shower chair. On 08/28/23 at 3:15 PM, the Surveyor interviewed CNA G. CNA G stated that R7 has involuntary movements of the bilateral upper extremities. CNA G indicated that R7 always stays in bed and needs assistance with all Activities of Daily Living (ADLs). CNA G indicated that she was always directed to stay with residents when seated in a shower chair, but verified she has received education to not leave any resident in a shower chair unattended. On 08/28/23 at 4:40 PM, the Surveyor conducted a telephone interview with CNA H. CNA H verified she had attended to R7 on 08/27/23. CNA H indicated she had another CNA assist with transferring R7 from the bed onto a shower chair with the use of a full mechanical lift. CNA H stated the other CNA left the room after the transfer. CNA H indicated R7 was seated on the lift sling on the shower chair and she had noticed she did not have a bath blanket to cover R7. CNA H stated R7 was naked on the chair. CNA H indicated that she looked out into the hall for assistance but did not see any staff, so CNA H thought she could quickly go get a bath blanket to cover R7 before transporting R7 to the shower room. CNA H indicated she was aware she should not have left R7 alone and should have waited for assistance from another staff. CNA H stated she left the room and retrieved a bath blanket and when she returned to the room, R7 was lying on his back next to the bed and his head was bleeding. CNA H indicated R7 was saying help me and CNA H left the room to get a nurse. CNA H stated R7 does have a shuffling movement of the upper body when in bed, but she did not see that movement when seated on the shower chair. CNA H indicated the shower chair brakes were on but the chair can still be moved with the brakes on. CNA H verified she had received education to not leave any residents alone while seated on a shower chair. On 08/29/23 at 8:25 AM, the Surveyor interviewed LPN I. LPN I stated she was called by a CNA that R7 had fallen and was on the floor. LPN I indicated when she entered the room, R7 was lying on his back and his head was bleeding. LPN I stated the shower chair was observed across the room. LPN I indicated she was not sure if the brakes were on as she was concerned with caring for R7. LPN I recalled seeing the lift sling on the shower chair but could not recall if the lift sling was laid on the chair as if R7 was sitting on it or if it was crumpled as if someone picked it up off the floor and put it on the chair. LPN I stated she was aware that R7 would have been seated on the lift sling on the shower char prior to the fall as the CNAs just transferred R1 with a full mechanical lift from bed onto the chair. LPN I stated she, another LPN, and the RN entered the room to assess the fall. LPN I indicated R7 was very stiff and has contractures and kind of thrashes around. LPN I stated R7 kept saying he was so cold and was observed lying in a fetal position and was rocking back and forth. LPN I indicated R7 was covered with bath blankets, as he was naked, and then R7 began to relax. LPN I stated education was immediately started for staff to not leave any residents unattended while seated on a shower chair. On 08/29/23 at 12:00 PM, the Surveyor interviewed RN J. RN J stated she received a call to come to R7's room. RN J indicted when she entered the room, R7 was lying on his back turned slightly on the left side. RN J stated R7 sustained about a 2 inch laceration to the front, right side of the head and was bleeding. RN J indicated the CNA should not have left R7 unattended on the shower chair especially because R7 has spastic movements and takes Baclofen. RN J stated R1 has intermittent spastic movements. RN J stated she received direction from the Director of Nursing to initiate education to staff to not leave any residents unattended on a shower chair. RN J indicated R7 would not recall any specifics related to the fall. On 08/29/23 at 3:00 PM, the Surveyor conducted a telephone interview with Family Member (FM) K. FM K stated she received a call at 9:58 AM and the nurse stated R7 had fallen and was going to be sent to the hospital. FM K indicated the nurse that called her stated that R7 fell from a shower chair and it was unacceptable that R7 was left alone while seated on the chair. FM K indicated that R7 was very contracted and could not maintain balance or brace himself from the fall as he has Parkinson's. FM K stated she was told that R7 had 15 stitches in the head and sustained a neck fracture. The failure to provide supervision to a resident with a history of falls created a finding of immediate jeopardy. The facility remove the jeopardy on 9/1/23 when it had completed the following: ~ The facility reviewed and revised facility policy and procedures regarding assistance needed and supervision required for residents utilizing shower chairs. ~ The facility assessed residents as indicated regarding the use of shower chairs within the facility and revised resident care plans as indicated. ~ Facility staff were trained on facility policies and procedures regarding supervision and use of shower chairs. ~ The facility established a QAPI process to ensure substantial compliance.

Based on record review and staff and family interview, the facility did not ensure 1 (R5) of 3 sampled residents received sufficient fluids to maintain fluid status. R5 was admitted to the facility with a diagnosis of sepsis, acute urinary tract infection (UTI) and urinary retention with a Foley catheter. The facility did not monitor R5's fluid intake. R5 developed a low blood pressure (BP), and was not feeling well. R5 was transferred to the hospital by the request from a family member. R5 was diagnosed with severe dehydration, lactic acidosis (lactic acid build up in the bloodstream which can be caused by severe dehydration) and hypovolemia (low fluid volume) and hyponatremia (low sodium level). Findings include: On 08/30/23 the Surveyor reviewed the facility's Hydration Policy dated 05/2023. ~ Nursing (Nrsg) will routinely monitor each resident for s/s (signs/symptoms) of dehydration . ~ Nrsg will routinely observe the resident's consumption of fluids to determine if individual residents have reduced fluid intake. Pertinent observations will be recorded in the medical record. ~ The Dietary Manager of dietician will estimate each resident's fluid needs on the initial and annual nutritional assessment. Residents identified with increased fluid needs may have an extra 4-8 ounces of beverage added to their lunch and dinner trays. ~ The facility will identify the resident's beverage preference on their dietary card. ~ Water will be made available and offered at a minimum at all meals and every shift for all residents unless otherwise restricted ~ The nrsg dept completes the hydration evaluation upon admission, readmission and with a significant change. Those residents at risk for dehydration will be referred to the dietician. ~ Residents who refuse water are provided with alt. (alternate) fluids that are tolerable to the resident. According to the Hospital Discharge Summary 08/01/23, indicated R5 transferred and admitted to the facility with diagnoses of ~ Acute UTI ~ Sepsis (admitted on oral Cipro) ~ Urinary retention with Foley catheter The facility developed a Care Plan on 08/01/23 for potential for dehydration. The resident has the potential for dehydration (related/to) r/t currently on chemo, poor mobility and prostate cancer. There was one intervention of: ~ Administer medications as ordered. Monitor/document for side effects and effectiveness. No other interventions were listed. There was no documentation located in R5's medical record that recorded fluid intake. The Discharge Summary indicated R5 had baseline lab values taken at the hospital on 07/31/23. The labs were indicated as follows: Blood Urea Nitrogen (BUN) 41 Creatinine (Cr) 1.21 Sodium (Na) 131 Was on an 1800 milliliters (ml) fluid restriction The facility recorded R5's BP and upon admission R5's BP was 119/82 and remained within normal limits until 08/06/23 and had dropped to 85/52. Medical record indicated no concerns until family came to pick up resident for the day and requested the resident be sent to the hospital. R5's Progress Notes indicated the following: 08/06/23 documented at 1115 (11:15 AM): son in law requesting for guest to be sent to emergency room (ER) for evaluation. Guest complained of weakness and back pain. States I'm sick. Registered Nurse (RN) in to assess. Guest noted to have increased fatigue and pasty white skin, more so in bilateral lower extremities (BLEs). Guest is own decision maker. BP 85/52, Pulse 114. 911 called . Change in condition Mental evaluation: altered level of consciousness. Increased confusion Functional status: general weakness. Cardiovascular status: resting pulse rate greater than 100 Pain: yes The Ambulance Report dated 08/06/23 indicated: Initial BP: 90/60 Pulse: 115 Administered 500 ml of normal saline BP rose to 109/52 Hospital Discharge Summary dated 08/10/23 indicated R5 was diagnosed with: ~ Severe Dehydration ~ Lactic Acidosis ~ Hypovolemic Hyponatremia While in the ER his BP was running low normal and he was tachycardic (fast heart rate) in the low 100s. He was clinically dehydrated, had dry mucous membranes and ulcerations on his tongue. Labs revealed hyponatremia of 128, hypochloremia (low chloride level) 96, Creatinine 1.7 and elevated lactic acid 3.7. He was found to be dehydrated. Low suspicion for infection. He was started on (intravenous) IV fluids and was admitted for further management. BUN elevated to 106. On 08/28/23 at 10:45 AM, the Surveyor interviewed LPN N (Licensed Practical Nurse). LPN N verified she worked with R5 on 08/06/23. LPN N indicated she was told by the receptionist that family wanted resident sent to the ER. LPN N indicated she went into the room with RN M (Registered Nurse) and R5's legs looked white and pasty and the rest of the body looked pale and R5 was alert and oriented. LPN N stated that R5 said he was sick and had back pain and family said R5 was more fatigued. LPN N indicated if residents are on a fluid restriction the amount is monitored and would be in the Medication Administration Record. LPN N stated the facility does not monitor fluid intake alone. LPN N indicated Certified Nursing Assistants (CNAs) document combined fluid and food intake with meals. LPN N stated if a CNA documents a meal at 25% or less the software would alert licensed nursing to review, but the licensed nurses would not be able to determine specific information for how much is fluid intake or how much is food intake. On 08/28/23 at 11:10 AM, the Surveyor interviewed RN M. RN M stated family wanted resident to be sent to the hospital as he wasn't feeling good. R5 looked very pain and was alert and oriented. RN M indicated R5's BP 85/52 and his heart rate was 114. Oral mucosa was pink/moist. Tongue moist. RN M stated she had not seen R5 prior to being alerted that R5's family requested transfer to the hospital. LPN M stated family said he doesn't look right and R5 said he was weak but was ok. Did not appear in any distress. On 08/29/23 at 9:40 AM, the Surveyor interviewed RN N. RN N stated she reviews intakes on residents that are designated to be on intake/output monitoring. Not aware if CNAs document fluid intake as she has never looked. RN N indicated if a resident appears ill, the CNAs would inform licensed nursing and an assessment would be done. RN N verified the facility did not monitor R5's fluid intake. On 8/29/23 at 9:50 AM, the Surveyor interviewed CNA D. CNA D stated that not all residents have intake documented only some residents that are designated to have fluid intake monitored. If a resident does not look well, she would notify the nurse. If a resident is not eating or drinking much for a couple meals then she would notify the nurse. On 08/29/23 at 10:10 AM, the Surveyor interviewed CNA G. CNA G stated the percentage documentation in the software system for meal intake includes both food and fluid intake and are not separated. Example is no fluid intake and meal intake was 75% then documentation would be 75%, but would be unknown if there was a deficit in food or fluid intake as the documentation is combined. On 08/29/23 at 10:45 AM, the Surveyor interviewed DON B (Director of Nusing). DON B stated there is no specific spot in the medical record that documented fluid intake even for residents on a fluid restriction. Nurses just know what can be given but unknown what was actually consumed. DON B indicated a hydration screen was not completed as the dietician has 7 days to complete and R5 was not at the facility for 7 days. DON B stated the dietician told her she had 7 days to complete a hydration screen. DON B also stated the facility had not completed an investigation of the events that lead to R5's transfer to the hospital and the facility did not have a policy on residents with a fluid restriction, regarding monitor fluid intake. On 08/31/23 at 2:30 PM, the Surveyor conducted a telephone interview with Advanced Practice Nurse Practitioner (APNP) O. APNP O stated residents that are on a fluid restriction should have fluid intake monitored. APNP O indicated R5 was admitted to the hospital on 08/06/23 with a diagnosis of dehydration.

Based upon observation, interview & record review, the facility failed to ensure 1 (R36) of 1 Residents reviewed with a modified consistency for their diet and swallow precautions received supervision as assessed and received a food tray with a mechanical soft consistency to prevent choking. Additionally, the facility did not ensure 1 (R22) of 5 Residents reviewed for falls had fall safety interventions being implemented. * On [DATE] and [DATE] R36 experienced choking episodes that occurred when R36 was not under the supervision of staff at mealtimes, who were to ensure that R36 took. small bites/sips, had a slow rate of intake, alternated a drink every ,d+[DATE] bites, and was in an upright position. On [DATE], R36 was served another resident's food trayfrom a Certified Nursing Assistant (CNA) who did not look at R36's meal card. The food on the tray provided to R36 was a regular consistency including a regular pork chop. R36 proceeded to eat the pork chop and choked. Staff were not supervising R36 at this time and a visitor for another resident had to alert nursing staff to R36 choking. R36 received the Heimlich Maneuver and expelled the piece of pork chop that she choked on. Some staff who assist with meal serving indicated they have received no training in ensuring the meal matches the meal ticket. Failure to ensure R36 received appropriate supervision to implement a swallow guideline and failure to ensure staff provided food in the consistency specified created a situation of immediate jeopardy (IJ) that began on [DATE]. Surveyor notified Administrator (A), Director of Nursing (B), and [NAME] Present (VP) of Clinical Operations (D) of the immediate jeopardy on [DATE] at 2:55 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of an E (potential for harm/pattern) as the facility implements their action plan for 13 Residents with modified diet and as evidenced by the following. * R22 has a history of falls and R22 did not have fall interventions in place during observation on the survey. Findings Include: 1.) During the survey, the facility was unable to provide Surveyor with a facility policy and procedure that addressed residents receiving the proper textured diet. The facility did provide a 'Dysphagia Orientation Instructor Review' updated ,d+[DATE], which documents the following: .1. Dysphagia means a guest is having difficulty swallowing 4. (Name of food service group) serves 3 solid diets. These include: a. Regular b. Mechanical soft-ground meat c. Pureed-baby food consistency 7. Whatever diet is in the matrix is the diet that guest should receive. It is based on speech language pathologist (SLPs) recommendation and is a physician's order. R36 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Chronic Kidney Disease, Stage 3, Hyperlipidemia, Essential Hypertension, Bipolar Disorder, and Major Depressive Disorder. R36 has a legal guardian. R36 was evaluated from [DATE]-[DATE] by SLP at time of admission and the following is documented on the discharge summary dated [DATE]: (R36) will implement swallowing precautions, including (small bites/sips, slow rate of intake, alternate a drink every ,d+[DATE] bites, upright for all meals), greater than 80% of the time, min cues. At time of speech therapy (ST) discharge, R36 met this goal less than 80% of the time. The ST summary documents that R36 and caregivers were instructed in functional memory techniques and safe swallow techniques in order to increase safety and decrease need for assistance with carryover demonstrated 75% of therapeutic opportunities, requiring the need for further instruction for implementation of instructions/techniques. Prognosis to maintain current level of functioning (CLOF)=good with consistent staff follow-through. Intake protocol: To facilitate safety and efficiency, it is recommended (R36) use the following strategies and/or maneuvers during oral intake: bolus size modifications and rate modification. Supervision for oral Intake=occasional supervision On [DATE] at 1:27 PM, Surveyor spoke with SLP-HH and asked what occasional supervision would be. SLP-HH stated it is, walking past, occasionally looking at . SLP-HH stated that during the evaluations of R36, R36 was able to follow directions only when prompted by SLP-HH. It is not clear how the specified swallowing precautions could be implemented with only occasional supervision. R36's Quarterly Minimum Data Set (MDS) dated [DATE] documents R36 has a Brief Interview for Mental Status (BIMS) score of 3, indicating that R36 demonstrates severely impaired skills for daily decision making. R36 requires supervision for eating. R36's current physician orders, last updated [DATE], documents R36 is on a low concentrated sweets diet, mechanical soft texture, thin consistency, no rice. Surveyor notes R36's Kardex, the tool that directs certified nursing assistants on how to take care of a Resident, documents the following for R36: Dining: Requires set up for all meals, small bites and sips at slow rate, alternate drink every ,d+[DATE] bites, upright for all meals and 30 minutes after. **encourage to eat in the dining room** Diet to be followed as prescribed: Mechanical soft with thin liquids On [DATE] at 1:59 PM, Surveyor read CNA-II R36's Kardex which documents for R36 to sip at slow rate, alternate drink every ,d+[DATE] bites, small bites. CNA-II stated that requires supervision, even eating in room would need supervision, meaning someone is sitting next to (R36). That's why we try and get (R36) up to the dining room to assist with eating like that. R36's comprehensive care plan details the following regarding R36's diet and swallowing problem: (R36) has a swallowing problem due to dysphagia. Interventions initiated: All staff to be informed of Resident's special dietary and safety needs Initiated [DATE] Alternate small bites and sips. Use a teaspoon for eating. Do not use straws. Initiated [DATE] Diet to be followed as prescribed: Mechanical soft with thin liquids. Initiated [DATE] Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards Initiated [DATE] Monitor for shortness of breath, choking, labored respirations, lung congestion Initiated [DATE] Monitor/document/report PRN (as needed) any signs/symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding Food in mouth. Several attempts at swallowing, refusing to eat, appears concerned during meals Initiated [DATE] Refer to speech therapist (SLP) for swallowing evaluation. [DATE]-coughing at meals, SLP to evaluate and treat as indicated [DATE]-choking episode [DATE] SLP to evaluate and treat as indicated for appropriate diet Initiated [DATE] (R36) to eat only with supervision. Initiated [DATE] Risk for aspiration Initiated [DATE] (R36) has the potential for nutritional deficit due hyperlipidemia, cerebral vascular accident, depression, dementia, diabetes mellitus, body composition analysis, seizure disorder, hypertension. Need for therapeutic diet. Acute kidney injury, history of dehydration Initiated [DATE] Interventions initiated: [DATE] No Rice Initiated [DATE] Allow (R36) sufficient time to eat. Initiated [DATE] Provide low concentrated sweets (LCS), mechanical soft/thin diet as ordered. Monitor intake and record every meal Initiated [DATE] Registered dietitian to evaluate and make diet change recommendations as needed Initiated [DATE] Intervention initiated applicable: [DATE] Offer (R36) to sit in common area for meals. Dining: Requires set for all meals, small bites and sips at slow rate, alternate drink every ,d+[DATE] bites. Upright for all meals and 30 minutes after. **encourage to eat in dining room** Initiated [DATE] (R36) has impaired cognitive function or impaired thought processes due to dementia. Initiated [DATE] Interventions initiated applicable: Ask yes/no questions in order to determine R36's needs. Initiated [DATE] Cue, reorient and supervise as needed Initiated [DATE] Engage (R36) in simple, structured activities that avoid overly demanding tasks. Initiated [DATE] Surveyor reviewed R36's electronic medical record (EMR) which identified R36 was observed coughing on [DATE]. Registered Dietitian (DD) documented that R36 was observed coughing with rice at lunch. Currently on LCS, Mechanical soft diet with thin liquids. SLP notified, orders for SLP to evaluate and treat as indicated. Tray cards updated to avoid rice. Care plan reviewed and updated. Surveyor notes that R36's current tray card documents No Rice. Surveyor reviewed the SLP discharge summary dated [DATE] for R36 and notes the following: Prognosis to maintain current level of functioning (CLOF)=excellent with consistent staff support. Swallow strategies/positions is for small bites/sips, slow rate of intake, take an occasional drink, upright for all meals, stay upright for 30 minutes after meals, no straws. (R36) continually educated on the purpose, goals and benefits of intervention. The summary documents that (R36) has had a mild/moderate decline since [DATE] with minimal cues and is now at 80% or greater requiring cues. Supervision for oral intake=no supervision/assistance required. On [DATE] at 6:28 PM, R36's EMR contains documentation that nursing was called to R36's room by R36's roommate due to R36 choking. The following was documented: (R36's) roommate called staff in that Resident was choking. Medtech and nurse ran to (R36's) room to find (R36) already got food down and was no longer in distress. (R36) was found with head of bed elevated, call light in reach and comfortably finishing (R36's) dinner. When asking (R36) what happened, (R36) was unable to give a clear story. Nurse Practitioner updated and ordered for respiratory assessment done every shift for 3 days for possible aspiration. Lung sounds clear. Surveyor notes on [DATE] that if R36 received the mechanical soft diet for dinner; the menu consisted of ground turkey and Swiss sandwich with mayonnaise, three bean salad, apple crisp, submarine roll, whole milk, choice of beverage. The only difference from the mechanical soft to the regular diet for dinner is the regular diet consisted of turkey and Swiss sub sandwich instead of the ground turkey and Swiss sandwich. Otherwise, both menus had the same items. On [DATE] at 10:23 AM, Surveyor asked Director of Nursing (DON-B) about R36's [DATE] choking episode. DON-B informed Surveyor that DON-B was unaware of the [DATE] choking incident. On [DATE] at 11:20 AM, DON-B informed Surveyor that DON-B spoke to the nurse about the incident. DON-B stated since there was no witness to R36 choking except for a roommate that is unreliable. Because there was no physical evidence of a choking episode for the [DATE], the facility did not do an investigation or a root/cause analysis of R36's choking episode. Surveyor notes a respiratory assessment was completed for R36 every shift for 3 days per R36's treatment administration records (TARs). R36 was evaluated by ST starting on [DATE] after the [DATE] choking episode. The evaluation documents R36 requires minimum to close supervision for swallowing abilities. ST intervention warranted to address continued by mouth intake, diet tolerance for potential upgrade and implementation of swallowing precautions. ST documents that R36 has had a mild decline in speech therapy goals since the last evaluation. On [DATE], R36's EMR contains the following documentation: (R36) had an episode of choking during lunch. Registered nurse (RN) provided Heimlich Maneuver. Nurse Practitioner and guardian notified. Interventions-speech and x-ray, RN assessment completed, notifications completed. On [DATE] at 8:02 AM, Surveyor reviewed the facility's investigation for R36's choking episode. The investigation indicates that a certified nursing assistant (CNA) observed R36 without a lunch tray. The CNA had a Resident who had refused their tray, so the CNA gave R36 the other resident's tray. The CNA's statement is that the CNA was unaware (R36) was on a mechanical soft diet. (R36) consumed the regular tray, which resulted in a complete airway obstruction. The RN performed the Heimlich Maneuver and dislodged the obstruction. RN assessment and chest x-ray confirmed there was no adverse outcome. Surveyor reviewed the menus for [DATE]. R36 received a savory baked pork chop filet instead of ground baked pork chop with broth; Candied carrots instead of soft, cooked candied carrots; Pineapple upside down cake instead of a plain yellow cake; and a dinner roll. Surveyor reviewed the ST documentation dated [DATE]. It is documented that (R36) has limited participation in self cares due to behaviors. (R36) is maximum dependent with self-cares due to impaired cognition, impulsivity. Impaired safety awareness. (R36) is at risk for choking and aspiration due to attention deficits, poor dental quality, and inefficient chewing. (R36) needs cues to slow down. Reports of PICA (will grab foods or objects such as puzzle pieces to eat) per nurses. Supervision for oral intake=occasional supervision, distant supervision. On [DATE] at 1:11 PM, Surveyor interviewed RN Assistant Chief Nursing Officer (Y) as RN-Y was the RN who performed the Heimlich Maneuver on R36. RN-Y stated on [DATE] RN-Y was the supervisor, manager, and helping with distributing medications. RN-Y stated the incident happened at lunch time; RN-Y was standing at the nurse's station going over paperwork when an unrelated family member to R36 notified RN-Y that R36 was choking. RN-Y stated that (R36), clearly did not have full air, not able to make any sound. RN-Y stated that R36's eyes were panicked. RN-Y stated that R36 was lodging the obstruction more trying to get the obstruction up by R36's self. RN-Y provided the Heimlich Maneuver which instantly brought relief to R36. RN-Y stated R36 choked on a pork chop. RN-Y confirmed no one was in the dining room at the time, as the staff were busy passing lunch trays. RN-Y informed Surveyor that a Resident's diet is clearly on the Kardex for the staff to check before distributing a tray. RN-Y stated, it was clearly an issue. On [DATE] at 1:59 PM, Surveyor interviewed CNA-II who was working on [DATE] on R36's unit. CNA-II was passing lunch trays up and down the hallway. CNA-II shared they can see the dining room only from certain areas of the hallway and otherwise is obstructed with viewing the dining room. CNA-II had heard a visitor tell the nurse that R36 was choking. It was during this interview that CNA-II indicated R36 requires supervision, even eating in room would need supervision, meaning someone is sitting next to (R36). That's why we try and get (R36) up to the dining room to assist with eating like that. On [DATE] at 8:21 AM, Surveyor observed R36 receiving supervision from CNA-JJ, but CNA-JJ was not providing any cueing or prompting or implementing R36's swallow guidelines. Surveyor observed no other Residents in the dining room at the time. On [DATE] at 8:25 AM, Surveyor observed R36 receiving supervision at breakfast. CNA-H was sitting at the table with R36 and was on her phone. CNA-H did not provide any cuing or prompting or implement R36's swallow guidelines. On [DATE] at 9:36 AM, Surveyor interviewed Registered Dietitian (RD-DD) who shared R36 is on a mechanical soft diet with no rice since [DATE]. RD-DD does not know if R36 would need supervision if eating in R36's room and is not sure if swallow precautions were in place prior to [DATE] but confirmed swallow precautions are in place now for R36. RD-DD stated that R36 is usually cooperative eating meals. Surveyor noted RD-DD indicated to Surveyor R36 was on a mechanical soft diet with no rice since [DATE] however, Surveyor noted R36 had received rice on [DATE] and R36's care plan indicates no rice was only implemented on the care plan on [DATE]. On [DATE] at 12:17 PM, Surveyor interviewed RD-DD again. RD-DD stated that R36's care plan did indicate that R36 required supervision with meals but that it was RD-DD's mistake that the care plan was not updated with the [DATE] SLP recommendation of occasional supervision. Surveyor questioned RD-DD regarding R36's [DATE] and the [DATE] coughing/choking episodes, R36 should have had supervision at both times/episodes, but according to documentation, there was no supervision. RD-DD provided no further information at this time. On [DATE] at 1:00 PM, Rehabilitation Manager (KK) informed Surveyor that currently there is not a speech therapist (ST) available in the facility as they have a ST available as needed. Surveyor asked RM-KK for clarification on what occasional supervision/safe strategies would be for R36. RM-KK stated, occasional is a very broad term and is not able to answer that question. On [DATE] at 8:30 AM, Director of Care Transitions (K) confirmed that DCT-K will help pass breakfast and lunch trays when staff is short. DCT-K stated the expectation of all department managers is to help and pass trays. DCT-K informed Surveyor that DCT-K does not recall receiving a training on checking diets on the tray prior to distributing the trays. On [DATE] at 9:03 AM, Surveyor interviewed RD-DD, Server (LL), Server (MM), Server (NN), Server (OO) at the same time in the kitchen. RD-DD, Server-LL, Server-MM, Server-NN, Server-OO all confirmed they help pass trays to Residents, especially when a replacement tray is ordered. Surveyor was informed it is all hands-on deck. All stated they have not received specific training recently to make sure tickets match the correct diet. On [DATE] at 9:58 AM, Dietary Consultant (PP) confirmed that DC-PP was assisting with distributing trays on [DATE]. On [DATE] at 10:28 AM, Executive Chef (U) stated that DC-PP is an independent contractor who started consulting on [DATE] for dietary. DC-PP stated the expectation would be DC-PP would be training on passing the correct tray with the correct diet to Residents. EC-U denies that any kitchen staff delivers trays to Residents but confirmed that EC-U will help distribute trays if needed. On [DATE] at 12:35 PM, Surveyor shared the serious concern with Administrator (A), DON-B, and VP of Clinical Operations (D) that the facility did not ensure adequate supervision was provided to R36 which resulted in R36 receiving a tray with a regular diet instead of mechanical soft diet, choked on a pork chop which required the Heimlich to clear R36's airway. Surveyor shared that R36's care plan and assessments are contradictory to the level of supervision R36 requires when eating. The facility's failure to ensure R36 received supervision to ensure safety at mealtimes related to R36's swallowing guidelines and that R36 received a modified diet created a reasonable likelihood for serious harm, resulting in a finding of immediate jeopardy that started on [DATE]. The facility removed the immediacy on [DATE] when the implemented the following plan: The CNA involved was re-educated. All direct care staff were educated on ensuring the correct meal trays are given to residents. All staff who directly deliver trays to residents will also be educated if they have not been already. Nursing staff will be educated on the meal supervision policy. The facility will re-assess all residents on an altered texture diet to determine the appropriate level of supervision required at mealtime. Everyone's care plan will be updated based on those assessments. All staff will be educated on the current standards of practice by the registered dietician and/or designee. When Speech Therapy evaluates a resident, his/her recommendations will be given to nursing leadership who is responsible for updating each resident's care plan. Therapists and Licensed Nurses will be educated on this. All staff will be trained on following resident swallowing guidelines. On [DATE] the facility will review the policy and procedure regarding meal monitoring with the IDT and Medical Director to determine if any additions or modifications are necessary to meet safe standards of practice. The facility will develop a Dysphagia Diet consistent with current standards of practice. On [DATE] the Diet Orders policy will be updated to the most up to date standards of practice. All staff will be educated on the new policy. Dining room tray audits and meal supervision will be conducted by nursing leadership daily for 2 weeks, 3x/week for 2 weeks, and weekly for 4 weeks. Tray cards will be audited for each meal to confirm accuracy. Tray cards will be audited for each of the 3 meals weekly thereafter, results of which will be brought to QAPI until such time the IDT determines that substantial compliance exists. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility identified there are 13 additional residents that have the potential to be impacted by the deficient practice. There also is deficient practice concerning fall interventions for R22. 