Every finding on record at Menomonee Falls Health Services

Based on observation, interview, and record review, the facility did not ensure 1 (R1) of 1 resident was assessed to be clinically appropriate to self-administer medications.*R1 was observed with 6 medication pills in a medication cup on the over bed table next to R1 while R1 slept. R1 does not have a self-administration assessment completed identifying R1 was approved for self-administration of medications.Findings include:Policy . Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.ProceduresMedication Administration . 4.Medications are to be administered at the time they are prepared.5. The person who prepares the dose for administration is the person who administers the dose.9. Verify medication is correct three times before administering the medication.10. Residents are identified before medication is administered using at least two resident identifiers.13. Explain to resident the type of medication being administered and the procedure.14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes.15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary (IDT), and in accordance with procedures for self-administration of medications and state regulations.19. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the medication administration record (MAR) is flagged. After completing the medication pass, the nurse returns to the missed resident to administer the medication.20. The resident is always observed after administration to ensure the dose was completely ingested. Documentation:1.The individual who administers the medication dose, records the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given.R1 was admitted on [DATE] with diagnoses of Rhabdomyolysis (skeletal muscle breaks down rapidly), Chronic Kidney Disease (progressive damage and loss of function in the kidneys), and Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R1 is her own person.R1's electronic medical record does have a documented self-administration of medication assessment indicating R1 is not approved for self-administration of medications.R1's quarterly MDS (minimum data set) with an assessment reference date of 9/10/25 documents a BIMS (brief interview mental status) score of 14, which indicates R1 is cognitively intact for daily decision making.On 10/14/25, at 9:21 AM, Surveyor observed R1 sleeping in bed. Surveyor observed on the over bed table to the left of R1, a medication cup containing 6 pills. The pill cup contained 1 green, 1 white, 2 pink, and 2 yellow pills. Surveyor observed there was not a licensed nurse and/or medication tech in R1's room.On 10/14/25, at 9:50 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who confirmed LPN-C had passed medications to residents including R1. LPN-C confirmed LPN-C had left R1's medications on the overbed table while R1 was sleeping.On 10/14/25, at 9:53 AM, Surveyor observed R1's cup of 6 pills remains on R1's overbed table.On 10/14/25, at 12:01 PM, Surveyor observed R1's cup of 6 pills remains on R1's overbed table and R1 is not in the room. Surveyor located R1 down the hall to the right in the therapy gym.On 10/14/25, at 12:27 PM, Surveyor interviewed R1. R1 informed Surveyor the nurses usually wake up R1 to take R1's medications every day and was surprised to see R1's medications sitting on the overbed table this morning. R1 confirmed R1 administered the medications to herself upon returning from therapy. R1 explained R1 is a late riser.On 10/14/25, at 12:43 PM, Director of Nursing (DON)-B confirmed that medications should not be left at bedside if a resident has not been evaluated to self-administer medications.R1's October 2025 MAR (medication administration record) documents LPN-C checked and initialed (which indicates medication was administered) the following medication:Cholecalciferol 1000 tablet, Loratadine 10 mg, Oxybutynin 5 mg, Sertraline 25 mg, Vitamin B-12, Zestoretic 12.5 mg (hold if SBP is less than 100) with all medications documented of an administration time of 7:00 AM.On 10/14/25, at 1:37 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B R1's 7:00 AM medications had been left at the bedside for R1 and R1 has not been assessed to be able to self-administer medications. R1 did not take the medications until after 12:00 PM.No additional information was provided as to why the facility did not ensure R1 was clinically appropriate to self-administer medications.

Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 6 residents (R6, R1, R10, and R22) reviewed for accidents. * On 2/13/2025, a Certified Nursing Assistant (CNA) transferred R6 not according to R6’s plan of care and bumped R6’s leg. R6 required surgical intervention to R6’s right leg as a result of the CNA not following R6’s plan of care for transferring. * R1 had a fall on 4/11/2025 and no documentation was located that the facility did a thorough investigation. * R22 had a fall out of bed when staff did not follow R22’s plan of care. R22 was receiving cares with assist of one when R22 rolled out of bed. R22’s plan of care was to have assist of 2. * R10’s Wanderguard was incorrectly placed on R10’s wheelchair according to the manufacturer guidelines. R10’s Wanderguard was placed directly on metal which would inhibit the Wanderguard from functioning properly. Findings include: The facility policy titled “Safe Resident Handling and Transfers” reviewed/revised 8/5/2022 documents: “Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. … Compliance Guidelines: … 10. Two staff members must be utilized when transferring residents with mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire. …13. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.14. Resident lifting and transferring will be performed according to the resident’s individual plan of care. …” 1.) R6 was admitted to the facility on [DATE] with diagnoses that include peripheral vascular disease, weakness, morbid/severe obesity, osteoarthritis, major depressive disorder-recurrent, dementia with psychotic disturbance, right and left artificial knee joints, and nonrheumatic aortic valve disorder. R6’s quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating that R6 had intact cognition. The MDS assessed R6 as needing extensive assist with staff member for upper and lower body dressing, repositioning, and personal hygiene and assist of 2 staff members for toileting hygiene. The MDS also documents that R6 required a Hoyer lift for transfers with 2 staff members. R6 has an activated power of attorney (POA). On 7/29/2025 at 9:58 AM, Surveyor observed R6 lying in bed with the right leg elevated on a pillow. Surveyor noted a kerlix wrap to R6’s right extremity and asked R6 what the wrap was for. R6 replied that a couple months ago R6’s leg got bumped during a Hoyer transfer and ended up needing a surgery to removed “blood build up” in the area. Surveyor asked how the area was healing. R6 stated slowly but is doing well. Surveyor asked R6 how R6’s leg got bumped during the transfer. R6 replied was not sure if R6’s leg hit the Hoyer lift or R6’s bed but stated R6’s leg swung hard into something. R6 stated the aide transferred R6 using the Hoyer lift alone. R6 could not remember who the aide was that did the transfer alone. On 7/29/2025, Surveyor reviewed R6’s medical record and noted the following in R6’s care plan and progress notes: R6’s activities of daily living (ADLs) deficit . care plan was initiated on 12/18/2023 with the following intervention:-Transfer: Hoyer lift with 2 assist, X-large sling. On 2/12/2025 at 23:52 (11:52 PM) in the progress notes nursing documented: (R6) asked for pain cream for R6’s right leg. (R6's) right leg was noted to be swollen, warm to touch, red color with a blister and some drainage present. (R6) stated that R6’s leg was bumped when transferred from R6’s chair to R6’s bed. … Order received to send out for further evaluation. On 2/13/2025 at 2:40 AM in the progress notes nursing documented: received phone call from emergency department and was informed (R6) will be admitted to the hospital for further evaluation and treatment due to a hematoma to the right leg with changes and R6 being on Eliquis (blood thinner). Surveyor reviewed R6’s hospital admission paperwork and noted that R6 underwent surgical excision of hematoma with Jackson Pratt (JP, surgical drain used to remove fluid from a surgical site) drain placement on 2/17/2025. On 2/24/2025 at 16:30 (4:30 PM) in the progress notes nursing documented: (R6) returned from the hospital following a surgical procedure for evacuation of a large hematoma (clot) to the right lower extremity. Assessment revealed a large ecchymotic (bruising) area to the extending right foot with pitting edema present. 13 centimeter incision, well approximated with 14 visible sutures, JP drain present. … On 7/29/2025 at 3:03 PM, Surveyor requested to view facility self-reports for R6 since January 2025. On 7/30/2025, Surveyor was provided a facility self-report that was initially submitted to the State Agency on 2/12/2025 at 11:52 PM. The final investigation was submitted to the State Agency on 2/18/2025 at 9:27 PM. Surveyor reviewed the facility self-report. Surveyor reviewed a written statement from CNA-O documenting CNA-O worked with (R6) on 2/12/2025. CNA-O put R6 into bed about 6:30 PM. CNA-O documented that R6 did hit R6’s leg on the side of the bed railing but R6 did not complain during the remainder of CNA-O’s shift. Surveyor reviewed the interview between Nursing Home Administrator (NHA)-A and CNA-O which documented that CNA-O did admit to transferring R6 with a Hoyer lift with only 1 assist and did not ask other staff for assistance to transfer R6. Surveyor noted that CNA-O is no longer employed with the facility and was not able to be reached for an interview. On 7/31/2025 at 10:14 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-Q who stated R6 requested some pain cream for R6’s leg. LPN-Q stated when went to get cream and looked at area on R6’s leg it was red and swollen. LPN-Q stated R6 told LPN-Q that R6's leg got bumped during a transfer. LPN-Q stated that the Director of Nursing (DON) and physician were contacted, and an order was received to send R6 out to get evaluated. LPN-Q stated that CNA-O did not ask LPN-Q for help and LPN-Q stated the other aides on duty were not asked to assist CNA-O for putting R6 to bed with the Hoyer lift. LPN-Q stated LPN-Q was not made aware that R6 bumped R6’s leg during a transfer. LPN-Q stated that facility policy is to have 2 staff assist with all mechanical lifts. On 7/31/2025 at 10:18 AM, Surveyor shared concerns with NHA-A and [NAME] President of Success (VPS)-D regarding R6 requiring surgical intervention after CNA-O transferred R6 using a Hoyer lift with one staff member instead of two staff members as indicated on R6’s plan of care. No additional information was provided. 2.) The facility's policy and procedure titled, NSG (nursing) Accidents and Supervision, last reviewed 7/14/22 documents in part: “Policy: The resident environment will remain as free of accidents 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)… 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…” R1 was readmitted to the facility on [DATE] with pertinent diagnoses that include chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed), lymphedema (a condition characterized by swelling that occurs when the lymphatic system fails to properly drain fluid from the tissues), restless legs syndrome (a condition that causes a very strong urge to move the legs. The urge to move usually is caused by an uncomfortable feeling in the legs. It typically happens in the evening or at night when sitting or lying down), and insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep).R1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/23/25, documents a Brief Interview for Mental Status (BIMS) score of 14, indicating that R1 is cognitively intact. The MDS documents R1 is understood and understands others. R1’s Patient Depression Questionnaire (PHQ-9) score was 00 indicating no depressive symptoms. R1 exhibited no behaviors during the look back period of the MDS assessment. R1 is documented to have had one fall since admission or prior assessment. R1’s care plan for “Resident is at risk for falls r/t (related to) Deconditioning/weakness , Disease process RESTLESS LEG SYNDROME, History of falls, Pain, use of psychotropic medications” revised on 5/14/25, has the following interventions: “4/11/25 IDT (interdisciplinary team) review fall- DOR (director of rehabilitation) provided R1 with reeducation regarding asking for assistance, remind resident to ask for assistance. Date Initiated: 4/11/2025 •Anticipate and meet the Resident's needs. Encourage the Resident to always call for assistance.Date Initiated: 9/26/2022 •Education the Resident on fall prevention measures. Assure Resident that calling for help is not a bother.Date Initiated:9/26/2022 •Ensure that the Resident is wearing appropriate footwear (specify)Date Initiated:9/26/2022 •Follow Therapy recommendations for transfers, mobility and ambulationDate Initiated:9/26/2022 •Place bed at lowest position.Date Initiated:9/26/2022 •Place call light or communication device within reach. Answer call light promptly - alwaysDate Initiated:9/26/2022 •PT (Physical Therapy) to eval (evaluate) and treat. Seat cushion to be assessed. Revision on: 5/14/2025 •Resident wheelchair needs to be halfway in the bathroom to transfer to the toilet from the wheelchair with the chair locked. Date Initiated: 10/6/2024 •Review information on past falls and attempt to determine cause of falls for prevention and to minimize injuries.”Date Initiated: 6/9/2024 R1’s care plan for “at risk for falls due to: arthritis, history of falls, impaired balance/poor coordination” revised on 9/30/2024, has the following interventions: “•Have commonly used articles within easy reach.Date Initiated: 9/30/2024 •Medication regimen review.Date Initiated: 9/30/2024 •Medications as ordered.Date Initiated: 9/30/2024 •Provide assist to transfer and ambulate as needed.Date Initiated: 9/30/2024 •Reinforce need to call for assistance.Date Initiated: 9/30/2024 •Reinforce w/c (wheelchair) safety as needed such as locking brakes.Date Initiated: 9/30/2024 •Reminders to resident to reposition while on the toilet to help prevent numbness in legs while on the toilet.Date Initiated: 12/23/2024 •Report development of pain, bruises, change in mental status, ADL (activities of daily living) function, appetite, or neurological status post fall.Date Initiated: 9/30/2024 •Therapy eval and treat as ordered.”Date Initiated: 9/30/2024 On 07/29/2025, at 8:58 AM, Surveyor interviewed R1 and was told that R1 had one fall, R1 stated they fell flat down. R1’s progress note dated 4/11/2025, written at 04:45 am, documents: “Resident was sitting on her butt with both legs stretched out in front and both hands by her side palms down on the ground. When asked what happened she stated that she was trying to go to the bathroom and her legs gave out. Resident was helped off the floor and back into her chair her ROM (range of motion) was WNL (within normal limits) VSS (vital signs stable), and neuro (neurological) checks have stared. All personnel have been notified per facility protocol No new orders at this time just continue wit POC (plan of care). Her immitted intervention was education her on planting her feet firmly on the ground and standing momentarily before she began to walk”. R1’s “Un-witnessed Fall” assessment dated [DATE] was reviewed. The assessment documents “no injuries at time of incident” and “no injuries observed post incident”. “Predisposing Environmental Factors” identified as “clutter”. “Predisposing Physiological Factors” identified as “sedated”. “Predisposing Situation Factors” identified as “ambulating with assist”. For “Statements” it is documented “no statements found”. On 07/30/2025, at 3:17 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding additional documentation on witness statements and investigation post fall for R1. Surveyor was told they will look to see if there's more information related to the fall. On 07/31/2025, at 3:42 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-Q, who completed the “Un-witnessed Fall” assessment on 4/11/25, and asked what is done to investigate after a fall. LPN-Q stated the nurse should get statements from people working with resident. Surveyor asked do you document when resident was last seen or toileted. LPN-Q stated that is asked in one of the assessment questions in the computer. Surveyor asked why LPN-Q had checked clutter as a predisposing environmental factor and was told it was probably on accident to be honest. Surveyor asked why LPN-Q checked ambulating with assistance for predisposing situation factors and was told it means R1 was using their walker. LPN-Q explained that the “Un-witnessed Fall” assessment is what nurses fill out, it is on the computer. Surveyor asked if there is a fall packet with additional information to complete and LPN-Q stated they were pretty sure there is a fall packet but may have been noncompliant and not completed it. On 08/04/2025, at 9:47 AM, Surveyor interviewed LPN-E regarding what is documented or completed post fall and was told in the computer system is the risk management documentation. The post fall assessment is all done in the computer, there is no fall packet to complete. On 08/04/2025, at 9:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-X regarding post fall sharing of information that is observed. Per CNA-X there is a form to complete that asks when last seen, toileted, where was seen, if the fall was witnessed, etc. Gave Surveyor a copy of document titled “Witness Statement” that has the following questions: name of resident, name of witness, date of event, location of event, time resident last seen, time resident last toileted, was resident in w/c (wheelchair), recliner, bed or other, was resident using walker, was resident incontinent, what was resident’s footwear, is there a change of condition noted with resident, and general statement of knowledge of the event. Surveyor noted neither the “Witness Statement” document or the information it asks for was located for R1’s 4/11/25 fall. On 08/04/2025, at 10:00 AM, Surveyor interviewed LPN-K regarding what is documented or completed post fall and was told in the computer system you document the fall under risk management. There is a section for statements, when the fall is witnessed this is completed. There is no packet or place for putting statements about when last saw or toileted the resident in the computer. LPN-K is unaware of any witness paper form to complete. On 08/04/2025, at 10:45 AM, Surveyor interviewed DON-B regarding how to document post fall and was told that vitals and neuro checks are done in the computer, the computer generates what to complete. Staff do witness statements. The medical doctor and Power of Attorney are updated, the resident is put on the 24-hour board for monitoring. On 08/04/2025, at 11:44 AM, Surveyor relayed concern regarding lack of documentation of post fall assessment for R1’s 4/11/25 fall to NHA-A and 2 consultants. No additional information regarding R1’s post fall assessment was provided. 3.) The facility policy titled “Resident Alarms”, with implementation date of 7/21/2022 and revision date of 9/9/2022 documents: “Policy: It is the policy of this facility to utilize resident alarms only in accordance with the resident’s needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being. … Definition: An “alarm” is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected. … … Types of alarms include: …e. wander/elopement alarms – includes devices such as bracelets, pins/buttons worn on the resident’s clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exists an area of the building. This includes devices that may be attached to the resident’s assistive device or other belongings. … The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms that includes risks vs benefits consideration… a. Interventions shall be communicated to all relevant staff, including frequency/time frames for alarm use b. When alarms are utilized, additional measures should be taken, including but not limited to: i. Verifying alarms are used in accordance with the resident’s care plan ii. Verifying alarms are working properly iii. Observing for adverse consequences associated with the use of the alarms, including psychosocial concerns. …” R10 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia without behavioral disturbance, and other recurrent depressive disorders. R10’s significant change Minimum Data Set (MDS) completed 1/3/25 documents R10’s Brief Interview for Mental Status (BIMS) score as 10, indicating moderate cognitive impairment. R10’s MDS documents no mood or behavior symptoms, and a wander/elopement alarm is used daily. R10’s MDS documents R10 uses a wheelchair independently and does not ambulate, and R10 requires maximal assistance for dressing, bed mobility, and transfers. The facility documents the cognitive loss/dementia Care Area Assessment (CAA) was triggered for R10 due to … “BIMS score of 10 … contributing factors include … dementia, change in mental status, and short term/long term memory loss … cognitive loss already care planned…” R10’s most recent quarterly MDS completed 7/4/25 documents R10’s BIMS score as 7, indicating severe cognitive impairment. R10’s MDS documents no mood or behavior symptoms, and a wander/elopement alarm is used daily. R10’s MDS documents R10 uses a wheelchair independently and does not ambulate, R10 requires maximal assistance with lower body dressing, and R10 requires moderate assistance for upper body dressing, bed mobility, and transfers. The most recent wandering risk assessment for R10 completed on 6/30/25 documents a score of 19.0, indicating R10 has a high risk for wandering. R10’s care plan documents “… resident has potential for elopement due to … Alzheimer’s disease … dementia, and other recurrent depressive disorder” with the following interventions: … -wander guard placement had been moved to wheelchair due to [history] of swelling of ankles/wrists and rashes to skin. Resident does not ambulate without use of wheelchair…, initiated 4/7/25 and revised 4/9/25 … -at moderate risk for elopement, [history] of following family outside. Redirect and provide distraction … and remind family to notify staff when leaving, initiated 11/24/24 and revised 4/7/25 … -check placement of wander guard on wheelchair and functioning per manufacturer recommendations and MD orders, initiated 4/7/25 and revised 4/14/25 … R10 has the following orders in place: -check wander alert bracelet function and expiration date daily every shift for elopement risk, active 4/9/2025 -check wander alert bracelet placement to wheelchair every shift for elopement risk, active 8/21/24 -okay to place wander alert bracelet for safety/elopement risk to wheelchair…, active 8/21/24 Surveyor reviewed a progress note dated 4/27/25 that documented R10 became anxious … tried leaving the facility multiple times … resident was not easily redirected. Wander guard in place . On 7/29/25, at 8:48 am, Surveyor observed R10 sitting in R10’s wheelchair in the hallway, wander guard observed on a metal bar behind the wheelchair seat on the back of the wheelchair. On 7/30/25, at 7:46 am, Surveyor observed R10 sitting in R10’s wheelchair in the hallway, wander guard observed on a metal bar behind the wheelchair seat on the back of the wheelchair. On 7/30/25, at 12:20 pm, Surveyor reviewed “Code Alert” wander management user essentials manual from RF Technologies, Inc. dated 2014. On page 5 of the manual, a highlighted “note” documents: “to monitor a resident in a wheelchair, attach the transmitter to the seat or the back of the chair, as the metal on the chair can interfere with the transmitter’s signal”. On 7/30/25, at 1:11 pm, Surveyor interviewed Director of Nursing (DON)-B regarding the use of wander guards. DON-B stated a nurse would do an assessment to determine potential elopement and then place a wander guard on the resident’s ankle or wheelchair. DON-B stated nursing staff tests the wander guard alarm system with a machine weekly and takes any residents with wander guards near the alarm to make sure the alarm is working. DON-B stated DON-B was not aware the wander guard should not be placed on a metal bar of a wheelchair. On 7/31/25, at 9:45 am, Surveyor spoke with Tech Support Code Alert (TSCA)-Z regarding wander guard placement for a resident in a wheelchair. TSCA-Z stated the transmitter could be wrapped around the handle of the wheelchair if needed. When Surveyor asked if the transmitter could be placed on a metal bar on a wheelchair, TSCA-Z stated to follow the manual instructions. On 7/30/25, at 3:00 pm, Surveyor shared the above concern with Nursing Home Administrator (NHA)-A and DON-B due to risk that R10’s attempts at elopement may go undetected. NHA-A and DON-B understood the concern. No additional information was provided. 4.) R22's diagnoses includes hypertension (high blood pressure), aphasia (language disorder that affects a person's ability to communicate) following cerebral infarction (condition where blood flow to the brain is disrupted leading to the death of brain tissue, also known as ischemic stroke), morbid obesity, seizure, and unspecified psychosis (mental health condition characterized by a loss of contact with reality). R22's ADL (activities daily living) self-care deficit care plan initiated 10/12/24 & revised 6/10/25 includes an intervention of BED MOBILITY: Dependent extensive assist of 2, does not ambulate. Initiated 10/12/24 & revised 5/9/25. R22's at risk for falls care plan initiated 10/12/24 & revised 4/28/25 documents the following interventions: *Encourage to transfer and change positions slowly. Initiated 12/31/24. *Have commonly used articles within easy reach. Initiated 12/31/24. *Medications as ordered. Initiated 12/31/24. *Reenforce need to call for assistance. Initiated 12/31/24. *Reenforce w/c (wheelchair) safety as needed such as locking brakes. Initiated 12/31/24. *Report development of pain, bruises, change in mental status, ADL (activities daily living) function, appetite, or neurological status post fall. Initiated 12/31/24. Therapy eval (evaluation) and treat as ordered. Initiated 12/31/24. R22's significant change MDS (minimum data set) with an assessment reference date of 6/23/25 assess R22 as having short & long term memory problem and documents that R22 has severely impaired cognitive skills for daily decision making. R22 is assessed as being dependent for toileting hygiene & chair/bed to chair transfer and substantial/maximal assistance for roll left and right. R22 has an indwelling urinary catheter and is always incontinent of bowel. R22 is assessed as not having any falls since prior assessment. R22's nurses note dated 6/24/25 written by Licensed Practical Nurse (LPN)-K documents: At approx. (approximately) 1040 am this morning Writer had resident positioned on her side in bed performing wound care to coccyx/sacrum. Resident was on her side near the center of the bed. After writer completed washing buttocks/sacral area and dried, skin prepped. During opening of the dressing prepping dressing to place resident started reaching toward window calling out Hey rolled toward side of air mattress. As writer tried to grab at resident to prevent rolling. Resident continued to roll face down and started sliding off side of air mattress and onto the fall mat on the floorHospice RN (Registered Nurse) and this writer further resident while in bed with x2 (times two) abrasions noted. Abrasions with some redness noted to left scapula and mid left side of back. Offers no s/sx (signs/symptoms) of pain or discomfort. Sites cleansed and left open to air. VSS (vital signs stable) stable T. (temperature) 97.4- P (pulse). 93- Resp (Respirations). 18- B/P (blood pressure) 122/70- POX% (pulse oximeter percentage) on room air 95. Respirations are even and unlabored. POA (power of attorney) contact called with message left to call back for update. Sister Emergency contact 1 [Name] updated and aware. [Medical Group Name] called APNP (Advanced Practice Nurse Prescriber) not available at the time. on call service to send message for her to call facility for update. NNOR from RN hospice nurse r/t incident. Will visit again tomorrow. Instructed to call for any changes or concerns. R22's Incident report dated 6/24/25 under incident description for nursing description documents: Writer had resident positioned on her side in bed performing wound care to coccyx/sacrum. Resident was on her side near the center of the bed. After writer completed washing buttocks/sacral area and dried, skin prepped. During opening of the dressing prepping dressing to place resident started reaching toward window calling out Hey rolled toward side of air mattress. As writer tried to grab at resident to prevent rolling. Resident continued to roll face down and started sliding off side of air mattress and onto the fall mat on the floor. Under action taken for description documents writer immediately called for help to speech therapist out in hall to assist while writer unlocked the bed to pull away from resident. Checked injury, no visible injury noted noted with skin intact. Range of motion at baseline and WNL (within normal limits) to all extremities. Speech therapy assisted placement of sling to hoyer resident off floor to get into bed. [Name] RN with [Name] Hospice arrive during this time and assisted as well. Resident then hoyered off floor back to bed to further assess for any injury and take vitals. After R22's fall on 6/24/25, R22's ADL self care deficit care plan was revised with an intervention Resident cares/respositioning/wound care: Dependent extensive assist of 2 does not ambulate. Initiated 6/26/25. Surveyor noted R22's care plan prior to R22's fall on 6/24/25 already had an intervention for bed mobility of dependent extensive assist of 2. On 7/31/25, at 9:59 a.m., Surveyor interviewed LPN-K regarding R22's fall on 6/24/25. LPN-K explained it was R22's treatment day. She pulled R22 all the way over literally in the exact center of the bed, a little past center, and had the treatment supplies set up. LPN-K informed Surveyor she went to apply medi honey noticed it wasn't cut appropriately but had an extra one. LPN-K indicated she pulled R22 a little more, covered R22 with a sheet, opened the medi honey and when she was cutting the medi honey R22 yelled hey, reached forward and went flat on R22's chest. LPN-K explained R22 only had a gown on, she tried pulling on R22's gown and tried to grab R22's shoulder but R22 slid on floor mat. LPN-K informed Surveyor she yelled for the speech therapist who was out in the hall, checked for injuries, didn't see any injuries and reassessed R22 every half hour. Surveyor asked LPN-K prior when doing R22's wound treatments did you do the treatments by yourself. LPN-K replied I never had any problem. Surveyor informed LPN-K R22's ADL care plan has an intervention which documents two people for bed mobility and this intervention was implemented prior to R22's fall. On 7/31/25, at 10:50 a.m., Surveyor asked Interim Director of Nursing (DON)-B if staff should follow a resident's plan of care. Interim DON-B replied yes. Surveyor informed Interim DON-B R22's ADL self care deficit care plan had an intervention prior to R22 fall on 6/24/25 to use two for bed mobility. Surveyor informed Interim DON-B LPN-K did not follow R22's plan of care. No additional information was provided.