38146 2.) R22 admitted to the facility on [DATE] and has diagnoses that include Dementia, Cerebral Infarction, Chronic Kidney Disease, Atrial Fibrillation, protein calorie malnutrition, Chronic Obstructive Pulmonary Disease, Emphysema and left femur fracture. The facility Policy and Procedure titled Fall Prevention revised ,d+[DATE] documents (in part) . . General: To ensure all residents have the necessary interventions in place to help prevent falls and promote safety in accordance with all state and federal regulations. Policy: Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility and after every fall in the facility. Every team member is responsible for checking the care plan of residents who are at risk for falls when beginning each day and throughout the assigned shift. R22's admission fall assessment dated [DATE] documents a score of 14, indicating high risk. R22's BIMS (Brief Interview for Mental Status) dated [DATE] documents a score of 9, indicating moderate cognitive impairment. R22's Care Plan Focus area documents: The resident is at risk for falls r/t (related to) weakness, impaired mobility, and dementia - date Initiated [DATE]. Interventions include: Anticipate and meet the resident's needs. Ensure bed brakes are locked. Ensure footwear fits properly. Encourage high traffic areas - date initiated [DATE]. Evaluate gait and ambulation capabilities, identify abnormalities - date initiated [DATE]. Monitor pain and alleviate using non-pharmacological interventions and medications as ordered - date initiated [DATE]. PT (Physical Therapy) Evaluation - date initiated [DATE]. STOP sign across the bathroom - date initiated [DATE]. Signs labeled STOP to help remind the patient to seek assistance - date initiated [DATE]. Low bed - date initiated [DATE]. Room Move to (room number) near nurses station - date initiated [DATE]. Anti-roll backs placed on wheel chair - date initiated [DATE]. Labs done for re-assessment - date initiated [DATE]. Medication review for increased behaviors - date initiated [DATE]. Encourage body pillows placed while resident is in bed - date initiated [DATE]. Encourage early get up - date initiated [DATE]. Encourage resident to wear hipsters - date initiated [DATE]. Encourage resident to wear leg beg while not in bed - date initiated [DATE]. Gripper socks to be worn while up in wc (wheelchair) - date initiated [DATE]. Soft touch call light - date initiated [DATE]. Sleep study - date initiated [DATE]. R22's Care Plan Focus area documents: The resident has impaired cognitive function or impaired thought processes r/t Dementia - date initiated [DATE]. Interventions include: Cue, reorient and supervise as needed. R22's Care Plan focus area documents: The resident has an alteration in musculoskeletal status r/t fracture Left trochanter and osteoarthritis of right knee - date initiated [DATE]. Interventions include: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Monitor/document for risk of falls. Educate resident/family /caregivers on safety measures that need to be taken in order to reduce risk of falls. (If resident has a care plan for falls, refer to this). R22's Certified Nursing Assistant Kardex as of [DATE] documents: Encourage body pillows placed while resident is in bed. Low bed. On [DATE] at 9:39 AM during initial screening of residents, Surveyor observed R22's bed was not in the low position and there were no body pillows in bed. On [DATE] at 12:37 PM Surveyor was advised by facility staff that R22's bed was not in low position because the lunch tray is the lowest it will go on the over-bed table, it will be put back in the low position when done eating. Surveyor observed no body pillows in bed. On [DATE] at 6:55 AM Surveyor observed R22's bed not in low position, was at regular height, and no body pillows in bed. On [DATE] at 9:24 AM Surveyor observed R22 lying in bed with the head of bed elevated, breakfast tray in front of him, bed in regular position and no body pillows in bed. On [DATE] at 1:14 PM Surveyor observed R22 lying on his back in bed asleep, with the head of bed slightly elevated. There were no body pillows in bed. Surveyor noted the bed height/top of the bed mattress at level approximately 3 inches above Surveyor's knee. On [DATE] at 11:35 AM Surveyor observed R22 in his wheelchair in the hallway wheeling himself toward his room. R22 asked Surveyor: Can you help me in there (pointing to room). Surveyor observed Nurse Manager-E walking by resident and Surveyor at the time he was asking for help to his room. Surveyor asked Nurse Manager-E the resident's name and confirmed it was R22. Surveyor left area for approximately 3 minutes and returned to R22's room. Surveyor observed Nurse Manager-E sitting at the nurses station (which is directly across from R22's room). Surveyor observed R22 in his room with the door open. Surveyor knocked and entered. Surveyor observed R22 propelling his wheelchair at the foot of his bed. R22 asked his roommate to move out of the way, which he did. R22 asked Surveyor to move the bedside table. When Surveyor asked why, R22 stated: Because I want to go to bed. R22 proceeded to propel his wheelchair next to his bed. Without locking the wheelchair brakes, R22 attempted to stand to get into bed. Surveyor intervened and asked R22 to sit down in the wheelchair. Surveyor spoke with R22 briefly about where he was from and what he did for a living. R22 responded to conversation and talked with Surveyor. Surveyor advised R22 that it was close to lunch time and asked if he was hungry. R22 stated: Yes, I'll go there then. R22 proceeded to turn his wheelchair and propel himself to the doorway of his room. R22 asked: Can you take me? Surveyor walked over to where Nurse Manager-E was sitting at the nurses station, across from R22's room and advised her of observation and R22's attempt to transfer himself into bed. Nurse Manager-E stated: Really? Ok, thank you. On [DATE] at 12:03 PM Surveyor observed R22's empty wheelchair at the foot of his bed. Surveyor observed Certified Nursing Assistant (CNA)-H and CNA-I sitting at the nurses station across from R22's room. Surveyor confirmed they were the CNA's for R22's unit. Surveyor asked if they usually work the unit, both stated yes. Surveyor asked if they were familiar with R22, both reported yes. Surveyor advised both CNA's, after reviewing R22's medical record, it was noted he's had falls. Surveyor asked CNA-H and CNA-I if they do anything for R22 when he is in bed, such as positioning devices or body pillows. CNA-I stated: No, I've never used any body pillows. CNA-H stated: I've never even seen body pillows for him. Surveyor entered R22's room and observed him lying in bed on his back, asleep. Surveyor noted the bed height/top of the mattress at approximately 3 inches above Surveyors' knee and there were no body pillows or positioning devices in bed with R22. Surveyor asked CNA-H to accompany Surveyor to room. Surveyor observed cords on the floor behind the head of the bed, but was unable to locate a bed control. Surveyor asked CNA-H how to control the bed. Surveyor was advised there is a hand bed control or there is a button at the foot of the bed. CNA-H proceeded to push a button at the foot of the bed and R22's bed moved down to the lowest position and stopped. Surveyor noted the bed height/top of the mattress was now approximately 1 inch below Surveyors' knee. R22's care planned fall interventions of bed in low position and body pillows were not implemented during survey. While lying in bed, R22's bed was not positioned at the lowest position. On [DATE] at 9:13 AM Nurse Manager-E advised Surveyor that R22 soiled his body pillows this morning and she sent them to laundry. She stated: I've been doing walk through's every morning to make sure fall interventions are in place and he's had body pillows. Surveyor advised Nurse Manager-E of observations on survey, bed not in low position and body pillows not in place. Nurse Manager-E asked: Was that in the morning or afternoon? Surveyor shared observations were both morning and afternoon. Surveyor reminded Nurse Manager-E of the day she was advised R22 was trying to get into bed without assistance and he was later put to bed and body pillows were not in place. Nurse Manager-E rolled her eyes and no additional information was provided. On [DATE] at 9:57 AM Director of Nursing (DON)-B was advised of observations and concern R22's fall interventions not in place. Surveyor also advised DON-B of observation [DATE] when R22 was attempting to get into bed without assistance. Surveyor shared concern that although R22 has had multiple falls and requires increased supervision, staff did not intervene when he was stating he wanted to go to room, so he propelled himself into his room and attempted to get into bed, all while in sight of staff. DON-B stated: Well, we can't force him to stay out of his room. No additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure that residents with Pressure Injuries receive appropriate care, treatment, and preventative interventions to promote healing for 2 of 6 residents (R58 and R22) reviewed for pressure injuries. ~ R58 was admitted to the facility [DATE] with no pressure injuries and at high risk for skin breakdown due to pressure, arterial, and diabetic comorbidities. R58 had a plan of care in place but no resident specific interventions to prevent skin breakdown. R58 was hospitalized [DATE] through [DATE]. Upon readmission, R58 was assessed by a Licensed Practical Nurse (LPN) and not a Registered Nurse (RN). Bruising, dry, flaky feet and a scab to left pinky toe was noted but was not assessed comprehensively or reported to the Nurse Practitioner (NP) or an MD R58 developed a skin tear to his buttocks on [DATE] that was not assessed comprehensively by an RN or reported to the NP or a physician. R58's family noted a wound that was causing pain to R58's right ankle on [DATE] and alerted the LPN on duty. The LPN charted the wound as a necrotic pressure injury and reported it to the Unit Manager RN. LPN stated the wound was 3 to 4 inches in length and 2 to 3 inches long when she saw it on [DATE]. There was no RN assessment of the wound and it was not reported to the NP or physician. Diabetic foot checks were recorded as completed but no nurse could recall or remember checking R58's feet the week leading up to the family reporting the wound and no Certified Nursing Assistant (CNA), that were interviewed, could recall or remember looking at R58's feet. R58 was transferred to the hospital on [DATE] at approximately 11:15 AM and the wound was noted in the emergency room documents by a Wound MD at 4:35 PM, as an Unstageable Pressure Injury along with numerous other diabetic wounds and a Stage 2 Pressure Ulcer to his sacrum. R58's wounds continued to worsen, needing debridement and eventually causing osteomyelitis. R58 passed away [DATE]. The facility's failure to have R58's wounds and skin comprehensively assessed by an RN, the failure to complete skin and foot checks, the failure to report the wounds to the MD/NP and prevent new wounds from forming created a finding of Immediate Jeopardy (IJ) that began on [DATE]. Surveyor notified Chief Clinical Operator (CCO)-H, VP of Operations (VPO)-I, VP of Clinical Operations-J, and Assistant Chief Nursing Officer (ACNO)-D of the IJ on [DATE] at 2:02 PM. The IJ was removed on [DATE], however the deficient practice continues at a scope/severity level of D (Potential for Harm/Isolated) as evidenced by: ~ R22 did not have a comprehensive skin assessment, along with treatment orders, upon readmission to the facility from a hospital stay. Findings include: The Mayo Clinic's website describes the complications of pressure injuries, including: o Sepsis. Sepsis occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure. o Cellulitis. Cellulitis is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. Cellulitis can lead to life-threatening complications. o Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteomyelitis) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications. http://www.mayoclinic.org/diseases-conditions/bedsores/basics/risk-factors/con-20030848 The AMDA (American Medical Directors Association) clinical practice guideline entitled 'Pressure Ulcers and Other Wounds,' dated 2017, 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 peri-wound 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 . Surveyor reviewed facility's Wound Policy & Procedure with a date of [DATE]. Documented was: Policy: The facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus. A commitment to the Wound Management Program is demonstrated by implementation of processes founded on accepted standards of practice, research-driven clinical guidelines, and interdisciplinary involvement . Procedure: Accountability The Wound Management Program identifies staff participation and accountability to include: -Person responsible for program oversight and coordination -Staff involved in prevention and treatment (and their roles) -Expectation of all caregivers to observe resident skin integrity during the daily provision of the resident's personal care Admission Wound Assessment and Management -At the time of admission, the discharge records from the prior facility are reviewed for information relating to wounds or alteration in skin integrity. Staging from another facility is not adopted for use in the facility -Any Wounds assessed will be captured in the PC nursing evaluation, in progress notes, or by completing in Wound Rounds via Quick Shot (within ,d+[DATE] hours of admission) -The admission wound assessment should include at a minimum: -Interview of resident or family about history of skin alterations -4 Physical evaluation to include identification of: -Skin alterations present on admission, skin discolorations and any evidence of scarring on pressure points -Signs/symptoms/diagnosis of peripheral vascular disease -Bed mobility Continence -Recent surgical procedure Head-to-toe skin assessment -Nutritional status and issues -Completion of Braden or Norton Skin Risk Assessment Tool -Comprehensive assessment of any wound to include: -Location of wound -Length, width, and depth measurements recorded in centimeters -Direction and length of tunneling and undermining -Appearance of the wound base -Type and percentage of tissue in wound -Drainage amount and characteristics including color, consistency, and odor -Appearance of wound edges -Description of the peri-wound condition or evaluation of the skin adjacent to the wound -Presence or absence of new epithelium at wound rim -Risk reduction measures such as use of heel protectors (designed for friction/shear reduction versus pressure reduction), elevation of lower extremities, participation in bowel and bladder program, etc. are initiated if determined appropriate -Discussion with the attending physician and resident/ representative includes notification of any skin impairment identified on admission -Orders are verified or obtained as needed -An admission/interim/ baseline care plan is developed -Assessments and interventions implemented are documented in the resident clinical record . Documentation and Care Planning -The wound management program documentation requirements include: o Identification of the location and frequency of wound documentation o Required comprehensive description of pressure ulcer weekly, at a minimum o Delineation of in-house documentation required (for example, weekly reports to the Director of Nurses) and by whom o Goals of the wound care plan collaboratively determined with the resident, family, and interdisciplinary team o Assigned responsibility/accountability for the initial care plan and for subsequent updating o Determined facility time frames for care plan updating -Resident risk factors and interventions are documented including: o Impaired mobility o Need for pressure relief such as support surfaces, repositioning, pressure relieving devices o Assigned responsibility/ accountability for the initial care plan and for subsequent updating o Nutritional status o Incontinence o Skin condition o Complications such as infection and pain o General treatment regimen (delineating specific treatment is not necessary) . Notification -A written protocol is established for: o Physician notification of pressure ulcer presence and responses to treatment o Family notification of pressure ulcer presence, treatment plan, response to treatment, and changes in treatment due to wound deterioration o In-house notification of interdisciplinary team members of the presence of a pressure ulcer and/or deterioration in wound status o MDS Coordinator notification of the number of pressure ulcers and stages . Surveyor reviewed facility's Skin Integrity policy with a date of [DATE]. Documented was: Policy: Based on the comprehensive assessment of the resident, facility clinical staff will ensure that the resident who enters the facility without a pressure sore(s) will not develop a pressure sore(s) unless the resident's clinical condition demonstrates that the condition was unavoidable. Procedure: The licensed nurse and interdisciplinary team will assess and periodically reassess each resident's risk for developing a pressure ulcer and take action to address any identified risks. -The interdisciplinary team will create a written plan for the identification of risk for and prevention of pressure ulcers. o Identification and evaluation of risk factors of: o Increased/decreased mobility and decreased functional ability o Cognitive impairment o Under-nutrition, malnutrition including significant weight loss with mobility/positioning concerns o Use of medications which may affect wound healing o Any decline in clinical status or co-morbid diagnoses affecting mobility/positioning or ability of skin to endure effects of pressure o History of healed ulcer(s) o Exposure of skin to urinary and fecal incontinence -The nurse will perform a full-body initial skin assessment to identify if the resident is at risk for a pressure ulcer within ,d+[DATE] hours of admission to the facility and weekly. o Identification, on admission of the presence of a pressure ulcer, or the presence of possible deep tissue injury or skin areas at risk for breakdown o Wound site and characteristics at the time of admission o Possibility of underlying tissue damage related to immobility or illness prior to admission o Skin condition on or within 24 hours of admission o History of impaired nutrition o History of previous pressure ulcers . -Care planning for pressure ulcers will: o Be based on assessment and will be consistent with resident's specific conditions, risks, needs, behaviors, preferences, and current standards of practice o Will include specific interventions/ services to prevent development of pressure ulcers and/or to treat existing pressure ulcers and potential associated complications and will include measurable goals and time tables and will include: o Pressure redistribution/relief based on identified resident needs including repositioning, heel protection, use of wheelchair, reclining chair, and bed/mattress pressure redistribution surfaces o Prevention of shearing and friction o Weekly skin assessments by licensed nurses and twice weekly skin observations by direct care providers o Identification of comorbid conditions affecting risk for and healing of pressure ulcers and efforts to stabilize conditions o Daily evaluation of status of dressing and surrounding skin o Pressure ulcer care and treatment as ordered by physician including type of dressing, frequency of dressing change, wound cleansing techniques, debridement of wound and prevention/ management of infections o Approaches to manage and monitor pain including preemptive measures if pain occurs during dressing changes o Resident and/or Responsible Party choices and preferences including alternative efforts if resident refuses or resists staff interventions to reduce risk or treat existing pressure ulcers o Care plan revisions will include: -Care plan will be revised to modify prevention strategies and address the presence and treatment of any newly developed pressure ulcer. 1.) R58 was admitted to the facility on [DATE] with diagnoses that included Cardiogenic Shock, End Stage Renal Disease (ESRD) with Dependence on Renal Dialysis, Type 2 Diabetes Mellitus (DM), Chronic Obstructive Respiratory Disease (COPD), Morbid (Severe) Obesity Due to Excess Calories, Absence of Other Left Toe(s), Ventricular Tachycardia, Personal History of Malignant Neoplasm of Bladder, Peripheral Vascular Disease, Gastrointestinal Hemorrhage, Coronary Artery Disease (CAD), and Peripheral Autonomic Neuropathy. Surveyor reviewed R58's Braden Scale for Predicting Pressure Sore Risks with assessment dates of [DATE], [DATE], and [DATE]. Documented for all was a score of 12 which indicated high risk. Surveyor reviewed R58's Admission Minimum Data Set (MDS) with an assessment reference date of [DATE]. Documented under Section C, Cognition was a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. Documented under Section G, Functional Status for Bed Mobility was ,d+[DATE] which indicated Limited assistance - resident highly involved in activity, staff provide guided maneuvering of limbs and other non-weight bearing assistance; One person physical assist. Documented under Transfers was ,d+[DATE] which indicated Total dependence - full staff performance every time during entire 7-day period; Two plus persons physical assist. Documented under Section M, Determination of Pressure Ulcer/Injury Risk was Is this resident at risk of developing pressure ulcers/injuries? Yes. Does this resident have one or more unhealed pressure ulcers/injuries? No. Surveyor reviewed R58's Care Area Assessment (CAA) related to Pressure Ulcer/Injury with an assessment date of [DATE]. Documented under Nature of the Problem/Condition was The [pressure injury] CAA triggered because this guest needs limited to extensive assistance with [activities of daily living (ADLs)], mobility, and [bowel and bladder (B&B)] management. This guest is at risk for pressure injury and skin breakdown. The plan is for nursing to monitor his skin integrity. The goal is for this guest to remain free of skin breakdown while participating in therapy to regain his strength and return to the community [at previous level of functioning - minimal assist (PLOF-MI)]. Surveyor reviewed R58's Comprehensive Care Plan with initiation date of [DATE]. Documented was: Focus: The resident has potential for impairment to skin integrity [related to (r/t)] limited mobility, heart failure, impaired mobility, ESRD, DM, CAD Goal: The resident will remain free of new skin impairment through the review date Interventions: ~ Apply barrier cream per facility protocol to help protect skin from excess moisture. ~ Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. ~ Change bedding/clothing if moist ~ Encourage activity as tolerated ~ Encourage good nutrition and hydration in order to promote healthier skin. ~ Encourage proper fitting footwear ~ Encourage that heels are elevated while resident is lying in bed ~ Encourage/assist resident reposition when in wheelchair every 2 hours ~ Encourage/assist with turning and repositioning every ,d+[DATE] hours ~ Monitor skin when providing cares, notify nurse of any changes in skin appearance ~ Use draw sheet when turning/repositioning. Surveyor noted there were no updates, revisions, or additional skin or wound care plans added to R58's chart throughout his stay at the facility. There were no resident specific interventions put in place for R58 to prevent skin breakdown. Surveyor reviewed R58's MD Orders. Documented with a start date of [DATE] was Diabetic foot checks [every bedtime (q HS)] at bedtime. Documented with a start date of [DATE] was Skin Checks Weekly Thursday AMS complete under evaluations in [electronic chart] every day shift every Thu for SKIN CHECK - Must open and document Skin Evaluation for each assessment (including no new areas found). R58 was hospitalized from [DATE] through [DATE]. Upon readmission, LPN-S assessed R58. Surveyor reviewed R58's readmission Nursing Evaluation with a date of [DATE]. Documented under the Skin Integrity was: a. Does the resident have skin integrity concerns? Yes. 1a. Skin Impairments: Document impairment site. Under Description document initial wound measurements and general evaluation: Site: 49) Right heel. Description: dry and hard; flaky skin. Site: 50) Left heel. Description: dry and hard; flaky skin. Site: 52) Left toe(s). Description: pinky toe healed scab. Site: Other (specify). Description: left and right arm bruising . There were no comprehensive assessment or measurement of the pinky toe wound or bruising to left and right arm by an RN. There were no other assessments of the wounds or measurements. There were no treatment orders or new preventative measures added to R58's care plan to prevent further breakdown. Surveyor reviewed R58's MD Orders. Documented with a start date of [DATE] was Diabetic foot checks q HS at bedtime. Documented with a start date of [DATE] was Skin Checks Weekly Monday AM every day shift every Mon - Must open and document Skin Evaluation for each assessment (including no new areas found). Surveyor reviewed R58's Skin Observation assessment with a date of [DATE]. Documented by Assistant Chief Nursing Officer RN (ACNO)-C was: A. Skin Observation. 1. Does the Resident have ANY Skin Issues Observed (including new and old)? B. No . Surveyor reviewed R58's Skin Observation assessment with a date of [DATE]. Documented by LPN-S was A. Skin Observation. 1. Does the Resident have ANY Skin Issues Observed (including new and old)? A. Yes. Document and Describe ALL Skin Issues. 2. Skin Issues: Site: 32) Left buttocks. Description: open area. 3. Other Observations: blank. 4. Wound Team Notified of new area? a. Yes. Surveyor reviewed R58's eINTERACT SBAR Summary for Providers with an assessment date of [DATE]. Documented was: Situation: The [Change In Condition/s (CIC)] reported on this CIC Evaluation are/were: Change in skin color or condition . - Skin Status Evaluation: Skin tear . Primary Care Clinician Notified: NO . Surveyor noted there was no comprehensive assessment of the wound bed by an RN. There were no other assessments of the wound or measurements. Surveyor reviewed R58's MD Orders. Documented by LPN-S with a start date of [DATE] was daily foam border to buttock every day and night shift for skin integrity. The order was discontinued on [DATE]. Documented by ACNO-C with a start date of [DATE] was daily foam border to buttock every day shift for skin integrity. Surveyor reviewed R58's Treatment Administration Record (TAR) for [DATE] through [DATE]. Diabetic foot checks were documented as completed on all dates from [DATE] through [DATE]. Surveyor reviewed R58's Pain Evaluation assessment with a date of [DATE]. Documented was .Numerical Pain Scale: 1b. Pain score out of 10 where 1 is mild pain and 10 is the worst pain: h. 7. 2. Pain Location: Site: 49) Right heel. Description: open necrotic area . Surveyor noted there was no further assessment of R58's pain or the wound causing the pain. Surveyor reviewed R58's Progress Notes. Documented on [DATE] at 11:15 AM was Resident's life vest starting alarming. Life vest delivered 2 shocks. 911 called. Instructions for life vest explained to paramedics. Extra life vest batteries sent with paramedics. Resident transferred to [hospital]. NP aware. Surveyor reviewed R58's Hospital Record from admission to theER on [DATE]. Documented at 3:05 PM was History of the Present Illness: [R58] presenting with a LifeVest shock. He was at his facility getting ready to go to dialysis when his life vest deep to (sic). He received 2 shocks 1 minute apart. He has been coughing for the last week or 10 days. He has also noticed a wound on his right ankle in the last day although it has been painful for a couple of weeks since he left the hospital and went to his current facility . Extremities: Wound with eschar right posterior ankle . ER MD requested a Wound Consult and Wound MD assessed R48 at 4:35 PM on [DATE]. Documented was: SUBJECTIVE: Chief Complaint: Lower leg ulcers Wound/Ulcer Present: Diabetic lower extremity ulcer: Wagner grade 1 (superficial diabetic ulcer). Diabetic foot exam performed? No. Current Vascular Assessment: Venous duplex study. Current Antibiotic Regimen: None. Current Offloading Modality: unsure. Additional Wound Category: None Maximum Baseline Ambulatory Status: Unable to assess History of Present Illness: [R58] with past medical history of hypertension, severe aortic stenosis, hypercholesterolemia, coronary artery disease, chronic kidney disease, renal calculi, diabetes type 2, and sleep apnea. Presenting to the ED with a LifeVest shock. He received 2 shocks 1 minute apart. Hx of Covid last week - currently in Covid isolation Wound care consulted to evaluate lower leg wounds and sacral wounds. Interval history ([DATE]): L/S [DATE] for lower leg wounds. States he noticed a wound on his right ankle for the past few days. X-ray ordered R ankle . Also complaining of sore on sacral that is uncomfortable . DIAGNOSES: Diabetic lower extremity ulcer, Wagner grade 1 (superficial diabetic ulcer) L toe Pressure ulcer of the lower extremity, stage Unstageable R heel Pressure ulcer, other site, stage II sacral, lower leg ulcers . Wound NP update on [DATE] documented: admitted for [bilateral lower extremities] wounds and sacral pressure ulcer - present on admission. Right heel and Achilles eschar is starting to slough from margins with tunneling proximally near Achilles and early cellulitis to peri wound. -Discussed with [Surgeon], patient, family: they are interested in pursuing further interventions to help with wound healing including surgical intervention. Aware that his PAD increases risk for wound non-healing and limb loss. Aware that patient may ultimately need an amputation in the future regardless of current wound care actions. -Surgical consultation for debridement vs amputation . -Can start with an X-ray of affected area, may need MRI depending on surgeries impression for debridement candidacy. Sacral ulcers tender. Needs to mobilize in bed, continue offloading surfaces. Left toe eschar is stable. Local wound care: Vashe moist packing strip to right Achilles tunnel and Vashe moist gauze to slough at wound margins. Cover with dry dressing. Change daily and PRN. Betadine paint to L toe eschar's and right knee scabs. Layer Lidocaine and Calazime cream to sacral pressure ulcer BID and PRN. Interdry to skin folds. Change daily and PRN. Vaseline daily to left heel callus. Prevalon boots at all times while in bed . Infectious diseases: Signs of cellulitis and turbid drainage from tunnel. Primary team starting empiric abx. Cultured today. Endocrine: Encourage glycemic control to promote wound healing. Nutrition: Encourage protein rich diet to promote wound healing. Offloading: At risk for pressure ulcers aggressive off-loading with a stage IV mattress with skin guard mattress. gel chair cushion and Prevalon boots at all times while in bed, Must turn at least q2 and reposition frequently. Hospital Discharge Summary with a date of [DATE] documented: Cause of Death: 1. Renal Failure Interval Between Onset & Death: Years Other Significant Conditions 1. Left foot osteomyelitis 2. Severe aortic stenosis 3. Pulmonary embolism 4. Ischemic cardiomyopathy 5. Chronic hypotension Hospital Course: .presented to ED after receiving 2 shocks from LifeVest. Patient was asymptomatic. Evaluated by electrophysiology, upon review of tracing LifeVest shock was due to an artifact. Hospital stay complicated by multiple events, initially epistaxis that required packing, severe hypotension despite midodrine that persisted despite increasing the dose to 15 mg [three times daily]. During hospital stay evaluated by Cardiology given known severe aortic stenosis but was deemed not a candidate for TAVR (transcatheter aortic valve replacement). Patient with very poor oral intake, after discussion with patient and his family decision was made to place a G-tube and was started on tube feeds up to goal. On admission patient with a wound on the right heel that during hospital stay worsen and required extensive surgical debridement, infection involved all the way down to the calcaneus bone. Patient treated with broad-spectrum antibiotics, amputation was considered but patient consider very high risk. Patient also developed a GI bleed with drop in hemoglobin requiring [blood] transfusion and stopping anticoagulation, since then hemoglobin remained stable but blood pressure consistently low to the point he could not tolerate dialysis x2. During hospital stay multiple family meetings were held with the family and palliative care, eventually as patient continued to decline on ,d+[DATE] decision was to transition to comfort care in the hospital. Patient eventually expired on ,d+[DATE] 1048. On [DATE] at 10:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-L. Surveyor asked if she remembers providing cares to R58? CNA-L stated maybe a couple of times. Surveyor asked if she would provide foot care to R58? CNA-L stated she does not remember. Surveyor asked if she remembers looking at his feet the week leading up to his discharge? CNA-L stated no, she does not remember. On [DATE] at 9:09 AM, Surveyor interviewed RN-N. Surveyor asked if she remembers looking at R58's feet the week leading up to his discharge? RN-N stated no, she does not remember. On [DATE] at 9:20 AM, Surveyor interviewed LPN-K. Surveyor asked if she remembers looking at R58's feet the week leading up to his discharge? LPN-K stated no, she does not remember. Surveyor asked if she remembers completing a diabetic foot check on [DATE] that she signed out as completed? LPN-K stated she thinks she put lotion on his feet once but not sure when that was. Surveyor asked if she remembers any open areas or wounds? LPN-K stated she does not remember. On [DATE] at 9:49 AM, Surveyor interviewed LPN-R. Surveyor asked if she remembers looking at R58's feet the week leading up to his discharge? LPN-R stated no, she does not remember. Surveyor asked if she remembers completing a diabetic foot check on [DATE] that she signed out as completed? LPN-R stated she does not remember. Surveyor asked if she remembers any open areas or wounds? LPN-R stated she does not remember. On [DATE] at 10:13 AM, Surveyor interviewed LPN-T. Surveyor asked if she remembers looking at R58's feet the week leading up to his discharge? LPN-T stated no, she does not remember. Surveyor asked if she remembers completing a diabetic foot check on [DATE] that she signed out as completed? LPN-T stated she does not remember. Surveyor asked if she remembers any open areas or wounds? LPN-T stated no, if he did have wounds there were no treatments on her shift (7:00 PM to 7:00 AM.) Surveyor asked if LPN-T found a wound who would she report it to? LPN-T stated she would chart it and then tell the unit manager assigned to that unit. On [DATE] at 10:23 AM, Surveyor interviewed NP-F who oversaw R58's care. Surveyor asked when was the last time she saw R58 before he discharged ? NP-F stated [DATE] she had a visit with him; that she did speak with him about Paxlovid a few days after that but did not assess him. Surveyor asked NP-F if R58 was ever out of bed? NP-F stated she always saw him in bed but he did have dialysis three times a week so he did get out of bed sometimes. Surveyor asked if she was updated on any wounds? NP-F stated she was unaware he had any wounds. Surveyor asked if she would expect to be updated with new wounds? NP-F stated yes. Surveyor noted the [DATE] and [DATE] wounds that were documented. NP-F stated that was a weekend so they may have called the on-call service. Surveyor noted they did not call the on-call service. Surveyor asked if she ever assessed R58's feet? NP-F stated not that she could recall. On [DATE] at 1:45 PM and [DATE] at 9:40 AM, Surveyor interviewed LPN-S. Surveyor asked if she finds an open area who does she report it to? LPN-S stated usually the unit manager (ACNO-C,) wound team, or the Director of Nursing (DON)-B. Surveyor asked who calls the MD and gets orders? LPN-S stated the nurse doing the assessment, either the unit manager or RN. Surveyor asked about the wound found to R58's buttocks on [DATE]. LPN-S stated it looked like a skin tear and she applied some cream to it. Surveyor asked if she reported this to anyone? LPN-S stated yes, to ACNO-C when she found it. Surveyor asked about the necrotic area to R58's ankle. LPN-S stated R58's spouse told her he was having pain from a wound on his ankle. LPN-S stated she was unaware of any wound and looked at R58's right ankle and found a 3 to 4 inches by 2 to 3 inches black necrotic area from his heel to his Achilles that looked like a pressure injury. LPN-S stated she either texted or called ACNO-C because it was a Sunday and she was going to follow up [DATE] which was a Monday. LPN-S stated on [DATE] ACNO-C followed up with her and told her it was not a pressure injury but rather a vascular wound. LPN-S stated she never heard about it agai [TRUNCATED]

UNCORRECTED ON REVISIT Based interview and record review the facility did not ensure 1 (R68) of 3 residents received the necessary hydration needs to prevent dehydration. On 3/8/23 R68 was transferred to the hospital due to a change in condition. The hospital record dated 3/8/23 indicated R68 was severely dehydrated and needed 14 liters of lactated ringers to rehydrate. R68 was receiving pureed foods and nectar thick liquids and the facility was not monitoring R68's fluid intake. Assistant Chief Nursing Officer CC stated R68 would refuse to drink at times. There is no evidence of R68 refusing to drink. There is no evidence R68 was educated on the importance of nectar thick liquids, options to the diet or discussion of possible waiver to the diet. Findings include: The facility policy for residents with thickened liquids dated November 2018 indicate . 5. Instructions on monitoring of residents on thickened liquids will be directed by Speech Therapy an/or provider as needed. 7. If a resident refuses to follow treatment plan, the physician will be notified, education done and the care plan updated to reflect the resident's non compliance . R68 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, acute respiratory failure, type 2 diabetes, dysphagia and cardiomyopathy. R68 was transferred to the hospital on 3/8/23 as a result of a change in condition. R68 did not return to the facility. The admission MDS (minimum data set) dated 2/19/23 indicates R68 was cognitively impaired, needed extensive assistance with bed mobility, transfers and dressing. R68 needed limited assistance with meals. The hospital speech therapist recommendations dated 2/9/23 indicate R68 is to have a pureed diet with nectar thick liquids and needs supervision with meals. Speech therapy DD's note dated 3/1/23 indicates she discussed with R68 that he would need to continue with the pureed foods and nectar thick liquids. The note indicates R68 expressed understanding and agreement. The comprehensive nutrition assessment dated [DATE] indicates R68 appeared thin, not well nourished and moderate fat and muscle loss. The assessment indicates R68 has evident protein calorie malnutrition related to acute on chronic condition AEB (as evidence by) hx (history) inadequate oral intake, muscle/fat wasting, decline in function. The nutrition intervention was mighty shakes TID (three times a day) with meals for nutritional supplementation. Probiotic BID (twice a day). Mechanically altered diet per SLP (speech language pathologist) recommendations. Staff continues to monitor and encourage intake, offer alternate as appropriate. Nutritional needs were assessed at 1910 calories, 83 grams protein and 2090 ml (milliliter) of fluids. Surveyor reviewed R68's meal intake, and noted it varied from 25% to 75% for intake. Surveyor noted the meal intake does not indicate how much fluids R68 was taking in. Surveyor reviewed the MAR (medication administration record) for R68. The MAR revealed Mighty shakes supplements were being given with meals but the amount that R68 drank is not calculated. The nutritional care plan indicates one of the interventions as Provide general, pureed/nectar thick liquids diet as ordered. Monitor intake and record every meal. The nurses note dated 3/8/23 indicates R68 became unresponsive, BP 60/30, sent out via 911, NP and family update. Surveyor obtained R68's hospital record for 3/8/23. The hospital record dated 3/8/23 indicates R68 came in with severe dehydration and hyperkalemia (high potassium). The hospital record indicates on 3/8/23 R68 received two liters of normal saline IV solution in the emergency department. On 3/9/23 R68 received a total of seven liters of lactated ringers solution and one 500 ml lactated ringers solution. On 3/10/23 R68 received total of two liters of lactated ringers and one 500ml lactated ringers solution. On 3/11/23 R68 received a total of two liters of lactated ringers solution. On 3/12/23 R68 received one liter of lactated ringers and one 500 ml of lactated ringers solution. On 3/13/23 at 11:30 a.m. Surveyor interviewed Assistant Chief Nursing Officer CC. Assistant Chief Nursing Officer CC stated on 3/8/23 R68 was found slumped over in his wheelchair and unresponsive with a low blood pressure. Assistant Chief Nursing Officer CC stated R68 was sent out 911 to the hospital. Surveyor explained to Assistant Chief Nursing Officer CC that R68 was admitted to the hospital with severe dehydration. Surveyor asked Assistant Chief Nursing Officer CC if R68's fluids were being monitored along with his meal intakes. Assistant Chief Nursing Officer CC stated they don't monitor fluids unless there is a doctor's order for it. Surveyor asked if R68 needed assistance with drinking. Assistant Chief Nursing Officer CC stated that R68 did need assistance and would at times refuse to drink the thickened fluid. Assistant Chief Nursing Officer CC stated she would offer R68 fluids while he was sitting near the nurses' station and R68 would refuse. Assistant Chief Nursing Officer CC stated R68's health was declining, and she was thinking a conversation about hospice would need to be discussed but this did not occur. Assistant Chief Nursing Officer CC stated fluids are monitored for residents on renal diets or fluid restrictions. On 3/13/23 at 2:00 p.m. Surveyor interviewed Speech Therapist GG. Speech Therapist GG stated R68 needed supervision with eating and drinking because of his dysphagia. Speech Therapist GG stated R68 did not refuse to eat or drink while she was working with him. Speech Therapist GG stated if a cup was given to R68 he would drink it. Speech Therapist GG stated if R68 was refusing then she would go down the education route, but it didn't get to that point with R68. On 3/13/23 at 2:10 p.m. Surveyor interviewed Certified Nursing Assistant (CNA) EE. Surveyor asked CNA EE if they took care of R68 and she stated she often did take care of him. Surveyor asked if R68 would refuse to eat or drink. CNA EE stated R68 did not refuse but did he did say he did not like the texture of the pureed food, but he ate it anyway. CNA EE stated when a cup was handed to R68 he would drink it. On 3/13/23 at 3:20 p.m. Surveyor discussed with Assistant Chief Nursing Officer D the concern R68 was admitted to the facility with diagnosis of dysphagia, had a nutritional assessment of R68 having inadequate oral intake and needed pureed food and nectar thick liquids and there was no monitoring of the liquid intakes. Surveyor explained Assistant Chief Nursing Officer CC stated R68 would refuse to drink the thickened fluids, but other staff interviews mention he did not refuse to drink. There is no evidence R68 refused to eat or drink. There is no evidence of monitoring of his fluids. There is no evidence if R68 was refusing that education was provided and the physician was made aware. Surveyor explained to Assistant Chief Nursing Officer D, R68 was admitted to the hospital on 3/8/23 with severe dehydration and there is no evidence the facility was monitoring R68 to prevent dehydration. Assistant Chief Nursing Officer D had no further information to provide.