Based on interview and record review, the facility did not ensure 1 of 5 Certified Nursing Assistants (CNA-S) received the required 12 hours of training per year. This has the potential to affect the total census of 35 residents.Findings include:On 7/29/25, Surveyor requested from Nursing Home Administrator (NHA)-A, evidence that CNA-S had completed the required 12 hours of annual training. Surveyor noted CNA-S was hired on 1/5/23.On 7/30/25, at 2:11 PM, NHA-A provided annual training that was completed by CNA-S. Surveyor noted to NHA-A that CNA-S completed 7.08 hours of training and did not receive the 12 hours of annual training as required. Surveyor notified NHA-A of concerns with CNA-A not receiving the required 12 hours of annual training. NHA-A acknowledged these concerns and stated NHA-A would investigate further.On 7/31/25, at 1:47 PM, NHA-A notified Surveyor she was unable to find additional training for CNA-S and acknowledged CNA-S did not complete the 12 hours of annual training required. Surveyor requested additional information if available. No additional information was provided.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection.This has the potential to affect the 35 residents currently residing in the facility. * R22 has Stage 4 sacrum pressure injury. There was no EBP (enhanced barrier precaution) sign on or around R22's door and there was no PPE (personal protective equipment) cart observed outside R22's room. Staff was observed not wearing the appropriate PPE during personal cares. * R28 is on EBP. Staff was observed entering R28's room without appropriate PPE. * The facility experienced a COVID 19 outbreak starting on 11/12/24 until 12/3/24. There is no information as to residents and/or staff tested during this outbreak and no documentation as to type of isolation residents were placed in. According to the outbreak summary health department was notified on 11/12/24. There is no information if the health department requested any information or provided the facility with an recommendations and if recommendations were provided what were these recommendations. * There is not documentation of an effective water management program to prevent the spread of Legionella. Findings include: The facility's policy, titled Enhanced Barrier Precautions and reviewed/revised 8/8/24 under Policy documents It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). Under Policy Explanation and Compliance Guidelines documents 2. Initiation of Enhanced Barrier Precautions documents b. An order for enhanced barrier precautions (in accordance with physician-approved standing orders) will be initiated for residents with any of the following: i. Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, peripherally inserted central catheters (PICCs), hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with MDRO. Ostomies, such as colostomies or ileostomies, are not defined as a wound for Enhanced Barrier Precautions. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). 1.) R22 has a Stage 4 sacrum pressure injury. On 7/29/25, at 9:26 a.m., Surveyor observed there is not an enhanced barrier precaution sign on or around R22's room door. Surveyor noted R22 is listed on the roster matrix has having a Stage 4 pressure injury. R22's significant change MDS (minimum data set) assesses R22 as having short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R22 is assessed as being dependent for toileting hygiene & chair/chair to bed transfer and substantial/maximal assistance for roll left and right. R22 has an indwelling urinary catheter and is always incontinent of bowel. On 7/30/25, at 9:39 a.m., Surveyor observed CNA-F & CNA-BB in R22's room wearing only gloves. CNA-F & CNA-BB do not have gowns on. CNA-F informed R22 they are going to reposition her and are going to put the head of her bed down. CNA-F removed the sheet and then CNA-F & CNA-BB removed pillows from under R22's lower legs and along each side of R22. CNA-F & CNA-BB repositioned R22 towards the right side of the mattress and then rolled R22 on the left side. CNA-F placed a pillow under R22's right upper side and then checked R22's incontinence product stating she's dry. A pillow was placed under R22's left arm and then CNA-F & CNA-BB repositioned R22 up in bed. CNA-F & CNA-BB placed pillows under R22's lower extremities and covered R22 with a sheet. CNA-F & CNA-BB removed their gloves, cleansed their hands, and left R22's room. On 7/31/25, at 1:04 p.m., during the infection control interview with Licensed Practical Nurse/Infection Preventionist (LPN/IP)-E and [NAME] President (VP) of Success-D Surveyor asked what is the criteria for placing a resident on Enhanced Barrier Precautions. LPN/IP-E informed Surveyor if the resident has a foley or wounds. LPN/IP-E informed Surveyor they place a sign on the door & PPE outside the room. Surveyor asked what is staff expected to wear for a resident on Enhanced Barrier Precautions. LPN/IP-E replied gowns and gloves. On 7/31/25, at 1:20 p.m., Surveyor informed LPN/IP-E R22 has a Stage 4 pressure injury and inquired why there isn't an enhanced barrier precaution sign on R22's door. LPN/IP-E replied I don't know, can't answer that. Surveyor informed LPN/IP-E Surveyor hasn't observed an Enhanced Barrier Precaution sign during the survey on R22's door. Surveyor informed LPN/IP-E of the observation of CNA-F and CNA-BB repositioning & checking R22's incontinence product without the appropriate PPE on as they were not wearing gowns. 2.) R28's diagnoses include end stage renal disease. R28 receives hemodialysis two times weekly. R28's at risk for infection r/t (related to) indwelling medical devise tessio cath (catheter) for dialysis, stem cell and bone marrow transplant initiated 4/5/24 & revised 5/2/25 has an intervention of Enhanced barrier precautions when performing high-contact care activities. Initiated 4/5/24. R28's quarterly MDS (minimum data set) with an assessment reference date of 6/13/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R28 is assessed as being dependent for toileting hygiene, requires partial/moderate assistance for rolling left and right, is frequently incontinent of urine, and always incontinent of bowel. On 7/29/25, at 9:31 a.m. Surveyor observed on R28's room door there are two signs posted. One sign states please wear face mask before entering room. The second sign is an enhanced barrier precaution sign. Surveyor also observed a PPE (personal protective equipment) cart outside R28's room. Surveyor observed these signs throughout the survey on R28's room door. R28's Certified Nursing Assistant (CNA) Kardex as of 7/30/25 under the infection control section documents Enhanced barrier precautions when performing high contact care activities. On 7/30/25, at 11:41 a.m., Surveyor observed Certified Nursing Assistant (CNA)-F cleanse her hands and enter R28's without any PPE to answer R28's call light. On 7/30/25, at 11:49 a.m. Surveyor observed CNA-F leave R28's room holding garbage bags. Surveyor asked CNA-F what R28 wanted. CNA-F replied change her. On 7/30/25, at 1:09 p.m., Surveyor asked CNA-F if PPE is kept in the residents room. CNA-F informed Surveyor there is a cart out side the room and they place PPE on before entering. Surveyor asked CNA-F why she didn't place any PPE on before entering R28's room. CNA-F informed Surveyor she put on a mask as the resident has cancer and does not have to put on any other PPE for her. On 7/31/25, at 1:04 p.m., during the infection control interview with Licensed Practical Nurse/Infection Preventionist (LPN/IP)-E and [NAME] President (VP) of Success-D Surveyor asked what is the criteria for placing a resident on Enhanced Barrier Precautions. LPN/IP-E informed Surveyor if the resident has a foley or wounds. LPN/IP-E informed Surveyor they place a sign on the door & PPE outside the room. Surveyor asked what is staff expected to wear for a resident on Enhanced Barrier Precautions. LPN/IP-E replied gowns and gloves. On 7/31/25, at 1:20 p.m. Surveyor asked LPN/IP-E if the expectation for staff is to place on gloves and a gown before entering R28's room. LPN/IP-E replied yes and masks because that's her preference. Surveyor informed LPN/IP-E of the observation of CNA-F not placing PPE prior to entering R28's room. When CNA-F was exiting room Surveyor asked what R28 wanted and CNA-F informed Surveyor to be changed. The facility's policy titled, COVID 19 Prevention, Response and Reporting last reviewed/revised 5/18/23 under Policy documents It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID 19 information will be reported through the proper channels as per federal stand and/or local health authority guidance. Under Policy Explanation and Compliance Guidelines documents 26. Responding to a newly identified SARS-CoV-2 infected HCP (health care personnel) or resident: a. The facility should defer to the recommendations of the jurisdiction's public health authority when performing an outbreak response to a known case. b. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. c. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach (e.g. unit, floor or other specific area(s) of the facility) approach is preferred if all potential contact cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. d. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. (See Coronavirus (COVID-19) Testing Policy for details). e. Empiric use of Transmission-Based Precautions residents and work restriction for HCP are not generally necessary unless resident meet the criteria as noted above (#13) or HCP meet criteria as noted in the Return to Work Criteria for Healthcare Personnel with COVID-19 Infection Exposure to COVID-19 Policy. 3.) On 7/31/25, at 1:37 p.m., during the infection control interview with Licensed Practical Nurse/Infection Preventionist (LPN/IP)-E and [NAME] President (VP) of Success-D Surveyor informed staff Surveyor had reviewed the one sheet COVID Outbreak Summary November 24 which was located in the infection control binder. Surveyor inquired if there is a line listing for staff and residents for this outbreak. Surveyor informed LPN/IP-E and VP of Success-D this summary indicates the health department was notified but does not indicate if the health department requested any information or if there were any recommendations for the facility. Also the summary outbreak indicates testing but there is no information as to who was tested and does not indicate type of isolation implemented. Surveyor also inquired if there were any other outbreaks. LPN/IP-E informed Surveyor she recently started being responsible for infection control and wouldn't have any information. VP of Success-D informed Surveyor she is pretty sure they tested both staff and residents as that's their protocol but will check. Surveyor asked LPN/IP-E and VP of Success to look for any information and get back to Surveyor. VP of Success-D informed Surveyor they will look for the information but the staff who would of been involved with the outbreak are no longer with the facility. On 7/31/25, at 1:51 p.m. VP of Success-D informed Surveyor she will have to ask Nursing Home Administrator (NHA)-A if there any other outbreaks. VP of Success-D informed Surveyor they do not have any testing information or any health department recommendations. VP of Success-D provided Surveyor with mapping and line listing for the November 2024 COVID outbreak. On 7/31/24, at 2;14 p.m., VP of Success-D informed Surveyor they had no other outbreaks. The facility's policy titled, Water Management Program Policy, and dated 7/16/22 under Policy documents It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) in the facility's water systems based on nationally accepted standards (e.g., ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers), CDC (Centers for Disease Control and Prevention), EPA (Environmental Protection Agency)). Under Policy Explanation and Compliance Guidelines documents 6. Control measures will be applied to address potential hazards at each control point. A variety of measure may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. The measures shall be specified in the water management program action plan. The facility's policy titled, Legionella Surveillance Policy, and dated 10/24/22 under Policy documents It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections. Under Policy Explanation and Compliance Guidelines documents 4. Principles of Legionella transmission: b. Legionella grows best in water temperatures of 77 degrees F (Fahrenheit) - 108 degrees F, particularly in water that is not moving or that does not have enough disinfectant (i.e. pH 6.5-8.5) to kill germs. 4.) On 7/30/25, at 1:48 p.m., Surveyor reviewed the facility's water management plan updated 1/23/25. Surveyor noted this plan under section II. Describe your building water systems documents [Name of Facility] water system is delivered in a loop. The water enters the building in the laundry room and then sent into boiler room and there are two water softeners that the water goes through and four hot water heaters that heat the water to 155 degrees. It is then sent through a mixing valve and brought back down. The water is circulated in a loop (see diagram) to the different areas and is kept at a minimum of 110 degrees. The 155 degree water is sent to the kitchen and laundry room. The cold water is distributed in a loop to all areas. Under the section III. Areas where Legionella could grown and spread documents The areas identified with the best conditions for the growth of legionella are in the dead end branches. Most have been eliminated. Two of the areas have been identified as a janitors closet and med (medication) room that don't get regular use. These will be put on a regular schedule to make sure water is run through these pipes. The other is a large dead-end branch that comes off the main in the boiler room. This will be eliminated in the future. Under section IV Control measures and monitoring documents Daily water temperatures and hot water heater checks will be made by the Maintenance Department to ensure everything is working as it should. Water will be flushed through pipes in areas that are not used on a weekly basis. Water management will be reviewed after any additions or changes to the building. All residents with symptoms will be evaluated. On 7/31/25, at 2:32 p.m. Surveyor met with MD (Maintenance Director)-I to discuss the facility's water management program. Surveyor asked MD-I what he is doing for the dead legs identified. MD-I replied running them every day. Run for 10 seconds and turn then off that's about it. I use these aquacheck pool testers or Hydrion ph strips. Surveyor asked MD-I what is he looking for with these strips. MD-I replied everything should be in. Surveyor asked MD-I in regards to legionella what is he testing for. MD-I replied anything high, really anything bad, anything that can be high is alkalinity. MD-I showed Surveyor daily checking of residents rooms, whether they are occupied or not, including the janitor's closet and medication room. Surveyor asked MD-I what he's doing for the large dead end branch in the boiler room. MD-I replied I didn't know we considered that, let me read that [Surveyor's name]. Surveyor showed MD-I this documentation. MD-I stated unless that's been eliminated that doesn't sound familiar to me. The only thing I drain is my tanks for the boiler. I think we need to up date this that is what we need to do. Surveyor asked MD-I for documentation for water temperatures and when he uses the pool strips. On 8/4/25, at 10:49 a.m., Surveyor met with MD-I to discuss the water testing and dead leg drain provided to Surveyor. The water testing documentation provided to Surveyor is a one page form with months listed on the left side of the form and across the top are the following sections testing completed, testing results, issues noted and initials. Surveyor noted monthly from January through July 2025 for testing results document good and for issues noted there is a check mark. Surveyor asked MD-I what good means. MD-I replied well nothing high. I was just talking with [Name of] Nursing Home Administrator (NHA)-A we are going to have to do a picture of my sample of how it comes out. MD-I informed Surveyor this is for the test strip just to see if anything is too high, alkalinity, chlorine, all that kind of stuff. The dead leg drain is completed monthly and for issues noted documents good. Surveyor inquired about this dead leg drain completed. MD-I informed Surveyor that's the draining of my boiler tanks. Surveyor asked what good means. MD-I informed Surveyor good means no dirt, no sand, nothing bad coming out of the tanks. Surveyor informed MD-I Surveyor has not been provided with any water temperatures for resident's rooms and requested these. On 8/4/25, at 12:00 p.m., Surveyor reviewed the water temperature logs taken Monday to Friday. Surveyor noted the facility's water management plan indicates water should be kept at a minimum of 110 degrees. Surveyor noted during June 2025 there are 165 documented temperatures under 110 degrees. In July starting 7/7/25 to 7/31/25 there are 154 documented temperatures under 110 degrees. Surveyor asked MD-I when the water temperatures in resident's rooms were below 100 degrees did he do anything. MD-I replied no because the water temperature can be between 105 and 110 degrees. Surveyor informed MD-I the water management plan states the water should be a minimum of 110 degrees. Surveyor informed MD-I the water management plan also documents dead ends, like the one in the boiler room, should be flushed weekly. MD-I informed Surveyor that needs to be changed and stated it's a bad water management plan. No additional information was provided. 08/03/2025 2:36 PM diagnoses includes:end stage renal disease, asthma, fibromyalagia, gerd, insomonia, chronic migraine without aura, chronic myeloid leukemia, BCR/ABL positive not having achieved remission, morbid obesity, pleural effusion, quarterly mds 6/13/25bims 15, eating set up, toileting hygiene dependent, roll left and right parital moderate, chair/bed to chair dependent frequently incontinent of urine, always incontinent of bowel, yes for dialysis

Based on interview and record review the facility did not ensure MDS (minimum data set) assessments were coded correctly for 4 (R22, R28, R5, & R3) of 13 reviewed for MDS accuracy. R22's significant change MDS with an assessment reference date of 6/23/25 was incorrectly coded for PASRR (preadmission screening and resident review), pressure injuries, and insulin. R28's quarterly MDS with an assessment reference date of 6/13/25 was incorrectly coded for antibiotic. R5's Significant Change in Status Minimum Data Set (MDS) with an assessment reference date of 5/20/25, did not accurately reflect that R5 has current tobacco use and antipsychotic medication. R3's quarterly MDS with an assessment reference date of 7/2/25 was incorrectly coded for dialysis. Findings include: The facility's policy titled, Conducting an Accurate Resident Assessment and dated 4/28/25 under Policy documents The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. On 7/31/25, at 9:04 a.m., Surveyor asked Senior Director of Clinical Reimbursement (SDCR)-G if Licensed Practical Nurse/Minimum Data Set Assessment Coordinator (LPN/MDS Assessment Coordinator)-H works at the facility or is remote. SDCR-G replied both and explained this facility is smaller and can't support a full time person. LPN/MDS Assessment Coordinator-H is in the building onsite two days a week otherwise is available by email or phone and if she is not available they contact her. SDCR-G explained LPN/MDS Assessment Coordinator-H calls in at least one day a week, goes into PCC (PointClickCare), the electronic medical record system, daily to see if there are any changes regarding new admissions, discharges, changes in payor, hospice and looks at the utilization review logs for residents that are skilled. Surveyor asked when LPN/MDS Assessment Coordinator-H is completing resident's MDS does she complete the MDS onsite. SDCR-G replied both. SDCR-G explained all documentation is uploaded and if the MDS is completed offsite and is unsure of documentation, she will notify the center to get clarification so they can be as accurate as they can. SDCR-G explained LPN/MDS Assessment Coordinator-H reviews the documentation in the record, any hospital paper work, labs, nurses notes, etc everything they have available. SDCR-G informed Surveyor if LPN/MDS Assessment Coordinator-H is in the facility she will assess the resident herself, she goes and talks with the resident and does a physical assessment. Surveyor asked SDCR-G if the assessments are completed by a LPN how does she ensure the assessments are accurate. SDCR-G replied my job is not to ensure that the coding is correct, I'm signing that it is complete. The RN signature is not for accuracy. On 7/31/25, at 9:38 a.m., Surveyor asked SDCR-G why are there so many items miscoded in the MDS. SDCR-G replied I don't know and explained it's very unusual to have that many. SDCR-G informed Surveyor she will get these modified & corrected and stated it is concerning. 1.) R22's diagnoses includes unspecified psychosis (a mental disorder characterized by a disconnection from reality), anxiety disorder, major depressive disorder and diabetes mellitus (high blood sugar). R22's Level II Referral Summary with a referral date of 4/1/25 for the question does the data about the person meet the federal definition of a serious mental illness documents yes. On 7/30/25, at 12:24 p.m., Surveyor reviewed R22's significant change MDS (minimum data set) with an assessment reference date of 6/23/25. Section 1500 Preadmission Screening and Resident Review (PASRR) for the question is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, no is coded. On 7/31/25 at 9:13 a.m. Surveyor asked Senior Director of Clinical Reimbursement (SDCR)-G why no was answered for the question is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. SDCR-G informed Surveyor should of been marked yes so that was coded incorrectly. SDCR-G stated I will modify and correct that by the way. R22's nurses note dated 6/17/25 at 13:30 (1:30 p.m.) by Licensed Practical Nurse (LPN)-K documents Returned on stretcher via ambulance at this time from [Hospital Name]. Alert at baseline. Skin warm an dry color WNL (within normal limits). Offers no s/sx (signs/symptoms) of pain or discomfort. Lungs clear, no SOB (shortness of breath) noted with respirations even and unlabored. Abdomen is soft with bowel sounds hypoactive. Per RN (Registered Nurse) report resident has not had a BM (bowel movement) in 7 days. Writer did rectal check with BM noted. MOM (milk of magnesia) given and took well with no complaints. Bruises noted to Bilateral arms/hands on left hand top of, right hand top of hand and near thumb. Right antecubital bruising noted post IV (intravenous) site. Stage 2 wound left buttock measuring 1x2.2, stage 3 to coccyx measuring 1.1x1.2x0.2. Redness to groin, redness under left breast. Nystatin applied after soap and water wash. General diet thin liquids to continue. Takes medications crush in applesauce or pudding. [Name] Hospice to come in this afternoon to admit into services, complete medications and to see resident. The pressure injury weekly tracker dated 6/17/25 which documents for site 53) sacrum, type is pressure, length 1.2, width 1.3, depth 0.4, & Stage 3. The pressure weekly tracker dated 6/17/25 which documents for site 31) Right buttocks, type Pressure, length 1.0, width 2.2 depth 0.1 and Stage 2. The pressure weekly tracker dated 6/19/25 which documents for site 31) sacrum, type is pressure, length 2, width 2, depth 0.1, and Stage is 3. The weekly pressure injury tracker dated 6/19/25 which documents for site 31) Right buttocks, type is pressure, length 1.5, width 3, depth 0.1 and Stage 2. R22's significant change MDS with an assessment reference date of 6/23/25 under section M0100 Determination of Pressure Ulcer/Injury Risk for the question Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, no is answered. Under section M0210 Unhealed Pressure Ulcers/Injuries for the question does this resident have one or more unhealed pressure ulcers/injuries no is answered. On 7/31/25, at 9:15 a.m., Surveyor informed SDCR-G R22's medical record includes pressure injury weekly trackers dated 6/17/25 & 6/19/25 which documents stage 3 sacrum pressure injury and stage 2 right buttocks and nurses notes which reference R22's pressure injuries but the significant change MDS is coded as R22 not having any pressure injuries. SDCR-G reviewed R22's electronic medical record and informed Surveyor the MDS should have been marked as a stage 2 & stage 3 as the documentation does support this. SDCR-G informed Surveyor the MDS was incorrect. Surveyor reviewed R22's physician orders and was unable to locate an order for insulin. Surveyor also reviewed R22's June 2025 MAR (medication administration record) and was unable to locate documentation insulin was administered to R22. R22's significant change MDS with an assessment reference date of 6/23/25 under section N0350 Insulin for A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days, 7 is coded. On 7/31/25, at 9:17 a.m., Surveyor informed SDCR-G Surveyor reviewed R22's physician orders and June 2025 MAR and was unable to locate R22 received insulin. Surveyor informed SDCR-G R22's significant change MDS is coded as having received 7days for insulin injections. SDCR-G stated let me go back and pull her MAR. Surveyor asked SDCR-G if she noted insulin for R22. SDCR-G replied no. R22's significant change MDS was incorrectly coded for insulin injections. 2.) R28's quarterly MDS (minimum data set) with an assessment reference date of 6/13/25 under section N0415 High-risk Drug Classes: Use and Indication for F. Antibiotic is checked for is taking and indications noted. According to the RAI manual for is taking, check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Surveyor reviewed R28's physician orders and noted a order dated 4/12/25 for Linezolid 600 mg (milligrams) every day until 4/26/25. Surveyor was unable to locate an antibiotic order after R28's 4/12/25 order. On 7/31/25, at 9:19 a.m., Surveyor informed SDCR-G R28's quarterly MDS with an assessment reference date of 6/13/25 is marked yes for an antibiotic. Surveyor noted an antibiotic order 4/12/25 but was unable to locate another antibiotic order. SDCR-G reviewed R28's electronic record and informed Surveyor there was an antiviral not antibiotic. SDCR-G informed Surveyor the MDS is miscoded. No additional information was provided. 3.) R5 was admitted to the facility on [DATE] with pertinent diagnoses that include malignant neoplasm of rectum (a cancerous tumor in the rectum, the final section of the large intestine), bipolar disorder (mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), and post-traumatic stress disorder (a mental health condition that can develop after a person experiences or witnesses a traumatic event, such as a natural disaster, accident, or act of violence). R5's Significant Change in Status Minimum Data Set (MDS) with an assessment reference date of 5/20/25, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R5 is cognitively intact. The MDS documents R5 is understood and understands others. R5’s Patient Depression Questionnaire (PHQ-9) score was 01 indicating no depressive symptoms. R5 exhibited no behaviors during the look back period of the MDS assessment. R5’s care plan for “tobacco use r/t (related to) smoking” initiated on 5/12/25, has the following interventions that were initiated on 5/12/25: •Determine if resident has desire to quit. •Educate on facility policy. •Educate resident/family on risks and health effects of tobacco use. •If resident would like to quit, contact provider to prescribe cessation aides. •Provide tobacco cessation information/assistance/resources. •Provide tobacco cessation material(s).” R5’s “Nicotine Assessment” forms were completed on 4/27/25 and 7/28/25 by the facility and R5 was deemed safe to smoke without supervision. R5’s Significant Change in Status MDS for “Current Tobacco Use” indicated “no” and was signed on May 22, 2025, at 11:32:53 AM. Surveyor noted a smoking care plan was initiated and a “Nicotine Assessment” was completed prior to the MDS being completed. On 7/31/25, at 2:43 pm, Surveyor interviewed Senior Director of Clinical Reimbursement-G and was told they would look at the MDS coding and get back to Surveyor. On 7/31/25, at 2:50pm, Senior Director of Clinical Reimbursement-G informed Surveyor that R5 had a care plan in place for smoking and “Nicotine Assessments” were done in April and July. A “Nicotine Assessment” should have been done with the Significant Change in Status MDS. Had Senior Director of Clinical Reimbursement-G done the MDS, they probably would have marked R5 as a smoker based on the assessment and care plan in place. Senior Director of Clinical Reimbursement-G stated they will do a correction MDS. On 7/31/25, during the end of day meeting, Surveyor let the facility representatives know the concern that R5’s 5/20/25 Significant Change in Status MDS was