Based on observation, interview, and record review, the facility did not ensure that 3 of 4 residents (R22, R28, R46) reviewed for pressure injuries received appropriate care to prevent the development of and/or promote the healing of pressure injuries. R22 was admitted with a pressure injury to his left buttock which subsequently healed. R22 was assessed by the facility to be high risk for pressure injury development. The facility did not implement interventions to prevent recurrence of the pressure injury. After 3 days of observations of staff not offering or assisting R22 with repositioning, a recurrent Stage 2 pressure injury was identified on R22's left buttock. In addition, R22 developed unstageable pressure injuries on both heels after admission to the facility. Facility documentation indicates R22 chooses not to follow interventions, however observations and interviews found R22 is not offered or assisted with implementing those interventions. R28 was admitted to the facility with a right tibia fracture for which an immobilizer is worn. R28 developed 7 pressure injuries, 6 of which were on his left leg, foot, and toes. The facility indicated the injuries were related to rubbing on the immobilizer but did not implement any measures to promote healing or prevent new pressure injuries from occurring. Observations of the areas found they were on bony prominences prone to pressure injury development. R46 was admitted to the facility following a below the knee amputation related to osteomyelitis in the left foot, peripheral vascular disease, and diabetes. The facility did not implement interventions to prevent the development of pressure injuries such as protecting R46's right foot from pressure. R46 subsequently developed a pressure injury to the right heel and was sent to the hospital for wound healing. An orthopedic consult recommended the use of a pressure relief boot for the right foot. The facility indicated R46 refused to wear it, however, the intervention was never added to the care plan and no physician's order was obtained. Findings include: Example 1: R22 was admitted to the facility on [DATE] with diagnoses including injury at the C5 (Cervical Spine 5), paraplegia, fusion of spine - cervical region, spastic quadriplegia,, protein calorie malnutrition, spinal stenosis of cervical region, and clinical depression. R22's admission Minimum Data Set (MDS) dated [DATE] was coded to indicate R22 had clear speech, understood and was understood by others, scored 15 on the Brief Interview for Mental Status (BIMS) suggesting intact cognition, and did not experience behavioral symptoms or refusal of care. R22 required total assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; had functional limitations in the bilateral upper and lower extremities; had an indwelling urinary catheter and was always incontinent of bowel. The MDS indicated R22 was at risk for developing pressure ulcers and was admitted with two Stage 3 pressure ulcers. Skin and wound treatments coded on the MDS included pressure reducing devices for the bed and chair, pressure ulcer and surgical wound care, and applications of dressings (with or without topical medications) other than to the feet. R22's Significant Change in Status MDS dated [DATE] was coded similarly; however, the MDS indicated the resident had a facility acquired Stage 2 pressure ulcer that was not present on the previous assessment. Skin and wound treatments include the items listed above and nutrition or hydration interventions to manage skin problems. R22's care plan included the following entry initiated 08/15/22, The resident has potential for impairment to skin integrity r/t (related to) impaired mobility . Interventions dated 08/15/22 included: Apply barrier cream per facility protocol to help protect skin from excess moisture, Encourage/Assist with turning and repositioning every 2-3 hours .Ensure that heels are elevated while resident is laying in bed. Additional interventions were added on the following dates: ~08/25/22: Assist resident in adjusting water temperature to prevent scalding/burns, remind resident when providing warm drinks. Encourage/assist resident to reposition when in wheelchair every 2 hours. ~09/19/22: Encourage good nutrition and hydration in order to promote healthier skin. ~09/20/22: Monitor skin when providing cares (care), notify nurse of any changes in skin appearance. A care plan entry was initiated on 09/19/22 and read, The resident has actual impairment to skin integrity r/t bilateral heels PU (pressure ulcer). Interventions dated 09/19/22 included: Educate resident/family/caregivers of causative factors and measures to prevent skin injury .Ensure that heels are elevated while resident is lying in bed .Evaluate and treat per physician orders .Evaluate resident for s/sx (signs/symptoms) of possible infections .Identify/document potential causative factors and eliminate/resolve where possible Nurse to assess/record/monitor wound healing with dressing changes .Assess and document status of wound perimeter, wound bed and healing progress. Report improvements or declines to the MD (Medical Doctor). A Pressure Ulcer Unavoidability document noted: 1. Site: 49) Right heel, Pressure: Length 3.5 (centimeters) Width: 5.0 (cm) Unstageable. 2. Site: 50) Left heel. Pressure: Length: 3.0 Width 2.5 Unstageable. Date noted: 9/19/22. ~Risk Factors: Other. Limited movement in BUE (bilateral upper extremities) and no movement in BLE (bilateral lower extremities) with foot drop. Two or more Diagnoses/Conditions: Quadreplegia [sic], continuous or chronic urinary incontinence, chronic bowel incontinence. Education given on importance of floating heels at all times. Also the importance of eating well balanced meals and how good nutrition aids in wound healing. ~Current and Prior Interventions: Floating heels, wound care, nutritional supplements, monitoring percentage of intake. ~Describe non-compliance with interventions: When up in chair and wheelchair he refuses elevating legs and using a pillow so his heals [sic] are not resting on a hard surface and limiting blood flow to the area. ~Summary: Patient in general has not been interested in being part of recovery. He tends to stay in bed and refuses going into recliner, etc. Guest is allowing us now (to) float heels, wound care nurse seeing weekly and nurse manager is changing dressing daily. Daily reminder of importance of nutritional intake. On 12/05/22 at 11:30 a.m., R22 was interviewed and indicated he had pressure ulcers on both of his heels that had developed since admission and were first identified on 09/19/22. At the time of interview the resident was in bed with his heels floated. R22 stated, The staff float my heels on pillows so my heels don't touch the mattress. They are supposed to come in every 2 hours and reposition me and adjust my pillows. Last time anyone came in to reposition me was around 8:00 a.m. today. No one has been back since then except to serve me my breakfast tray and give me my medications. R22 was subsequently observed in bed lying on his back, with his heels floated from 11:30 a.m. to 3:10 p.m. During the observation he was not repositioned. R22 verified he had not been repositioned during that time. On 12/06/22 at 8:30 a.m., R22 was observed in bed on his back with the head of the bed raised eating his breakfast with his heels floated. R22 indicated he had last been turned by the night shift around 6:30 a.m. and had not seen any day shift CNAs (Certified Nursing Assistant) yet. R22 was observed from 8:30 a.m. to 12:15 p.m. At 11:32 a.m., CNA-I was observed exiting R22's room. During interview, CNA-I indicated she was assigned to take care of R22 that day and said she had stopped in to see if R22 needed anything. CNA-I stated she had not repositioned R22 since she came on duty and said that R22, Asks when he wants to be repositioned. At 12:15 p.m., R22 verified he had not been repositioned or had his pillows adjusted since the day shift staff came on duty. R22's Care Kardex as of 12/06/22 included: Bed mobility. Patient requires physical assist x1-2 (of one to two staff) for repositioning (from) side to side every 2 hours. Physical assist x2 for bed positioning. Skin: Ensure that heels are elevated while resident is lying in bed. Monitor skin when providing cares (care), notify nurse of any changes in skin appearance. Tubi-grips on BLE (bilateral lower extremities) on AM off HS (on in the morning and off at night. Transfers: Resident requires physical assist x1 with sit to stand mechanical lift. On 12/07/22 at 8:15 a.m., R22 was observed on his back with the head of the bed elevated. The resident indicated he was ready for breakfast. The night shift had repositioned him and given him something to eat to tide him over until breakfast. Breakfast was delivered at approximately 8:40 a.m. During observation from 8:15 a.m. to 11:10 a.m., R22 remained in the same position, on his back with the head of the bed raised. At 11:10 a.m., R22 was interviewed and indicated the night staff told him he was getting a bedsore on his buttocks so he had better start getting up out of bed more. R22 said, They offered me Tubigrips to wear on my legs but they are not always put on. Once in a great while they put them on me. After I was here for a month and a half, I got sores on both my heels. The only thing I have done to keep my feet off the bed is have pillows placed under my legs. I have never been offered any types of boots to wear in bed or when up. A nurse talked about some type of cushion that could be placed between my legs so my feet would stay off the mattress. Nothing was ever brought to my room to try and no one ever mentioned it again. I don't wear any footwear except gripper socks which I wear all the time. R22 stated he had last been repositioned by the night shift about 6:00 a.m. R22 stated it was much easier to reposition when two staff assisted as he can't help at all with repositioning. R22 indicated no day shift staff had repositioned him on 12/07/22. R22's care plan was updated on 12/8/22 to indicate R22 had a pressure injury to the left buttock. Interventions dated 12/08/22 included, Apply barrier cream per facility protocol to help protect skin from excess moisture .Avoid scratching and keep hands and body parts from excessive moisture .Keep fingernails short .Encourage good nutrition and hydration in order to promote healthier skin .Use a draw sheet or lifting device to move resident .Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface .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, by wound nurse or provider. Surveyor requested to review Wound Round notes or other information related to R22's skin assessments/pressure injuries since admission. The following information was provided by DON-B (Director of Nursing) on 12/13/22: 8/27/22 Admission: Does the resident have any skin issues observed (including new and old)? No. No skin issues described. Wound team notified of new areas? No. 9/3/22 Other: Does the resident have any skin issues observed (including new and old)? No. No skin issues described. Wound team notified of new areas? No. 9/10/22 Weekly: Does the resident have any skin issues observed (including new and old)? No. No skin issues described. Wound team notified of new areas? No. 10/01/22 Weekly: Does the resident have any skin issues observed (including new and old)? No. No skin issues described. Wound team notified of new areas? No. 10/22/22 Admission: Does the resident have any skin issues observed (including new and old)? Yes. Document and Describe All skin issues: 50) Left Heel Description: PU (pressure ulcer). 49) Right Heel. Description: PU. Wound team notified of new areas? Yes. 11/05/22 Admission: Does the resident have any skin issues observed (including new and old)? Yes. Document and Describe All skin issues: Other. Description: Bilateral heels pressure. Wound team notified of new areas? No. 11/12/22 Admission: Does the resident have any skin issues observed (including new and old)? Yes. Document and Describe All skin issues: Other Bilateral heels PU healing well. Wound team notified of new areas? No. 12/08/22: Does the resident have any skin issues observed (including new and old)? Yes. Document and Describe All skin issues: 32) Left buttock. Description: open area. 31) Right buttock. Description: open area. Wound team notified of new areas? Yes. Wound Round Notes: 12/08/22: Braden Score (Scale for Predicting Pressure Ulcer Risk): 10 (High Risk). Active Wounds (Active/Closed) Active Wounds: Wound Site: L buttocks. Date Identified: 12/8/22. Type: Pressure. Classification: Ulceration. Status: Active. Clinical Stage: Stage 2. Wound Site: L Heel. Date Identified: 9/19/22. Type: Pressure. Classification: Ulceration. Status: Active. Clinical Stage: Unstageable. Wound Site: R heel. Date Identified: 9/19/22. Type: Pressure. Classification: Ulceration. Status: Active. Clinical Stage: Unstageable. Inactive Wounds (healed): .Wound Site: L buttocks: Date Identified: 8/16/22. Type: Pressure. Classification: Ulceration. Status: Healed. .Wound Site: R heel. Date Identified: 9/19/22. Type: Pressure. Classification: Ulceration. Status: Healed. Clinical Stage: Unstageable R22's progress Health Status notes entered on 12/08/22 by RN-H (Registered Nurse) indicated, .left buttocks. Measurements recorded. Peri wound: WNL (within normal limits), wound bed light pink/red, nongratulating (non-granulating) tissue. No c/o (complaints of) pain or discomfort to area. L buttocks cleansed, barrier cream applied. Resident and NP updated. A Wound Assessment Detail Report dated 12/08/22 and written by RN-H stated, Assessment Date: 12/8/2022 10:29 a.m. Wound: L buttocks. Status: Active. Type: Pressure. Classification: Ulceration. Source: Facility acquired. Date identified: 12/8/2022. Clinical Stage: Stage 2. Tissue Type: pink or red non-granulating = 100%. Exudate: None/ Periwound Criteria: normal. Wound Edge: Distinct and attached. Pain Scale: 0. Outcome; Probable improvement. Size: 0.50 x 0.50 x 0.10 (L x W X D) On 12/8/22 at 11:46 a.m., R22 indicated he was told by the night staff that he had a new pressure ulcer on his buttocks. The nurses looked at it this morning and told me it was a new pressure ulcer. On 12/08/22 at 12:10 p.m., RN-H was interviewed and stated, R22 does have a pressure ulcer on his left buttocks. It is a Stage 2. He has a standing order for preventative barrier cream. All residents get this ordered on admission to the facility. I took a picture with a measurement. This new pressure ulcer is facility acquired. I don't know why R22 no longer gets out of bed. When he worked with therapy he was out of bed in his chair. If he wants to get up or be repositioned, he can ask us. Residents should be repositioned every 2 hours or as requested. On 12/13/22 at 10:00 a.m., RN-L was interviewed and indicated R22 was alert and oriented times 4 and was able to make his needs known. RN L indicated she felt R22 was reliable with what he told staff. RN-L said, He is very particular about how he wants his care provided. Every 2 hours he is to be repositioned and his pillows adjusted. It really takes two staff to reposition him as he is unable to assist. He has very limited movement of his arms. He has never refused to be repositioned for me. I have not heard other staff say he refuses cares. He used to get up when he went to therapy. I do not know why they stopped getting him up. He developed pressure ulcers on his bilateral heels in September. We were floating his heels since he was admitted . He is high risk to develop pressure ulcers. We are now using 3 pillows under his legs to float his heels. He likes a towel placed between his legs also. I don't remember him ever refusing to have the pillows placed under his lower extremities in bed. He was admitted with pressure ulcers on his buttocks that have healed. RN-L stated R22 developed a pressure ulcer last week (12/08/22) on his buttocks. The pressure ulcer was facility acquired. RN-L stated she had not seen R22's pressure injury as he transferred to a different neighborhood last week. Example 2: Resident #28 (R28) was admitted to the facility on [DATE] with diagnoses including right fractured tibia with right lower leg immobilizer, renal failure, history of falls, diabetes, and heart disease. The resident's MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15. R28 was non-ambulatory due to a leg fracture and required extensive assistance with bathing and personal hygiene. The MDS indicated the resident was at risk for pressure ulcer development but did not have a pressure ulcer at the time of the assessment. The resident's care plan initiated 10/28/22 indicated the resident had the potential for impairment to skin integrity related to impaired mobility. Interventions included, Apply barrier cream per facility protocol to help protect skin from excess moisture .Encourage activity as tolerated .Encourage good nutrition and hydration in order to promote healthier skin .Ensure proper fitting footwear Monitor skin when providing cares, notify nurse of any changes in skin appearance .Encourage/assist with turning and repositioning every 2-3 hours .Ensure that heels are elevated while resident is lying in bed .Identify/document potential causative factors and eliminate/resolve where possible . R28's physician orders included: ~10/28/22: Braden (skin assessment) to be completed in Point Click Care one time a day every 7 day(s) for 4 weeks ~11/05/22: Knee immobilizer to RLE (right lower extremities) at all times. May loosen while in bed. Every shift. ~11/05/22: Wound consult as needed This was ordered again on 12/08/22. ~11/05/22: Skin checks weekly. Every day shift every Wed, Sat (Wednesday, Saturday) -Must open and document skin evaluation for each assessment. This was ordered again on 12/08/22. ~12/06/22: Tubigrip (tubular support bandage) every shift. On 11/23/22 a podiatry consult was ordered with a scheduled date for 01/24/2023. During interview with R28 on 12/09/22 at 2:00 p.m., the resident reported he had several open areas on his left front leg, left ankle, left toes and a toe on his right foot. The resident stated he didn't know how they occurred but staff told him, it must be from rubbing up against the immobilizer. R28 stated that he was supposed to have Tubigrip to wear but he never received it. The resident was observed wearing white ankle socks on both feet. No dressings were observed covering the wounds. He stated he just got an order to remove the knee immobilizer today, 12/09/22. He also started physical therapy. The resident stated, I wear my shoes when I go out from the facility and when I'm working with physical therapy. R28 had a Braden Scale for Predicting Pressure Ulcer Risk score of 15 indicating moderate risk was documented on 12/08/22. The resident's record indicated the resident developed the following open areas after admission to the facility and described as trauma and abrasions as indicated below. Active wounds at that time included: Active wounds at the time of survey included 1. 12/06/22 the fourth right toe Trauma / abrasion was measured at 2 cm x 1 cm x blank (not entered by staff); 2. 12/13/22 the left lower leg measurements were 2 cm x 0.50 cm x 0 cm; 3. 12/13/22 the left ankle lower (heel) measurements were 0.5 cm x 0.5 cm x 0 cm; 4. On 12/13/22 the left fifth toe measurements were Sm. Area; 5. On 12/13/22 the left fourth toe measurements were 1 cm x 0.5 cm x blank; 6. On 12/13/22 the left third toe measurements were 2 cm x 1 cm x blank; and 7. On 12/13/22 the left second toe measurements were 1 cm x 1 cm x 0 cm. The wounds on the right fourth toe, left fifth toe, left fourth toe, left third toe, left second toe wound, and left lower leg were first identified on 11/25/22 as a trauma/abrasion with necrotic soft adherent tissue 100%. Observation of a photo indicated the open area was over a bony prominence. The left ankle medial wound was first identified on 12/06/22 as a trauma/abrasion with bright pink or red tissue-100%. Observation of a photo indicated the open area was over a bony prominence. Example 3: R46 was admitted to the facility on [DATE] with diagnoses that included left foot osteomyelitis, status post left below the knee amputation, peripheral vascular disease, sepsis, COVID-19, end stage renal disease, and diabetes. The comprehensive MDS dated [DATE] and quarterly MDS dated [DATE] indicated a BIMS score of 13 and 14, which indicated intact cognition, and that R46 required extensive to total assistance of one with ADLs. The MDS comprehensive and quarterly MDSs indicated R46 was at risk for skin breakdown; did not have a pressure ulcer or diabetic foot ulcer; had surgical wound (identified in comprehensive MDS); and used pressure reducing device in bed and chair, surgical wound care, and application of ointments/medications to other than feet. R46's care plan initiated on 05/06/22 included the following statement: Focus: The resident has potential for impairment to skin integrity r/t impaired mobility. Interventions included: ~Apply barrier cream per facility protocol to help protect skin from excess moisture. Date Initiated: 05/08/2022 ~Change bedding/clothing if moist. Date Initiated: 05/10/2022 ~Dietary Consult as needed. Date Initiated: 05/10/2022 ~Do not allow linens to be creased/folded under resident, keep bedding as smooth as possible. Date Initiated: 05/10/2022 ~Encourage activity as tolerated. Date Initiated: 05/06/2022 ~Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 05/06/2022 ~Encourage/assist with turning and repositioning every 2-3 hours. Date Initiated: 05/10/2022 ~Ensure proper fitting footwear. Date Initiated: 05/08/2022 ~Monitor skin when providing cares, notify nurse of any changes in skin appearance. Date Initiated: 05/08/2022 ~PT/OT Consultation. Date Initiated: 05/10/2022 ~Use draw sheet when turning/repositioning Date Initiated: 05/06/2022 A second care plan focus area initiated on 05/08/22 stated, The resident has actual impairment to skin integrity. 1. Right heel. Interventions dated 05/08/22 included the following: ~Encourage good nutrition and hydration in order to promote healthier skin ~Nurse to assess/record/monitor wound healing with dressing changes. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements or declines to the MD ~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, by wound nurse or provider Provider orders were as follows: ~05/06/22: Podiatrist Consult as Needed. ~05/06/22: Diabetic foot checks at bedtime. ~05/06/22: LLE (left lower extremity) amputation site- cleanse with NS, pat dry. Cover incision with ABD FB kerlix daily, prn (as needed) every day shift AND as needed for wound care. ~05/6/22: Wound Consult as needed ~06/10/22: Wound Consult as needed. ~08/23/22: Santyl Ointment 250 UNIT/GM (Collagenase) Apply to R heel topically every day shift for wound care. ~09/10/22: Wound Consult as needed. ~09/10/22: Collagenase Ointment 250 UNIT/GM Apply to right foot 1,2 toe topically one time a day for infection. ~09/10/22: Podiatrist Consult as Needed. ~09/12/22: Santyl Ointment 250 UNIT/GM (Collagenase) Apply to R heel topically every day shift for wound care santyl FB foam dressing. ~09/27/22: Betadine R 2nd and 3rd toe BID every shift for wound care. Skin observation notes were reviewed the time period R46 was at the facility (05/08/22 to 11/02/22) in PCC and showed two entries: *07/24/22 that indicated R46 had No new skin lesions. *08/20/22 indicated New Skin Issue: Right Heel PU (pressure ulcer) and PU (pressure ulcer) 2nd and 3rd toe on R foot. According to document review, the identification and status of R46's right heel wound included the following: 08/20/22 eINTERACT SBAR Summary for Providers Late Entry by RN-FF stated, .Skin wound or ulcer started 08/20/22 . Pressure ulcer/injury Right heel PU, Date of clinical notification: 08/20/22(.) The right heel wound was identified as a pressure ulcer/injury however a description including measurements was not included in the document. 08/22/22 Orthopedic Consult to Evaluate Prosthesis recommended R46 wear pressure relief boot on R foot when in bed. Surveyor did not find an order for pressure relief boots in the electronic health record on or after this date. The boots were not added to the care plan and there was no documentation provided indicating the resident used pressure relief boots. An evaluation of R46's right heel wound was conducted on 10/29/22 through Telehealth Evaluation. The visit summary note described the wound to have Purulent Drainage a left [sic] heal [sic] wound. Pt (patient) reports redness of the heal [sic] starting about 4 weeks ago. He hasn't noticed much change since that time though. He hadn't noticed wheezing [sic] from the wound (though it is present on my exam). He denies fever or other complaint such as dysuria or abdominal pain. He has not been on abx (antibiotics) recently for the foot and is awaiting a vascular surgeon consult per the RN. Three days after the telehealth evaluation, on 11/01/22, a Physician-Progress Note states, R46 reports pain in the right foot, intensity 3/10, duration chronic, frequency intermittent, described as dull and non-radiating. Functional gains limited by pain and weakness. Pain right foot pain. There were no recommendations regarding intervention for the pain. One week after the telehealth evaluation was conducted, R46 was discharged to the hospital. According to an eINTERACT Transfer Form dated 11/02/22, resident was discharge(d) to Hospital for Wound to heel. During interview on 12/13/22 at 3:18 p.m. DON-B indicated R46's right heel wound was a diabetic ulcer of the heel; a WOUND ASSESSMENT DETAILS REPORT was provided, with assessment date of 08/22/22. According to the assessment, the wound was described as Vascular Diabetic/Ulcer Facility-acquired 08/22/2022, Superficial 2.50 x 1.50 x Unknown (L x W x D) 3.75 cm 2. The form indicated R46 had a Braden Score of 15 on 10/02/22 with risk factors that included: Braden Score 15 - high risk; Sensory = 2 very limited; Moisture = 3 occasionally moist; Activity = 2 chairfast; Mobility = 3 slightly limited; Nutrition = 3 - adequate; and Friction and Shear = 2 - potential problem. DON-B indicated R46 was followed by the vascular surgeon beginning toward the end of October 2022. R46 was not assessed by the wound care nurse until 11/01/22. During the exit meeting on 12/14/22, DON-B indicated R46 refused to wear a pressure relief boot. There was no indication R46 refused to wear a pressure relief boot. There was no evidence the facility implemented an alternative such as using a pillow to float the heel off the mattress. There was no evidence the recommendation was shared with the physician to obtain an order and the intervention was not added to the care plan.

Based on observation, interview and record review the facility did not ensure 2 of 2 residents (R17 and R10) reviewed for weight loss maintained acceptable parameters of nutritional status, such as usual body weight. R17 was to have weight monitored per physician order daily for 3 days, once a week for 3 weeks, and then once a month thereafter. R17 was weighed on 10/24/22 and 11/1/22. When R17's weight was obtained on 12/6/22 after inquiry from Surveyor, it was found R17 had a 15.4 pound weight loss in 1 month. R17 did not consistently receive a supplement with all meals, and did not consistently receive a snack. Amount of supplement and snacks consumed were not documented. R10 had an over 100 weight gain in 3 days. This was significant weight change was not identified and a reweigh was not completed. Findings include: On 12/05/22 at 1:45 p.m., ADON-C (Assistant Director of Nursing) provided a facility policy and procedure for managing weights that was last revised November 2018 that stated: All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly. Weekly weights will also be done with a significant change of condition, food intake decline that has persisted for more than one week, or with a physician order .All weights, upon completion, will be given to the DON or designee to determine a list of reweighs. Once the reweighs have occurred any resident with an unexplained significant to insidious weight loss will have a weight loss investigation completed. Dietary recommendations will be forwarded to the physician or NP by the DON or designee. Example 1: R17 was admitted on [DATE] with multiple medical conditions including Parkinson's Disease, encephalopathy, tremors, diabetes, and failure to thrive. R17's admission MDS completed on 10/24/22 indicated the resident scored 9 on the BIMS suggesting the resident had moderately impaired cognition. The resident had clear speech and was usually understood by others, and required limited assistance for eating. R17's admission weight was 148 pounds at 5 feet 4 inches and the resident had no problems with eating and was on a mechanical soft diet. A lab result dated 10/20/22 indicated R17 had an albumin of 3.4 grams per deciliter (gm/dL); normal range is from 3.4 to 4.8 gm/dL. R17 had an order dated 11/04/22 for Magic Cup Dessert with meals for Nutritional Supplementation 1 cup with meals TID (three times a day) . which was to be provided by dietary). On 12/06/22 at approximately 9:00 a.m. R17 was observed sitting in her wheelchair in the common area where the TV was located with a meal tray in front of her. The resident was not eating her breakfast and no Magic Cup nutritional supplement was on the tray. LPN-V (Licensed Practical Nurse) was asked if the resident received a supplement. LPN-V stated, Yes, she gets a Magic Cup. LPN-V was asked if the Magic Cup was provided by nursing. LPN-V said, No, dietary brings that up from the kitchen. On 12/06/22 during the noon meal, R17 was observed refusing to eat. The staff offered R17 several options which she refused. There was no Magic Cup or other supplement on the tray or offered to the resident. Review of documented weights indicated the resident was weighed on admission and then on 11/01/22 and weighed 148 pounds. A current weight could not be located in the record. On 12/06/22 at 10:00 a.m. the Surveyor asked ADON-C about R17's current weight. The resident was weighed on 12/06/22 at 2:32 p.m. following inquiry by Surveyor and weighed 132.6 pounds, a 15.4-pound or 10.4% weight loss in 1 month. There was no documentation found to support the resident was weighed according to provider orders: One time only for 1 Day AND one time a day for 3 Days AND one time a day every 7 day(s) for 3 Weeks AND one time a day starting on the 1st and ending on the 5th every month. R17's meal intake was to be documented by staff. Review of meal intake records indicated the resident's intake was not consistently documented. Meal intake was only recorded on 13 days and did not include meal intake for all three meals. R17 had an order for a bedtime snack dated 10/24/22; documentation indicated the snacks were provided on 14 days of the past 30 days that included: 11/13/22, 11/15/22, 11/19/22, 11/20/22, 11/24/22, 11/26/22, 11/27/22, 11/28/22 to 12/01/22, 12/05/22, 12/09/22, and 12/10/22. The type of snack was not documented and there was no information that indicated the amount of the snack consumed by R17. There was also no documentation in the medical record was found to indicate if R17 had consumed the Magic Cup supplement that is to be provided at each meal. On 12/07/2022 at 8:52 a.m. R17 was refusing breakfast. A supplement drink was on the resident's tray. A Dietary Note dated 12/07/22 at 1:08 p.m. stated, Weight 12/06/22 132.4 lbs (pounds) weight is down 15.6 lbs. x 2 months (10.5%) . Surveyor was told the weight change was 15.4 pounds as calculated above. Doetary note continues, .Guest declines meals at times, declining Magic cup supplement. Nutrition Diagnosis: Significant weight loss related to inadequate oral intake intervention: Boost supplement trialed with guest, states she would drink supplement RD (Registered Dietitian) recommendation. Intervention: House supplement/Boost/Ensure 1 carton/bottle po TID for nutrition supplement .Discontinue Magic cup TID. Staff continues to monitor and encourage intake. Monitoring and Evaluation: Weight: maintain at 132 lbs. +/- 3%. Intake: >50% meals. 100% supplement. Labs: monitored per MD/NP. Example 2: R10 was admitted to the facility on [DATE] MDS completed on 11/24/22 was coded to indicate the R10 scored 11 on the BIMS suggesting moderately impaired cognition, required limited assistance with eating, and weighed 215 pounds. The care plan initiated on 08/19/22 indicated R10 had the potential for nutritional deficit related to heart disease, diabetes, and obesity. The goal was to maintain adequate nutritional status as evidenced by maintaining weight without any unplanned significant changes. The interventions included: Allow resident sufficient time to eat. Date Initiated: 08/19/2022 Diabetic diet as ordered. Date Initiated: 08/19/2022 Evaluate any weight changes. Determine percentage changed and follow facility protocol for weight change. Date Initiated: 08/25/2022 Obtain and document weights per MD orders and facility protocol. Date Initiated: 08/19/2022 Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 08/25/2022 Nursing Provide LCS [low concentrated sweets], REGULAR/THIN diet as ordered. Monitor intake and record every meal. Date Initiated: 08/25/2022 RD to evaluate and make diet change recommendations PRN. Date Initiated: 08/19/2022 The resident's Kardex (undated) included direction to staff related to the resident's eating/nutrition as follows: Diabetic diet as ordered. Provide LCS, Regular/Thin diet as ordered. Monitor intake and record every meal. R10 had a physician's order dated that read, Weights - one time only for 1 Day AND one time a day for 3 Days AND one time a day every 7 day(s) for 3 weeks AND one time a day starting on the 1st and ending on the 5th every month. A comprehensive nutrition assessment dated [DATE] and completed by a Registered Dietitian stated, Assessment: Guest .RD recommendations: 1. Change diet to LCS, regular/thin. Intake adequate to meet estimated nutritional needs. Staff continues to monitor and encourage intake. Offer alternates as appropriate. Weight: fluctuation anticipated with diuretic therapy intake: 75% meals. Labs: monitored per MD/NP orders. There were no subsequent nutrition notes. The resident's weight record indicated the resident weighed the following in pounds: 11/05/22 - 225.0 (standing) 11/29/22 - 218.6 (standing) 12/02/22 - 332 pounds (standing); A weight gain of 113.4 pounds. The resident was not reweighed on this date. Although the record documented other weight fluctuations, the 113.4 pound recorded weight gain was not identified or addressed. R10 was interviewed on 12/06/22 at 12:15 p.m. while eating the noon meal. The resident denied having problems with care and services and stated the food quality was Alright.