coded incorrectly indicating that R5 did not use tobacco. No additional information was provided regarding R5’s MDS being coded incorrectly for tobacco use. R5's Significant Change in Status Minimum Data Set (MDS) with an assessment reference date of 5/20/25, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R5 is cognitively intact. The MDS documents R5 is understood and understands others. R5’s Patient Depression Questionnaire (PHQ-9) score was 01 indicating no depressive symptoms. R5 exhibited no behaviors during the look back period of the MDS assessment. R5’s care plan for “at risk for adverse effects r/t (related to) use of antipsychotic medication” initiated on 5/12/25, has the following interventions that were initiated on 5/12/25: • Antipsychotic Medication: Report adverse effects such as dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling, EPS (Extrapyramidal symptoms) symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). •Notify MD (medical doctor) of decline in ADL (activities of daily living) ability or mood/behavior related to a dosage change. •Provide resident teaching of risks and benefits of medications as needed. •Psychiatrist consult and follow up as needed. •Reduce environmental noise/distractions to facilitate sleep. •Sleep assessment per facility guidelines (Upon admission, initiation of, change of, quarterly, and PRN (as needed)). •TARGET BEHAVIOR 1: RuminatingIntervention #1: Let resident ventIntervention #2: Letting resident express themselves through art and provide art suppliesIntervention #3: offer resident a change of scenery to get mind off of things.” R5’s “Psychosocial Assessment” and “Mood Interview” forms were completed on 5/20/25 by the facility. R5’s physician order dated 5/10/25 documents “Seroquel oral tablet 100mg. Give 2 tablet by mouth at bedtime related to bipolar disorder…”. Surveyor noted R5 was on Lamotrigine 25 mg before starting the Seroquel. The Seroquel was increased by 50mg every 3 days from 5/1/25 until the current dose was reached on 5/10/25. R5’s Significant Change in Status MDS for “antipsychotic medication” indicated “no” and was signed on May 22, 2025, at 11:32:53 AM. Surveyor noted an antipsychotic care plan was initiated before the assessment, R5 had a physician order for Seroquel, and the “Psychosocial Assessment” and “Mood Interview” were completed in relation to the MDS. On 7/31/25, at 2:43 pm, Surveyor interviewed Senior Director of Clinical Reimbursement-G and was told they would look at the MDS coding and get back to Surveyor. On 7/31/25, at 2:50pm, Senior Director of Clinical Reimbursement-G informed Surveyor that R5 should have been marked yes for antipsychotic on the MDS. Senior Director of Clinical Reimbursement-G stated they will do a correction MDS. On 7/31/25, during the end of day meeting, Surveyor let the facility representatives know the concern that R5’s 5/20/25 Significant Change in Status MDS was coded incorrectly indicating that R5 did not take an antipsychotic medication. No additional information was provided regarding R5’s MDS being coded incorrectly for antipsychotic medication use. 4.) R3 was admitted to the facility on [DATE], with diagnoses that include chronic kidney disease (advanced stage of kidney disease where the kidneys are not functioning properly) and dependence on renal dialysis (a life sustaining treatment that replaces the function of failing kidneys by removing waste products and excess fluid from the blood). On 07/29/2025, at 8:59 AM, Surveyor reviewed R3’s Quarterly Minimum Data Set (MDS) dated [DATE]. Section O0100 Dialysis for the question is the resident currently receiving dialysis treatments, no is coded. On 7/31/25, at 9:04 a.m., Surveyor asked Senior Director of Clinical Reimbursement (SDCR)-G if Licensed Practical Nurse/Minimum Data Set Assessment Coordinator (LPN/MDS Assessment Coordinator)-H works at the facility or is remote. SDCR-G replied both and explained this facility is smaller and can't support a full-time person. LPN/MDS Assessment Coordinator-H is in the building onsite two days a week otherwise is available by email or phone and if she is not available, they contact her. SDCR-G explained LPN/MDS Assessment Coordinator-H calls in at least one day a week, goes into PCC (PointClickCare), the electronic medical record system, daily to see if there are any changes regarding new admissions, discharges, changes in payor, hospice and looks at the utilization review logs for residents that are skilled. Surveyor asked when LPN/MDS Assessment Coordinator-H is completing resident's MDS does she complete the MDS onsite. SDCR-G replied both. SDCR-G explained all documentation is uploaded and if the MDS is completed offsite and is unsure of documentation, she will notify the center to get clarification so they can be as accurate as they can. SDCR-G explained LPN/MDS Assessment Coordinator-H reviews the documentation in the record, any hospital paperwork, labs, nurses notes, etc everything they have available. SDCR-G informed Surveyor if LPN/MDS Assessment Coordinator-H is in the facility she will assess the resident herself, she goes and talks with the resident and does a physical assessment. Surveyor asked SDCR-G if the assessments are completed by a LPN how does she ensure the assessments are accurate. SDCR-G replied my job is not to ensure that the coding is correct, I'm signing that it is complete. The RN signature is not for accuracy. Surveyor then asked SDCR-G if LPN/MDS Assessment Coordinator-H is responsible for filling out section O on the MDS. SDCR-G replied yes part of it and clarified LPN/MDS Assessment Coordinator-H is responsible for filling out all of section O except the therapy section. Surveyor asked SDCR-G why dialysis was marked no on R3’s Quarterly MDS dated [DATE]. SDCR-G stated it should have been marked yes and SDCR-G stated she will get it corrected. On 7/31/25, at 1:52 PM, Surveyor notified Nursing Home Administrator (NHA)-A of concerns with R3’s Quarterly MDS dated [DATE], as discussed with SDCR-G. NHA-A acknowledged these concerns. Surveyor requested additional information if available. None was provided.

Based on interview and record review, the facility did not ensure 8 (R2, R6, R3, R23, R4, R8, R22, and R28) of 9 residents were notified of the reason for transfer/discharge and bed hold policy in writing to the resident and their representative and the rate to reserve the resident bed was not documented in the facility’s transfer/ bed hold notice forms. * R2 was transferred to the hospital on 5/12/2025 and 7/23/2025, a transfer notice and bed hold rate was not provided in writing to R2 and/or R2’s representative. * R6 was transferred to the hospital on 2/13/2025, a transfer notice and bed hold rate was not provided in writing to R6 and/ or R6’s representative. * R3 was transferred to the hospital on 3/20/2025, 5/4/2025, and 5/14/2025, a transfer notice and bed hold rate was not provided in writing to R3 and/ or R3’s representative. * R23 was transferred to the hospital on 6/4/2025, a transfer notice and bed hold rate was not provided in writing to R23 and/ or R23’s representative. * R4 was transferred to the hospital on 3/2/2025, 5/22/2025, and 5/27/2025, a transfer notice and bed hold rate was not provided in writing to R4 and/ or R4’s representative. * R8 was transferred to the hospital on 3/7/25, 4/8/25 & 5/1/25. A transfer notice and bed hold rate was not provided in writing to R8 and/ or R8’s representative. * R22 was transferred to the hospital on 6/11/2025, a transfer notice and bed hold rate was not provided in writing to R22 and/ or R22’s representative. * R28 was transferred to the hospital on 4/5/2025, a transfer notice and bed hold rate was not provided in writing to R28 and/ or R28’s representative. Findings include: The facility policy titled “Transfer and Discharge (including Against Medical Advise (AMA)” reviewed/ revised on 7/15/2022 documents: “Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by resident, necessary for the health and safety of resident or other individuals are endangered, or as otherwise permitted by applicable law. … 7. Emergency transfers/ Discharges … i. Provide a notice of the resident’s bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer.j. Provide transfer notice as soon as practicable to resident and representative. …” 1.) R2 was admitted to the facility on [DATE] and has diagnoses that include cognitive communication deficit, traumatic hemorrhage of cerebrum and concussion with loss of consciousness, chronic kidney disease stage 3, and bradycardia. R2 had an activate power of attorney (POA). On 5/12/2025, at 1600 (4:00 PM) in the progress notes nursing documented: Order received to send R2 to emergency room for evaluation for distended abdomen, nausea, and vomiting. R2’s POA called and notified of transfer to emergency room. R2 was readmitted to the facility 5/16/2025. On 7/23/2025, at 11:00 AM, in the progress notes nursing notes it documented: Resident in bathroom with aide, resident lethargic, diaphoretic, dark and loose stools on the toilet. … sent to emergency room for further evaluation. On 7/23/2024, at 18:02 (6:02 PM), in the progress notes nursing notes it documented: Call placed to hospital for follow up on R2 … R2 admitted to the hospital. … Bed hold initiated. Surveyor reviewed R2’s medical record and noted a verbal confirmation of transfer and bed hold was obtained form R2’s POA. There is no documentation that R2’s POA was provided a written copy of transfer notice or bed hold rate for R2’s hospitalization on 5/12/2025 and 7/23/2025. 2.) R6 was admitted to the facility on [DATE] and has diagnoses that include peripheral vascular disease, major depressive disorder, and dementia with psychotic disturbance. R6 has an activated power of attorney (POA). R6's nursing note documents that R6 was transferred to the hospital on 2/13/25. Surveyor was unable to locate any documentation that R6 or R6's representative was provided with a bed hold and or transfer notice as required. On 7/31/2025, at 10:12 AM, a Surveyor interviewed licensed practical nurse (LPN)-K what the process was when a resident is sent to the hospital for further evaluation. LPN-K stated if a residents POA is activated the nurse will typically call to get an ok to send the resident to the hospital. LPN-K stated there is a bed hold form that gets filled out when a verbal is provided from the POA and then the sheet goes to social services coordinator (SSC)-J, director of nursing (DON)-B, or nursing home administrator (NHA)-A. LPN-K was not aware what happened to the bed hold form after filled out. On 7/31/2025, at 10:22 AM, a Surveyor interviewed SSC-J who stated nursing staff handles the paperwork when a resident is sent to the hospital for further evaluation. SSC-J stated that at times SSC-J will assist with any paperwork but not on a routine basis. SSC-J replied no when asked if send resident representatives the bed hold policy. On 7/31/2025, at 10:30 AM, a Surveyor interviewed DON-B who stated nursing does the bed hold when a resident gets sent to the hospital and the bed holds are given to business office manager (BOM)-L. DON-B was not sure what staff provided the resident representative a transfer notice or bed hold policy in writing. On 7/31/2025, at 10:38 AM, a Surveyor interviewed BOM-L who stated BOM-L receives the bed holds and scans them into point click care (PCC, Healthcare software). BOM-L stated that is all that BOM-L does with the bed hold paperwork and replied no when asked if BOM-L gives the resident’s representative a bed hold/ transfer notice. On 7/31/2025, at 10:42 AM, a Surveyor interviewed NHA-A and asked what the process was for transfer notice/ bed hold policy was for when a resident gets sent out to the hospital for further evaluation. NHA-A stated the nurse that is calling the resident’s representative should fill out the bed hold form after getting verbal confirmation that the representative would like to do a bed hold, then the bed hold form goes into medical records and is scanned into PCC. A Surveyor asked is a transfer reason and bed hold policy/ rate sent to the resident representative, NHA-A replied no, the facility does not mail them a transfer notice or bed hold policy/rate. On 7/31/2025, at 3:10 PM, Surveyor shared concerns with NHA-A, DON-B, DON-C, and vice president of success (VPS)-D when R2 was transferred to the hospital on 5/12/2025 and 7/23/2025, a transfer notice and bed hold rate was not provided in writing to R2 and/or R2’s representative. Surveyor also informed concern when R6 was transferred to the hospital on 2/13/2025, a transfer notice and bed hold rate was not provided in writing to R6 and/ or R6’s representative. 3.) R3 was admitted to the facility on [DATE], with diagnoses that include chronic kidney disease (advanced stage of kidney disease where the kidneys are not functioning properly), dependence on renal dialysis (a life sustaining treatment that replaces the function of failing kidneys by removing waste products and excess fluid from the blood), absence of right leg below the knee, absence of left leg below the knee, and history of venous thrombosis and emboli (history of blood clot). R3’s Electronic Medical Record (EMR) documents R3 was transferred to the hospital on 3/20/25, 5/4/25, and 5/14/25 for a change in condition. There is no documentation that R3 was provided a written copy of transfer notice or bed hold rate for R3’s hospitalizations on 3/20/25, 5/4/25, and 5/14/25. 4.) R23 was admitted to the facility on [DATE], with diagnoses that include hemiplegia (weakness affecting one side of the body), hemiparesis (weakness affecting one side of the body), weakness, aphasia (inability to properly communicate), chronic kidney disease (disease where the kidneys are not functioning properly), and history of Urinary Tract Infection (UTI (infection in the urine). R23’s EMR documents R23 was transferred to the hospital on 6/4/25 for a change in condition. There is no documentation that R23’s POA was provided a written copy of transfer notice or bed hold rate for R23’s hospitalizations on 6/4/25. On 7/31/2025, at 10:12 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-K about bed hold notice when a resident is transferred to the hospital. LPN-K stated the resident receives verbal notice then facility staff will fill out the bed hold form and gives to the Director of Nursing (DON), Nursing Home Administrator (NHA)-A, or Social Worker (SW). On 07/31/2025, at 10:22 AM, Surveyor interviewed Social Services Coordinator (SSC)-J regarding bed hold policy. SSC-J stated the bed hold policy is at the nurse’s station but stated it does not get sent to the resident or resident’s representative. On 07/31/2025, at 10:30 AM, Surveyor interviewed Interim DON-B regarding bed hold notices. Interim DON-B stated staff would ask the resident if the resident would like a bed hold, or the resident’s representative would give verbal consent. Interim DON-B stated the bed hold notices are given to the Business Office Manager (BOM). On 07/31/2025, at 10:38 AM, Surveyor interviewed BOM-L regarding bed hold notices who stated BOM-L only uploads the bed hold notice into the resident’s EMR and was unaware if the bed hold notice was provided in writing to residents or resident’s representative. On 7/31/25, at 11:27 AM, NHA-A notified Surveyor the facility does not have bed hold notices and transfers for R3 and R23. Surveyor notified NHA-A of concerns with R3 and R23 not having bed hold and transfer notices. NHA-A acknowledged these concerns. 5.) R4 was admitted to the facility on [DATE] with diagnoses including idiopathic gout, cognitive communication deficit, DMT2, alcoholic cirrhosis of liver without ascites, hypertensive chronic kidney disease stage 5, end stage renal disease, dependence on renal dialysis, polyneuropathy, and depression. R4 is their own person. R4 was transferred and admitted to the hospital on [DATE], 5/22/25, 5/28/25, and 6/13/25. R4 readmitted to the facility on [DATE], 5/23/25, 5/31/25, and 6/28/25. Surveyor reviewed R4’s electronic medical record and could not locate a transfer and bed hold notice for R4’s hospitalizations on 3/2/25 or 5/22/25. Surveyor located a bed hold and notice of transfer document dated 5/27/25, however, there is no documentation of R4’s consent, and there is no documented bed hold rate. On 7/31/2025, at 10:12 AM, a Surveyor interviewed Licensed Practical Nurse (LPN)-K about bed hold notice when a resident is transferred to the hospital. LPN-K stated the resident receives verbal notice then staff fills out the bed hold form and gives to the Director of Nursing (DON), NHA, or social worker. On 07/31/2025, at 10:22 AM, a Surveyor interviewed Social Services Coordinator (SSC)-J regarding bed hold policy. SSC-J stated the bed hold policy is at the nurse’s station but stated it does not get sent to the resident or resident representative. On 07/31/2025, at 10:30 AM, a Surveyor interviewed Interim DON-B regarding bed hold notices. Interim DON-B stated staff would ask the resident if the resident would like a bed hold, or the Power of Attorney (POA) would give verbal consent, then the bed hold notices are given to the Business Office Manager (BOM). On 07/31/2025, at 10:38 AM, a surveyor interviewed BOM-L regarding bed hold notices. BOM-L replied BOM-L only uploads the bed hold notice into the resident’s electronic health record and was unaware if the bed hold notice was provided in writing to residents or resident representatives. On 07/31/2025, at 10:42 AM, a Surveyor interviewed NHA-A regarding the process on bed hold notices when a resident is transferred to the hospital. NHA-A stated typically the nurse on the floor would initiate the bed hold notice or would ask NHA-A or SSC-J for assistance, and if a resident’s POA is activated, staff would get verbal consent from POA. NHA-A stated the bed hold policy is part of the admission agreement, but no written notification is provided to the resident or the resident representative when transferred to the hospital. On 8/4/25, at 8:48 am, Nursing Home Administrator NHA-A confirmed no bed hold and notice of transfer documentation was found for R4’s hospitalizations on 3/2/25 or 5/22/25. NHA-A confirmed only the first page of the bed hold and notice of transfer document was located for R4’s hospitalization on 5/27/25 which does not include R4’s consent or bed hold rate information. NHA-A understood Surveyor’s concern with R4 not receiving a written bed hold notice No additional information was provided. 6.) R8 was admitted to the facility on [DATE] with diagnoses that include bladder cancer and anemia. Surveyor reviewed R8’s electronic medical record. R8 was discharged to the hospital for evaluation on 3/7/25, 4/8/25 and 5/1/25. There is no documentation that R8’s POA was provided a written copy of transfer notice or bed hold rate for R8’s hospitalizations on 3/7/23, 4/8/25 and 5/1/25. On 7/31/2025, at 10:12 AM, a Surveyor interviewed LPN-K what the process was when a resident is sent to the hospital for further evaluation. LPN-K stated if a residents POA is activated the nurse will typically call to get an ok to send the resident to the hospital. LPN-K stated there is a bed hold form that gets filled out when a verbal is provided from the POA and then the sheet goes to SSC-J, DON-B , or NHA-A. LPN-K was not aware what happened to the bed hold form after filled out. On 7/31/2025, at 10:22 AM, a Surveyor interviewed SSC-J who stated nursing handles the paperwork when a resident is sent to the hospital for further evaluation. SSC-J stated that at times SSC-J will assist with any paperwork but not on a routine basis. SSC-J replied no when asked if send resident representatives the bed hold policy. On 7/31/2025, at 10:30 AM, a Surveyor interviewed DON-B who stated nursing does the bed hold when a resident gets sent to the hospital and the bed holds are given to business office manager (BOM)-L. DON-B was not sure what staff provided the resident representative a transfer notice or bed hold policy in writing. On 7/31/2025, at 10:38 AM, a Surveyor interviewed BOM-L who stated BOM-L receives the bed holds and scans them into point click care (PCC, Healthcare software). BOM-L stated that is all that BOM-L does with the bed hold paperwork and replied no when asked if BOM-L gives the resident’s representative a bed hold/ transfer notice. On 7/31/2025, at 10:42 AM, a Surveyor interviewed NHA-A and asked what the process was for transfer notice/ bed hold policy was for when a resident gets sent out to the hospital for further evaluation. NHA-A stated the nurse that is calling the resident’s representative should fill out the bed hold form after getting verbal confirmation that the representative would like to do a bed hold, then the bed hold form goes into medical records and is scanned into PCC. A Surveyor asked is a transfer reason and bed hold policy/ rate sent to the resident representative, NHA-A replied no, the facility does not mail them a transfer notice or bed hold policy/rate. On 8/4/25 at 11:00 AM, Surveyor shared concerns with NHA-A and vice president of success (VPS)-D when R8 was transferred to the hospital on 3/7/25, 4/8/25 and 5/1/25 that a transfer notice and bed hold rate was not provided in writing to R8 and/or R8’s representative. No additional information was provided by the facility at this time. 7.) R22's diagnoses includes hypertension (high blood pressure), aphasia (language disorder that affects a person's ability to communicate) following cerebral infarction (condition where blood flow to the brain is disrupted leading to the death of brain tissue, also known as ischemic stroke), morbid obesity, seizure, and unspecified psychosis (mental health condition characterized by a loss of contact with reality). R22’s nurses note dated 6/11/25 documents On 6/10 at approximately 1745 (5:45 p.m.), writer was called to res (resident) room by floor nurse regarding res having seizure-like activity. writer entered res room and observed res lying in bed with jerking movement noted, eyes opened starring, writer asked staff to call 911, floor nurse was asked to obtain res vitals and to stay with res ensuring res safety, writer placed a call to POA (Power of Attorney), left a message to call facility for an update, writer printed res face sheet/med list/ code status, writer gave all documents to EMT (emergency medical technician) staff, called placed to [Name] Community Memorial Hospital Menomonee Falls, triage nurse received a report regarding res current status, res left facility approximately 1800 (6:00 p.m.) in route to [hospital initials], [Name] NP (Nurse Practitioner) gave verbal order to send res out for further eval (evaluation), writer will f/u (follow up) with hospital for an update regarding res current status R22 was readmitted to the facility on [DATE]. R22’s Wisconsin Bed Hold and Notice of Transfer form for date of transfer 6/10/25 is checked for the transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility, including hospital transfer. Under the section Bed Hold Request Form phone confirmation has been completed with a date of 6/11/25. Surveyor was unable to locate in R22’s medical record evidence R22 and R22’s POA were provided in writing a bed hold policy and reason for transfer for R22’s discharge on [DATE]. 8.) R28’s diagnoses includes end stage renal disease, chronic myeloid leukemia (cancer), pleural effusion (accumulation of excessive fluid in the pleural space that surrounds each lung), and bradycardia ( slow heart rate). R28’s nurses note dated 4/5/25 documents Call from hospital doctor with results of resident blood culture and is positive for bacteria. Orders received to send to [Hospital name] main campus for admission to room [ROOM NUMBER]C fac Bed 4. Mother [Name] is aware of transfer. R28 was readmitted to the facility on [DATE]. Surveyor reviewed R28’s medical record and was unable to locate a transfer notice and bed hold policy was provided to R28 and/or R28’s representative. On 7/31/25, at 12:33 p.m., [NAME] President (VP) of Success-AA informed Surveyor they were unable to locate the bed hold policy and transfer notice for R28. No additional information was provided.

Based on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 3 (R5, R4, and R2) of 5 residents reviewed for immunizations. * R5’s medical record does not contain any documentation as to whether R5 was offered, received, or declined the COVID-19 immunization. * R4’s medical record does not contain any documentation as to whether R4 was offered, received, or declined the COVID-19 immunization. *R2’s medical record does not contain any documentation as to whether R2 was offered, received, or declined the COVID-19 immunization. Findings include: The facility's policy and procedure dated as revised 9/17/2024 and titled, Covid-19 Vaccination documents: “Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine… 8. COVID-19 vaccinations will be offered to residents when supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine… 11. The facility will educate and offer the COVID-19 vaccine to residents and staff and maintain documentation of such… 14. Consent will be signed prior to admission of the COVID-19 vaccine. This information will be retained in the resident’s medical record or the staff’s medical file… 16. Residents or resident representatives retain the right to accept, decline or change their decision about COVID-19 immunization. If declined, the residents will adhere to the protocols set forth by specific facility policy. Facility should consider completion of Risk Vs Benefit UDA for residents declining immunization. 17. The resident’s medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or; c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal…” 1.) R5 was admitted to the facility on [DATE] with pertinent diagnoses that include malignant neoplasm of rectum (a cancerous tumor in the rectum, the final section of the large intestine), bipolar disorder (mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), and post-traumatic stress disorder (a mental health condition that can develop after a person experiences or witnesses a traumatic event, such as a natural disaster, accident, or act of violence). R5's Significant Change in Status Minimum Data Set (MDS) with an assessment reference date of 5/20/25, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R5 is cognitively intact. The MDS documents R5 is understood and understands others. R5’s Patient Depression Questionnaire (PHQ-9) score was 01 indicating no depressive symptoms. R5 exhibited no behaviors during the look back period of the MDS assessment. Surveyor reviewed R5's electronic medical record and was unable to locate evidence whether R5 was offered, received, or declined the COVID-19 immunization. On 08/04/2025, at 1:42 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E regarding R5 being offered or receiving the COVID-19 immunization. LPN-E stated they review R5's medical record and get back to surveyor. On 8/04/2025, at 2:23 PM, [NAME] President of Success-D let Surveyor know there is not documentation of risk versus benefit regarding R5’s COVID-19 vaccination. Surveyor stated this is a concern. No additional documentation of R5 being offered or refusing the COVID-19 vaccination at or since admission to the facility was provided. 2.) R4 was admitted to the facility on [DATE] with diagnoses that include hypertension (high blood pressure), diabetes mellitus (high blood sugar) and end stage renal disease. On 8/4/25, at 12:49 p.m., Surveyor reviewed R4's immunizations and noted R4 received the Covid 19 vaccine on 4/20/21. Surveyor was unable to locate in R4's medical record R4 was offered and/or refused the Covid 19 vaccination after she was admitted on [DATE]. On 8/4/25, at 1:42 p.m. Surveyor informed Licensed Practical Nurse/Infection Preventionist (LPN/IP)-E Surveyor noted in R4's medical record R4 received the Covid 19 vaccination on 4/20/21 but was unable to locate in R4's medical record R4 was offered and/or refused the Covid vaccine after she was admitted . LPN/IP-E informed Surveyor she will look into this and get back to Surveyor. On 8/4/25, at 2:23 p.m. [NAME] President (VP) of Success-D informed Surveyor that the facility had no documentation regarding R4 being offered a Covid vaccine for R4. 3.) R2 was admitted to the facility on [DATE] with diagnoses that include Cognitive Communication Deficit, Chronic Kidney Disease and Weakness. On 8/4/25 at 12:30 p.m., Surveyor reviewed R2's immunization. Surveyor was unable to locate in R2's medical record if R2 was offered and/or refused the Covid 19 vaccination after she was admitted on [DATE]. On 8/4/25 at 1:42 p.m. Surveyor informed Licensed Practical Nurse/Infection Preventionist (LPN/IP)-E Surveyor noted they were unable to locate in R2's medical record whether R2 was offered and/or refused the Covid vaccine after she was admitted . LPN/IP-E informed Surveyor she will look into this and get back to Surveyor. On 8/4/25, at 2:25 p.m. [NAME] President (VP) of Success-D informed Surveyor that they had no documentation on whether or not R2 was offered and/or refused the Covid vaccine after their admission to the facility.