Based on observation, interview, and record review, the facility did not ensure 8 of 11 sampled residents (R5, R3, R6, R17, R4, R12, R2, and R17) reviewed for falls/accidents received appropriate care and supervision to prevent incidents. R5 experienced 3 falls while at the facility. The second fall resulted in a fractured nose and a fractured wrist. The third fall resulted in a subdural hematoma. The facility implemented new interventions after the falls, but did not conduct a thorough investigation to determine the cause of the falls. Upon admission, R3 was to have anti-roll back brakes installed on their wheelchair. This was not done. On 10/18/22, R3 had a fall which the facility indicated the wheelchair rolled back on R3 causing a fall. The facility identified anti-roll back brakes as a new intervention following the fall. R3 was diagnosed with a hip fracture following this fall. Following return from hospitalization for the hip fracture, R3 had another fall where the wheelchair rolled back. The facility again identified anti-roll back brakes as a new intervention for R3. R3 had an additional 4 falls where the facility did not thoroughly investigate the falls in order to identify the root cause and did not implement interventions that addressed the causes of the falls. R46 had multiple falls at the facility. Following each fall, the facility implemented new interventions, but did not conduct a thorough investigation to determine the root cause of R46's attempts at self transfer. R17 had 6 falls with 5 of those being from bed. Although the facility implemented interventions after each fall, they did not address the root cause of the falls from bed and did not implement interventions to limit falls from bed. R4 had 3 falls while at the facility. The fall assessments did not address if all care planned interventions were in place at the time of each fall. Following those falls, there was no reassessment and/or modifications to the care plan interventions. There was no investigation to determine the root cause of R4's falls. R12 experienced 5 falls. There was no evidence that orders for an x-ray and for resident to be sent to the emergency room were followed through for 2 falls. There was also no evidence of the findings and treatment required. There was no investigation to determine the root cause of R12's falls and no new interventions added to the care plan despite being identified in the fall assessment. R2 had 6 falls in the last 2 months. Although R2 was able to tell staff what he was trying to do at the time of the falls, these statements were not taken into consideration while identifying the root cause and to develop care plan approaches to reduce the risk of falls. Observations made by Surveyor found that care planned interventions were not consistently implemented related to falls. R2 had an intervention that he was to be served hot beverages in a cup with a lid following an incident where he spilled hot coffee on himself while using a foam cup. If R2 refused to use a cup with a lid, staff were to stay with R2 while he drank the hot beverage. These interventions, which were verbalized by the NHA (Nursing Home Administrator) and DON (Director of Nursing) were not added to the care plan and were not know by staff. Multiple observations of R2 using a foam cup found that the cup would bend/fold while R2 was trying to drink from it. There were no staff supervising R2 while he drank hot beverages from the foam cup. R17 had a Speech Therapy intervention to eat in the dining hall for all meals related to an episode of aspiration. R17 was observed on multiple occasions to be eating in the TV area and her room without any supervision. Findings include: On 12/05/22, ADON-C (Assistance Director of Nursing) provided the facility policy and procedure that addressed Fall Prevention that was dated 11/2020. The policy stated, .Every resident will be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility, and after every fall in the facility . Surveyor reviewed the facility's fall documentation and noted there had been 351 falls at the facility since 04/01/22. NHA-A (Nursing Home Administrator) and DON-B (Director of Nursing) shared that a new process for managing falls was implemented approximately three months prior to the survey. Falls for the past 3.5 months (09/15/22-12/05/22) were reviewed and 172 falls were documented. Example 1: R5 was admitted to the facility on [DATE] and had diagnoses including mental health disorders, dementia, unsteadiness on feet, and diabetes; R5 had a recent injury of the head and fracture of the lower end of right radius on 11/06/22. R5's admission Minimum Data Set (MDS) completed on 09/22/22 included a BIMS (Brief Interview for Mental Status) score of 3 suggesting the resident had severely impaired cognition. According to the MDS, the resident required limited assistance with bed mobility and transfers. The resident was non-ambulatory with a wheelchair and was totally dependent on staff for locomotion. The resident's care plan dated 09/17/22 indicated the resident was at risk for falls related to weakness. The goal was to keep the resident free of minor injury through the review date. Interventions included: ask visitors to inform staff when leaving, ensure footwear fits properly, and encourage resident to stay properly hydrated, educate that dehydration increases risk of falls. The resident's Kardex was not available for review because the resident was no longer in the facility. According to facility documentation, R5 experienced 3 falls since admission. Facility documentation related to the resident's falls, provided by ADON-C was reviewed. ~10/21/22 - R5 experienced a non-injury fall on 10/21/22 at 10:18 p.m.: Resident was observed by CNA (Certified Nursing Assistant) sliding out of wheel chair onto the dining hall floor .Guest stated she was trying to remove herself from the dining area back to her room. A note added to the incident report on 10/24/22 included, Resident is alert with confusion and needs moderate assist with ADLs (activities of daily living) and transfers . MD and family made aware of the above incident and in agreement to the current POC (plan of care) with the addition to putting Dycem under the w/c (wheelchair) cushion to prevention of falls. All interventions were in place at the time of the fall .IDT (Interdisciplinary Team) reviewed and revised the POC to meet her needs. On 10/21/22, a Fall Risk Evaluation was conducted post fall. The [NAME] II Fall Risk Model documented score was 17 indicating the resident was at high risk for falls. R5's care plan was updated to include approaches of Dycem under the cushion, do not leave resident unattended in the bathroom, educate resident/family/visitors on need to call for assistance when transferring in/out chair. ~10/30/22 - R5 experienced a fall with subsequent injury on 10/30/22 at 8:15 p.m.: CNA reports pt (patient) is on the floor in hallway outside of room while conducting rounds Resident Unable to give Description. No witnesses found. Fall interventions in place at time of incident. The report indicated the resident was transferred to the emergency room . According to the ED (emergency department) report, Guest is an [AGE] year old female with history of dementia .Assist of 1 with ADLs and transfers .abrasion to top of right hand with c/o (complaints of) pain, hematoma above left eye and bruising to bridge of nose .Guest returned with fracture to nose and right wrist. Interventions in place at time of fall. IDT (Interdisciplinary Team) reviewed with new intervention to offer a walk when notice guest becoming agitated or restless. On 10/30/22 a Fall Risk Evaluation was conducted post fall. The [NAME] II Fall Risk Model documented score was 17 indicating the resident was at high risk for falls. R5's care plan was updated to include interventions of evaluate gait and ambulation capabilities, identify abnormalities, physical therapy to evaluate, and when restless and agitated offer a walk. ~11/06/22 - According to an incident report R5 experienced a fall with subsequent injury on 11/06/22 at 2:30 a.m.: Guest was observed on the floor of bedroom laying on her left side bleeding from head and nose .guest very confused and doesn't remember getting out of bed or the reason she got out of bed. No witnesses found. Fall safety interventions in place at time of incident. A note added to the report, dated 11/07/22 stated, .guest was observed on the floor in front of her bathroom lying on her left side with apparent injury to her head. First aid was administered, and resident was sent out immediately to r/o (rule out) an acute head injury .Resident was observed about an hour prior to incident sleeping in the bed and toileted at 12:30 a.m. and was last observed at 1:00 a.m. According to the Incident report, Resident did return with a subdural hematoma. Hospice was ordered. All interventions will remain in place for preventatives along with encouraging hipsters because resident has poor safety awareness of her impaired cognition r/t dementia. The IDT reviewed and revised the POC to meet her needs. On 11/06/22, a Fall Risk Evaluation was conducted post fall. The [NAME] II Fall Risk Model documented score was 17 indicating the resident was at high risk for falls. On 11/06/22 at 7:58 a.m., an entry in the progress notes indicated the resident returned to the facility from the Emergency Department. The resident was alert and awake. On a 11/12/22 at 4:05 p.m., the resident was found Nonresponsive, no vital signs, no sign of life, apical pulse absent. Resident was a DNR (do not resuscitate) awaiting hospice on Monday. The incident reports for falls on 10/21/22, 10/30/22, and 11/06/22 did not address whether all care planned interventions were in place including whether the resident was kept hydrated, whether the resident was wearing the appropriate footwear (gripper socks), etc Although the facility added interventions following each fall, the facility did not conduct a root cause analysis to identify or investigate the reason for the falls. Example 2: R3 was admitted on [DATE] with readmitted s of 09/09/22 and 11/02/22. The resident's diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), protein-calorie malnutrition, muscle weakness, lack of coordination, muscle wasting and atrophy, chronic kidney disease Stage 4, and dementia. On 10/21/22, R3 had a closed left hip fracture. R3's MDS dated [DATE] was coded to indicate R3 scored 13 on the BIMS indicating intact cognition; required limited assistance with bed mobility, transfers, walking in room, and personal hygiene; and required extensive assistance with dressing and toilet use. When ambulating, R3 was not steady but he was able to stabilize without staff assistance; when moving from seated-to-standing position and during surface-to-surface transfers, the resident was not steady but he was able to stabilize with assistance. Moving on and off the toilet and turning around did not occur. According to the MDS, R3 had functional limitations in range of motion in one lower extremity and used a walker for mobility. The MDS indicated the resident had falls within the last month and within the last 2-6 months. No MDS was completed following the resident's 11/02/22 re-admission. R3's current care plan indicated the resident was at risk for falls r/t weakness. Interventions included the items listed below. All interventions were initiated on 09/09/22 unless otherwise noted. Anti-roll backs Anticipate and meet the resident's needs Ensure bed brakes are locked Ensure footwear fit properly Ensure that resident's call light is within reach and encourage the resident to use it for assistance as needed. Follow facility fall protocol Re-education for assistance (added on 09/17/22) Assist resident into wheelchair before all meals (added on 09/19/22) No plastic/paper draw sheets to be used in bed (added on 09/19/22) PT to evaluate and treat as ordered or PRN (added on 10/10/22) Med review (added on 11/13/22) Body pillows to L, R (Left, Right) sides while in bed (added on 12/08/22 following inquiry by Surveyor) Bed in low position (added on 12/09/22 following inquiry by Surveyor) Stop sign in place to remind resident to call for assistance when needing assistant (added on 12/09/22 following inquiry by Surveyor) Room change (added on 12/14/22; was related to the resident being positive for COVID-19) Scoop mattress (added on 12/13/22 following inquiry by Surveyor) The resident's current care plan included a statement dated 09/09/22 indicating the resident had an ADL self-care performance deficit and limited physical mobility r/t weakness. Interventions included: 09/09/22: Bed mobility assist x1 09/09/22: Toileting: Resident requires A-1 (assist of one) with toileting 09/09/22: Uses wheelchair: Self propels wheelchair (Does not use foot pedals, ask resident to lift feet if pushing w/c) 09/12/22: Ambulation: x1 staff physical assist (use gait belt) and 2 ww (wheeled walker) in room. 09/12/22: Transfers: Resident requires assist A-1 with 2 ww and gait belt for transfers A care plan problem dated 09/12/22 stated, The resident has impaired cognitive function or impaired thought process r/t primary DX (diagnosis): acute toxic encephalopathy, r/t (related to) UTI, dementia, weakness. Interventions included: Ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Use task segmentation to support short term memory deficits. Break tasks into one step at a time. Fall Risk Evaluations completed on 07/13/22, 07/29/22, 09/09/22, 09/17/22, 09/19/22, 10/08/22, 11/01/22, 11/07/22, 11/08/22, 11/13/22, and 12/13/22 indicated the resident was at high risk for falls. R3 had orders for psychotropic medication including Seroquel, an antipsychotic medication, which increased the resident's risk for falls. A Behavioral and Psychotropic Medication Evaluation dated 11/16/22 stated, Guest has had a GDR (gradual dose reduction) on ordered Seroquel. Guest is impulsive leading to falls, verbally aggressive to spouse, confusion. Evaluation: Appears controlled. Review of Incident Reports provided by AC-C indicated that since October 22 the resident experienced six falls. ~10/08/22 - R3 fell on [DATE] at 7:31 a.m. The report stated, CNAs observed resident on the floor next to bed with his pillow and blanket sleeping during rounds. R: (Resident) Stated around 0230 (2:30 a.m.) he attempted to get into bed but didn't make it and didn't want to yell for help so he pulled a pillow and blanket on the floor to sleep. Resident stated no pain. Immediate action: Wife and MD updated. DON and weekend manager notified. VSS no visual injuries noted. Neuro checks negative. No c/o pain. NNO (No New Orders). ROM WNL .Other info: Fall safety interventions in place at time of incident. Notes included in the incident report dated 10/17/22 indicated, On [DATE] around 0731 he was observed lying on the floor with his pillow and sheet. Resident stated he fell around 0230 and fell asleep there. Statements show he was not on the floor around that time. All interventions were in place at the time of the incident. The MD and family were made aware of the above incident and in agreement to the current POC with the addition of therapy working on strengthening. The IDT reviewed and revised his POC to meet his needs . On 12/15/22, NHA-A provided additional information including a Fall Risk Check List, Fall Scene Investigation Report and Interview/Statement Records related to the fall that occurred on 10/18/22. The Fall Risk Check List indicated an Immediate Intervention was put in place on the care plan. Therapy was to follow up. The Fall Scene Investigation Report stated, (R3) stated he was trying to get into bed. Mental Status: Unknown. Usual mental status: Alert and oriented x3. Re-creation of Last 3 hours before fall: Patient was in bed around 4:30 a.m. to 5:00 a.m. Re-enactment of Falls: Resident self transferred. Fall Huddle: No new changes. Root cause of fall: (symbol for no was entered). Initial root cause: Poor judgement. Initial intervention: Call don't fall sign. Fall Team Meeting Notes: Summary of meeting: No systemic issues. Conclusion: Will have therapy P/U (pick up) for strengthening. An interview statement from the CNA who was responsible for R3's care at the time of the fall indicated the last time he had observed R3 was between 4-5:30 a.m. The intervention of therapy evaluation does not immediately reduce the risk of falls or injuries from falls. ~10/18/22 - An incident report indicated that R3 fell on [DATE] at 2:57 p.m. The report stated, .heard thumping coming from resident's room. noted bathroom door locked, after opening door resident was laying on his back on the floor with his pants at his ankle. Resident statement: Stood up after using the bathroom and pants got stuck under shoe and I slipped. Immediate action: Vitals, neuro check, ROM, skin assessment, md and family updated. No injuries observed at time of incident. Oriented x4. No injuries observed post incident. Situation Factors: transferring independently, ambulating without assistance. Other Info: Fall safety interventions in place at time of incident. On 12/15/22 NHA-A provided additional information including a Fall Risk Check List, Fall Scene Investigation Report, and Interview/Statement Records related to the fall that occurred on 10/18/22. The Fall Risk Check List indicated an Immediate Intervention was put in place on the care plan. Anti-roll brakes were added. According to the care plan, this was an intervention put in place in September. The Fall Scene Investigation Report stated, Resident was attempting a self transfer. Mental Status: Alert and Oriented x4. Usual mental status: Wearing shoes and socks. Baseline. Re-creation of Last 3 hours before fall: Resident sitting in wheelchair watching TV drinking water. Call light not on resident didn't need anything. Re-enactment of Falls: Resident self transferred to the bathroom .Root cause of fall: Amount of assistance in effect, footwear. Initial root cause: Self transferring in bathroom. Initial intervention: Anti roll back w/c .Conclusion: Resident took self to the bathroom and when he attempted to get back into w/c it rolled back. Additional care plan/nurse aide assignment updates: Will add anti roll backs. One CNA interview/statement indicated the CNA had last seen R3 in his chair in hallway at 10:30 a.m. Two other staff members interviewed indicated they had not seen the resident that day. The facility did not consider the resident's statement (pants got stuck on shoe causing resident to slip) when indicating anti-roll back brakes as an intervention. In addition, anti-roll back brakes were an intervention that was to be in place as of 9/9/22. On 12/13/22 at 10:00 a.m., Surveyor interviewed RN-L about the anti-roll back brakes. RN-L could not recall if the anti-roll backs were on R3's wheelchair at the time of the fall. If the anti-roll backs were on the chair at the time of the fall this would not be a new intervention. RN L did not know if R3 had anti-roll backs on his wheelchair currently. On 12/7/22 at 10:20 a.m., CNA K was interviewed. She did not know if R3 had anti-roll backs on his wheelchair. On 12/13/22 at approx. 2:00 p.m., Surveyor spoke with NHA-A and DON-B. No additional information was received indicating when the anti-roll back brakes were applied. Although no injury was apparent at the time of the fall, R3 began to experience an increase in pain beginning on 10/21/22: ~10/21/22 at 9:41 p.m. - a nurse added the following: Evaluation: Pain (uncontrolled). Outcome of Physical Assessment: Pain Status Evaluation: Does the resident/patient have pain? Yes. ~10/21/22 at 10:46 p.m. - Daily Skilled Note: .Most recent pain level: 9 on 10/21/22 at 8:53 p.m. ~10/22/22 at 2:15 a.m. - a nurse added the following: Resident sent to ER via Bell Ambulance at the request of POA and family due to bruising and swelling of the left hip, resident admitted to St. Luke's Medical Center for closed left hip fx. (fracture). The resident remained at the hospital until readmission on 11/02/22. Fall documentation continues: ~11/07/22 - According to an incident report, R3 had a fall on 11/7/22 at 2:10 a.m. The report stated, Guest was observed lying on the floor next to bed. Call light in reach but not activated. And guest is barefoot .Stated he was trying to get himself up to look for (sic) and rolled onto the floor .VS stable, ROM WNL, denies pain, assisted back to bed, no SKIN alteration noted neuro checks WNL. Pain: 0 Oriented to person and time. Psychological Factors: confused. Situation: improper footwear and none. Call light in reach. Transferring independently. Other Info: Fall safety interventions in place at time of incident. Education/non skid footwear applied. POA called 0222 (2:22 a.m.). Notes dated 11/07/22 and included in the report indicated, Guest found lying on the floor next to bed. Call light within reach but was not sounding. Guest was barefoot at time of fall. Staff checked on guest approximately 10-15 minutes prior to fall and guest was not soiled and stated he did not need anything. Urostomy in place. Nursing assessment completed with no injury noted. ROM WNL .Interventions in place at time of fall. IDT reviewed with new intervention to encourage use of gripper socks Summary: Encourage use of gripper socks . On 12/15/22, NHA-A provided additional information including a Fall Risk Check List, Fall Scene Investigation Report, and Interview/Statement Records related to the fall that occurred on 11/07/22. The Fall Risk Check List indicated the Immediate Intervention put in place on the care plan was gripper socks. The Fall Scene Investigation Report indicates the fall was on 11/07/22 at 2:10 a.m. The report read, Fall summary: found on floor .Resident was attempting a self transfer. Mental Status: Alert and Oriented x2. Normal mental status. Footwear: barefoot. Re-creation of Last 3 hours before fall: Guest in bed sleeping. Aide checked on him about 15 minutes prior to fall, guest dry and stated he did not need anything. Re-enactment of Fall: Resident was up looking for significant other .Initial root cause: Self transferring/confusion. Initial intervention: Encourage gripper socks .Conclusion: Resident continues to self transfer. Additional care plan/nurse aide assignment updates: Will encourage gripper socks to help prevent falls. Two CNA interview statements indicated they had last seen R3 laying down watching tv at 2:00 a.m. ~11/13/22 - R3 had a fall on 11/13/22 at 3:53 p.m. The report stated, Pt was observed on the floor sitting up next to the wheelchair .reports he slipped out of his wheelchair reaching for his shoe under the bed. Immediate Action Assisted patient with gait belt back into his wheelchair after assessment. Skin assessment, ROM, Neuro assessment completed and all baseline. No injuries noted. Oriented to person and place. Physiological: confused. Situation factors: call light in reach and transferring independently. Other information: Fall safety interventions in place at time of incident. Family notified at 1558 (3:58 p.m.). Notes dated 11/14/22 included the following: On 11/13/22 around 1400 (2:00 p.m.) guest was found on the floor next to bed stated he was looking for his shoes. Resident was last seen around 12:30 (p.m.) sitting in his wheelchair watching tv. All interventions were in placed at the time of the incident .The MD and family were made aware of the above incident and in agreement to the current POC with the addition to doing a med review. The med review consists of a GDR of his Seroquel. The IDT reviewed and revised the POC to meet his needs . On 12/15/22 NHA-A provided additional information including a Fall Risk Check List, Fall Scene Investigation Report, and Interview/Statement Records related to the fall that occurred on 11/13/22. The Fall Check Risk Check List indicated the Immediate Intervention that was put in place on the care plan was shoes on. The Fall Scene Investigation Report included: Fall summary: found on floor .Reaching for something - reaching for shoe. Mental Status: Alert and Oriented x2. Mental status: unchanged. Footwear: slippers. Re-creation of Last 3 hours before fall: Prior to fall resident was in wheelchair watching tv. Re-enactment of Falls: Resident has had increased confusion. Fall Huddle: Nothing Different. Root cause of fall: (symbol indicating no was documented). Initial root cause: Resident did not ask for assistance. Initial intervention: Anti roll backs, gripper socks, low bed, see C.P. (care plan). Fall Team Meeting Notes .Will do medication review to GDR Seroquel to r/o (rule out) possible increased fall risk from S/E (side effects). Conclusion: Resident continues to self transfer. Additional care plan/nurse aide assignment updates: Med review add for intervention. Anti-roll back brakes were to be in place on 9/9/22 per the care plan and were also identified as an intervention following the 10/18/22 fall. ~12/09/22 - According to an incident report, R3 had a fall on 12/09/22 at 4:27 a.m. The report stated, (R3) was found laying on his back on his left side of his bed. He was wrapped in his bedding. Resident alert, responding clearly. Vitals WNL. No apparent injuries Movement in upper and lower extremities. Continent of bowel. Urine leaking from urostomy bag. Resident states he rolled out of bed while sleeping, denies hitting head or pain. Immediate action: neuro checks completed, Vital signs assessed, transferred resident back to bed with assistance from CNA. No injuries observed at the time of the incident. Mental status: Oriented to person, situation and time. Mobility: Bedridden. Interventions in place at time of fall: low bed. On 12/13/22 at 10:00 a.m., DON-B provided the Fall Scene Investigation Report which did not identify if the bed was in the low position. Additional care plan/nurse aide assignments updates were: Low bed and stop sign. The statements from staff do not identify if the bed was in the low position. DON-B indicated this was the completed investigation. No additional information was available. On 12/13/22 at 10:00 a.m., DON-B provided the Fall Risk Check List which identified immediate interventions put in place and added to the care plan, the Fall Scene Investigation Report, and Interview/Statement Records related to the fall that occurred on 12/09/22. The Fall Scene Investigation Report incorrectly identified the date of the fall as 11/13/22 at 2:10 p.m. rather than 12/09/22 at 4:27 a.m. The report documented, Fall summary: found on floor unwitnessed .rolling/sliding out of bed. Mental Status: Alert and Oriented. Mental status: Baseline. Footwear: slippers. Re-creation of Last 3 hours before fall: resident was in bed watching tv. Re-enactment of Falls: Patient confused, unable to say what he was trying to do. Root cause of fall: None. Initial root cause: Resident rolled out of bed while sleeping. Initial intervention: proper bed positioning, bed linen straightened out, so resident doesn't tangle and slip out .Summary of meeting: No systemic condition. According to the conclusion: Resident is confused at times, had body pillows in place .Additional care plan/nurse aide assignment updates: Low bed and stop signs. On 12/05/22 at approximately 10:00 a.m. during the initial tour, R3's room door was observed closed. A sign on the door indicated Contact/Droplet Precautions were implemented for the resident. A Personal Protective Equipment (PPE) cart was observed outside of the resident's room. R3's door remained closed from 11:20 a.m. to 12:39 on 12/05/22 when CNA-I was observed donning PPE and delivering R3's noon meal tray. CNA-I indicated R3 was eating the meal while in bed. CNA-I stated, (R3) requires assistance with ambulation and transfers. (R3) had quite a few falls while trying to transfer himself. CNA-I said that nursing staff had been instructed to keep all resident room doors closed due to the COVID-19 outbreak and indicated that R3 was checked every 2 hours to see if he needs anything. According to CNA-I, R3 did not use his call light. CNA-I stated, We have not been instructed to check on the residents any more often than every 2 hours. R3's room door remained closed from 1:00 p.m. to 4:00 p.m. No staff were observed donning PPE to enter the room. On 12/05/22 at 4:02 p.m., CNA-K indicated during interview that she had not provided any care for R3 that day. At 4:05 p.m., CNA-I indicated she had not done anything for R3 since delivering his lunch tray. At 4:10 p.m. CNA-J stated she had not checked on R3 since that morning. On 12/06/22 at 8:15 a.m., CNA-J stated she had not been in R3's room that morning and indicated that she had been busy assisting her other assigned residents. At 8:20 a.m. CNA-J donned PPE and delivered R3's breakfast tray. Upon exiting R3's room, CNA-J verified that R3 was eating breakfast in bed that morning. CNA-J said, R3 tries to get up by himself and has had falls. He tries to take himself to the bathroom. The facility does not use any type of alarms. On 12/06/22 at 9:35 a.m., RN-L exited R3's room after administering his medication and discarding his breakfast containers. RN-L said that R3 was in bed watching television. From 9:35 a.m. until 12:25 p.m., when CNA-I donned PPE and delivered R3's noon meal tray, no staff was entering or exiting R3's room. CNA-I indicated she helped R3 transfer into his wheelchair for lunch and placed the call light within reach. During periodic observations on 12/07/22, R3's room door was closed whenever the Surveyor walked past the resident's room. On 12/13/22 at 10:00 a.m., RN-L was interviewed and indicated R3 had a cognitive deficit and was very impulsive. RN-L stated, In the late afternoon he gets really agitated especially when his wife comes in and he sun downs. (R3) requires assistance of one staff, with a gait belt and wheeled walker to transfer and ambulate. After his hip fracture he required assistance of two staff. He tries to transfer himself all the time. I don't think he could remember how to use the call light even if told how to. I don't know if he would read a stop sign instructing him to ring for assistance prior to transferring. He maybe could understand the sign if it was read to him. Not sure how long he would remember it. I don't believe he has ever had a low bed. The facility does not use any type of alarms or floor mats. Nursing staff are instructed to monitor residents every 2 hours and provide toileting and repositioning. Nursing has never been instructed to increase the frequency of checking on (R3). No change in how often to check on him since administration instructed us to keep the room doors closed due to the COVID outbreak. R3 was a high fall risk - when he was on his previous unit and on this unit, he is in a room close to the nurses' station for closer monitoring. I've never been here when he had a fall. I don't ever remember R3 having body pillows, any different type mattress than what all the residents routinely have, a toileting schedule, a wider bed or a stop sign in his room. On 12/13/22 at 11:40 a.m., CNA-Q was interviewed. CNA-Q indicated R3 was very confused and was often trying to get out of his bed or wheelchair. He takes himself to the bathroom even though he is not supposed to. We have to keep his room door along with all the other resident's room doors on the unit closed due to the COVID outbreak. I don't ever remember being told to increase the monitoring of R3. He is checked on every 2 hours or when we have time. I don't remember any different type of mattress (scoop or wider), body pillows, low bed, or a stop s [TRUNCATED]

Based on observation, interview, and record review, the facility did not provide the necessary treatment and services to prevent development of a pressure injury and promote healing for 2 (R59 and R62) of 2 Residents with pressure injuries. *R59 developed 2 unstageable pressure injuries to the left and right heel discovered on 09/19/22. On 09/19/22, a dressing was observed to R59's left foot dated 9/1. R59 complained of heel pain on 9/1 and a dressing was placed and not changed until brought to the attention of the facility by Surveyor. Licensed Practical Nurse (LPN) D did not document any heel pain from R59 or that a dressing was placed on his left foot. The facility was unaware of any skin impairment to R59 until it was brought to their attention on 09/19/22. This resulted in actual harm to R59. *R62 was admitted on [DATE] with a deep tissue injury to his left heel. Although Director of Nursing (DON) B was assessing the area as a deep tissue injury, another individual was incorrectly inputting the assessment data into the computerized wound assessment as a blister/other. The facility was not aware of this data entry error until questioned by Surveyor. R62 was observed to have a deep tissue pressure injury to his left heel. Surveyor observed R62's left heel lying directly on the mattress. R62's care plan incorrectly identified the wound as a blister. In addition, R62's care plan did not address the need to offload R62's heels until 09/19/22 and did not address the use of boots. As of 09/20/22 the deep tissue injury has decreased in size. Findings include: 1. On 9/20/22 the facility's policy and procedure titled, Skin Policy and Procedure dated 3/20 was reviewed and read: The nurse will conduct a full-body skin assessment for each resident weekly to ensure no risks have developed. Care planning for pressure ulcers will include specific interventions to prevent development of pressure ulcers and/or treat existing pressure ulcers including pressure redistribution/relief including heel protection. Approaches to manage and monitor pain. R59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R59 was also admitted with a Stage 3 pressure injury to his left buttock that healed on 8/30/22. R59's information indicated he makes decisions for himself. On 9/20/22 R59's admission MDS (Minimum Data Set) dated 8/18/22 was reviewed and indicated R59 had a Brief Interview for Mental Status (BIMS) score of 15 indicating R59 had fully intact long and short-term memory. The MDS also indicated R59 was at risk for developing pressure injuries. On 9/19/22 at 11:45 am, R59 was interviewed in his room. R59 was lying in his bed and indicated he had a sore on his left foot and nobody had looked at it or changed the dressing in about 3 weeks. R59 indicated his heel did not hurt and both feet were observed to be elevated on pillows and gripper socks were on both feet. Certified Nursing Assistant (CNA) E then came in the room and removed R59's gripper socks. A dressing was observed to R59's left heel that was approximately 50% covered with dried reddish-brown drainage. When CNA E lifted R59's left foot, the dressing had moved exposing R59's left heel and blood was observed dripping onto R59's pillow that was under the foot. A wound was observed to the left foot. The dressing on R59's left foot was dated 9/1 on PMs. This was verified by CNA E. CNA E then held up R59's right foot and a discolored area was observed to the foot. On 9/19/22 at 11:55 AM, Director of Nurses (DON) B came into R59's room and indicated R59 had no pressure injuries at that time. DON B observed R59's feet and indicated she was unaware of the pressure injuries. DON B observed the date on the bandage of 9/1 on PM shift. On 9/19/22, R59's pressure injury measurements were reviewed dated 9/19/22 at 1:04 PM which read: left heel, pressure, facility acquired, unstageable, scant serosanguineous (blood mixed with clear fluid) drainage, 100% deep maroon, 2 centimeters (cm) long by 3 cm wide, no depth. Right heel, pressure, facility acquired, unstageable 100% deep maroon, 2.5 cm long by 3 cm wide, no depth. On 9/19/22 at 1:15 PM, LPN D was interviewed and indicated she put the dressing on R59's left foot on 9/1/22 because he was complaining of pain to the foot. LPN D indicated she looked at the foot and saw intact skin to R59's left heel. LPN D indicated she should have made a note in R59's chart about placing the dressing but was not sure if she did. On 9/19/22, R59's medical record was reviewed and no documentation of the bandage on R59's left foot or complaints of foot pain were found. There was no evidence that R59's physician was notified of any pressure injuries or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/19/22 at 10:30 AM R59's care plan for potential for skin impairment with a date of 8/15/22 was reviewed and read: R59 has a potential for skin impairment related to impaired mobility. Interventions included: ensure that heels are elevated while lying in bed. A care plan for actual impairment to skin integrity related to bilateral heel pressure injuries was not added until 9/19/22 after the surveyor brought the pressure injuries to the facilities attention. On 9/20/22, the 24 hours communication sheets that would have included R59 were reviewed from the timeframe of 9/2/22 to 9/18/22 and did not indicate any pain, dressing, or impairment of either of R59's heels. DON B indicated when she provided the communication sheets that the sheet from 9/1/22 could not be found. On 9/20/22, R59's skin risk assessments dated 9/5/22 and 9/12/22 were reviewed and indicated R59 was at high risk for pressure injury development with a score of 10 (10-12 = high risk). On 9/20/22, R59's weekly skin check sheets dated 9/3/22, 9/10/22, and 9/17/22 all completed by Registered Nurse (RN) C were reviewed and indicated R59 had no skin issues new or old. On 9/20/22 at 1:02 PM, RN C was interviewed and indicated she took off R59's dressing to his left foot when she did the skin checks on 9/3/22, 9/10/22, and 9/17/22 and his skin was intact. RN C indicated she didn't know what she did after she removed the dressings. Surveyor informed RN C that the dressing observed on R59's left foot was dated on 9/1 and consisted of a [MEDICATION(S)] wrapped around the ankle and foot. RN C indicated she could not remember or answer any further. On 9/21/22 at 12:30 PM, DON B was interviewed and indicated that she was not aware of any standard of practice of applying a padded dressing to a resident to relieve pain. DON B indicated any pain should be documented and communicated to the next shift for follow up. The above findings were shared with the Administrator and DON at the daily exit meeting on 9/20/22. Additional information was requested if available. None was provided. 2. On 9/19/22 at 10:57 AM, Surveyor observed R62 laying in bed. R62 was laying on their right side with their bare feet directly on the mattress. R62 was queried about the left heel. R62 was not aware of the area, nor had any concerns. R62's medical record was reviewed by Surveyor. R62 was admitted to the facility on [DATE]. The Wound Assessment of the left heel, completed on 9/8/22, indicates an intact blister measuring 2 cm (centimeter) by 3 cm (centimeter), with a pressure ulcer scale for healing (Push) score of 8. The Push score ranges from 0 to 17 with higher scores reflecting a more severe ulcer. Included in this assessment is a colored picture of the wound. Surveyor observed the picture and observed what appeared to be a flat irregular discoloration of the left heel wound with [MEDICATION(S)] on it. The picture did not show an open area or a blister. The Admission MDS (Minimum Data Set) completed on 9/13/22 indicated a deep tissue injury on the left heel measuring 2 cm by 3 cm. Surveyor spoke with DON (Director of Nursing) B on 9/22/22 at 1:45 pm for clarification of left heel wound. According to DON B, R62 was admitted with a deep tissue injury, and this has been consistent since admission. The Wound Assessment drop down box was clicked as other and blister, rather than as a deep tissue injury. DON B stated this was an error in the point click care data entry classification. DON B reported the area has been assessed as a deep tissue injury every week since admission, as supported by weekly pictures and measurements. DON B does the wound assessments, and another staff does the data entry. DON B was not aware of the data entry error of identifying the deep tissue injury as an intact blister until it was questioned by Surveyor. R62's Plan of Care for the left heel blister was initiated 9/8/22. Surveyor noted the care plan addresses the wound on the left heel as a blister and not as a deep tissue injury. The care planned interventions do not include off-loading of the left heel until 9/19/22. The care planned interventions also do not address the use of boots. Surveyor spoke with DON B on 9/22/22 at 1:45 pm. DON B stated upon admission R62 had heel boots and to float heels, which were not indicated on the Care Plan. DON B reported R62 does move feet and kicks off the pillow and doesn't like heel boots. R62 does utilize proper footwear and nutrition to promote healing. R62 has a standard pressure reduction mattress. Surveyor noted R62 received physician ordered treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/20/22 at 9:25 AM, Surveyor observed R62's pressure injury treatment with DON B. R62 was sitting up in a wheelchair. R62 has an intact deep tissue injury on the outer aspect of the left heel. The 9/20/22 assessment which included colored pictures of the area indicated the measurement was 1.5 by 1.5 centimeters, indicating the area has decreased in size since admission. The physician ordered treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B was queried regarding preventative measures. DON B was not aware that off-loading of the heels was not on the plan of care. Surveyor also shared their observation of R62's heels resting against the mattress. On 9/20/22 at 3:00 PM at the facility Exit Meeting, Surveyor shared the concerns with R62's pressure injury interventions.

Based on observation, interview and record review the facility did not ensure its infection control program was implemented regarding a COVID-19 outbreak. On [DATE] R3, who resides on the 200 unit and who has a history of pneumonia, acute and chronic [CONDITION(S)], [CONDITION(S)], history of tuberclosis and is on oxygen, became more congested and developed a cough. Nursing suspected he might have COVID-19 but did not test him and did not implement isolation precautions. Two days later, on [DATE] using a Rapid test, R3 tested positive for COVID-19. The facility did not implement their outbreak procedures/testing on [DATE], waiting to conduct staff and resident testing on [DATE]. This gave COVID a four-day head start. On [DATE] R3's PCR (polymerase chain reaction) test came back on [DATE] with the results inconclusive and said no swab-test not performed. Over the next week, additional PCR tests came back with no results because staff had incorrectly performed the test. On [DATE], three staff who worked the 200 unit tested positive for COVID-19. R3 was not on the facility Infection control line listing even though R3 tested positive for COVID-19 on [DATE]. Staff were not clear as to when R3 was placed in isolation and when R3 was taken off of isolation. The facility was not routinely testing staff based on the transmission rate for the county. During staff interviews, staff were unaware of proper isolation for residents with COVID or suspected COVID. Facility staff working on the 200 unit with residents who were suspected and/or positive with COVID were not wearing N95's, but instead were wearing KN 95's. Staff were not always wearing PPE appropriately. On [DATE] the facility had ten residents on 200 unit and five staff positive for COVID 19. This deficient practice has the potential to affect all units with census of 103 at the time of the survey. The Facility's failure to implement their outbreak procedure at the start of the COVID outbreak created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA (Nursing Home Administrator) A of the immediate jeopardy on [DATE] at 12:30 p.m. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of F (potential for more than minimal harm that is not immediate jeopardy/widespread) as the facility continues to implement and monitor the effectiveness of its removal plan. Finding include: Policy and Procedures: Covid 19 Policy with revision date of [DATE] CDC guidelines will be reviewed on an ongoing basis by the Chief Clinical Officer and policy revisions completed as needed. Process: To prevent the introduction of respiratory illness in the facility the following steps should be taken: -Post signs at the entrance instructing visitors not to visit -Ensure employees who are sick stay home; make sure to track call ins and symptoms on facility log. -Instruct all employees to clean their hands before and after contact with residents after contact with contaminated surfaces or equipment and after removing Personal Protective Equipment (PPE). -All staff are required to wear face masks upon entering the building and at all times while in the facility 1. The guest will remain on precautions until they are free of signs and symptoms per Centers for Disease Control and Prevention (CDC) guidelines (cough, fever, periorbital redness, etc) 2. If a guest develops signs or symptoms of COVID-19 including acute fever >100.4 F, cough, sore throat, shortness of breath or difficulty breathing, vomiting and/or diarrhea, chills, muscle pain, headache, new loss of taste or smell, please refer to policy item number #5. 3. Documentation of signs and symptoms of COVID-19 will be documented in the electronic medical record by exception. Signs and symptoms of COVID-19 may include cough, sore throat, shortness of breath or difficulty breathing, vomiting and/or diarrhea, chills, muscle pain, headache, new loss of taste or smell. 4. If a guest becomes symptomatic for COVID-19: place a mask on the resident, place them in a room by themselves, shut the door, place them on droplet and contact precautions with eye protection and notify the DON (Director of Nursing) and physician. Request orders from the physician for: a. influenza swab b. respiratory pathogen panel and/or COVID-19 testing c. Bloodwork to include WBC count d. Chest X- ray 5. Place the appropriate signage on the door. The staff assigned to the guest will be the only individuals allowed in the room until the guest is asymptomatic and deemed appropriate by the provider for isolation precautions to be discontinued. 6. Keep guest in strict droplet and contact precautions until asymptomatic and provider deems appropriate to remove isolation precautions. Monitor oral temperature and SpO2 frequently per provider order 9. PPE for droplet precautions will include face masks, eye protection, gloves and gowns. Place a trash can near the exit inside any resident room on isolation to make it easy for employees to discard PPE. 14. All COVID-19 positive guest will remain in isolation for 10 days from the date of the initial positive test. In accordance with CDC guidelines a time-based stragety will be followed. At the end of the 10 day period, isolation precautions may be discontinued and the guest transferred out of the COVID unit if the guest has been asymptomatic for signs and symptoms of COVID-19 for 24 hours at the end of the 10 day period. Guest continuing to exhibit symptoms of COVID-19 at the end of the 10 day period will continue to remain in contact and droplet precautions on the COVID unit until guest is no longer symptomatic. The decision to discontinue isolation precautions will be determined by the Medical Director and/or CNO. 19. If not providing direct resident care and/or completing an aerolized generating procedure, Ignite staff may wear a mask only for residents and guests in their 14 day observation period. The facility's Federal COVID-19 Vaccine Mandate Policy dated [DATE] indicate: Face coverings: Face coverings must be worn by all individuals regardless of vaccination status. Ignite medical resorts will require the use of those face coverings that comply with federal mandate/guidance at the time said Mandate/guidance is implemented. Covered individuals who are not fully vaccinated as defined by the state(s) in which they practice, are required to wear all federally and state specific mandated PPE, including but not limited to an N95 face mask while working in resident care areas. 1. On [DATE] Surveyor reviewed R3's medical record. R3 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)], unspecified organism, pneumonia, unspecified organism, acute and chronic [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)], pneumothorax, unspecified, personal history of [CONDITION(S)], [CONDITION(S)], primary pulmonary hypertesnion, abnormal weight loss, interstitial pulmonary disease, unspecified, etc. R3's record documents R3 refused the COVID-19 vaccination dose 1. The facility utilizes a computer based Daily COVID Assessment listing signs and symptoms (s/sx) of COVID -19 which the assessor is able to check mark. The available signs and symptoms included: fever, cough, headache, muscle pain, vomiting, diarrhea, new loss of taste, sore throat, none of the above present R3's progress notes document and medical record reflects: On [DATE] (Friday) at 1:50 pm the Daily COVID Assessment indicates: Category: No positive response. None of the above are present (referring to fever, cough, headache, muscle pain, vomiting, diarrhea, new loss of taste, sore throat) Temperature: 97.5 - date [DATE] 11:36 am [DATE] 15:15 (3:15 pm) Daily COVID Assessment: Category: No positive response. None of above present. Temperature: 97.7 - date [DATE] 10:26 am [DATE] 13:20 Physician/PA/PN progress note: . History of Present Illness: . Patient complains of upper respiratory congestion X 2 weeks, which is intermittent, increased in the morning, occurs daily, and resolves as the day goes on negative issues with appetite, negative fevers, swelling, weakness, nausea,/vomiting .Pt opted for Mucinex 400 mg q 8 h PRN congestion. On [DATE] at approximately 8:30 am, Surveyor interviewed Director of Nursing (DON) B as to when R3 was placed in isolation and when R3 was removed from isolation. Surveyor asked DON B when R3 was taken off of isolation. DON B stated she went back to [DATE] (two days prior to when R3 tested positive for COVID-19) because that is when she thought R3's symptoms began. DON B stated [R3] came in with pneumonia, TB other respiratory systems and thought this was an exacerbation of pneumonia. Despite suspecting that R3 might have symptoms of COVID, the facility did not test R3 on this date. Lack of such testing prevented staff from immediately implementing precautions to prevent COVID from spreading if R3 had tested positive. [DATE] (Saturday 4:05 am) Daily COVID Assessment: Category: No positive response. None of above present. Temperature: 97.7 - date [DATE] [DATE] (Sunday 3:48 am) Daily COVID Assessment: Category: No positive response. None of above present. Temperature: 98.4 - date [DATE] Although no signs and symptoms of COVID were noted on the [DATE] Daily COVID Assessment, Surveyor noted the following on [DATE]. [DATE] 20:37 (8:37 pm) eINTERACT SBAR (situation, background, assessment, recommendations) Summary for Providers. The change in condition (CIC) reported on this CIC Evaluation are/were: Respiratory infection other change in condition. At time of evaluation resident/patient vital signs, weight and blood sugar were: Blood pressure: BP ,d+[DATE]-[DATE] 23:09 position: sitting/arm, Pulse: P95 . Temp: T 97.3, Pulse Oximetry: O2 95.0% Oxygen via nasal cannula . Positive findings reported on the resident/patient evaluation for this change in condition were: .Respiratory Status Evaluation: Cough other respiratory changes . [DATE] 23:48 (11:48 pm) Resident tested positive for COVID via rapid test at 2037 (8:37pm). Resident complaint (sic) of sore throat, productive cough with yellow sputum, and a slight headache. VSS stable. Resident expressed he does not want any medication for COVID Tx (Treatment). MD notified. NNO (No new order). Unit Manager notified. [DATE] (Monday 11:01 am) Daily COVID Assessment: Category: One positive response. Does the resident have any of the following? Cough Temperature: 98.1 - date [DATE] 10:32 am Highlighted in red, the computerized Daily COVID Assessment states, Notify Nursing Administration immediately of the above answers. [DATE] 16:18 (4:18pm) Physician/PA/NP Progress Note: Chief complaint: Mobility and ADL impairment due to [CONDITION(S)], PNA, Acute on chronic [CONDITION(S)], PTX, severe protein calorie malnutrition, and dysphagia, now with cough ,d+[DATE] COVID-19 History of present illness: Pt complains of continued cough, which is constant, increased in the morning, productive of [MEDICATION(S)], and not associated with other sx. Has been diagnosed with COVID-19 since last visit. Denies SOB (shortness of breath) . Assessment: .COVID-19 .Plan/Recommendations: Discussed plan of care with patient. Patient opted for scheduled Mucinex 400 mg TID X5days for congestion. Will continue current medications and rehabilitation services per orders. He has deferred specific treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The first charting indicating that R3 had been placed in isolation was on [DATE], although the Director of Nurses stated on [DATE] at 8:30 am that this had occurred on [DATE]. [DATE] (Tuesday) Daily COVID Assessment: No daily COVID Assessment noted on this date. [DATE] 05:42 notification note: Primary Chief Complaint: Respiratory: COVID-19 rule out . Summary: noted pt with positive COVID test refusing medications vitals stable pt on isolation . [DATE] 8:52 am Physician/PA/NP progress note: .Chief complaint: Mobility and ADL dysfunction due to [CONDITION(S)] . now with COVID-19 [DATE] (Wednesday) Daily COVID Assessment: No daily COVID Assessment was noted on this date. [DATE] 16:57 (Thursday 4:57pm) Daily COVID Assessment: Category: One positive response. Does the resident have any of the following: Cough. Temperature: 99.2 - date [DATE] 08:23 am Highlighted in red, the computerized Daily COVID Assessment states, Notify Nursing Administration immediately of the above answers. [DATE] 21:34 (9:34pm) Daily COVID Assessment: Category: No positive response. None of above present. Temperature: 97.7 - date [DATE] 21:45 [DATE] 17:08 Reason for skilled services: Primary Dx: COVID + [DATE] (strict isolation, all services are being provided to resident in his room .Special precautions: blank [DATE] (Friday) 4:18 am The pt is COVID pos. Pt is on strict isolation and in a single room. Pt is asymptomatic. [DATE] 12:38 pm . Chief Complaint .now with fatigue . History of illness: . positive for congestion, cough . Assessment: COVID-19 [DATE] (Saturday) 10:22 Daily COVID Assessment: Category: No positive response. None of above present. Temperature: 97.0 - date [DATE] 9:15 am [DATE] (Sunday) 11:13 am Daily COVID Assessment: Category: No positive response. None of above present. Temperature: 97.5 - date [DATE] 10:12 am [DATE] 6:35 am. Isolation remains-afebrile. VSS. Denies pain, SOB. [DATE] 10:53 am, Reason for skilled services: Primary Dx. COVID = [DATE] (Strict isolation, all services are being provided to resident in his room) . special precautions: blank [DATE] 3:30 am (Monday) Daily COVID Assessment: Category: No positive response. None of above present. Temperature: 98.2 - date [DATE] 3:30 am [DATE] 13:50 (1:50 pm) Chief Complaint: Mobility and ADL impairment due to [CONDITION(S)], PNA, acute on chronic [CONDITION(S)], PTX, PCM, COVID-19 and dysphagia, now with fatigue .positive for cough .Assessment: . COVID-19. [DATE] 3:23 am Daily COVID Assessment: Category: One positive response. Does the resident have any of the following? Cough Temperature: 97.6 - date [DATE] 2:30 am [DATE] 10:08 am Daily COVID Assessment: Category: No positive response. None of above present. Temperature: 97.4 - date [DATE] 10:08 am The line list did not indicate when R3 came off precautions. Surveyor noted according to the CDC (Centers for Disease Control and Prevention) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated [DATE], states; Patients with mild to moderate illness who are not moderately to severely immunocompromised: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g. cough, shortness of breath) have improved. Surveyor noted according to the facility's eInteract SBAR summary dated [DATE] 20:38 (8:37 pm) R3 experienced a change in condition in regards to R3's respiratory status with cough other respiratory changes . and with R3 testing positive for COVID via rapid test at 2037 (8:37pm). The facility's documentation indicates R3 complained of sore throat, productive cough with yellow sputum, and a slight headache and at which time the MD was notified. Surveyor noted R3 had a confirmed COVID -19 test on [DATE]. R3 should have been in isolation for 10 days until [DATE]. Surveyor noted R3 had not been in isolation as of [DATE] at 10:29 am. On [DATE] at 1:30 pm, Surveyor spoke with LPN AA who was working on the [NAME] (200) unit. LPN AA reported there is a cart outside a resident's room door and a sign on the door if a resident is on isolation. LPN AA reported she has worked this unit for the last week and a half. LPN AA stated [R3] was not on her group however he should have had a cart in front of his door and a sign indicating isolation when he had COVID. LPN AA stated residents stay in isolation for 7 days if they are COVID positive. LPN AA stated she has had training and they had us sign a paper. On [DATE] at approximately 1:35 pm, Surveyor spoke with Housekeeper E who reported there is always a sign on the door and a cart outside the door for a resident who is in isolation. Housekeeper E reported she has worked the [NAME] (200) unit in the last week and a half. Housekeep E stated she wears a KN95, gown, gloves, and goggles when going into the rooms with a sign on the door. Surveyor observed Housekeeper E presently wearing a KN95 with goggles. Housekeeper E stated the last time she worked was last Sunday ([DATE]) and there was a cart outside of [R3]'s room and a sign on [R3]'s door. Housekeeper E stated she works first shift from 7:00 am until 3:30 pm. Housekeeper E stated this (200 unit) is where most of the residents who are in isolation are. Housekeeper E stated sometimes there are carts outside of a resident's room for storage but the resident is not on isolation, you always have to look for the sign taped to the outside of the door. On [DATE] at 1:45 pm, Surveyor interviewed CMA BB who was working on the [NAME] (200) unit. CMA BB stated she believed [R3] was in isolation on Monday [DATE]. On [DATE] at 1:46 pm, Surveyor interviewed CNA F who works the [NAME] (200) unit from 7:00 am until 7:00 pm who stated there would be a note on a resident's door and a cart outside the room if a resident was on isolation. CNA F stated [R3] was in isolation and may have gone off on Monday ([DATE]) however CNA F was off on Monday ([DATE]). CNA F reported receiving training and wears goggles and a KN95 for this unit. On [DATE] at 7:20 am, Surveyor asked Assistant Chief Nursing Officer (ACNO)/RN Unit Manager for the [NAME] (200) unit- R if she recalled when R3 was taken off isolation. RN R stated on Monday ([DATE]) she asked who could come off as she was off the week before. Surveyor asked RN R if she removed the sign on R3's door and the cart from outside of R3's room. RN R stated, probably, it had to be in the am was playing catch up. RN R reported that off the top of her head she could not say when [R3] was placed in isolation and saying she could have sworn he was placed in isolation right before RN R went out on Tuesday ([DATE]). On [DATE] at approximately 8:30 am, Surveyor interviewed Director of Nursing (DON) B as to when R3 was placed in isolation and when R3 was removed from isolation. Surveyor informed DON B R3 tested positive for COVID-19 on [DATE]. Surveyor observed the first note of R3 being in isolation was on [DATE] and as of [DATE] at 10:29 am, R3 was no longer in transmission based precautions/isolation. Surveyor also informed DON B that it was noted R3 was not on the facility's COVID-19 Infection control line listing. DON B informed Surveyor she had forgotten to put R3 onto the line listing. DON B stated she placed R3 into isolation on [DATE] when he was positive for COVID-19. DON B indicated they conducted a rapid COVID test on R3 on [DATE] in which he was positive however it was faint. They followed this up with a PCR (polymerase chain reaction) lab test with the results sent back on [DATE] with the test resulting in an error as it could not be processed. DON B stated the facility started testing everyone (staff and other residents) on [DATE]. Surveyor noted on [DATE], the facility should have considered R3's positive COVID-19 status as a facility outbreak and should have started the COVID-19 testing for staff and residents on [DATE] and not wait until [DATE]. Surveyor also noted 3 staff (Staff R, Staff DD, and Staff EE) who worked on the 200 unit tested positive for COVID-19 on [DATE]. Surveyor noted if R3 has symptoms starting on [DATE] the 10 days of transmission based precautions/isolation would have continued to have been implemented until [DATE]. Surveyor also noted if the symptoms were first noted on [DATE], R3 should have been placed in isolation on [DATE] and not on [DATE] as indicated by DON B. Surveyor also noted R3 was not placed into isolation until the Rapid COVID 19 test resulted in a positive finding on [DATE] and 10 days of isolation would have been implemented until [DATE], which was not the case for R3. On [DATE] DON B provided Surveyor with the Laboratory Report dated [DATE] for the PCR test which had documented that the test was not performed and No swab in Vial. On [DATE] at 9:30 am, Surveyor interviewed Infection Preventionist C who reported starting in May of 2022. Infection Preventionist- C stated if we believe a resident may have COVID, we do a test and put the resident in precautions. Infection Preventionist-C indicated the facility policy indicates the duration of isolation would then be 7 days as long as they have no symptoms. Infection Preventionist-C stated she thought [R3]'s COVID symptoms started on [DATE] so that the 7-day isolation time frame would have ended on [DATE]. Surveyor noted the duration of a 7-day isolation for a resident who has been tested positive for COVID-19 is not consistent with the CDC recommendations. Surveyor also reviewed the facility's Coronavirus (COVID-19) policy dated February 2020 and revised on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] which states in part; Guest will remain on precautions until they are free of signs and symptoms per CDC guidelines (cough, fever, periorbital redness, etc.) All COVID-19 positive guests will remain in isolation for 10 days from the date of the initial positive test. In accordance with CDC guidelines a time-based strategy will be followed. At the end of the 10-day period, isolation precautions may be discontinued and the guest transferred out of the COVID unit if the guest has been asymptomtic for signs and symptoms of COVID-19 for 24 hours at the end of the 10 day period The facility could not identify when R3 was initially placed in isolation and when R3 was removed from isolation. R3 was not placed in isolation on [DATE] if this is the date identified by DON B as R3 having COVID-19 symptoms. When R3 had a confirmed COVID-19 test on [DATE] the facility did not conduct resident and staff testing until [DATE]. Staff R, Staff DD, and Staff EE who worked on the 200 unit tested positive for COVID-19 on [DATE]. Surveyors noted the lab could not always process resident COVID-19 tests due to not having a swab in the vial. Surveyors also noted staff not to be wearing Personal Protective Equipment (PPE) correctly and/or not wearing the CDC recommended PPE, such as wearing N95's. On [DATE] at 12:05 pm, Administrator A informed Surveyors, we have been using KN95's since the building opened and we don't do fit testing. Administrator A showed Surveyors the Central Supply room where Surveyors observed the following: 17 boxes @ 20 in each box Particulate Respirator (total 680)- Central Supply G stated these are KN95's. 1 box Niosh N95 @ 25 in each box (total 25). ,d+[DATE] box Niosh N95 in Administrator's office. Central Supply G stated they had 10 boxes of N95's coming in and when she checked her computer Central Supply G stated, Oh they are here. We go by what's going on in the building. Had 7 boxes of N95's coming and they were delivered yesterday ([DATE]), will go find them. Will be putting them on the [NAME] (200) unit. All units presently have KN95. I could put some out to the other units but think other units do not have a COVID outbreak. According to the CDC Heath Care Professionals (HCP) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e. goggles or a face shield that covers the front and side of the face.) Observations: 2. On [DATE] Surveyor received a list of residents who were COVID-19 positive. The list consisted of R43, R44, R45, R46, R2, R33, R47, R48 and R49. All residents resided on the 200 unit. On [DATE] at 11:00 a.m. Surveyor observed all the COVID positive residents listed in rooms with PPE and a droplet and contact sign on the door or on the PPE cart, except for R46 and R2. R46 and R2 did not have any signage or PPE outside of their rooms. During the survey, Surveyor observed facility staff on the COVID unit ([NAME]/200 unit) with KN95 masks on and goggles. Surveyor reviewed the outbreak line list and a total of 5 staff and 10 residents tested positive for COVID on [DATE]. R26 tested positive for COVID 19 and died on [DATE] (Cross reference F684.) During record review, Surveyor noticed R3 tested positive for COVID-19 on [DATE]. On [DATE] it was observed R3 did not have any PPE outside the room and no droplet or/and contact precaution sign outside the door. R3 is not listed on the infection line list. Interviews: On [DATE] at 1:30 p.m. Surveyor interviewed Director of Nursing (DON) B regarding the COVID outbreak and infection control. DON B stated two staff tested positive on [DATE], so the facility tested every resident and staff for COVID-19. DON B stated they implemented their outbreak policy on [DATE]. DON B stated they are testing staff and residents every Monday and Thursday. DON B stated prior to the outbreak on [DATE] they were testing staff weekly. DON B stated the infection control nurse was on vacation during this outbreak and returned to the facility on [DATE]. DON B stated she has been in charge of the outbreak. Surveyor asked DON B about R3 testing positive for COVID [DATE] and that R3 is not on the infection line list. DON B stated she must have missed that one. Surveyor asked DON B why staff were wearing KN95s instead of N95s. DON B stated they were told by public health that they can wear KN95s during an outbreak and with COVID-19 positive residents. On [DATE] at 8:00 a.m. Surveyor interviewed IP (infection preventionist) C. IP C stated she was on vacation from [DATE] and back to work on [DATE]. IP C stated DON B took charge of the Covid outbreak. IP C stated staff not fully vaccinated (which includes the booster) are tested weekly but with the outbreak all staff are tested twice a week. IP C stated when she spoke with public health department, she was told KN95 masks are sufficient for outbreaks. IP C stated new admission residents that are not fully vaccinated (including boosters) are placed in isolation and tested on admission and day 5 for COVID-19. After testing negative on day 5 and with no symptoms, the new admission residents are taken off isolation on day 7. IP C stated fully vaccinated new admissions are not put in isolation but still tested on admission and day 5 for COVID-19. On [DATE] at 12:30 p.m. Surveyor interviewed IP C. Surveyor asked IP C how often does she test staff not fully vaccinated (prior to the [DATE] outbreak). IP C stated weekly and it's based on the county infection rates. Surveyor asked IP C how does she keep track of the county infection rates. IP C stated DON B gets the data and forwards the data to IP C per email. Surveyor asked to see the emails from [DATE] to current. IP C printed the rates out for Surveyor. Surveyor asked IP C, based on the data the county was high on [DATE]th and continued to stay high, how did she know to test the staff not fully vaccinated only once a week. IP C stated she's not sure, she would have to look at the grid and decided how often to test. IP C stated it changes so often. According to Centers for Medicare and Medicaid Services (CMS) QSO-,d+[DATE] NH revised [DATE], staff who are not up-to-date should be tested twice a week when the level of COVID-19 Community Transmission is substantial and high. The facility should have ensured routine staff testing was conducted twice a week for those staff who are not-up to date with their COVID-19 vaccinations and when the Community Transmission of COVID-19 was substantial and high. On [DATE] at 11:00 a.m. Surveyor asked DON B if the facility had a policy regarding the use of antiviral medications for residents experiencing COVID symptoms. DON B stated they do not have a policy regarding the use of antiviral medications for COVID. DON B stated no resident, positive with COVID in the facility, is prescribed an antiviral medication for COVID symptoms. On [DATE] Surveyor called, the public health nurse, whom the facility communicates with, and the public health nurse did not call back during the survey. According to a [DATE] memo put out by the Wisconsin Department of Public Health, Older adults are at highest risk of getting very sick from COVID-19. More than 81% of COVID-19 deaths occur in people over age 65. The number of deaths among people over age 65 is 97 times higher than the number of deaths among people ages ,d+[DATE] years. According to information from the Wisconsin Department of Health Services data through [DATE] shows, People who were unvaccinated died at a rate 6.4X the rate of people who had been vaccinated with a primary series only, and 3.5X the rate of those who had the primary series and booster dose. Similarly, failure to offer an antiviral medication increased the risk for hospitalization and death. In an analysis of over 40 clinical trials involving mostly unvaccinated individuals, [NAME] University in Ontario found: Molnupiravir and Paxlovid each lowered the risk of death beyond standard care or placebo with moderate certainty (10.9 fewer deaths per 1,000 patients; 95% confidence interval [CI], 12.6 to 4.5 fewer for molnupiravir and 11.7 fewer deaths per 1,000; 95% CI, 13.1 fewer to 2.6 more for Paxlovid). A total of 10 trials with 5,575 patients reported 252 hospitalization s over a median follow-up of 21 weeks. The researchers assumed a baseline risk of 54.4 hospitalization s per 1,000 patients. Paxlovid lowered the risk of hospitalization by 46.2 admissions per 1,000 (95% CI, 50.1 to 38.9 fewer) with high certainty, while molnupiravir likely reduced the risk of hospitalization s by 16.3 per 1,000 (95% CI, 27.2 to 0 fewer) with moderate certainty. Lab Results Surveyor reviewed R43's COVID lab results. R43 COVID swab results collected on [DATE] indicate a positive result for COVID 19. Surveyor reviewed R44 COVID lab results. R44 COVID swab results collected on [DATE] indicate test not performed due to no swab and another swab was collected on [DATE] which indicate test not performed due to invalid media. No other COVID swab tests were done. Surveyor reviewed R45 COVID Lab results. R45 COVID swab results collected on [DATE] indicate test not performed due to no swab and another swab was collected on [DATE] which indicates test not performed due to invalid media. No other COVID swab tests were done. Surveyor asked DON B if staff were trained and are knowledgeable to collect COVID swabs accurately. DON B stated she's not sure what happened but did ask the staff that collected the swab and was told they followed the instructions. DON B states she thinks it was a lab mistake. DON B was unable to provide Surveyors with a sampled swab and instructions for the collection of the sample. 3. On [DATE] at 12:25 PM, Surveyor observed Licensed Practical Nurse (LPN)-CC on the 200 unit with positive COVID-19 residents with no eye protection on. On [DATE] at 12:20 PM, Surveyor observed LPN-Z on the 100 unit at the nurses' station with other staff members present. LPN-Z had a surgical mask hanging down on one ear and eye protection glasses on top of the head. LPN-Z put the mask on when Surveyor approached but pulled the mask down when talking. On [DATE] at 1:30 PM, Surveyor [TRUNCATED]

Based on observation, interview and record review the facility did not ensure 3 (R26, R5 and R24) of 26 residents reviewed received the treatment and care in accorance with professional standards of prctice, the comprehensive person-centered care plan, and the resident's choices. On [DATE] R26 was diagnosed with COVID-19 and there was no RN comprehensive assessment of R26 on [DATE] and [DATE]. Once diagnosed with COVID-19 nursing never asked if the resident wanted an antiviral medication. STAT lab orders were obtained on [DATE] due to a high pulse rate. The lab results indicated a critical result of WBC (white blood count) at 20.1 and the ordering physician was not notified of the lab result. On [DATE] R26 was found deceased . The Facility's failure to comprehensively assess R26 while he was experiencing COVID-19 symptoms, not asking if R26 wanted an antiviral medication, and the failure to notify a physician of the result of a critical lab created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA (Nursing Home Administrator) A of the immediate jeopardy on [DATE] at 12:30 p.m. The immediate jeopardy was removed on [DATE]; however the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan and as evidenced by; * R24 did not have an assessment or treatment to wounds on the toes. * R5 did not have consistent and completed wound care treatment. Findings include: 1) The facility's policy regarding notification of the physician with date of [DATE] indicate: 1. Nursing will notify resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental or emotional status. c. There is a pattern of refusing treatment or medication. d. The resident wants to be discharged or leave AMA e. It is deemed necessary or appropriate in the best interest of the resident. 2. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and physician orders. 3. The communication with the resident and their responsible party as well as the physician will be documented in the resident record or other appropriate documents. 4. The care plan coordinator will be notified so that changes can be made to the care plan. R26, who was [AGE] years-old, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (minimum data set) dated [DATE] indicates R26 is alert and oriented and is his own decision maker. It also indicates R26 needs extensive assistance with bed mobility, dressing and hygiene. The medical record indicates R26 had a signed DNR (do not resuscitate) form dated [DATE] and refused the Covid vaccines. The nurses note dated [DATE] indicates R26 tested positive for COVID-19 after the facility tested all residents and staff because of a COVID-19 outbreak. There is no documentation that staff asked R26 if he wanted an antiviral medication for COVID-19. The vital signs summary indicate on [DATE] at 6:14 a.m. R26 BP ,d+[DATE], pulse 118, respiration 18, temperature 98 and pulse ox 97% on room air. On [DATE] at 10:05 a.m. R26 BP ,d+[DATE], pulse 106, respiration rate 16, temperature 98.1 and pulse ox 92% on room air. R26's pulse oxygen has dropped from 97% to 92%. There was no assessment of R26's lung sounds. The facility's Daily COVID assessment dated [DATE] at 10:37 a.m. indicates R26 had the following symptoms: headache and cough with temperature of 98.1. No other assessment information is documented. The nurses note dated [DATE] at 11:12 a.m. indicates R26 had an elevated heart rate and the NP (nurse practitioner) was made aware and ordererd STAT (immediate) labs and IV (intravenous) fluids. The nurses note dated [DATE] at 11:46 a.m. indicates 20 gauge IV placed in R (right) arm. NS (normal saline) fluids running at 75ml/hr (milliliters/hour). The SBAR (situational, background, assessment, recommendation) dated [DATE] at 11:47 a.m. indicates BP ,d+[DATE], pulse 106, respiration rate 16, temperature 98.1 and pulse ox 92% on room air. There are no further assessments conducted after the SBAR note dated [DATE] at 11:47 a.m. There was no documented assessment of R26's lung sounds and no monitoring of vital signs for the rest of the day on [DATE]. Surveyor reviewed the lab results for R26. The lab report indicates the specimen was collected on [DATE] at 2:34 p.m. and the final report was generated on [DATE] at 11:28 p.m. The lab results indicate WBC (white blood cell) count was critically high at 20.1 (reference range: 4.,d+[DATE].8). Other note worthy lab results are platelet count 137 (reference range ,d+[DATE]), neutrophils percent 80.6 (reference range ,d+[DATE]), eosinophils percent 0 (reference ,d+[DATE]) and lymphocytes percent 4.2 (reference range ,d+[DATE]). On [DATE] at 12:31 a.m. R26 BP ,d+[DATE], pulse 85, temperature 97.7, respiration rate 18 and pulse ox 91% on room air. The facility's Daily COVID assessment dated [DATE] at 2:18 a.m. indicates R26 did not exhibit any symptoms with a temperature of 97.7. No other assessment information is documented. There were no subsequent vital signs or assessment of R26. The nurses note dated [DATE] at 9:53 a.m. indicates writer went into resident's room today to give morning medications and take vitals. Writer noticed resident's chest was not moving and he appeared pale. Pulse ox was not able to get a reading. Management notified, DNR status confirmed. Management was not able to find a pulse or auscultate any heart sounds. Writer called resident's spouse, no answer. Waiting call back at this time. On [DATE] at 10:25 a.m. Surveyor interviewed RN H. RN H stated R26 was positive for Covid on [DATE] and on [DATE] R26 oxygen level dropped to 91%, had a pretty bad cough and a high pulse rate. RN H stated she notified the NP and received orders for 1 liter of NS at 75ml/hr and STAT lab work. RN H stated she started the IV fluids on her shift but it was at a slow rate so it didn't finish on her shift. RN H shift was from 7:00 a.m. until 7:00 p.m RN H stated the STAT labs were obtained on her shift but the results did not come back on her shift. RN H stated when she came back on [DATE] in the morning she noticed the lab results on the desk at the nurses station but did not look at it. RN H stated she did not look at it until after she noticed R26 deceased . RN H stated the night shift did not report any critical lab results to her and did not report any changes regarding R26. On [DATE] at 12:20 p.m. Surveyor called [MEDICATION(S)] Laboratory that provided the lab results. [MEDICATION(S)] representative indicated the critical lab result was called in to a nurse (LPN I) on [DATE] at 12:55 a.m They also indicate they attempted to call the facility on [DATE] at 11:56 p.m. and [DATE] at 12:12 a.m. and finally reached LPN I at 12:55 a.m. to report the critical lab result. On [DATE] at 6:25 a.m. Surveyor interviewed LPN I. LPN I stated she worked the 7:00 p.m. to 7:00 a.m. shift on [DATE] into [DATE]. LPN I stated RN 26 normally didn't sleep much at night. LPN I stated she saw R26 around 9:00p.m. for his evening medications. LPN I stated he was coughing at that time because of Covid. LPN I stated she then saw R26 about 4:00 a.m. or 4:30 a.m. and R26 was sitting up in bed alert and doing his word search puzzle. LPN I stated R26 was coughing but looked normal and seemed stable. Surveyor asked LPN I if she received a call from Lab with a critical lab for R26. LPN I stated she doesn't remember getting a call from lab. LPN I stated all calls come to her nurses station and then she forwards then to the appropriate unit if necessary but doesn't remember a call from lab. LPN I stated if she did receive a call with a critical lab result she would notify the physician on call. On [DATE] at 2:00 p.m. Surveyor interviewed MD J. MD J is the physician for R26. MD J stated her service did not get a call from the facility on [DATE] regarding a critical lab result for R26. MD J stated she would have expected the nursing staff to call her or whoever was on call that night with the critical lab. MD J stated she wouldn't have done or prescribed anything differently (although the nurse responsible for calling would not have known what the MD's response would be). MD J stated the lab results were indicative of COVID. On [DATE] at 3:00 p.m. during the daily exit meeting with DON B and NHA A, Surveyor explained the concerns R26 did not have regular comprehensive assessments while he was experiencing COVID symptoms and the critical lab result along with the other abnormal lab results were not communicated to the physician. Surveyor explained the concern R26 was found deceased without documentation indicating R26 health status prior to being found deceased . On [DATE] at 11:00 a.m. Surveyor asked DON B if the facility had a policy regarding the use of antiviral medications for residents experiencing COVID symptoms. DON B stated they do not have a policy regarding the use of antiviral medications for COVID. DON B stated no resident, positive with COVID in the facility, is prescribed an antiviral medication for COVID symptoms. According to a [DATE] memo put out by the Wisconsin Department of Public Health, Older adults are at highest risk of getting very sick from COVID-19. More than 81% of COVID-19 deaths occur in people over age 65. The number of deaths among people over age 65 is 97 times higher than the number of deaths among people ages ,d+[DATE] years. According to information from the Wisconsin Department of Health Services data through [DATE] shows, People who were unvaccinated died at a rate 6.4X the rate of people who had been vaccinated with a primary series only, and 3.5X the rate of those who had the primary series and booster dose. Similarly, failure to offer an antiviral medication increased the risk for hospitalization and death. In an analysis of over 40 clinical trials involving mostly unvaccinated individuals, [NAME] University in Ontario found: Molnupiravir and Paxlovid each lowered the risk of death beyond standard care or placebo with moderate certainty (10.9 fewer deaths per 1,000 patients; 95% confidence interval [CI], 12.6 to 4.5 fewer for molnupiravir and 11.7 fewer deaths per 1,000; 95% CI, 13.1 fewer to 2.6 more for Paxlovid). A total of 10 trials with 5,575 patients reported 252 hospitalization s over a median follow-up of 21 weeks. The researchers assumed a baseline risk of 54.4 hospitalization s per 1,000 patients. Paxlovid lowered the risk of hospitalization by 46.2 admissions per 1,000 (95% CI, 50.1 to 38.9 fewer) with high certainty, while molnupiravir likely reduced the risk of hospitalization s by 16.3 per 1,000 (95% CI, 27.2 to 0 fewer) with moderate certainty. The failure to assess R26, who was experiencing serious COVID-19 symptoms, the failure to not ask R26 if he wanted an antiviral medication for COVID, and the failure to notify the physician or a critical lab result, created a reasonable likelihood for serious harm given R26's age and vaccination status, thus creating a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], when the facility completed the following: ~ The facility has provided re-education with all licensed nurses regarding notification of physician on policy and procedures regarding changes of condition, including timely reporting of abnormal lab results to the provider. ~ Staff education with licensed nurses further has included education regarding the immediate notification and assessment by a designated RN in-house and/or on call. Staff education with licensed nurses has also included immediate notification of the provider in the event a critical lab result is received. Continuing staff re-education will occur for all licensed nurses prior to the start of shift until education is fully completed with all licensed nursing staff. ~ Changes of condition will be assessed immediately by a designated RN in-house and noted on the daily staffing sheet. Changes of condition will be discussed in verbal report each oncoming and off going shift by the licensed nurse, as well as reviewed during the daily clinical meeting by the DON and/or designee. Changes of condition, including assessment by the RN, provider notification, and any new orders or treatments received will be noted in the electronic medical record by the licensed nurse. ~ The DON and/or designee will review the 24 hour report board daily to ensure any changes of condition are reported to the provider in accordance with facility policy and procedure The Change of condition policy and procedure has also been added to the orientation and training agenda to be reviewed with all new licensed nurses. These updates occurred as of [DATE]. On [DATE] the facility policy regarding Changes of Condition was updated to specify timely notification of critical labs to the provider. Current standards of practice, as well as Medical Director review has occurred and will be reviewed on a monthly basis at the facility QAPI (Quality Assurance Program Improvement) committee meetings regarding the Changes of Condition policy and procedure. The Director of Nursing and/or designee will conduct audits daily x 2 weeks, weekly x 8 weeks, and monthly x 3 months to ensure resident changes of condition are timely reported to the provider, including abnormal and critical lab results. Audits will further ensure compliance with RN assessment of changes of condition, as well as ensuring shift to shift communication regarding changes of condition occurs in accordance with facility policy and procedure. Audits will be integrated into the quality assurance process and facility assessment. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy) based on the following examples: 2. R24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (minimum data set) with an assessment reference date of [DATE] documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. The nursing evaluation dated [DATE] under the skin integrity section documents yes for the question does the resident have skin integrity concerns. Under site documents Other (specify) and description BLE (bilateral lower extremity) weeping. Under site documents Other (specify) and description left lower leg diabetic ulcers. Surveyor noted there is no documentation of necrotic tissue on R24's great left toe or left 5th toe. The nurses note dated [DATE] documents New admit via ambulance transferred from [name of] hospital. DX (diagnosis) multifocal pneumonia. [CONDITION(S)] present to LLE (left lower extremity) two open areas posterior of left calf. 7 sutures removed at hospital left outer knee. Dressing to be changed daily. HX (history) [CONDITION(S)] (hypertension) DM2 (diabetes mellitus) hemodialysis in house. [CONDITION(S)] machine in evening. Resident full code alert orientated x (times) 4 VSS (vital signs stable) afebrile received all vaccines. Signed consents. On [DATE] at 10:35 a.m. Surveyor observed R24 in bed on his back. R24 is not wearing a gripper sock on his left foot today and Surveyor observed necrotic tissue on the top of R24's left great toe & left 5th toe. Surveyor inquired about these areas. R24 informed Surveyor developed these areas from new diabetic shoes. R24 informed Surveyor he hasn't worn the shoes at the Facility as his stump has [CONDITION(S)] and not able to wear his prosthetic leg. On [DATE] at 1:10 p.m. Surveyor reviewed R24's medical record and was unable to locate an assessment for the two necrotic areas on R24's left great & 5th toe. There is no treatment on R24's July or August TAR (treatment administration record). On [DATE] at 1:31 p.m. Surveyor asked ACNO (Assistant Chief Nursing Officer)-R what happens when a Resident is admitted with skin alterations. ACNO-R informed Surveyor the admission nurse takes pictures of the areas, measures the areas and makes sure there is a treatment. ACNO-R informed Surveyor the next day she or RN (Registered Nurse) Supervisor-K will assess the wounds and make sure everything is appropriate for that wound. Surveyor asked ACNO-R where would Surveyor be able to locate the assessment for R24's left great toe and 5th toe wound. ACNO-R informed Surveyor RN Supervisor-K took pictures today and R24 had left leg front surgical wound is what she saw. Surveyor asked ACNO-R if she observed R24's toes. ACNO-R informed Surveyor RN Supervisor-K has the list. Surveyor asked ACNO-R if R24's wound assessments has been completed. ACNO-R informed Surveyor she doesn't know if RN Supervisor-K has completed R24's wound assessments. Surveyor asked ACNO-R if she could get in contact with RN Supervisor-K for Surveyor. On [DATE] at 1:39 p.m. Surveyor asked RN Supervisor-K if she completed with R24's wound assessment. RN Supervisor-K replied all finished. Surveyor asked RN Supervisor-K where Surveyor would be able to locate the assessment for the necrotic areas on R24's left great & 5th toes. RN Supervisor-K informed Surveyor when R24 was admitted she was never informed of these areas on R24's toes. RN Supervisor-K informed Surveyor she looked at R24 on the 27th ([DATE]) for the surgical wound. RN Supervisor-K informed Surveyor she would look at R24's toes. Surveyor asked for a copy of the assessment when completed. The left 5th toe wound assessment dated [DATE] documents under wound information for type trauma, classification abrasion and source facility-acquired. Under tissue types documents Necrotic Hard, Firm, Adherent= 100%. Under measurements documents for size 0.50 x (times) 0.50 x Unknown. The R (right) great toe wound assessment dated [DATE] documents under wound information for type trauma, classification abrasion and source facility-acquired. Under tissue types documents Necrotic Hard, Firm, Adherent: 100%. Under measurements documents for size Length - 0.50 cm (centimeters) Width - 0.50cm Depth - Unknown. Surveyor noted this assessment is for the left great toe as R24 has a right below knee amputation. The SBAR (situation, background, assessment, recommendation) note dated [DATE] at 15:14 (3:14 p.m.) includes documentation of Nursing observations, evaluation, and recommendations are: scabbed over area to L (left) great toe and L 5th toe. Measuring 0.5x 0.5 for both. Will be followed in wound rounds. [MEDICATION(S)] BID (twice daily). The nurses note dated [DATE] at 15:27 (3:27 p.m.) documents stated shoes did not fit right. Has been wearing slippers for months before admission to facility. Slippers observed at residents bedside. NP (nurse practitioner) updated, TX (treatment) in place. The necrotic areas on R24's left great and 5th toe were not assessed and a treatment was not ordered until Surveyor brought these areas to the attention of Facility staff. On [DATE] at 3:19 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above. 3. The Facility Wound Policy and Procedure dated March, 2020 documents (in part) . .Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus. Procedure: Risk reduction measures such as use of heel protectors (designed for friction/shear reduction versus pressure reduction), elevation of lower extremities, etc. (etcetera) are initiated if determined appropriate. Discussion with the attending physician and resident/representative includes notification of any skin impairment identified upon admission. Orders are verified or obtained as needed. Comprehensive wound assessment documentation will be completed by the Wound Care Nurse and/or designee. R5 admitted to the facility on [DATE] and discharged on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Hospital Discharge Summary dated [DATE] did not include any wound care orders. R5's Wound Assessment Details Report dated [DATE] documented: Left small toe venous stasis ulcer present on admission. An assessment and measurements was completed and documented. Right great to venous stasis ulcer present on admission. An assessment and measurements was completed and documented. Right outer calf venous stasis ulcers present on admission. An assessment and measurements was completed and documented. R5's June, 2022 Treatment Administration Record (TAR) indicated no treatment was ordered or implemented for R5's right great toe ulcer upon admission. On [DATE] an order was obtained for [MEDICATION(S)] to right great toe every day shift. Documentation revealed this treatment not signed out as having been completed on [DATE], [DATE] and [DATE]. On [DATE] orders were obtained for normal saline wash to the great toe, pat dry, followed by Santyl and dry dressing daily. Surveyor noted the [MEDICATION(S)] treatment was not removed from the TAR. Documentation revealed this treatment not signed out as having been completed during the time R5 resided in the facility. R5's June, 2022 TAR indicated no treatment was implemented for R5's left small toe ulcer during the time R5 resided in the facility. R5's June, 2022 TAR indicated no treatment was ordered for R5's right outer calf ulcers upon admission. Orders were obtained on [DATE] for normal saline wash to bilateral lower extremities, pat dry followed by Unna Boots 2x (two times) a week, change every Tuesday and Friday AM. Documentation revealed this treatment not signed out as having been completed on [DATE] and [DATE]. Surveyor review of subsequent assessment and measurements indicated no decline in R5's wounds, ulcers were smaller in size according to last documented measurements on [DATE] (4 days before R5 discharged ). On [DATE] at 9:45 AM Surveyor spoke with Licensed Practical Nurse (LPN)-Z who worked with R5 on [DATE], [DATE] and [DATE]. LPN-Z reported she did not remember doing Unna Boots for R5. Surveyor showed LPN-Z the 2 different treatment orders for R5's great toe. LPN-Z reported she did not remember which treatment she completed. On [DATE] at 9:00 AM, Surveyor spoke with Director of Nursing (DON)-B regarding R5's ulcer treatments. DON-B reported R5 did not have Unna Boot wraps on his lower extremities until she applied them on [DATE] after speaking to R5's daughter, who reported he wore them at home. Surveyor advised DON-B of concerns regarding delay in treatment, 2 different treatment orders for R5's great toe, and missing documentation of treatment having been completed for R5's venous stasis ulcers. DON-B reported ongoing education is provided to nurses to complete and sign out treatments. DON-B reported the facility has eliminated agency staff and has new department heads as of June, 2022. No additional information was provided.