Based on staff interview and record review the Facility did not ensure 2 (R4 & R2) of 5 Resident reviewed were offered the influenza and/or pneumococcal immunization. R2 received the pneumococcal 23 on 5/18/12. R2's medical record does not have evidence R2 was offered and/or declined the pneumococcal vaccine 15, 20, or 21. R2's medical record does not have evidence R2 was offered and/or declined the influenza vaccine. R4's medical record does not have evidence R4 was offered and/or declined the Pneumococcal vaccine 15, 20, or 21. Findings include: The facility's policy titled, Pneumococcal Vaccine (Series) and last reviewed/revised 3/25/25 under policy documents It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC (Centers for Disease Control and Prevention) guidelines and recommendations. Under Policy Explanation and Compliance Guidelines documents 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record. a. The individual receiving the immunization, or the resident representative, will be provided with a copy of CEDC's current vaccine information statement (VIS) relative to that vaccine. b. If necessary, the vaccine information statement will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding. 4. The resident/representative retains the right to refuse the immunization. The facility will document in the clinical record the reason for refusal or the medical contraindication of the immunization. 6. The type of pneumococcal vaccine (PCV15, PCV20, PCV21 or PPSV23) offered will depend upon the recipient's age, having certain risk conditions, and previously received pneumococcal vaccines, in accordance with current CDC guidelines and recommendations. The facility's policy titled, Influenza Vaccination and last revised 9/13/24 under Policy documents It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer works annual immunization against influenza. Under Policy Explanation and Compliance Guidelines documents 1. Influenza vaccinations will be routinely offered annually when it becomes available to the facility, unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. 9. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization and that the resident received or did not receive the immunization due to medical contraindication or refusal. Consider the use of the Risk vs Benefit UDA in the electronic medical record as a means to capture the resident's choice to not receive the influenza vaccination. 1.) R4 was admitted to the facility on [DATE] and is [AGE] years old. Diagnoses includes hypertension (high blood pressure), diabetes mellitus (high blood sugar) and end stage renal disease. On 8/4/25, at 12:49 p.m., Surveyor reviewed R4's immunizations and noted R4 received the PPSV23 (pneumococcal poly-saccharide vaccine) on 5/18/12. There is no evidence in R4's medical record R4 was offered and/or refused the PCV 15, PCV 20, or PCV 21. According to current CDC recommendations age [AGE]-49 years with certain underlying medical conditions or other risk factors (R4 has end stage renal disease and receives dialysis) who have previously received only PPSV23: 1 dose PCV15, or 1 dose PCV20 or 1 dose PCV21, at least 1 year after the last PPSV23 dose. Surveyor was unable to locate in R4's medical record R4 had received the influenza vaccine prior to admission, received the influenza vaccine after being admitted or refused the influenza vaccine. On 8/4/25, at 1:42 p.m., Surveyor informed Licensed Practical Nurse/IP (LPN/Infection Preventionist)-E, Surveyor was unable to locate R4 was offered and/or declined the PCV15, PCV20, or PCV21 and the influenza vaccine. LPN/IP-E informed Surveyor she will look into this and get back to Surveyor. On 8/4/25, at 2:32 p.m., [NAME] President (VP) of Success-D informed Surveyor they do not have documentation that R4 was offered and/or declined the PCV15, PCV20, or PCV21 and the influenza vaccine. No additional information was provided. 2.) R2 was admitted to the facility on [DATE] and is [AGE] years old. Diagnoses includes Cognitive Communication Deficit, Chronic Kidney Disease and Weakness On 8/4/25 at 12:30 p.m., Surveyor reviewed R2's immunizations and noted R2 received the PPSV23 (pneumococcal poly-saccharide vaccine) on 5/6/04. There is no evidence in R2's medical record R2 was offered and/or refused the PCV 15, PCV 20, or PCV 21. On 8/4/25 at 1:42 p.m., Surveyor informed Licensed Practical Nurse/IP (LPN/Infection Preventionist)-E, Surveyor was unable to locate whether R2 was offered and/or declined the PCV15, PCV20, or PCV21 vaccine. LPN/IP-E informed Surveyor she will look into this and get back to Surveyor. On 8/4/25 at 2:32 p.m., [NAME] President (VP) of Success-D informed Surveyor they do not have any additional information regarding R2 being offered and/or declining the PCV15, PCV20 or PCV21 vaccine. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure a resident's hospice notes were readily available for communication and collaboration of care in accordance with professional standards of practice for 1 (R5) of 2 residents reviewed for hospice services.Hospice visit notes were not updated in R5's medical record or in R5's hospice binder until Surveyor requested the information.Findings include:The facility's policy and procedure titled, Hospice Services Facility Agreement, dated 7/15/2022 was reviewed. The policy documents: Policy Explanation and Compliance Guidelines.:4. The written agreement(s) will set out at least the following.:d. A communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.R5 was admitted to the facility on [DATE] with pertinent diagnoses that include malignant neoplasm of rectum (a cancerous tumor in the rectum, the final section of the large intestine), bipolar disorder (mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), and post-traumatic stress disorder (a mental health condition that can develop after a person experiences or witnesses a traumatic event, such as a natural disaster, accident, or act of violence).R5's Significant Change in Status Minimum Data Set (MDS) with an assessment reference date of 5/20/25, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R5 is cognitively intact. The MDS documents R5 is understood and understands others. R5's Patient Depression Questionnaire (PHQ-9) score was 01 indicating no depressive symptoms. R5 exhibited no behaviors during the look back period of the MDS assessment. R5 is documented to receive hospice care.R5's care plan for R5 choose hospice care due to invasive metastatic rectal CA (cancer), secondary liver mets (metastatic) prognosis revised on 5/19/25 has the following interventions that were initiated on 5/14/25:-Administer medications per MD (medical doctor) orders.-Allow resident/family to discuss feelings, etc.-Assist to reposition.-Assist with ADL (activities of daily living) care and pain management as needed.-Dietary to evaluate and modify meal and snack plan as needed.-Encourage to participate in activities as able.-FYI (for your information): Vitas Hospice.-Hospice staff to visit to provide care, assistance, and/or evaluation.-Provide supportive, private environment for resident and family.-Report skin breakdown, lack of analgesia effectiveness, unexpected weight loss or decline in appetite.The Vitas Hospice contract dated 12/12/24 documents in part 4.3 Communication - The parties will communicate pertinent information with each other verbally or in the Residential Hospice Patient's record at least weekly and/or at each hospice patient visit to ensure that the needs of each Residential Hospice Patient are addressed and met 24 hours per day. Documentation of such communication shall be included in the Residential Hospice Patient's medical record. On 7/31/25, at 10:10 am, Surveyor reviewed R5's hospice binder and was unable to locate any documentation of communication within the binder. Surveyor then reviewed R5's electronic medical record and was unable to locate any documentation of communication.On 7/31/25, at 11:19am, Surveyor interviewed Licensed Practical Nurse (LPN)-K regarding how to communicate with hospice and was told by phone or when the nurse visits, they come and always talk to the facility nurse. Surveyor asked if there is any written communication and LPN-K replied not that that they are aware of.On 07/31/2025, at 1:35 PM, Surveyor requested documentation of communication of hospice visits from Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A.On 08/04/2025, at 8:06 AM, Surveyor reviewed paperwork provided that documented hospice visits starting 5/12/25 through 7/30/25. All the documents had Run by Vitas Hospice Coordinator-Y on 7/31/25 on the bottom.On 08/04/2025, at 10:08 AM, Surveyor interviewed Social Services Coordinator (SSC)-J who is the facility hospice coordinator and asked what the expectation for communication is related to hospice visits. SSC-J- stated that before and after hospice sees a resident, they should follow up with multiple people in the facility regarding order changes and what is going on with resident. Surveyor asked if paperwork is provided and was told if it was not left then hospice will send over schedule and post visit summaries electronically. Surveyor asked who Vitas Hospice Coordinator-Y is and was told they are the Vitas Hospice Coordinator.On 08/04/2025, at 11:44 AM, Surveyor relayed concern of hospice communication not being in the medical record or binder to NHA-A and 2 consultants.No additional information was provided regarding R5's hospice visit notes not being updated in R5's medical record or in R5's hospice binder that was provided.

Based on observation, interview, and record review, the facility did not ensure medications were labeled or properly stored for 1 of 2 medication carts reviewed for medication storage. The facility did not ensure expired medications were properly removed from facility stock and individually prescribed medications. * R2 had medication stored in a medication cart with no date listed as to when medication had been opened*During the medication storage task, six vials of expired magnesium supplements were discovered in the facility's medication room and 1 vial of opened expired magnesium supplement was discovered in a medication cart.Findings include:On 8/4/25 at 9:20 AM, Surveyor observed the Magnolia unit medication cart named with Surveyor observed R2's lubricant eye drop vial without an open date. On 8/4/25 at 9:25 AM, Surveyor showed Licensed Practical Nurse/Infection Preventionist (LPN/IP)-E R2's lubricant eye drop vial and asked if they could see any opened date on the vial. LPN/IP-E responded that they could not see an opened date on R2's lubricant eye drop vial. The medication was removed from the Magnolia unit medication cart.On 8/4/25 at 9:10 AM, Surveyor observed the facility's medication room. Surveyor noted six vials of Major brand Magnesium 500 mg with an expiration date of 6/2025. Surveyor reviewed medication cart. Surveyor noted 1 opened vial of Major brand Magnesium 500 mg with an expiration date of 6/2025. On 8/4/25 at 9:25 AM, Surveyor showed IP the opened vial of Major brand Magnesium 500 mg with an expiration date of 6/2025 that was discovered on the Magnolia unit medication cart. The medication was removed from the Magnolia unit medication cart.On 7/19/21 at 11:30 AM, Surveyor met with Nursing Home Administrator (NHA)-A to share concerns related to R2's undated opened lubricant eye drops. Surveyor shared concerns related to the six vials of Major brand Magnesium 500 mg with an expiration date of 6/2025 found in the facility's medication room and one opened vial of Major brand Magnesium 500 mg with an expiration date of 6/2025 found on the medication cart. No additional information was provided to Surveyor related to undated and expired medications.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R22 & R2) of 2 Residents reviewed for pressure injuries. *R22 was readmitted to the facility on [DATE] with a right buttocks & sacrum pressure injury. The facility did not comprehensively assess R22's right buttocks pressure injury on admission as there are no percentages of the wound bed listed in R22's admission assessment. R22's right buttock pressure injury was incorrectly staged on 6/17/25, 6/19/25, 6/27/25, & 7/3/25. On 6/27/25, R22's sacrum pressure injury was incorrectly staged as Stage 4. The assessment documents a depth of 0.1 and the wound bed is 50% slough and 50% granulation. This assessment does not document any exposed bone, tendon, or muscle and there is no tunneling or undermining. *R2 did not have a comprehensive wound assessment done on R2’s mid thoracic upper back pressure injury when admitted to the facility on [DATE] until 5/9/2025. R2 did not have a comprehensive wound assessment done on R2’s mid thoracic upper back pressure injury when R2 readmitted into the facility on 5/16/2025 until 5/23/2025. Findings include: The facility's policy dated as reviewed/revised 7/20/22 and titled, Pressure Injuries and Non pressure injuries documents: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. The following protocols should guide prevention and treatment efforts, unless specified by a physician otherwise. Under the Pressure Injury Staging for Stage 2 Pressure Injury section it documents: Partial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Under the Policy Explanation and Compliance Guidelines section it documents: 1. Upon admission: a. A head-to-toe body evaluation will be completed on every resident upon admission/readmission and will be documented on the Admission/readmission Evaluation UDA. If skin is compromised: i. If pressure injury: initiate the Pressure Injury Weekly Tracker UDA - one per wound. 