Based on interview and record review the facility did not ensure the environment for 2 residents (R14 and R13) remained as free of accident hazards as possible and received adequate supervision and assistance devices to prevent accidents. * R14 had multiple falls at the facility. The facility did not thoroughly investigate the falls to determine a root cause or identify if previous fall interventions were in place at the time of the falls. On 6/30/22, R14 had a fall that resulted in a [CONDITION(S)] requiring sutures. R14 had a subsequent fall on 7/12/22 resulting in an identified altered mental status and transfer to the hospital. * R13 had falls while at the facility. The facility did not thoroughly investigate the falls to determine a root cause, nor implement fall prevention interventions to prevent future falls. Findings include: The facility policy, entitled Fall Prevention, dated November 2020, states: General: To ensure all residents have the necessary interventions in place to help prevent falls and promote safety in accordance with all state and federal regulations. Policy: Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility and after every fall in the facility. Interview the resident and/or responsible party to determine any factors that may predispose the resident for fall and/or activities that have helped prevent falls in the resident's previous environment. Ensure optimal communication regarding the resident's condition and potential for fall with other providers: during shift changes; including all disciplines; when sharing information about the resident; with the resident and family about the fall prevention issues and any fall prevention activities to be carried out for the resident. The interdisciplinary team will develop a plan of services to improve or maintain the resident's standing and sitting balance and other interventions to reduce the resident's risk for fall. The plan will include specific, individualized information about the resident's routine and personal habits that may place the resident at risk for fall such as night time voiding or night time wandering. The effectiveness of the fall reduction activities, including assessment, causal factors, interventions, and education will be evaluated by the Interdisciplinary Care Plan team at the time of each comprehensive assessment. 1. R14 was admitted to the facility on [DATE] with diagnoses that include: Encephalophy, [CONDITION(S)], other abnormalities of gait and mobility, dysarthria and anarthia, unspecified falls, cognitive communication deficit, lack of coordination, unspecified protein calorie malnutrition, [CONDITION(S)], type 2 diabetes with diabetic [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. R14 was discharged to the community on 7/20/22. R14's Admission MDS (Minimum Data Set) assessment, dated 4/25/22, documents: a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment for daily decision making; Patient Health Questionnaire (PHQ-9) score of 15, indicating moderately severe depressive symptoms; requires limited assistance of one person for transfers, walking, dressing, toilet use and personal hygiene; balance is not steady and only able to stabilize with human assistance when moving from seated to standing, walking, turning around and facing opposite direction when walking, moving on and off the toilet and surface to surface transfers; occasionally incontinent of bladder and bowel; had a fall within 1 month of admission to the facility, had a fall within 2-6 months of admission to the facility, had a fall since admission to the facility without injury, and has received anticoagulant medication 7 times over the last 7 days and diuretic medication 6 times over the last 7 days. R14's care plan, dated 4/19/22, documents: The resident is at risk for falls r/t (related to) HX: (history) of [CONDITION(S)] (cerebral vascular accident). Interventions dated 4/19/22: Anticipate and meet the resident's needs; Ensure bed brakes are locked; Ensure footwear fits properly; Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Follow facility fall protocol. On 4/18/22, upon admission to the facility, R14 was assessed to be at high risk for falls. Fall 1 On 4/23/22, at 9:30 AM, R14's medical record documents the resident had an unwitnessed fall in the dining room. Nursing Description: resident stood up and w/c (wheelchair) brakes not locked and w/c rolled back and resident sat on floor. Resident Description: resident tried to stand and landed on the floor, w/c moved brakes not locked. No injuries noted; resident mental status: oriented to person, place and situation; no predisposing environmental factors; predisposing physiological factors section is left blank; predisposing situation factors: wheelchair unlocked; Post Fall Neurological Evaluation, dated 4/23/22, 09:00 (9:00 AM) documents: oriented to person, verbalizes appropriately, alert, confused, no baseline changes in grip strength; overall status: is left blank. Surveyor was unable to locate documentation the facility thoroughly investigated the fall to determine the root cause. There is no documentation of when R14 was last seen by staff, last assisted to the bathroom, last ate or why R14 was attempting to stand unassisted. On 4/23/22, R14 was assessed to be at a high risk for falls. On 4/23/22, at 14:31 (2:31 PM), R14's medical record documents: facts on falls education was not done due to resident cognitive status. Patient unaware to not stand up alone. On 4/24/22, R14's care plan was updated to include fall prevention intervention: W/C brakes locked when sitting in w/c auto lock brakes on w/c to prevent roll back. On 4/25/22 R14's medical record documents: MD (Medical Doctor) documents: resident is impulsive with ambulation and transfers, sometimes abandoning 2 WW (wheeled walker). Remind patient of need for assistance and during mobility tasks. Risk for falls, patient is a fall risk will continue gait, balance, and coordination in training with therapy team. Nursing unit fall protocols in place. Surveyor is unable to locate documentation of R14's impulsive behavior with ambulation and transfers and abandoning the 2 ww address in R14's care plan. Fall 2 On 5/2/22, at 19:00 (7:00 PM), R14's medical record documents, R14 had an unwitnessed fall in his room. Nursing Description: Resident stated that he had fallen asleep lying on his R (right) side and rolled out of bed. Abrasion x2 (two abrasions) noted to L (left) knee. Daughter updated. Resident Description: see above. Injury Type: Abrasion right front knee; Mental Status: oriented to person and place; Predisposing Environmental Factors: None is check marked; Predisposing Physiological Factors: gait imbalance, balance problems, incontinent; Predisposing Situation Factors: other equipment being used is checked; Other Info: rolled out of bed; Witnesses: no witnesses found. Post Fall Neurological Evaluation form, dated 5/2/22, 19:00 (7:00 PM), documents: oriented to person and place and not oriented x4; verbalizes appropriately; alert; evaluation grip strength for baseline changes: no baseline changes; over all status: evaluation indicates no changes from baseline. Surveyor was unable to locate documentation the facility thoroughly investigated the fall to determine the root cause. There is no documentation of when R14 was last seen by staff, last assisted to the bathroom, if the call light was on or within R14's reach or when R14 was assisted to bed. On 5/3/22, R14's care plan was updated to include fall prevention intervention of: encourage body pillows while in bed. Fall 3 On 6/4/22, at 09:32 (9:32 AM), R14's medical record documents R14 had a witnessed fall in the dining room. Incident description documents: Nursing Description: Witnessed resident slide slowly from w/c onto floor near dining room table, softly landing on bottom. Resident fell asleep in w/c after eating b-fast (breakfast). Writer could not run to resident fast enough. Did not injure self. Did not hit head. Denied pain. Vitals stable. Neuro (Neurological) assessment at baseline and within normal limits. Resident able to stand up with assist of gait belt and assist of one back into w/c. ROM (Range of Motion) at baseline-within normal limits. Resident Description: Speech unclear, able to make out I fell asleep and slipped. Immediate Action Taken: Ran towards resident to try and avoid him from sliding/sitting on floor, unable to approach and prevent fast enough. Assessed range of motion, hand grasps, assesses pain. Neurological assessment completed. Vitals taken. Assessed skin and bony prominence's. Transferred back into w/c. Practitioner notified. RN (Registered Nurse) supervisor on call notified. Spouse [name of spouse] and brother of resident notified. Injuries observed at time of incident: No injuries observed at time of incident. Mental Status: oriented to: person, situation, place, time, x4; Predisposing Environmental Factors: None is check marked; Predisposing Physiological Factors: confused, gait imbalance, balance problems, behaviors, difficulty with communication, impaired memory, loss of leg or arm movement, weakness/fainted, incontinent; Predisposing Situation Factors: other, wheelchair locked, wheelchair used, other-fell asleep in w/c, slid to floor from low w/c seat onto bottom, gait belt used. Surveyor was unable to locate documentation the facility thoroughly investigated the fall to determine the root cause. There is no documentation of when R14 was last assisted to the bathroom, how R14 slept last evening or when R14 was assist out of bed that morning. On 6/6/22, R14's care plan was updated to include fall prevention interventions of: encourage to lay down after meals and sign in room to remind guest to call for assistance. These interventions were added to R14's care plan 2 days after his fall on 6/4/22, and on the same day R14 fell for the 4th time while in the facility. Fall 4 On 6/6/22 at 15:45 (3:45 PM), R14's medical record documents R14 had an unwitnessed fall in his room. Nursing Description: Writer was approached by CNA (Certified Nursing Assistant), found patient on the floor in sitting position. Upon writer's arrival, resident was found on the floor. Resident Description: Pt (Patient) states I was trying to get up. Immediate Action Taken: Writer took vital signs and assessed alertness. The CNA and I got patient up in wheelchair, then CNA helped resident to the bed. No injuries observed at time of incident. Mental status: Oriented to person, situation, and place. Predisposing Environmental Factors: wet floor. Predisposing Physiological Factors: agitated, incontinent. Predisposing Situation Factors: ambulating without assistance. Witnesses: no witnesses found. Post Fall Neurological Evaluation, dated 6/6/22 at 15:45 (3:45 PM), documents: oriented to person place and situation; verbalizes appropriately; alert; evaluate grip strength for baseline changes: no baseline changes; overall status: this is left unchecked. Surveyor was unable to locate documentation the facility thoroughly investigated the fall to determine the root cause. There is no documentation of when R14 was last seen, last assisted to the bathroom, if R14 fell from his bed or his wheelchair and if R14 was encouraged to lay down after meals and if the floor was wet due to R14 being incontinent or for other reasons. On 6/6/22, R14's care plan was updated to include fall prevention interventions of: encourage to lay down after meals and sign in room to remind guest to call for assistance. Fall 5 On 6/24/22, at 03:25 (3:25 AM), R14's medical record documents the resident had an unwitnessed fall in his room. Incident Description Nurses Description: Called to pt (patient) room, CNA found pt on floor sleeping next to bed. Resident Description: Pt stated, He tired. Immediate Action Taken: Pt assessed then returned to bed, no injuries noted. Mental Status: Oriented to person, place, and time; Predisposing Environmental Factors: Interventions in place at time of fall, low bed; Predisposing Psychological Factors: incontinent; Predisposing Situation Factors: footwear in place, transferring independently; Witnesses: no witnesses found. Post Fall Neurological Evaluation, dated 6/24/22, at 03:25, documents: oriented: to person, place, and situation; verbalizes appropriately; alert; evaluate grip strength for baseline changes: no baseline changes; overall status: evaluation indicates no changes from baseline. Surveyor was unable to locate documentation the facility thoroughly investigated the fall to determine the root cause. There is no documentation of when R14 was last seen, last assisted to the bathroom, if R14 fell from his bed or his wheelchair, if the call light was within R14's reach or if it was on and, if R14 was in bed, were body pillows in the bed as per the 5/3/22 care planned intervention. On 6/24/22, R14's care plan was updated to include fall prevention interventions of: low bed. Per the facility fall documentation on 6/24/22 at 3:25 AM, a low bed was documented as being in place at the time of the fall. No other fall prevention interventions were documented following this fall. Fall 6 On 6/30/22, at 15:55 (3:55 PM), R14's medical record documents R14 had an unwitnessed fall in the dining room. Incident Description Nursing Description: Writer notified resident had unwitnessed fall in dining room. Observed resident sitting on floor next to wc (wheelchair), RN performing assessment. Resident not able to verbalize how fall occurred. Able to answer yes/no questions. Laceration noted to L (left) eyebrow. No c/o (complaint of) pain or discomfort, able to move extremities freely. Resident transferred back to bed. POA (Power of Attorney), agrees for resident to be sent to [name of hospital] ER (emergency room ), NP (Nurse Practitioner) updated. Resident Description: Resident unable to give description. Immediate Action Taken: sent to [name of hospital] ER. Injuries Observed at Time of Incident: Abrasion to left front of knee; laceration to face; and abrasion to other. Surveyor noted there was no description of location of the abrasion identified as other. Mental Status: oriented to person, situation; Predisposing Environmental Factors: none; Predisposing Physiological Factors: incontinent, calm; Predisposing Situation Factors: wheelchair used; Witnesses: no witnesses found. Post Fall Neurological Evaluation, dated 6/30/22 at 15:55 (3:55 PM) documents: oriented to person, not oriented x4, verbalizes appropriately, alert, evaluate grip strength for baseline changes: no baseline changes; Overall Status: Evaluation indicates no changes from baseline. Surveyor notes R14's orientation is documented as having declined from the Post Fall Neurological Evaluation completed on 6/24/22. This decline is not identified as an overall status decline for R14 by the facility. On 6/30/22, at 2300 (11:00 PM) R14's medical record documents: Res (resident) returned to facility 2300 6/30. Returned with new orders for stitches to left eyebrow laceration. Surveyor was unable to locate documentation the facility thoroughly investigated the fall to determine the root cause. There is no documentation of when R14 was last seen, last assisted to the bathroom, if the wheelchair brakes were locked and if auto lock brakes were on the wheelchair, if R14 agreed to lay down after meals and if so when was R14 assisted out of bed. Surveyor notes this is R14's 3rd fall in the dining room. On 7/1/22, R14's care plan was updated to include fall prevention interventions of: wedge cushion in wheelchair. Fall 7 On 7/12/22, at 11:15 AM, R14's medical record documents R14 had a witnessed fall in the dining room. Incident Description Nursing Description: fell asleep in w/c and fell forward out of wheelchair. Did hit front of head with small indent observed. No active bleeding. Is on [MEDICATION(S)] and NP did order for resident to be transported to [name of hospital] for CT (Computed Tomography) scan of head. ROM (Range of Motion) WNL (Within Normal Limits), h/o (history of) stroke with [CONDITION(S)]. Falling asleep in w/c. Self-reported pain to area of head that hit floor. Vitals stable, Blood sugar reading read HI (high). Resident Description: Stated he fell asleep and fell out of wheelchair. Immediate Action Taken: Notified daughter [name of daughter], NP [name of NP], nurse manager of unit and report called into [name of ambulance company] for transport as well as ER charge nurse. Mental Status: oriented to person, situation, and place; Injuries reported post incident: no injuries observed post incident; Predisposing Environmental Factors: none; Predisposing Physiological Factors: drowsy, balance problem, incontinent; Predisposing Situation Factors: none; Witnesses: no witnesses found. Post Fall Neurological Evaluation, dated 7/12/22, at 11:16 AM documents: orientation to person and situation; right and left pupil equal and reactive to light; right pupil is brisk and left pupil is sluggish; verbalizes appropriately, alert; lethargic, drowsy; evaluate grip strength for baseline changes: no baseline changes; overall status: evaluation indicates no changes from baseline. Surveyor notes R14's left pupil is documented as being sluggish and R14 is describes as being lethargic and drowsy. R14 is assessed as having declined since the prior neurological assessment completed on 6/30/22. This decline is not identified as an overall status decline for R14 by the facility. On 7/12/22, at 15:29 (3:29 PM) R14's medical record documents: Res returned from [name of hospital] with no new orders received. [Name of transport company] transported, BMP (Basic Metabolic Panel) Electrocardigram, CT of cervical spine and head w/o (without) contrast completed with no new findings. VSS, neuro assessment at baseline. Dtr (daughter) [name of daughter] aware. Surveyor was unable to locate documentation the facility thoroughly investigated the fall to determine the root cause. There is no documentation of when R14 was last seen, last assisted to the bathroom, if the wheelchair brakes were locked and if auto lock brakes were on the wheelchair, if R14 agreed to lay down after meals and if so when was R14 assisted out of bed and if a wedge cushion was in the wheelchair at the time of the fall. Surveyor notes this is R14's 4th fall in the dining room. R14's care plan was not updated with new fall prevention interventions after this fall. On 8/3/22, at 1:15 PM, Surveyor interviewed Director of Nursing (DON)-B, who stated all information related to R14's fall investigations can be found in the electronic medical record (EMR). DON-B stated the fall investigation documentation in the ERM should indicate what fall prevention interventions were in place at the time of the fall. DON-B stated the fall investigation should document what fall prevention intervention was put in place to prevent future falls and the interventions should address the reason for the resident's fall. Surveyor informed DON-B of the concern R14's fall investigations do not document what fall prevention interventions were in place at the time of the fall, when R14 was last seen or assisted by staff or identify root cause of R14's falls. DON-B stated she would look into these concerns but would expect all information related to an investigation of a fall would be documented in the resident's medical record. On 8/4/22, surveyor informed Nursing Home Administrator-A and DON-B of the concern the facility did not thoroughly investigate R4's fall nor identify the root cause of the falls. 2. R 13 was admitted to the facility on [DATE] with diagnosis that included Toxic [CONDITION(S)], and Muscle Weakness. An admission Minimum Data Set (MDS) was not completed as R13 discharged home against medical advice on 5/17/22, before 14 days at the facility. On 8/2/22 R13's fall risk evaluation dated 5/6/22 was reviewed and indicated R13 was at high risk for falls and had a recent fall before admission to the facility. On 8/2/22 R13's falls care plan dated 5/8/22 was reviewed and indicated risk for falls related to Gait/balance problems, Vision/hearing problems and R13 intentionally slides/falls to floor related to behaviors. On 8/2/22 R13's fall investigations were reviewed and read: 5/10/22: R13 found lying on the floor in his room. States he rolled out of bed. No other investigation was found as to when R13 was last seen or toileted or if falls interventions were in place at the time of the fall. 5/11/22: R13 found lying on the floor in supine position, next to his wheelchair. R13 indicated he slipped out. No other investigation was found as to when R13 was last seen or toileted or if falls interventions were in place at the time of the fall. 5/13/22: R13 on the floor next to his bed. R13 stated he was trying to sit up and slipped out of bed. No other investigation was found as to when R13 was last seen or toileted or if falls interventions were in place at the time of the fall. Interventions were added to R13's care plan after each fall to help prevent future falls but since the investigations were not through it is unclear if these interventions were appropriate as the reason for the fall was not fully investigated. On 08/3/22 at 1:00m the Surveyor interviewed Director of Nursing (DON)-B and DON-B indicated she had no more information on R13's falls and there should be a through investigation with each fall. On 08/3/22 at 3:00 pm The Surveyor shared above findings with the Administrator and DON-B. Additional information was requested if available. None was provided.

Based on interview and record review, the facility did not ensure that a residents with pressure injuries received necessary care and treatment to promote healing, prevent infection and prevent new pressure injuries from developing and residents without pressure injuries do not develop pressure injuries for 3 (R1, R3, R2) of 5 Residents reviewed for pressure injuries. *R1 developed pressure injuries on 12/14/21 that were not present upon admission to the facility on [DATE]. R1 did not have an individualized repositioning program. R1's wound assessments were not completed weekly. R1's wound treatments were not completed as ordered. R1 had no evidence of a pressure relieving chair cushion being provided during [CONDITION(S)] to prevent further pressure and breakdown of stage 2 sacral pressure injuries. *R3 was documented as having a Stage 3 pressure injury to the right buttock with no observations of turning and repositioning offered to R3. *R2 was assessed to be at risk for the development of pressure injuries and was observed without heels up cushion in place in bed and without compression stockings which were identified as pressure injury preventative measures. Findings include: The Facility's Wound Policy & Procedure, dated December 2020, documents: under policy The facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcer, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus. A commitment to the Wound Management Program is demonstrated by implementation of processes founded on accepted standards of practice, research-driven clinical guidelines and interdisciplinary involvement. Under procedure for Admission Wound Assessment and Management documents At the time of admission, the discharge records from the prior facility are reviewed for information relating to wounds or alteration in skin integrity. Staging from another facility is not adopted for use in the facility. * Any wounds assessed will be captured in the PCC (point click care) nursing evaluation, in progress notes, or by completing in Wound Rounds via Quick Shot (within 2-6 hours of admissions). * The admission wound assessment should include at a minimum: Interview of resident or family about history of skin alterations. * Physical evaluation to include identification of: Skin alterations present on admission, skin discoloration and any evidence of scarring on pressure points. Signs/symptoms/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Bed mobility. Continence. Recent surgical procedure. Head to toe skin assessment. Nutritional status and issues. * Completion of Braden or Norton Skin Risk Assessment Tool. * Comprehensive assessment of any wound to include: Location of wound. Length, width, depth measurements recorded in centimeters. Direction and length of tunneling and undermining. Appearance of the wound base. Type and percentage of tissue in wound. Drainage amount and characteristics including color, consistency, and odor. Appearance of wound edges. Description of the peri-wound condition or evaluation of the skin adjacent to the wound. Presence or absence of new epithelium at wound rim. * Risk reduction measures such as use of heel protectors (designed for friction/shear reduction versus pressure reduction), elevation of lower extremities, participation in bowel and bladder program, etc. are initiated if determined appropriate. * Discussion with the attending physician and resident/representative includes notification of any skin impairment identified on admission. * Orders are verified or obtained as needed. * An admission/interim/baseline care plan is developed. * Assessments and interventions implemented are documented in the resident clinical record. 1.) R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set) assessment, dated 11/26/21, indicated R1 was moderately cognitively impaired. R1 required extensive assistance of 1 staff for bed mobility, dressing, and toileting. R1 was dependent on 2 staff for transfer assistance. R1's MDS Section M for skin integrity, indicated R1 was at risk for pressure injuries, had MASD (Moisture Associated Skin Damage) with pressure relief on bed and chair, ointments, but no repositioning program. R1's 11/26/21, MDS CAA (Care Area Assessment) indicated R1 was a short term guest recently hospitalized for AKI/[CONDITION(S)] (Acute Kidney Injury/ End Stage Renal Disease) with new HD (Hemodialysis), acute on chronic CHF (Congestive Heart Failure), bilateral pleural effusions s/p (status/post) thoracentesis, C-diff ([CONDITION(S)]), debility, malnutrition, dysphagia, pneumonia, hematuria, GI ([CONDITION(S)], acute blood loss [CONDITION(S)], weakness, hypoalbuminemia. Other medical hx (history) includes but is not limited to a-fib ([CONDITION(S)]), HLD (High Density Lipoprotein), DM2 (Diabetes Mellitus type 2), [CONDITION(S)] (hypertension), gout, [CONDITION(S)], CAD (Coronary Artery Disease), GERD (Gastroesophageal Reflux Disease), and right [CONDITION(S)] following [CONDITION(S)]([CONDITION(S)]). R1 triggered the pressure ulcer CAA because R1 needs assist with bed mobility and had episodes of incontinence. R1 is at risk for further functional decline and skin breakdown. Plan is for R1 to participate in MD (Medical Doctor) ordered therapies and to monitor for skin breakdown. Goal is for R1 to return to his PLOF (Previous Level of Function) (modified independence) and to not have avoidable skin breakdown. R1's Care Plan, dated 11/23/21, indicated Potential for Impairment to skin integrity r/t (related to) immobility, dated 11/23/21. Interventions included: Apply barrier cream to protect skin from excess moisture, initiated 11/23/21; Encourage activity as tolerated, initiated 11/23/21; Encourage good nutrition and hydration in order to promote healthier skin, initiated 11/23/21; Monitor skin when providing cares, notify nurse of any changes in skin appearance, initiated 11/23/21; Pressure reduction bed mattress, initiated 11/23/21; Incontinence Care every 2-3 hours and prn (as needed), cleanse peri area and apply barrier cream, initiated 1/13/22; Encourage/assist with turning and repositioning every 2-3 hours, initiated 1/13/22; Use draw sheet when turning/repositioning, initiated 1/13/22; Use pillow/cushion between bony prominences, initiated 1/13/22; Educate resident/family importance of changing positions for prevention of pressure ulcers, initiated 1/17/22; Educate resident/family/caregivers of causative factors and measures to prevent skin injury, initiated 1/17/22. R1's Care Plan Focus: RESOLVED: 12/12/21 R1 has actual impairment to skin integrity-admitted with MASD to bilateral buttocks and groin. R1's November 2021, Treatment Administration Record (TAR) documents: Skin checks order, dated 11/23/21 through 1/16/22 on Wed (Wednesday)/Sat (Saturday). The ordered skin checks were not documented as being completed on 11/24/21 and 11/27/21. R1's Wound Rounds, documented on 12/14/21, indicated R1 developed a facility acquired Stage 2 Sacral Pressure Injury measuring: 1.5 cm (centimeters) x 1.5 cm x 0.1 cm, with 100% pink/red non-granulating tissue. R1's 12/14/21, progress note indicated: the open area to the sacrum as well as an additional right buttock open area measured as 0.5 cm x 0.5 cm x 0.1 cm. Right heel is dark purple measured 0.5 cm x 0.5 cm. Treatment orders for sacrum and right buttock: Cleanse with NS (Normal Saline), Skin Prep to Periwound, apply this layer of happy butt cream with foam border dressing-change every day and prn (as needed), Air mattress, Turn every 2-3 hours & (and) prn, Pressure relieving boots. The facility also documents R1's right buttock pressure injury as being on the distal sacrum. R1's Care Plan, dated 12/14/21 indicated: R1 has actual impairment to skin integrity r/t (related to) Pressure Ulcer-1. Sacrum, 2. Distal Sacrum. Interventions included: Apply barrier cream to protect skin from excess moisture, initiated 12/14/21; Educate resident/family/caregivers of causative factors and measures to prevent skin injury, initiated 12/14/21; Encourage good nutrition and hydration in order to promote healthier skin, initiated 12/14/21; Evaluate and Treat per Physician orders, initiated 12/14/21; Evaluate (R1) for signs/symptoms of possible infections, initiated 12/14/21; Keep skin (sic) & dry, Use lotion on dry skin, initiated 12/14/21; Low Air Loss Mattress, initiated 12/14/21; Prevalon Boots, initiated 12/14/21; Weekly treatment Documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue, and exudate and any other notable changes or observations by wound nurse or provider initiated 12/14/21. Skin checks on the treatment administration record (TAR), dated: 11/23/21 through 1/16/22 on Wed (Wednesday)/Sat (Saturday) were not documented as completed in R1's December 2021 TAR on 12/1/21, 12/8/21, 12/18/21, 12/22/21, 12/25/21, and 12/29/21. New treatment orders dated: 12/14/21 through 1/7/22 indicated: Sacral wounds: Cleanse with NS (Normal Saline), Medi-honey, apply foam border dressing every other day and prn (as needed). Treatments were not documented in the December 2021 TAR as being completed on: 12/18/21, 12/20/21, 12/22/21, 12/24/21, 12/28/21, 12/30/21. Assessments of R1's Facility Acquired Sacral Pressure Injury in R1's Medical Records (Wound Rounds) indicated: On 12/17/21, Sacral Pressure Injury Stage 2, measured 1.4 cm x 1.4 cm x 0.1 cm with 100% pink/red non-granulating tissue. Distal Sacral Pressure Injury Stage 2 measured 0.4 cm x 0.3 cm x 0.1 cm. On 12/26/21, Sacral Pressure Injury Stage 2 measured 1.2 cm x 1 cm x 0.1 cm with 100% pink/red non-granulating tissue. Distal Sacral Pressure injury Stage 2 measured 0.4 cm x 0.3 cm x 0.1 cm. The 12/26/21 wound assessment was completed 9 days after R1's last assessment. On 1/6/22, Sacral Pressure Injury Stage 2, measured 1.2 cm x 1 cm x 0.1 cm with 100% pink/red non-granulating tissue. Distal Sacral Pressure injury Stage 2, measured 2.8 cm x 3.0 cm x 0.1 cm. The 1/6/22 wound assessment was completed 11 days after last assessment. On 1/7/22, Sacral Pressure Injury Stage 2 measured 0.3 cm x 0.3 cm x 0.1 cm with 100% pink/red non-granulating tissue. Distal Sacral Pressure injury Stage 2 measured 2.8 cm x 3.4 cm x 0.1 cm. Surveyor noted the wound round records do not include wound characteristics beyond measurements for the distal sacrum wound. The treatment to the sacral wounds was changed on 1/7/22. The new treatment order is to cleanse with NS, Medi-honey, apply foam border dressing every day and prn. On 1/9/22, R1's Braden score was 15, indicating R1 was at risk for developing pressure injuries. On 1/13/22, R1 had a pressure ulcer unavoidability form completed which indicated the new pressure injuries identified on 12/14/21, with a sacral pressure injury, stage 2 measuring 0.3 cm x 0.3 cm x 0.1 cm and a distal sacral pressure injury, stage 2 measuring 2.8 cm x 3.4 cm x 0.1 cm were unavoidable. R1's Risk Factors documented include: [CONDITION(S)], Diabetes, [MEDICATION(S)] Abnormality, [CONDITION(S)], and [CONDITION(S)] with Chronic Urinary Incontinence and Renal [CONDITION(S)]. The pressure ulcer unavoidability form indicated the sacral pressure injury development was unavoidable on 12/14/21 using the wound assessment completed on 1/7/22. On 1/13/22, R1's care plan was updated: Incontinence Care. Interventions include: Incontinence care every 2-3 hours and prn, cleanse peri area and apply barrier cream, initiated 1/13/22; Encourage/assist with turning and repositioning every 2-3 hours, initiated 1/13/22; Use draw sheet when turning/repositioning, initiated 1/13/22; Use pillow/cushion between bony prominences, initiated 1/13/22. On 1/15/22, Sacral Pressure Injury Stage 2, measured 0.3 cm x 0.3 cm x 0.1 cm with 100% pink/red non-granulating tissue. Distal Sacral Pressure injury Stage 2, measured 2.0 cm x 1.6 cm x 0.1 cm. Surveyor noted there are no characteristice of the distal sacral wound identified in the assessment. R1's pressure injury assessment was completed 8 days after the last assessment. Skin checks were changed to weekly on 1/16/22. TAR interventions initiated in November 2021 indicated to complete skin checks Wednesdays and Saturdays. On 1/21/22, Sacral Pressure Injury Stage 2, measured 1.8 cm x 2.5 cm x 0.1 cm with 100% pink/red non-granulating tissue. Distal Sacral Pressure Injury Stage 2, measured 1.8 cm x 1.7 cm x 0.1 cm. On this same date also in Wound Rounds, there is an entry indicating on 1/21/22, Sacral Pressure Injury Stage 2 measured 0.8 x 2.5 cm x 0.1 cm with 100% pink/red non-granulating tissue. Surveyor noted the assessments of R1's Sacral Pressure Injury in the Wound Rounds section do not match, despite both being dated 1/21/22. On 1/21/22, NP-R's (Nurse Practitioner) progress note indicated: R1 had a wound to Sacrum and R1 felt some tenderness to buttocks and wounds are still there. Air mattress in place. On 1/28/22, R1's Sacral Pressure Injury is now documented as a facility acquired DTI (Deep Tissue Injury) Pressure injury measured 5.8 cm x 5 cm x 0.1 cm with 50% deep maroon, 50% Bright Beefy Red tissue. Surveyor noted there is no longer reference to a distal sacral wound at this time. It is not indicated if the measurements reflect two areas now joined together into one larger wound or what occurred to the distal sacral wound. On 1/28/22, NP-R's progress notes indicated R1 was having labs drawn due to some confusion. R1 on an air mattress for a few weeks with continual decline. Will request maintenance to switch bed out for an alternating pressure mattress. Discussed with staff the importance of rolling patient on to his side to offload the wound. DTI to sacrum was a full thickness wound measuring 5.8 cm x 5 cm x 0.1 cm with the base 50% deep purple/50% granular. Moderate amount of serosanguineous drainage, periwound with blanchable [CONDITION(S)], painful, no signs of infection. Pressure induced deep tissue damage of sacral region. Surveyor noted the change from a Stage 2 to DTI designation despite qualifying the wound as full thickness indicating inaccurate staging. A full thickness wound indicates that damage exists below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue or beyond into muscle, bone, tendons. R1's Treatments were not changed/updated given the significant change and decline in the sacral wound. Despite emphasis from Nurse Practitioner on repositioning surveyor noted the intervention continued to not be individualized for R1 with possible increased frequency and continued to be turn and reposition every 2-3 hours. Surveyor noted NP-R did document they would request maintenance to switch R1's bed out for an alternating pressure mattress. Surveyor reviewed the facility bed specifications and only 2 types of beds were available: a redistribution memory foam mattress indicated for pressure injuries up to Stage 2 and a low air loss/alternating pressure air mattress which R1 was documented as being on the low air loss mattress since 12/14/21. On 2/4/22, R1's medical record documents: Sacral DTI Pressure Injury measured 8 cm x 9 cm x 0.1 cm with 90 % deep maroon, 10% bright beefy red tissue. In addition: Right Ischial tuberosity was facility acquired DTI Pressure injury measured 4.5 cm x 5.5 cm x 0.1 cm with 90 % deep maroon, 10% bright beefy red tissue. Right trochanter was facility acquired DTI pressure injury measured 5.5 cm x 4.5 cm x 0 cm with 100 % deep maroon tissue. On 2/4/22, NP-R's progress notes indicated R1 had wounds to sacrum, left hip, and left ischium with overall decline and new areas of skin breakdown. DTI to sacrum was full thickness wound measure 8 cm x 9 cm x 0.1 cm with base 90% deep purple, 10 % granular. Moderate amount of serosanguineous drainage, periwound with blanchable [CONDITION(S)], painful, no signs of infection painful-Status declined, Treatment: Border foam change daily, alternating pressure mattress with aggressive turning. DTI to Left ischium was deep purple with partial thickness wound measured 4.5 cm x 5.5 cm, status new wound, Treatment: Happy Butt cream 4 times/ (per) day, offload with turning. DTI to Left hip was 5.5 cm x 5.5 cm status new wound. Treatment: offload with turning. Surveyor noted there was no changes to R1's care plan to individualize the turning & reepositioning despite NP-R indicating agressive turning in their documentation. Surveyor noted the documentation discrepancy between the pressure injuries being located on the right side of R1 versus left side of R1 with the documentation on 2/4/22. On 2/14/22, at 2:40 PM, Surveyor interviewed NP-R (Nurse Practitioner Wounds) who stated R1 declined and on 1/28/22 R1 had a DTI (Deep Tissue Injury) with full thickness wound in the center. NP-R stated on 2/4/22 that R1 developed new DTI's with further decline and multiple new areas of breakdown. NP-R stated R1 had continual decline of wounds probably due to questionable oral intake. On 2/16/22, at 9:58 AM, Surveyor interviewed LPN WC -P (Wound Care Licensed Practical Nurse-PM Supervisor) who stated she was a PM supervisor and pushed into the role of wound care nurse when the previous nurse walked out. WC-P stated she had no formal training and had to learn the wound care rounds computer program by herself. WC-P stated this facility has a standard of reposition every 2-3 hours and not individualized which she has never seen before. WC-P would prefer to train and educate at least every 2 hours repositioning for the residents. WC-P stated R1 was clinically up/down after COVID diagnosis (1/4/22) and developed C-diff diarrhea with many days too weak to get out of bed. WC-P stated R1 had significant weight loss, and was not eating. WC-P stated R1 developed wounds with the diarrhea which also hindered healing. WC-P stated R1's health was declining and it was hard to heal huge wounds with possible signs of terminal ulcer. WC-P stated R1 changed from 1/21/22 to 1/28/22 and the repositioning was not changed or individualized. WC-P stated the facility could have repositioned R1 more often. WC-P stated R1 was a little difficult to reposition. WC-P stated R1 did not have an air mattress for a few weeks. WC-P stated the facility expected R1 to get up more often and be repositioned but R1 needed an air mattress. WC-P stated treatment changes are up to NP-R and she enters the orders. WC-P stated that on 2/4/22, NP-R stated [MEDICATION(S)] is no longer appropriate and all there is to do is pressure relief. Surveyor was also unable to find any documentation R1 was provided a chair cushion to offload sacrum during R1's need for [CONDITION(S)] 3 days/week. R1's Task list for turning and repositioning every 2-3 hours and prn indicated no documentation of R1 being turned or repositioned on 1/18/22, 1/19/22, 1/22/22, 1/23/22, 1/24/22, 1/28/22. 1/29/22, 1/30/22 and 2/3/22. R1's January 2022 TAR indicated documentation completed by the nurses once on days and once on nights that repositioning was completed every 2-3 hours except 1/3/22 and 1/29/22 day shift. Interviews indicated R1 declined due to not eating, poor nutritional status, questionable oral intake and weight loss. On 2/14/22, at 2:40 PM, NP-R stated R1 had continual decline of wounds probably due to questionable oral intake. On 2/16/22, at 9:58 AM, WC-P stated R1 had significant weight loss and was not eating. R1 was being dialyzed with weights monitored as dry weights post-[CONDITION(S)] after fluid removal. R1's 12/8/21 weight was 62.8 kg = 138.16 lbs (pounds). R1's 1/8/22 weight was 61.5 kg = 135.3 lbs. R1's 2/2/22 weight was 54.5 kg = 119.9 lbs. Surveyor identified R1 had a 13.22% weight loss in 2 months. Surveyor reviewed R1's documented meal intake percentage. No meals intake percentages were recorded for R1 on: 1/19/22, 1/23/22, 1/24/22, 1/26/22, 1/27/22, 1/29/22, 1/30/22, 1/31/22, 2/1/22, 2/2/22, 2/3/22. R1's meal intake percentages were recorded as: On 1/18/22, at 11:39 AM, 76-100% percentage of meal eaten. On 1/20/22, at 9:32 AM and 2:30 PM, 51-75% percentage of meal eaten. On 1/21/22, at 12:39 PM, 51-75% percentage of meal eaten. On 1/22/22, at 2:31 PM, duplicate documentation of refusal & 76-100% percentage of meal eaten. On 1/25/22, at 12:20 PM, 51-75% percentage of meal eaten. On 2/16/22, at 4:01 PM, this Surveyor shared above concerns with VP-Q and NHA-A. 2. R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS assessment dated [DATE] indicates R3 requires extensive assistance of 2 staff with bed mobility and total assistance of 2 staff with transfers. R3 requires total assistance of 1 staff with dressing, toileting and personal hygiene. A Braden assessment, dated 2/2/22, with a score of 10 indicates R3 is at high risk for pressure injuries. Surveyor reviewed R3's skin integrity care plan, dated 12/13/21, which indicates R3 acquired a pressure injury to the buttock on 1/29/22. R3's care plan interventions include: wound treatments per order, repositioning every 1-2 hours, pressure relieving heel boots and weekly documentation of wounds. Surveyor reviewed R3's weekly wound assessments. R3's wound assessment, dated 2/2/22, notes a stage 3 pressure injury to the right buttock measuring 4.0 cm x 3.0 cm x 0.1 cm with yellow slough tissue. R3's wound assessment dated [DATE] notes a stage 3 pressure injury to the right buttock measuring 3.5 cm x 3.5 cm x 0.1 cm with yellow slough tissue. R3's wound assessment dated [DATE] notes a stage 3 pressure injury to the right buttock measuring 3.0 cm x 3.3 cm x 0.1 cm with yellow slough tissue. On 2/16/22 at 7:40 am, Surveyor observed R3 in bed laying on their right side with pressure relieving boots in place. On 2/16/22 at 9:45 am, Surveyor observed R3 in bed laying on their right side with pressure relieving boots in place. On 2/16/22 at 10:30 am, Surveyor observed R3 in bed laying on their right side with pressure relieving boots in place. On 2/16/22 at 11:15 am, Surveyor observed R3 in bed laying on their right side with pressure relieving boots in place. On 2/16/22 at 12:25 pm, Surveyor observed R3 in bed laying on their right side with pressure relieving boots in place. On 2/16/22 at 1:20 pm, Surveyor observed R3 in bed laying on their right side with pressure relieving boots in place. On 2/16/22 at 1:35 pm, CNA (Certified Nursing Assistant)-U and Wound Care Nurse-P performed incontinence cares for R3. Surveyor conducted interview with CNA-U. Surveyor asked CNA-U how often R3 should be repositioned while in bed. CNA-U responded that R3 should be repositioned at least every 2 hours. Surveyor asked when R3 had last been repositioned. CNA-U responded that they had last repositioned R3 around 7:30 am and that they do not have enough help to provide care to R3 sometimes as R3 requires 2 staff members to assist in turning and repositioning. CNA-U confirmed that R3 had not been repositioned from 7:30 am to 1:35 pm as CNA-U was the only CNA working on the unit and caring for 22 residents this morning. On 2/16/22 at 1:25 pm, Surveyor conducted interview with Wound Care Nurse-P. Surveyor asked Wound Care Nurse-P how often R3 should be repositioned. Wound Care Nurse-P told Surveyor that she would hope that residents in bed should be repositioned at least every 2 hours. Surveyor asked Wound Care Nurse-P if R3 is dependent on staff for repositioning. Wound Care Nurse-P told Surveyor that R3 usually needs extensive to total assistance with repositioning depending on how alert R3 is. On 2/16/22 at 3:30 pm, Surveyor conducted interview with NHA (Nursing Home Administrator)-A. Surveyor asked NHA-A how often residents should be repositioned while in bed. NHA-A responded that they would think a resident should be repositioned at least every 2 hours. Surveyor notified NHA-A of concerns that R3 has a facility acquired pressure injury to the right buttock and that they were not repositioned from 7:30 am to 1:30 pm. R3's care plan indicated that R3 should be repositioned at least every 2 hours. No additional information was provided. 3. R2 was admitted to the facility 1/5/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's admission MDS (Minimum Data Set) assessment, dated 1/8/22, indicates has a BIMS (Brief Interview of Mental Status) score of 15, indicating R2 is cognitively intact and able to participate in daily decision making. R2 requires extensive assistance of 2 staff for bed mobility and transfers. R2 has limited function to bilateral lower extremities. On 1/5/22 , R2 has a Braden score of 17, indicating R2 is at risk for pressure injuries. R2's skin integrity care plan, dated 1/6/22, lists interventions including: application of compression stockings to be worn during the day and removed in the evening; repositioning every 2 hours and offloading heels while in bed with a heels up cushion. On 2/15/22 at 10:15 am, Surveyor made observations of R2 in bed with their heels directly on the mattress. A heels up cushion was noted on R2's dresser. Surveyor did not observe R2 to be wearing compression stockings at this time. On 2/15/22 at 12:30 pm, Surveyor made observations of R2 in bed with their heels directly on the mattress. A heels up cushion was noted on R2's dresser. Surveyor did not observe R2 to be wearing compression stockings at this time. On 2/15/22 at 2:00 pm, Surveyor made observations of R2 in bed with their heels directly on the mattress. A heels up cushion was noted on R2's dresser. Surveyor did not observe R2 to be wearing compression stockings at this time. On 2/15/22 at 3:30 pm, Surveyor made observations of R2 in bed with their heels directly on the mattress. A heels up cushion was noted on R2's dresser. Surveyor did not observe R2 to be wearing compression stockings at this time. On 2/15/22 at 4:05 pm, Surveyor conducted interview with R2. R2 was up in a wheelchair and dressed in a shirt and pants. Surveyor asked R2 if they wear compression stockings during the day. R2 showed Surveyor that they were not currently wearing compression stockings at this time. Surveyor asked R2 if staff position their feet off of the mattress while they are in bed. R2 told Surveyor that staff will sometimes apply the cushion to the bed but not always. On 2/16/22 at 7:15 am, Surveyor made observations of R2 in bed with their heels directly on the mattress. A heels up cushion was noted on R2's dresser. Surveyor did not observe R2 to be wearing compression stockings at this time. On 2/16/22 at 9:30 am, Surveyor made observations of R2 in bed with their heels directly on the mattress. A heels up cushion was noted on R2's dresser. Surveyor did not observe R2 to be wearing compression stockings at this time. On 2/16/22 at 11:40 am, Surveyor made observations of R2 in bed with their heels directly on the mattress. A heels up cushion was noted on R2's dresser. Surveyor did not observe R2 to be wearing compression stockings at this time. On 2/16/22 at 1:00 pm, Surveyor made observations of R2 in bed with their heels directly on the mattress. A heels up cushion was noted on R2's dresser. Surveyor did not observe R2 to be wearing compression stockings at this time. On 2/16/22 at 1:25 pm, Surveyor conducted interview with Wound Care Nurse-P. Surveyor asked Wound Care Nurse-P how often R2 should be repositioned. Wound Care Nurse-P told Surveyor that she would hope that residents in bed should be repositioned at least every 2 hours. Surveyor asked Wound Care Nurse-P if R2 is dependent on staff for repositioning. Wound Care Nurse-P told Surveyor that R2 requires extensive assistance with repositioning in bed. Surveyor asked how staff would know if a resident is supposed to have skin integrity interventions in place such as a heels up cushion or compression stockings. Wound Care Nurse-P told Surveyor that this information would be found in a resident's care plan and CNA (Certified Nursing Assistant) kardex. Surveyor asked Wound Care Nurse-P why R2 would not have skin integrity interventions in place. Wound Care Nurse-P responded that it is possible that CNAs may forget to put these interventions in place or forget to check the resident's care plan. On 2/16/22, at 3:30 pm, Surveyor conducted interview with NHA (Nursing Home Administrator)-A. Surveyor asked NHA-A how staff would know if a resident is supposed to have skin integrity interventions in place such as a heels up cushion or compression stockings. Wound Care Nurse-P told Surveyor that this information would be found in a resident's care plan and CNA kardex. Surveyor shared concerns with NHA-A that R2 was observed on 2/15/22 and 2/16/22 without compression stockings or heels up cushion in place. R2's care plan indicated compression stockings and a heels up cushion were to be in place. No additional information was offered at this time.

Based on interview and record review, the Facility did not ensure that a resident who enters the Facility with a pressure injury receives necessary care and treatment and Residents without a Pressure Injury (PI) does not develop pressure injuries, and receives appropriate care, treatment & preventative measures to promote healing for 3 (R1, R8, & R11) of 3 Residents reviewed for pressure injuries. * R1 was admitted to the facility on [DATE] with a Stage 2 pressure injury on R1's coccyx & left heel. There was no treatment implemented to the Stage 2 pressure injury on R1's coccyx & left heel when R1 was admitted . The admission nursing evaluation was completed by an LPN. There was no Registed Nurse (RN) assessment until 2 days later on 9/16/21 when the coccyx pressure injury declined to unstageable with measurements of 1.5 cm (centimeters) x (times) 0.6 cm x 0.1 cm. There was no treatment started on 9/16/21. On 9/21/21 R1's coccyx pressure injury was assessed by the wound RN and wound Nurse Practitioner (NP). R1's coccyx pressure injury had further declined and the measurements are now 7.5 cm x 7.0 x unknown depth. A treatment was ordered on 9/21/21. The Facility did not revise R1's actual skin integrity care plan after 9/23/21 even though R1's pressure injury continued to decline and treatments were not consistently initialed as being completed. On 10/12/21 R1's coccyx pressure injury measured 9.5 cm x 6.2 cm x 3.00 cm. R1 was transferred to the hospital where the pressure injury was debrided and R1 was placed on IV antibiotics. R1's hospital final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . * R8 was admitted to the facility on [DATE] and was assessed to be at risk for developing pressure injuries. On 10/19/21, R8 was identified with 2 facility acquired unstageable pressure injuries to the right heel and coccyx. The facility did not implement ordered interventions including daily dressing changes, pressure relieving boots, repositioning schedule and an air mattress as ordered by facility's Wound Care Nurse Practitioner on 10/19/21. On 10/26/21, R8 was noted with 3 additional facility acquired pressure injuries, with no physician contact for treatment orders. R8 was discharged from the facility on 11/1/21 with a total of 5 facility acquired pressure injuries. The facility did not implement preventative interventions prior to the development of 5 facility acquired pressure injuries. The Facility's failure to measure or assess R1's coccyx pressure injury upon admission, have an RN assess the pressure injury until 2 days after admission, obtain a treatment until seven days after admission, initially identify how often R1 should be repositioned, to revise the care plan after 9/23/21 and implement treatment orders; and The Facility's failure to identify R8's pressure injuries until they were unstageable, obtain an appropriate mattress timely, obtain timely treatments and implement these orders, and to document R8's alleged refusal of repositioning and develop approaches addressing these refusals created a finding of Immediate Jeopardy (IJ) which began on 9/16/21. The Surveyor notified Administrator-A, DON (Director of Nursing)-B, ADON (Assistant Director of Nursing)-F and ADON-N on 12/7/21 at 1:32 p.m. of the IJ for R1 & R8. The immediate jeopardy was removed on 12/14/21. The deficient practice continues at a scope and severity of a G (harm/isolated) as the facility continues to implement its action plan and for R11 as evidenced by; * R11 developed a Facility acquired unstageable sacrum pressure injury. The Facility did not implement preventative interventions prior to the pressure injury being developed. Findings include: (Cross Reference F580) The Facility's Wound Policy & Procedure dated December 2020 documents under policy The facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcer, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus. A commitment to the Wound Management Program is demonstrated by implementation of processes founded on accepted standards of practice, research-driven clinical guidelines and interdisciplinary involvement. Under procedure for Admission Wound Assessment and Management documents * At the time of admission, the discharge records from the prior facility are reviewed for information relating to wounds or alteration in skin integrity. Staging from another facility is not adopted for use in the facility. * Any wounds assessed will be captured in the PCC (point click care) nursing evaluation, in progress notes, or by completing in Wound Rounds via Quick Shot (within 2-6 hours of admissions). * The admission wound assessment should include at a minimum: Interview of resident or family about history of skin alterations. * Physical evaluation to include identification of: Skin alterations present on admission, skin discoloration and any evidence of scarring on pressure points. Signs/symptoms/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Bed mobility. Continence. Recent surgical procedure. Head to toe skin assessment. Nutritional status and issues. * Completion of Braden or Norton Skin Risk Assessment Tool. * Comprehensive assessment of any wound to include: Location of wound. Length, width, depth measurements recorded in centimeters. Direction and length of tunneling and undermining. Appearance of the wound base. Type and percentage of tissue in wound. Drainage amount and characteristics including color, consistency, and odor. Appearance of wound edges. Description of the peri-wound condition or evaluation of the skin adjacent to the wound. Presence or absence of new epithelium at wound rim. * Risk reduction measures such as use of heel protectors (designed for friction/shear reduction versus pressure reduction), elevation of lower extremities, participation in bowel and bladder program, etc are initiated if determined appropriate. * Discussion with the attending physician and resident/representative includes notification of any skin impairment identified on admission. * Orders are verified or obtained as needed. * An admission/interim/baseline care plan is developed. * Assessments and interventions implemented are documented in the resident clinical record. 1. R1 is a [AGE] years old admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital after visit summary dated 9/14/21 for coccyx pressure injury dated 9/14/21 documents Stage 2, wound bed granulated, pink, wound status is improving, topical agent is barrier cream with zinc and wound dressing is foam with border dressing. There are no hospital measurements documented on 9/14/21. The facility's admission nursing evaluation dated 9/14/21 under the skin integrity section yes is answered for the question does the resident have skin integrity concerns. Under site documents 23) Coccyx & Description documents stage 2. A second site is documented as 50) Left heel & Description documents stage 2. There are no measurements of R1's pressure injuries, no description of the wound bed and no treatment initiated. This evaluation was completed by Wound Nurse LPN (Licensed Practical Nurse)-M. There was no treatment ordered for R1's coccyx or left heel pressure injuries on 9/14/21 and the pressure injuries were not assessed by an RN (Registered Nurse). Surveyor noted R1's left heel pressure injury healed on 9/21/21. The baseline potential for impairment to skin integrity care plan initiated 9/14/21 has the following interventions, all dated 9/14/21, of: * Apply barrier cream per facility protocol to help protect skin from excess moisture. * Encourage activity as tolerated. * Encourage good nutrition and hydration in order to promote healthier skin. * Ensure proper fitting footwear. * Monitor skin when providing cares, notify nurse of any changes in skin appearance. * Pressure reduction bed mattress. R1's September TAR (treatment administration record) includes with an order date of 9/14/21 Barrier cream apply after incontinent episodes as needed per nursing judgement as needed for skin protective ointment. Surveyor noted there are no initials as this treatment being applied anytime during September. The nurses note dated 9/15/21 documents Resident PAD (post admission day) #1, post covid pneumonia and respiratory failure. Resident is alert, but staff has to anticipate Residents needs. VSS (vital signs stable). Skin warm and dry. Resident needs assistance with feeding. Resident on continuous O2 (oxygen). Resident incontinent of bowel and bladder. Will continue to monitor. The nurses note dated 9/16/21 documents, Guest seem to be resting well but, awake for the most part. Guest has an OA (open area) on her buttocks and the area as (sic was) cleansed per order. Surveyor attempted to speak to with LPN-W on 12/6/21 who wrote this note as there is no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound assessment dated [DATE] documents site as Coccyx, clinical stage is Unstageable The length is 1.5 cm (centimeters), width 0.60 cm and depth 0.10. The tissue type is documented as 100% pale pink non granulating. Exudate is scant serosanguineous. This assessment was completed by RN (Registered Nurse)/Prior Wound Nurse-V who is no longer employed at the Facility. A treatment was not started until 5 days later on 9/21/21 when R1's coccyx pressure injury had declined to unstageable. The potential for impairment to skin integrity care plan initiated 9/20/21 has the same interventions dated 9/20/21 as the baseline potential for impairment to skin integrity care plan initiated on 9/14/21. The actual impairment to skin integrity care plan initiated 9/20/21 documents the following interventions: * Encourage good nutrition and hydration in order to promote healthier skin. Initiated 9/20/21. * Nurse to assess/record/monitor wound healing with dressing changes. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements or declines to MD (medical doctor). Initiated 9/20/21. * Use a draw sheet or lifting device to move resident. Initiated 9/20/21. * 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, by wound nurse or provider. Initiated 9/20/21. * Low Air Loss Mattress - ensure functioning properly. Initiated 9/23/21. The CNA (Certified Nursing Assistant) kardex printed on 12/7/21 under bed mobility documents * Bed Mobility: Physical Assist. Under the skin section documents * Low Air Loss Mattress - ensure functioning properly. The skin/wound note dated 9/21/21 documents Writer and wound NP (nurse practitioner) to see guest. Guest just received a bed bath upon arrival. Guest is laying is (sic in) bed on right side. Guest does not verbally respond when asked if she has any pain, fever or chills at this time. Guest does not seem to be in any distress at this time. Wound care provided. Treatment plan in place. Guest is laying in bed positioned on the left side upon departure with call light within reach. Guest has heel protecting boot in place and pillows for positioning. This note was written by RN/Prior Wound Nurse-V who is no longer employed at the Facility. Wound Care NP-X is no longer at the Facility. The wound assessment completed by RN/Prior Wound Nurse-V dated 9/21/21 documents site as Coccyx, clinical stage is Unstageable The length is 7.5 cm, width 7.00 cm and depth unknown. The tissue type is documented as 90% non blanchable [CONDITION(S)] and 10% pale pink non granulating. Exudate is scant serosanguineous. Wound Care NP-X note dated 9/21/21 includes documentation of Sacral deep tissue injury unstageable. The area measures 7.5 cm x (times) 7.0 cm by less than 0.1 cm unstageable. There is a small area that is with pink tissue with 90% remainder of the tissue as deep purple in color or necrotic. No peri wound [CONDITION(S)] present. Minimal to moderate serosanguineous drainage is present. Status-patient did have an area present on admission however now with deep tissue injury. Plan cover with a border foam and change every day. Patient will get an alternating pressure reducing mattress. Will ensure that the patient is wearing her left heel offloading boot. And also she has a pressure reducing cushion for in the wheelchair. Every 2 hours. Keep the area clean and dry. Reposition frequently. Surveyor noted the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's actual skin impairment care plan was not revised until 9/23/21, two days later. Review of R1's September TAR (treatment administration record) reveals the border foam dressing is not initialed as being completed on 9/24/21. On 12/6/21 at 4:03 p.m. Surveyor called LPN-FF to inquire if she completed R1's treatment on 9/24/21. Surveyor left a message on LPN-FF's phone asking for a return call. LPN-FF did not return Surveyor's call. The admission MDS (Minimum Data Set) with an assessment reference date of 9/21/21 documents a BIMS (brief interview mental status) score of 3 which indicates severely impaired. R1 is coded as not having any behavior including not refusing care. R1 requires extensive assistance with two plus person for bed mobility, is dependent with two plus person physical assist for transfer, doesn't ambulate, is dependent with one person physical assist for toilet use and requires extensive assistance with one person physical assist for eating. Yes is checked for indwelling catheter and R1 is coded as always continent of bowel. R1 is at risk for pressure injury development and is coded as having one unstageable slough and or eschar present on admission. Surveyor noted R1's admission evaluation dated 9/14/21 documents Stage 2. R1's September TAR starting on 9/22/21 indicates R1 should be repositioned every 2 hours for wound care. On 9/25/21 R1 had an unwitnessed fall. R1 hit her head on the floor and sustained a large hematoma above the let eye. R1 was transferred to the hospital and returned on 9/26/21 with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure ulcer/injury CAA (care area assessment) dated 9/27/21 for analysis of findings under nature of the problem/condition documents 63 y/o (year old) female admitted for short term rehab after recent hospital stay for COVID-19 (9/1/21) with pneumonia and respiratory failure, [CONDITION(S)], catheter-related [CONDITION(S)] (urinary tract infection), dehydration, metabolic [CONDITION(S)]. Will need PT, OT, ST (physical therapy, occupational therapy, speech therapy); Other medical hx (history): cavitary lung lesion, PVD ([CONDITION(S)]), GERD (gastroesophageal reflux disease), chronic pain, [CONDITION(S)], OSA (obstructive sleep apnea), OA (open area), endometrial cancer, right BKA (below knee amputation), [CONDITION(S)] (hypertension), hx (history of) PE/DVT (pulmonary embolism/deep vein [CONDITION(S)]), HLD ([CONDITION(S)]), colon polyp, [CONDITION(S)], constipation, gastric bypass, lumbar stenosis/DDD ([CONDITION(S)] disc disease), MS ([CONDITION(S)]), seizures, sinusitis, latent TB (pulmonary [CONDITION(S)]) lung, CAD (coronary artery disease). The ADL (activity daily living) CAA triggered because [R1] has pressure injury to her coccyx/left heel and needs limited to extensive assistance with ADL's mobility and B & B (bowel and bladder) management. [R1] is at risk for additional pressure injury and skin breakdown. The plan is for nursing to monitor her skin integrity with appropriate treatments. The goal is for [R1] to remain free of additional skin breakdown with optimal healing of the left heel and coccyx areas while participating in therapy to regain her strength and return to the community at PLOF (prior level of functioning) (A) (assist). Will proceed to care plan. The NP note dated 9/27/21 under review of systems for skin documents Positive for color change (Bruising and contusion to left forehead) and wound (Pressure ulcer to sacrum). Negative for rash. There is no assessment of R1's pressure injury in this NP note. The Braden assessments dated 9/28/21, 10/4/21, & 10/12/21 all have a score of 14 which indicates moderate risk. The wound assessment completed by RN/Prior Wound Nurse-V dated 9/28/21 documents site as Coccyx, clinical stage is Unstageable The length is 8.5 cm, width 7.00 cm and depth unknown. The tissue type is documented as 50% slough white fibrinous and 50% necrotic hard, firm, adherent. Exudate is none. There was no revision in R1's actual skin integrity care plan. Wound Care NP-X note dated 9/28/21 includes documentation of Sacral deep tissue injury unstageable. The area measures 8.5 cm x 5.7 cm x 0.1 unstageable. Malodorous today. Scant purulent drainage. No peri wound [CONDITION(S)] 50% dry eschar to the wound bed 50% yellow nonviable tissue. No overt signs or symptoms of infection. Status-declined. Plan: Wash the area with dermal wound cleanser and pat dry. Place silver alginate to the base of the wound, followed by a large border foam to cover the area. Change every day and as needed. Follow-up in 1 week for recheck. The previous alternating pressure air mattress was removed because patient did fall out of bed. Will discuss with the wound nurse the possibility of reissuing the alternating air pressure given that the wound has declined. The wound nurse will get her a bariatric pressure reducing mattress to help reduce the potential of falling out of bed. The skin/wound note dated 9/28/21 documents Writer and wound NP to see guest. Guest laying in bed upon arrival. Guest does not verbally respond when asked does she have any pain, fever, or chills at this time. Guest does not seem to be any (sic in) any distress or pain at this time. Wound care provided. Air mattress replaced. Heel protecting boot in place. Guest provided with pillows for support. Floor mat in place. Staff educated on turning and repositioning schedule and proper positioning. Treatment in place. This note was written by RN/Prior Wound Nurse-V who is no longer employed at the Facility. R1's September TAR for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] & 9/30/21. The nurses note dated 9/29/21 documents Writer updated [name of telehealth] MD (medical doctor) [name of physician] on lab results for 9/28/21. NOR (new order received) for Protein shakes BID (twice daily). Surveyor noted the 9/28/21 comprehensive metabolic panel includes [MEDICATION(S)] with a low result of 2.5. The reference range is 3.4-4.8 gm/dl (grams/deciliter). The skin/wound note dated 10/1/21 documents Writer to see guest. Guest laying in bed. Guest denies any fever, pain or chills at this time. Wound NP contacted. New treatment plan in place. Guest bed in lowest position, call light within reach upon departure. This note was written by RN/Prior Wound Nurse-V. There is no documented assessment of the wound bed or measurements of R1's coccyx pressure injury on this date. The new treatment ordered on 10/1/21 was cleanse wound with mild soap and water. Pat dry. [MEDICATION(S)] to base of wound. Apply to base of wound. Apply silicone boarder foam dressing daily and prn. R1's October TAR for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] & prn is not initialed as being completed on 10/3/21 & 10/5/21. The nurses responsible for the treatment on 10/3/21 & 10/5/21 are no longer employed at the Facility. The wound assessment completed by RN/Prior Wound Nurse-V dated 10/5/21 documents site as Coccyx, clinical stage is Unstageable The length is 9.2 cm, width 7.00 cm and depth unknown. The tissue type is documented as 10% slough white fibrinous and 90% necrotic hard, firm, adherent. Exudate is none. There was no revision in R1's actual skin integrity care plan. Wound Care NP-X note dated 10/5/21 includes documentation of Sacral deep tissue injury unstageable. The area measures 9.2 cm x 7.0 cm x 0.1 cm unstageable. Malodorous today. Copious amount of drainage today, serosanguineous drainage preset. 90 percent eschar 10 granular around the edges. No peri wound [CONDITION(S)] present no overt signs or symptoms of infection. Alternating pressure mattress will be moved from previous room to current room. Status- declined. Plan: Interventionist to move the air mattress from her previous room to the current room. Position patient every 2 hours. Wheelchair cushion when up patient is on a pressure reducing mattress bed today. Wash area with dermal wound cleanser, pat dry. Place Santyl to the base of the wound follow by border foam. The skin/wound note dated 10/5/21 documents Writer and wound NP to see guest. Guest in bed upon arrival. Guest denies any pain at this time. Guest will be placed back on alternating air mattress. Wound care provided. Guest does not have a fever at this time. treatment plan in place. Guest bed in lowest position with call light within reach upon departure. This note was written by RN/Prior Wound Nurse-V who is no longer employed at the Facility. R1's October TAR for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] & 10/9/21. The nurse on 10/7/21 is no longer employed at the Facility. See interview below with LPN-S for 10/6/21 & 10/9/21. The NP note dated 10/8/21 under review of systems for skin documents Positive for color change (Bruising and contusion to left forehead) and wound (Pressure ulcer to sacrum). Negative for rash. There is no assessment of R1's pressure injury in this NP note. The nurses note dated 10/10/21 documents VSS throughout the shift. Wound care and [name of telehealth company] aware of bottom wound drainage. The NP note dated 10/11/21 under review of systems for skin documents Positive for color change (Bruising and contusion to left forehead) and wound (Pressure ulcer to sacrum). Negative for rash. There is no assessment of R1's pressure injury in this NP note. The wound assessment completed by RN/Prior Wound Nurse-V dated 10/12/21 documents site as Coccyx, clinical stage is Unstageable The length is 9.5 cm, width 6.2 cm and depth 3.00 cm. The tissue type is documented as Bright pink or red 10% Necrotic Hard, firm, adherent 90%. Exudate is Moderate, Purulent. There is no assessment from Wound Care NP-X on 10/12/21 in R1's medical record. The skin/wound note dated 10/12/21 documents Writer and Wound NP to see guest. Guest in bed upon arrival. Guest VSS. Guest wound decline. Daughter and husband notified. Attending NP notified. [Name of ambulance company] contacted for transport to [name of hospital] ER (emergency room ). ER updated on guest arrival. The emergency department provider note dated 10/12/21 at 12:08 p.m. under history of present illness documents [R1] is a [AGE] year old female with a hx (history) of right lower extremity amputation below the knee who presents to the ED (emergency department) for evaluation of a bedsore. There are no further complaints or modifying factors at this time. Under physical exam for skin documents General: Skin is warm and dry. Findings: No [CONDITION(S)]. Comments 10 cm (centimeter) by 10 cm necrotic wound of sacral area Serous drainage from the bottom aspect. Under radiology results for CT abdomen pelvis with contrast (final result) under impression documents 1. A decubitus ulcer overlies the coccyx and extends deep to the surface of the coccyx where focal osseous destruction compatible with [CONDITION(S)] involves the fist coccygeal segment. 2. Extending laterally and caudally from the decubitus ulcer is extensive soft tissue gas and a large abscess within the right gluteus maximus muscle measuring approximately 4.5 x (times) 3 x 8 cm. The differential diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/2/21 at 1:06 p.m. Surveyor asked WN (Wound Nurse)/LPN (Licensed Practical Nurse)-M about her role as wound nurse when R1 was admitted . WN/LPN-M explained she was floor nurse and in mid October she was promoted to weekend supervisor. WN/LPN-M informed Surveyor the same week she was promoted RN/Prior Wound Nurse-V walked out and she was asked to cover wound rounds the next day. WN/LPN-M informed Surveyor she kind of kept doing wound rounds. Surveyor inquired about the admission nursing evaluation dated 9/14/21 which WN/LPN-M completed. WN/LPN-M explained the floor nurses complete the admission nursing evaluation and what is entered under the skin assessment automatically goes into wound rounds which is triggered for the wound nurse. Surveyor asked if she visualized R1's pressure injuries. WN/LPN-M informed Surveyor she did. Surveyor informed WN/LPN-M Surveyor did not note any measurements or assessment of the wound bed. WN/LPN-M informed Surveyor she typically doesn't do this and explained the wound nurse would follow up with measurements. WN/LPN-M informed Surveyor the wound nurse would go back, assess and start the treatment. Surveyor asked who would revise the skin integrity care plan. WN/LPN-M informed Surveyor the wound nurse would be responsible for this care plan and the nurse managers update the other care plans. On 12/6/21 at 8:19 a.m. Surveyor asked DON-B if she could provide Surveyor with a timeline of when R1 received an air mattress and when it was changed. DON-B informed Surveyor she would get back to Surveyor. On 12/6/21 at 8:45 a.m. Surveyor asked CNA-Y if she remembered R1. After showing CNA-Y a picture of R1 in the computer, CNA-Y informed Surveyors she worked with R1. CNA-Y informed Surveyor R1 didn't receive a shower but a bed bath. CNA-Y informed Surveyor she was the shower aide when R1 was at the Facility. CNA-Y informed Surveyor she used to help feed her, combed her hair, and placed creams on her body. Surveyor asked if she helped reposition R1. CNA-Y replied yes. Surveyor asked how often. CNA-Y informed Surveyor every two hours. On 12/6/21 at 10:03 a.m. Surveyor asked DON-B who is responsible for revising care plans. DON-B informed Surveyor any of the nurses, managers and MDS does care plans as well. DON-B informed Surveyor for skin integrity care plans the wound nurse would be responsible for revising these. Surveyor informed DON-B R1 was admitted on [DATE] and Wound nurse LPN-M completed the admission nursing evaluation. Surveyor inquired when would a RN assess R1's pressure injury. DON-B informed Surveyor an RN would look at the evaluation within 24 hours to verify the assessment is correct. Surveyor inquired where the RN assessment could be found. DON-B informed Surveyor may be in the progress note and they are pretty much verifying the assessment is correct. On 12/6/21 at 12:34 p.m. Surveyor informed DON-B R1's 10/10/21 nurses note indicates [name of telehealth company] was notified of R1's wound drainage but Surveyor was unable to locate a note from the telehealth doctor. Surveyor asked if there is a note from [name of telehealth company]. DON-B informed Surveyor she will look into this and get back to Surveyor. Surveyor asked for the education provided which is referenced in Prior Wound Nurse/RN-V's 9/28/21 skin/wound note. On 12/6/21 at 2:33 p.m. Surveyor asked DON-B when a Resident goes to the hospital do they complete a skin assessment upon their return. DON-B informed Surveyor if a resident is not in the hospital for 24 hours then they would not do a skin assessment upon their return. On 12/6/21 at 3:47 p.m. DON-B informed Surveyor she could not find a note from [name of telehealth doctor] and will look in her email. Surveyor informed DON-B R1's actual skin impairment care plan includes an intervention of nurse to assess/record/monitor wound healing with dressing changes. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements or declines to MD. Surveyor asked where this documentation could be located. DON-B informed Surveyor it's the weekly assessment. Surveyor informed DON-B this intervention is in regards to dressing change. DON-B informed Surveyor she was not able to locate any education sheets and isn't sure what Prior Wound Nurse/RN-V educated staff on. On 12/7/21 at 7:51 a.m. Surveyor asked CNA (Certified Nursing Assistant)-EE if she remembered R1. CNA-EE informed Surveyor she does remember R1 but didn't really help her as she is in the front line up. CNA-EE informed Surveyor if someone needed help she would assist and thinks R1 was a feeder. CNA-EE informed Surveyor she doesn't remember R1 getting out of bed and informed Surveyor there's a lot of Residents that come and go. Surveyor asked CNA-EE if she remembers R1 refusing anything. CNA-EE informed Surveyor she wouldn't eat sometimes and didn't think she talked very much. CNA-EE informed Surveyor she did have to help reposition R1 but doesn't know if R1 was a reposition every two hours. On 12/7/21 at 7:51 a.m. Surveyor informed LPN-S, Surveyor had noted the 10/10/21 nurses note she wrote about R1's wound drainage and asked if she could explain about the drainage. LPN-S informed Surveyor she remembers R1 had a wound on her bottom, doesn't remember everything exactly and knows the wound was cultured. Surveyor asked when a culture was taken for R1's pressure injury. LPN-S informed Surveyor she doesn't remember. Surveyor asked LPN-S if she spoke with someone at [name of telehealth company] or did she have to leave a message and if she left a message did [name of telehealth company] get back to her. LPN-S informed Surveyor all she remembers is the wound culture and she told the wound nurse about it. Surveyor asked LPN-S if she knew why R1's coccyx pressure injury declined. LPN-S informed Surveyor she didn't know. Surveyor informed LPN-S she was the nurse on duty responsible for R1's pressure injury treatment on 9/30/21, 10/6/21, & 10/9/21. Surveyor informed LPN-S the treatment is not initialed as being completed on these dates and asked if she remembers doing the treatment. LPN-S informed Surveyor she knows she did treatments but doesn't know about these dates. On 12/7/21 at 8:08 a.m. Surveyor asked LPN-AA if she remembers R1. LPN-AA replied no. Surveyor informed LPN-AA Surveyor was going to ask her if she completed R1's treatment on 9/29/21. LPN-AA replied Sorry, I don't remember her. On 12/7/21 at 8:25 a.m. Surveyor asked LPN-T if she remembers R1. LPN-T informed Surveyor the name sounds familiar then looked at R1's picture in the computer. LPN-T informed Surveyor she took care of R1 a couple of times. LPN-T informed Surveyor she remembers R1 was a feeder and didn't talk much. Surveyor asked if R1 refused to be repositioned. L [TRUNCATED]

Based on interview and record review, the facility did not notify the resident's responsible party or physician when there was a significant change in condition for 4 (R8, R1, R3 and R9) of 5 sampled residents. *R8's physician and responsible party was not notified of multiple pressure injuries that R8 acquired while residing at the facility from 10/8/21 to 11/1/21. *R1's physician and responsible party were not notified of R1's pressure injury upon admission to the facility on . R1's physician and responsible party were not notified when R1's pressure injury deteriorated. *R3's physician was not notified that a STAT laboratory draw was not performed in accordance with R3's physician orders. *R9's responsible party was not notified of a change in R9's condition or when R9's had a room change at the facility. Findings include: (Cross Reference F686) The facility's NOTIFICATION OF THE PHYSICIAN policy and procedure, revised October 2021, states It is the policy of the facility, except in medical emergency, to alert the resident, resident's physician and resident's responsible part of a change of condition. The policy states 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. B. There is a significant change in resident's physical, mental or emotional status e. It is deemed necessary or appropriate in the best interest of the resident. 2. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident or responsible party if appropriate of the issue and physician orders. 3. The communication with the resident and their responsible part as well as the physician will be documented in the resident record or other appropriate documents. 4. Incidents that occur defined as non-injury occurring on the night shift may be reported on the following day shift to the responsible party or DPOA [designated power of attorney]. 5. The Care Plan Coordinator will be notified so that changes can be made to the care plan. The wound policy & procedure dated December 2020 under procedure for notification documents A written protocol is established for: * Physician notification of pressure ulcer presence and responses to treatment. * Family notification of pressure ulcer presence, treatment plan, response to treatment, and changes in treatment due to wound deterioration. 1. R8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] and weakness. R8 was previously diagnosed with COVID 19 in September 2021 prior to admission to facility. R8's Admission MDS with an assessment reference date of 10/11/21 indicates R8 required limited to extensive assistance with bed mobility, transfers, dressing, toileting, bathing and personal hygiene. R8's Admission MDS noted R8's skin to be intact upon admission to the facility and free from pressure injuries. Surveyor reviewed R8's Braden assessments conducted on 10/12/21 and 10/22/21 with scores of 16, indicating resident was at risk for pressure injuries. On 10/8/21, the facility conducted an admission assessment which noted R8's skin to be intact and free of pressure injuries. On 10/19/21, a wound assessment of R8's right heel reads: Status: Active, Type: Pressure, Source: Facility acquired, Date identified: 10/19/21, Identified by: Wound Care LPN-M, Clinical stage: Unstageable, tissue type: non-blanchable [CONDITION(S)] 100%, exudate: moderate serosanguineous and measurements of 4.6 cm x 4.2 cm x 0.1 cm. Surveyor reviewed R8's progress notes. On 10/19/21 Wound Care NP-X documented an unstageable pressure injury to the R8's right heel measuring 4.6 cm x 4.2 cm x 0.1 cm with full thickness tissue loss. On 10/19/21, Wound Care NP-X gave orders for R8 to wear pressure relieving boots at all times (except during therapy), daily dressing changes to the right heel, referral to the facility's registered dietician and repositioning every 2 hours. Surveyor did not identify any documentation of R8's responsible party being notified of the discovery of R8's pressure injury to the right heel. On 10/22/21, Wound assessment of R8's coccyx reads Site: Coccyx, Type: Pressure, Classification: Ulceration, Source: Present-on-admission, Date Identified: 10/19/21 by DON-B. No documentation of any measurements or wound characteristics of R8's coccyx wound were noted from 10/19/21 when it was discovered by Director of Nursing (DON)-B. On 10/22/21, wound assessment of R8's coccyx reads: Assessment date: 10/22/21, performed by: DON-B, Clinical stage: Unstageable .size: 2.5 x 4.0 x 0.2 cm with 25% epithelial tissue and 75% slough tissue Surveyor did not identify any documentation of R8's physician or responsible party being notified on of the discovery of R8's pressure injury to the coccyx. There was no treatment change. By the next wound measurement four days later the wound was 100% necrotic. On 10/26/21, wound assessment of R8's coccyx reads: Assessment date: 10/26/21, performed by Wound Nurse-LPN-M, clinical stage: unstageable .tissue types: necrotic, hard, firm, adherent, 100%, outcome: probably decline, size: 2.8 x 2.4 x 0.1 cm, unstageable , 100% necrotic with scant serosanguineous drainage. Surveyor reviewed R8's progress notes. Surveyor was not able to locate documentation of notification of R8's physician related to their unstageable coccyx pressure injury. Surveyor reviewed R8's TAR. Surveyor was unable to identify documentation of wound treatment to R8's unstageable coccyx pressure injury until 10/25/21. Surveyor did not identify any documentation of R8's physician or responsible party being notified of the deterioration of of R8's pressure injury to the coccyx. On 10/26/21, Wound assessment documentation reads: Site: Left heel, Status: Active, Type: Pressure, Source: Facility Acquired, Date identified: 10/26/21, Identified by: Wound Nurse LPN-M, Clinical stage: Deep tissue pressure injury, Tissue types: intact skin 20% Deep Maroon 60%, Exudate: none, size: 2.8 cm x 3.5 cm. Surveyor reviewed R8's TAR. A treatment order was implemented on 10/26/21 for application of skin prep swab to left heel pressure injury daily. Surveyor did not identify any documentation of R8's physician or responsible party being notified of the discovery of R8's pressure injury to the left heel. On 10/26/21, Wound assessment documentation reads: Site: Sacrum, Status: Active, Type: Pressure, Source: Facility Acquired, Date identified: 10/26/21, Identified by: Wound Nurse LPN-M, Clinical stage: unstageable, Tissue types: bright pink or red 50% slough loosely adherent 50% Exudate: scant serosanguineous, size: 0.5 cm x 0.6 cm x 0.1 cm. Surveyor did not identify any documentation of R8's physician or responsible party being notified of the discovery of R8's pressure injury to the sacrum. On 10/26/21, Wound assessment documentation reads: Site: R buttock, Status: Active, Type: Pressure, Source: Facility-acquired, Date identified: 10/26/21, Identified by: Wound Nurse LPN-M, Clinical Stage: Stage 1, Tissue types: Bright pink or red 100%, exudate: scant-serosanguineous, size: 0.5 x 1.0 x 0.1 cm. Surveyor did not identify any documentation or R8's physician or responsible party being notified of the discovery of a pressure injury to R8's right buttock. There were no treatment changes initiated on 10/26/21 for any of these wounds. On 12/2/21 at 12:55 PM, Surveyor conducted interview with Wound Nurse LPN-M. Surveyor asked Wound Nurse LPN-M if a resident's physician should be notified if they are noted with a pressure injury. Wound Nurse LPN-M told Surveyor that a physician should be notified of any new wounds. Surveyor asked Wound Nurse LPN-M if a resident has a pressure injury that deteriorates whether or not a resident's physician should be notified. Wound Nurse LPN-M responded that a physician should be made aware if a wound is deteriorating as a treatment may need to be changed. Surveyor asked Wound Nurse LPN-M why they had not notified R8's physician on 10/26/21 when R8's right heel and coccyx pressure injuries had declined. Wound Nurse LPN-M responded that they are still receiving training in capacity as the facility's wound nurse and is working closely with PM shift RNs on wound care. Wound Nurse LPN-M could not provide additional information as to why they did not notify a physician of R8's declining wounds. Surveyor asked Wound Nurse LPN-M if a resident's responsible party should be informed when they experience a change in condition, such as development or worsening of a pressure injury. Wound Nurse LPN-M responded that it would depend on if the resident is their own person whether or not they would update a resident's responsible party. On 12/3/21 at 1:30 PM, Surveyor conducted an interview with DON-B. Surveyor asked DON-B if a resident's physician should be notified if they are noted with a pressure injury. DON-B responded to Surveyor that a physician should be notified of any new wounds. Surveyor asked DON-B if a resident has a pressure injury that deteriorates whether or not a resident's physician should be notified. DON-B responded Yes. Surveyor asked DON-B if a resident's responsible party should be informed when they experience a change in condition, such as development or worsening of a pressure injury. DON-B responded, Yes, they should be made aware. On 12/7/21 at 10:25 AM, Surveyor conducted interview with Physician-CC. Surveyor asked Physician-CC if they had ever been made aware of R8's pressure injuries that developed during their stay at the facility. Physician-CC responded The facility has never called me about any of their resident's pressure injuries. The Nurse Practitioners may have been aware but I don't know anything about R8's pressure injuries. The facility does not update me. On 12/7/21 at 10:40 AM, Surveyor conducted interview with Nurse Practitioner (NP)-Z. NP-Z was R8's assigned NP while they resided at the facility. Surveyor asked NP-Z if they had been made aware of R8's pressure injuries while R8 resided at the facility. NP-Z responded that they had been made aware of R8's right heel pressure injury and had directed nursing staff to have Wound Care-NP-X assess and follow R8's wound. Surveyor asked NP-Z whether or not they would expect staff to update them if new pressure injuries were discovered or if a wound deteriorated. NP-Z responded that they would expect the facility staff to notify the wound care team including a wound care NP if there were any changes in wound status. Surveyor informed NP-Z that upon discharge from the facility that R8 had acquired 5 pressure injuries while residing at the facility. NP-Z added that they had only been made aware of R8's right heel pressure injury on 10/19/21. On 12/7/21 at 1:00 PM, Surveyor shared concerns related to lack of documentation of R8's physician being made aware of 4 of 5 facility acquired pressure injuries. Surveyor shared concerns related to R8's responsible party not being made aware of 5 of 5 facility acquired pressure injuries. No additional information was available from the facility at this time. 2. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility's face sheet lists R1's daughter as Emergency contact #1 and R1's spouse as Emergency contact #2. The admission MDS (minimum data set) with an assessment reference date of 9/21/21 documents a BIMS (brief interview mental status) score of 3 which indicates severely impaired. The admission nursing evaluation dated 9/14/21 under the skin integrity section yes is answered for the question does the resident have skin integrity concerns. Under site documents 23) Coccyx & Description documents stage 2. A second site is documented as 50) Left heel & Description documents stage 2. There is no documentation R1's physician/NP (nurse practitioner) was consulted with regarding these pressure injuries to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The wound assessment dated [DATE] documents site as Coccyx, clinical stage is Unstageable The length is 1.5 cm (centimeters), width 0.60 cm and depth 0.10. The tissue type is documented as 100% pale pink non granulating. There is no documentation R1's physician was consulted with regarding R1's unstageable coccyx pressure injury to obtain a treatment and there is no evidence R1's emergency contacts were notified of the unstageable pressure injury. Surveyor noted R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor was unable to interview the wound nurse as she is no longer employed at the Facility. The wound assessment dated [DATE] documents site as Coccyx, clinical stage is Unstageable The length is 7.5 cm, width 7.00 cm and depth unknown. The tissue type is documented as 90% non blanchable [CONDITION(S)] and 10% pale pink non granulating. On 9/21/21 a treatment was ordered to cleanse wound with mild soap and water. Pat dry. Apply boarder foam dressing daily and prn (as needed) every day shift for wound care. There is no evidence R1's representative was informed of the decline in R1's coccyx pressure injury and the new treatment. The wound assessment dated [DATE] documents site as Coccyx, clinical stage is Unstageable The length is 8.5 cm, width 7.00 cm and depth unknown. The tissue type is documented as 50% slough white fibrinous and 50% necrotic hard, firm, adherent. On 9/28/21 there was a change in the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. Apply silver calcium alginate to base of wound. Apply silicone boarder foam dressing daily and prn (as needed). There is no evidence R1's representative was informed of the decline in R1's coccyx pressure injury and change in treatment. On 10/1/21 there was a change in the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. [MEDICATION(S)] to base of wound. Apply to base of wound. Apply silicone boarder foam dressing daily and prn. There is no evidence R1's representative was informed of this change in treatment. The wound assessment dated [DATE] documents site as Coccyx, clinical stage is Unstageable The length is 9.2 cm, width 7.00 cm and depth unknown. The tissue type is documented as 10% slough white fibrinous and 90% necrotic hard, firm, adherent. On 10/5/21 there was a change in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. Santyl to base of wound. Apply silicone boarder foam dressing daily and prn. There is no evidence R1's representative was informed of the decline in R1's coccyx pressure injury and change in treatment. On 12/6/21 at 3:47 p.m. during the daily exit meeting Surveyor informed DON-B Surveyor was unable to locate R1's representative was notified of the decline in pressure injury and the change in treatments in R1's medical record. On 12/7/21 Surveyor was provided with a handwritten note which documents POA (power of attorney) activation 10/11/21 we would not have called with treatment orders. At 8:54 a.m. Surveyor asked DON-B why R1's representatives were not notified when there was a decline in the coccyx pressure injury and a change in treatment. DON-B informed Surveyor R1's POA was not activated until 10/11/21 so they wouldn't of notified anyone. Surveyor informed DON-B even if R1's POA was not activated according to regulations the resident representative should have been notified of these changes. On 12/7/21 at approximately 9:16 a.m. Surveyor informed DON-B Surveyor was unable to locate R1's physician was notified at time of admission the Stage 2 coccyx pressure injury to obtain a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 3. The STAT MEDICAL TEST REQUESTS policy and procedure, dated April 2020, states The facility will ensure medical vendors are able to support stat testing when ordered by the physician. The policy states 2. Stat requests will be fulfilled by the medical vendor as soon as possible, if the vendor communicates any barriers or delays in service alternative solutions to ensure testing is completed may be employed by the facility, including but not limited to transfer to the emergency department. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes on 11/13/21 at 1:43 pm document Resident noted to have a increase in confusion, calling out even after needs have been met. Resident spoke with wife and stated he wanted 911 called, 1:1 given and resident did settle down. VSS [vital signs stable]. Writer spoke with wife several times today and she stated that resident becomes confused prior to having [CONDITION(S)]. His regular schedule is MWF [Monday, Wednesday, Friday]. Resident did not recv [receive] [CONDITION(S)] Friday. NM [Nurse Manager] is aware. NP [Nurse Practitioner] is aware and is here today assessed resident and ordered stat labs .Resident currently resting quietly in bed. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note on 11/13/21 at 5:01 pm by LPN (licensed practical nurse)-O document stat cbc [complete blood count] with differential, cmp [complete metabolic panel], lactic acid STAT for confusion not able to draw labs. There is no documentation a physician was notified of R3's stat labs being unable to be drawn. On 12/6/21 at 10:03 am the surveyor interviewed LPN-O. LPN-O was unable to recall R3, any incidents with his labs, or if a physician was notified. On 12/6/21 at 3:15 pm the surveyor informed NHA-A (Nursing Home Administrator)-A and DON (Director of Nursing)-B of being unable to find notification of R3's physician being notified of stat labs being unable to be drawn. On 12/7/21 at 7:26 am NHA-A informed the surveyor of being unable to find any additional information about the labs orders on 11/13/21 for R3. 4. R9's resident representative was not notified with a significant change in the resident's physical status with a need to alter R9's treatment plan and when R9 had a change in room assignment. *R9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Admission MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 10/24/21, documents: Resident does not want or need an interpreter; preferred language: this area was left blank; speech is clear; understands others and is understood by others; BIMS (Brief Interview of Mental Status (BIMS) score of 13, indicating R9 is cognitively intact for daily decision making; PHQ-9 (Patient Health Questionnaire) score of 2, indicating minimal depressive symptoms. On 11/8/21 at 12:07 PM, R9's medical record documents: .Guest will be moved to the COVID part of the building and be put on COVID isolation. Surveyor unable to locate documentation R9's responsible party was notified of R9's room change. On 11/9/21, at 18:42 (6:62 PM), R9's medical record documents: PT (patient) oxygen was 85% this morning on room air, no c/o (complaints of) SOB (Shortness of Breath); PT was put on 1L (1 liter) O2 (oxygen) then 93%. NP (Nurse Practitioner) [Nurse Practitioner's name] ordered STAT (immediate) cxr (chest x-ray) and labs; lab results pending and cxr results came back negative and NP aware. PT was weaned off of the O2 later in shift, VSS (vital signs stable). Surveyor was unable to locate documentation of R9's responsible party being notified of the change in condition. On 11/17/21, at 15:45 (3:45 PM), R9's medical record documents: NP [name of NP] ordered STAT CBC (Complete Blood Count), CMP (Complete Metabolic Panel), CRP (C-reactive protein) procalcitonin, and chest xray for [CONDITION(S)]. NP [name of NP] also ordered to wean off of oxygen from 4L to 2L, will continue to monitor; labs and x-rays ordered and obtained; awaiting results. 11/17/21, at 18:13 (6:13 PM), R9's medical record documents: Pt oxygen 88% without supplemental O2. PT is now on 2L at 95%. 11/17/21, at 23:09 (11:09 PM), R9's medical record documents: Spoke to NP regarding lab and CXR (Chest x-ray) results. NOR (New Order Received). Pt (Patient) received first dose of [MEDICATION(S)] immediately. Six more doses to follow. Pt positive for pneumonia. Will push fluids and continue to monitor pt closely. 11/18/21, at 06:09 (6:09 AM), R9's medical record documents: at 0530 (5:30 AM), writer updated [R9's] son [name of son] on mother's condition and that she is positive for pneumonia. Writer relayed that mother is already on ABT (antibiotic) and her condition at this time is stable. R9 is documented to have experienced a change in condition on 11/17/21 at 3:45 PM and R9's responsible party was not notified of the change in condition until 11/18/21 at 5:30 AM after R9 was diagnosed with pneumonia and already received antibiotics. On 12/1/21, at 2:22 PM, Surveyor interviewed Social Worker (SW)-L, who stated families should be notified of any room change that occurs and any change in medical status. SW-L stated responsible parties should be informed of resident change in condition and room changes. SW-L stated such notifications are the responsibility of the nursing staff. On 12/1/21, at 2:55 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F, who stated he would expect families/responsible parties to be notified of a residents change in condition or a room change as soon as possible. On 12/6/21, at 3:47 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern R9's responsible party was not notified of R9's room change and was not notified of R9's change in condition until after lab results were obtained, results were received and antibiotics were started.

Based on interview and record review the facility did not ensure 2 (R13 and R1) of 5 sampled residents were free from significant medication errors. -R13 received another resident's medications, requiring transfer to the emergency department and administration of [MEDICATION(S)] and [MEDICATION(S)] intravenously. -R1 did not receive their antibiotic as ordered. Findings include: The facility's Administration of Medications policy and procedure, with a revision date of March 2019 states, 14. Identify resident by reading wrist band or checking the picture in the MAR [medication administration record], if no picture is visible verify by confirming resident name and date of birth. 1. R13 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's plan of care includes a focus area of The resident has fluid overload or potential fluid volume overload r/t [related to] kidney failure. Interventions include Administer medications as ordered. Monitor/document for side effects and effectiveness initiated on 7/23/20. On 7/26/20 a SNF (skilled nursing facility) to ED (emergency department) Handoff note documents, Key clinical Information: Medication variance. Recommended transfer by [physician] for evaluation. Reason for Transfer: Medication variance. A statement by LPN (licensed practical nurse)-D states, On 7/26/2020 at 2135 [9:35pm], I administered the wrong medication to a resident. Prior to administration of the medication, I was outside of rooms [room [ROOM NUMBER]] and [room [ROOM NUMBER]] with the medcart preparing medication for the HS [hour of sleep] med pass. While preparing the medications for [room [ROOM NUMBER]], a resident from [room [ROOM NUMBER]] was yelling out for help. The nurse I was training and myself put the medications back in the cart and went to assist the resident in [room [ROOM NUMBER]]. Once we finished assisting that resident, I continued to prepare the medications for room [room [ROOM NUMBER]], during this time the resident in [room [ROOM NUMBER]] had called out again needing her blinds closed, the nurse I was training assisted her with that and had come back out of [room [ROOM NUMBER]] just as I had finished preparing the meds for room [room [ROOM NUMBER]]. We grabbed the medications to administer and entered [room [ROOM NUMBER]], I said, Hi [different first name then R13's] in which she responded hi back. I told her that I had her medications to give her and administered the following medications orally to the resident in room [room [ROOM NUMBER]]: [MEDICATION(S)] 5mg, [MEDICATION(S)] 2mg, [MEDICATION(S)] 100mg, [MEDICATION(S)] 6mg, [MEDICATION(S)] 25mg, multivitamin, [MEDICATION(S)] 150mg, perservison [MEDICATION(S)], [MEDICATION(S)] 20mg, [MEDICATION(S)] 5-325mg, [MEDICATION(S)] 250mg. After walking out of her room, I instantly realized that the wrong medication had been administered to that resident. I took the residents vital signs as a baseline and 15 mins [minutes] later took another set of vital signs. The MD was contacted and gave the order to send her out to St. Luke's hospital. The resident was informed as she is her own person, and per her request her son was updated and informed. The Director of Nursing also contacted and informed of the medication error. The resident was sent to St. Luke's via ambulance. Hospital records document in the emergency department R13 required 40mg of [MEDICATION(S)] IV, 1mg [MEDICATION(S)] IV. R13 returned to the facility on [DATE]. Progress notes on 7/28/20 document, Patience [sic] apprehensive about taking HS meds. Took meds after carefully checking them. B/P [blood pressure] 113/56. The surveyor was unable to interview LPN-D due to LPN-D no longer working at the facility. On 12/9/20 at 11:14 am the surveyor interviewed DON (Director of Nursing)-B. The surveyor asked how staff should verify a resident prior to giving medications. DON-B informed the surveyor there are pictures of residents in the MAR, and would ask the resident their name. DON-B stated staff should verify in some way. DON-B informed the surveyor she had not been at the facility when R13 experienced the medication error. 2. R1 was admitted to the facility on [DATE] and discharged on [DATE]. R1 was reviewed as a closed record. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 received [CONDITION(S)] at Concerto which is located on site at Ignite Medical Resort and was scheduled to receive [CONDITION(S)] on Monday, Wednesday and Friday. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R1's November MAR (medication administration record) and noted for [MEDICATION(S)] Solution 2000 mg 11/18/20 (Wednesday) is blank, and is initialed as being administered on 11/23/20 (Monday) & 11/25/20 (Wednesday). [MEDICATION(S)] 3000 mg is initialed as being administered on 11/20/20 (Friday) and on 11/27/20 (Friday) is coded with 09 which indicates there is a progress note. The Medication Administration note dated 11/27/20 documents, [MEDICATION(S)] Solution Reconstituted Use 3000 mg intravenously one time day every Fri for bacteremia given in [CONDITION(S)] given at [CONDITION(S)]. On 12/7/20 at 1:21 p.m. Surveyor met with APNP (Advanced Practice Nurse Prescriber)-J at Concerto [CONDITION(S)] to discuss R1. APNP-J informed Surveyor R1 was scheduled for [CONDITION(S)] on Monday, Wednesday, & Fridays and R1's first treatment was 11/18/20. R1 also received [CONDITION(S)] on 11/20/20 (Friday), 11/23/20 (Monday), & 11/25/20 (Wednesday). APNP-J informed Surveyor R1 during the week of Thanksgiving they changed their [CONDITION(S)] day to Saturday and R1 was scheduled to receive [CONDITION(S)] on 11/28/20 (Saturday) but R1 went to the hospital. Surveyor inquired if medications are provided during a Resident's [CONDITION(S)] treatment. APNP-J informed Surveyor they administer medications prescribed by the nephrologist and medications for their [CONDITION(S)] protocol. Surveyor asked APNP-J if they administer antibiotics. APNP-J replied no and explained that is something the nursing home staff would do. Surveyor informed APNP-J R1 had orders to receive [MEDICATION(S)] Solution 2000 mg on Monday & Wednesday and 3000 mg on Friday during [CONDITION(S)]. APNP-J informed Surveyor that is not something she would administer and did not know about the [MEDICATION(S)]. On 12/8/20 at 11:52 a.m. Surveyor spoke with LPN (Licensed Practical Nurse)-G to inquire on R1's November MAR for 11/20/20 (Friday) & 11/23/20 (Monday) which shows a check and her initials for [MEDICATION(S)] 2000 mg & [MEDICATION(S)] 3000 mg what does the check and her initials mean. LPN-G informed Surveyor the [CONDITION(S)] nurse gives the medication to R1 and explained this medication is given during [CONDITION(S)]. Surveyor asked LPN-G if she administered the medication to R1 at [CONDITION(S)]. LPN-G replied no and explained they just check it off that R1 is getting the medication at [CONDITION(S)] but she does not administer the medication. On 12/9/20 at 9:40 a.m. Surveyor informed DON (Director of Nursing)-B there is no evidence R1 received [MEDICATION(S)] Solution 2000 mg and [MEDICATION(S)] Solution 3000 mg according to physician orders. Surveyor informed DON-B Surveyor had spoken to APNP-J and LPN-G and asked if there was anyone else Surveyor should speak to. DON-B informed Surveyor she'll look into this and get back to Surveyor. On 12/9/20 at 11:46 a.m. Surveyor informed Administrator-A and DON-B of the above. Surveyor was not provided with any additional information.