1.) R22's diagnoses includes hypertension (high blood pressure), aphasia (language disorder that affects a person's ability to communicate) following cerebral infarction (condition where blood flow to the brain is disrupted leading to the death of brain tissue, also known as ischemic stroke), morbid obesity, seizure, and unspecified psychosis (mental health condition characterized by a loss of contact with reality). R22's nurses note dated 6/17/25 at 1330 (1:30 p.m.) by Licensed Practical Nurse (LPN)-K documents: Returned on stretcher via ambulance at this time from [Hospital Name]. Alert at baseline. Skin warm an dry color WNL (within normal limits). Offers no s/sx (signs/symptoms) of pain or discomfort. Lungs clear, no SOB (shortness of breath) noted with respirations even and unlabored. Abdomen is soft with bowel sounds hypoactive. Per RN (Registered Nurse) report resident has not had a BM (bowel movement) in 7 days. Writer did rectal check with BM noted. MOM (milk of magnesia) given and took well with no complaints. Bruises noted to Bilateral arms/hands on left hand top of, right hand top of hand and near thumb. Right antecubital bruising noted post IV (intravenous) site. Stage 2 wound left buttock measuring 1x2.2, stage 3 to coccyx measuring 1.1x1.2x0.2. Redness to groin, redness under left breast. Nystatin applied after soap and water wash. General diet thin liquids to continue. Takes medications crush in applesauce or pudding. [Name] Hospice to come in this afternoon to admit into services, complete medications and to see resident. R22's nurses note dated 6/17/25 at 17:16 (5:16 PM) written by Interim Director of Nursing (DON)-B documents: Skin impairments are present, complete appropriate weekly tracker UDA. admission Wounds 6/17: tx (treatment) in place, CP (care plan), updated, res (resident) added to Nurse Practitioner (NP)-N wound nurse roster. The pressure injury weekly tracker dated 6/17/25 for site documents: 31) right buttock, type is pressure, length is 1.0, width 2.2, and depth 0.1. Stage is II (2), tissue type documents granulation, drainage is serosanguinous light and for the question verbalizes or demonstrates signs of pain related to wound no is answered, This assessment was completed by Interim DON-B. Surveyor noted there is no percentage for wound bed and Stage 2 pressure injury does not have granulation tissue. The pressure injury tracker dated 6/19/25 for site documents: 31) right buttocks, type is pressure, length is 1.5, width 3, depth is 0.1 and stage is II (2). Tissue type documents granulation, drainage is serosanguinous, & amount of drainage is light. This assessment was completed by Registered Nurse (RN)-M. Surveyor noted there is no percentage for wound bed and Stage 2 pressure injury does not have granulation tissue. Wound NP-N wound evaluation and management summary dated 6/19/25 for right buttocks documents: Etiology- pressure, MDS (minimum data set) 3.0 Stage documents 2. Wound size (L (length) x (times) W (width) x D (depth)) documents 1.5 x 3 x 0.1 cm (centimeters). Exudate is light sero sanguinous and dermis documents open areas with exposed dermis. R22's pressure injury weekly tracker dated 6/27/25 documents: Site 31) right buttocks, type is pressure, length 5, width 2.5, depth is 0.2 and stage is II (2). Tissue type is granulation. Granulation % (percentage) documents 50 and Slough % documents 52. Drainage is serosanguinous and amount of drainage documents moderate. This assessment was completed by Interim DON-B. Surveyor noted R22's right buttocks pressure injury was incorrectly staged and should have been staged as unstageable. Wound NP-N wound evaluation and management summary dated 6/27/25 for right buttocks documents: Etiology- pressure, MDS 3.0 Stage documents 2. Wound size is 5 x 2.5 x 0.1 cm. Exudate is moderate sero-sanguinous and dermis documents open areas with exposed dermis. Surveyor noted the facility's pressure injury weekly tracker and Wound NP-N's assessment do not match. R22's pressure injury weekly tracker dated 7/3/25 documents: Site 31) right buttocks, type is pressure, length 6, width 4 depth 0.1 Stage III (3). Tissue type is slough, slough % documents 100%. Drainage is serosanguinous and amount of drainage documents moderate. This assessment was completed by Interim DON-B. Wound NP-N 'swound evaluation and management summary dated 7/3/25 documents: Right buttocks, Etiology- pressure, MDS 3.0 Stage documents 3. Wound size is 6 x 4 x 0.1 cm. Exudate is moderate sero-sanguinous and slough documents 100%. Surveyor noted the facility's pressure injury weekly tracker and Wound NP-N's assessment incorrectly stages R22's right buttocks pressure injury. 100% slough should be staged as Unstageable. R22's right buttocks pressure injury healed on 7/10/25. On 8/4/25, at 9:11 a.m., Surveyor asked Interim DON-B if a stage 2 pressure injury has granulation tissue. Interim DON-B replied usually no but I go according to the notes from Wound NP-N. Surveyor informed Interim DON-B her assessment dated [DATE] & 6/19/25 does not indicate the percentages of the wound bed. Interim DON-B informed Surveyor she refrains from percentages until the wound NP sees the resident and goes by her. Interim DON-B stated not really my area of expertise. The pressure injury weekly tracker dated 6/17/25 documents: 31) sacrum, type is pressure, length is 1.2, width 1.3, and depth 0.4. Stage is III (3), tissue type documents granulation and drainage is serosanguinous, and amount of drainage is moderate. This assessment was completed by Interim DON-B. Surveyor noted there is no percentage for wound bed. The pressure injury weekly tracker dated 6/19/25 documents: 31) sacrum, type is pressure, length is 2, width 2 and depth 0.1. Stage is III (3), tissue type documents granulation, drainage is serosanguinous and amount of drainage is light. This assessment was completed by RN-M. Surveyor noted there is no percentage for wound bed. Wound NP-N's wound evaluation and management summary dated 6/19/25 for R22's Sacrum documents: Etiology pressure, MDS 3.0 Stage documents 3. Wound size (L (length) x (times) W (width) x D (depth)) is 2 x 2x x 0.1 cm. Exudate is light sero-sanguinous, slough documents 10% and granulation tissue is 90%. Reason for no sharp debridement documents Chronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor closely for now. The pressure injury weekly tracker dated 6/27/25 documents: 31) sacrum, type is pressure, length is 3.5, width 2.8, and depth 0.1. Stage is IV (4), tissue type documents granulation, granulation % documents 50 and slough % documents 52. For presence of exposed structures: bone, tendon, muscle. None is checked. Drainage is serosanguinous, and amount of drainage is moderate. Tunneling or undermining is no. This assessment was completed by Interim DON-B. Wound NP-N's sacrum wound evaluation and management summary dated 6/27/25 documents: etiology pressure, for MDS 3.0 Stage documents 4. Wound size is 3.5 x 2.8 x 0.1 cm. Exudate is moderate sero-sanguinous, slough documents 50% and granulation tissue is 50%. R22's sacrum pressure injury was surgical debrided. Surveyor noted further weekly assessment for R22's sacrum stage 4 pressure injury. On 8/4/25, at 9:14 a.m. Surveyor asked Interim DON-B how it was determined R22's sacrum pressure injury on 6/27/25 was a Stage 4. Surveyor informed Interim DON-B the wound bed was 50% granulation & 50% slough, documentation doesn't indicate presence of bone, tendon or muscle and there was no tunneling or undermining. Interim DON-B informed Surveyor R22's pressure injury looked worse and this is the stage Wound NP-N stage it at. Interim DON-B informed Surveyor she takes Wound NP-N's information and then does the wound tracker. On 8/4/25, at 9:27 a.m. Surveyor telephoned Wound NP-N and left a message asking for a return call. Wound NP-N did not return Surveyor's call. No additional information was provided. 2.) R2 was admitted to the facility on [DATE] and has diagnoses that include fractured superior rim of left pubis, cognitive communication deficit, weakness, traumatic hemorrhage of cerebrum with loss of consciousness and concussion, and pressure ulcer of the back. R2’s admission Minimum Data Set (MDS) dated [DATE] indicated R2 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The facility assessed R2 to be a high risk for pressure injury risk with a Braden score of 16.0. R2 was documented to have an unstageable pressure injury to the mid upper back on admission. R2’s hospital discharge paperwork had the following documented R2 presented to the hospital on 4/26/2025 after a fall at home. Per R2’s family member it is unknown how long R2 was on the floor. Wound assessments completed in the hospital documents the following skin assessments for R2: …4/28/2025:1. Spine, unstageable pressure injury- full thickness, 2.5 X 3.3 X unable to determine (UTD) (length X width X depth)-base is 100% yellow slough (dead, moist, stringy/fibrous tissue on wound surface), light amount of serous (clear, watery fluid) drainage- Peri wound (around the wound) with erythema (redness) … 5/1/2025:1. Spine, unstageable pressure injury- Full thickness, 2.5 X 2.5 X UTD- base is 100% yellow slough, light amount of serous drainage- peri wound with erythema Surveyor reviewed R2’s admission skin assessment dated [DATE] that documented:1. Vertebra (mid-upper back), unstageable pressure injury- 3.0 X 2.6 On 5/9/2025 there was a VOHRA wound assessment note that documented:1. Mid- thoracic upper back, Stage 4 Pressure injury- Full thickness, 3 X 3 X not measurable- 100% slough, moderate purulent drainage- Additional note: post- debridement assessment of this previously unstageable wound has revealed the underlying deep tissue at the muscle/fascia level, which had been on obscured by slough prior to this point. This wound has now revealed itself to be a stage 4 pressure injury. This is not wound deterioration. Surveyor noted that a comprehensive assessment was not completed on admission for R2’s mid thoracic upper back pressure injury until 5/9/2025 when the wound nurse practitioner (wound NP)-N assessed R2’s pressure injury on 5/9/2025. R2 was sent to the hospital on 5/12/2025 and readmitted to the facility on [DATE]. Surveyor reviewed R2’s admission skin assessment dated [DATE] that documented:1. Mid-thoracic upper back, Unstageable- 3 X 2.6 On 5/23/2025 there was a VOHRA wound assessment note that documented:1. Mid- thoracic upper back, stage 4 pressure injury- 2.5 X 2.5 X 0.1- 90% slough, 10% granulation tissue, moderate serosanguinous drainage Surveyor noted that a comprehensive assessment was not completed on re-admission for R2’s mid thoracic upper back pressure injury until 5/23/2025 when wound NP-N assessed it on 5/23/2025. Surveyor noted R2 continues to get weekly assessments showing improvement in R2’s mid thoracic upper back pressure injury with the most recent measurements documenting. 7/31/2025:1. Mid thoracic upper back, stage 4 pressure injury- 0.8 X 0.7 X 0.1, light pink wound bed, no erythema noted around the wound- 50% slough, 50% granulation tissue, no drainage noted- Wound NP-N scraped off biofilm (slimy/ discolored film on the wound bed that can prevent healing of a wound) On 8/4/2025, at 9:03 AM, Surveyor interviewed Director of Nursing (DON)-B who stated when a resident is admitted / readmitted to the facility or a new area of concern is noted, nursing is to get a comprehensive assessment documented. Surveyor asked what the expectation for a comprehensive assessment is for a wound. DON-B stated the comprehensive assessment would state if the area is swollen, red, and has drainage. Surveyor asked who completes the comprehensive wound assessments. DON-B stated a registered nurse (RN) would complete the comprehensive wound assessment, and if DON-B is in the facility at the time DON-B would complete the comprehensive assessment. Surveyor asked how a wound base would be described and staged. DON-B stated DON-B refrains from describing the wound base or staging until wound NP-N is able to assess the wound because DON-B is not comfortable with the staging of a wound. Surveyor shared concern that R2 did not have a comprehensive wound assessment completed on admission on [DATE] and readmission on [DATE] to R2’s mid thoracic upper back pressure injury. DON-B stated that DON-B was not the DON a the time R2 was admitted and noted that wound comprehensive assessments were not always completed accurately and the facility has been working on educating staff. DON-B stated DON-B would look to see if any information could be found regarding comprehensive assessments on 5/7/2025 and 5/16/2025 for R2’s pressure injury. On 8/4/2025, at 10:05 AM, [NAME] President of Success (VPS)- D stated a comprehensive wound assessment for R2’s mid thoracic upper back pressure injury was unable to be located for R2’s admission on [DATE] and readmission on [DATE]. On 8/4/2025, at 12:48 PM, Surveyor shared concerns with nursing home administrator (NHA)-A, DON-B, DON-C, and VPS-D that R2 did not have a comprehensive assessment completed on admission on [DATE] to R2’s mid thoracic upper back pressure injury until 5/9/2025 and on readmission on [DATE] until 5/23/2025. No additional information was provided.

Based on record review and interview, the facility did not ensure that it did not employ individuals who were found guilty of abuse, neglect, exploitation or mistreatment by failing to conduct and maintain completed criminal background checks for 5 of 8 Certified Nursing Assistant (CNA) (CNA-S, CNA-T, CNA-U, LPN-V, and RN-W) facility staff reviewed.Findings include:On 7/30/25, Surveyor reviewed facility employee files to ensure completed background checks.Certified Nursing Assistant (CNA)-S, with a hire date of 1/5/23, was noted to not have a Department of Justice (DOJ) background check completed until 11/21/23, a Background Information Disclosure (BID) check completed until 10/14/23 and an Integrated Background Information System Letter (IBIS) check completed until 11/21/23.CNA-T, with a hire date of 5/16/23, was noted to not have both a DOJ and IBIS background check completed until 4/18/24.Licensed Practical Nurse (LPN)-V, with a hire date of 8/15/23, was noted to not have a BID background check completed until 8/1/24, DOJ and IBIS background check completed until 4/10/25.Registered Nurse (RN)-W, with a hire date of 9/13/24, was noted to not have a BID background check completed until 6/27/25.On 7/30/25, at 2:11 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Business Office Manager (BOM)- L. Surveyor asked the facility process for completing background checks. BOM-L states the BID, DOJ, and IBIS are completed after a new employee is given an offer letter of employment. BOM-L states the employee cannot work prior to the background check process is completed, which includes completion of the BID, DOJ, and IBIS.NHA-A stated Corporate performed audits of background checks on 6/25/25. Surveyor notified NHA-A and BOM-L of concerns with the above findings. NHA-A and BOM-L acknowledged these concerns. Surveyor requested additional information if available. No additional information was provided.

Based on observations, interviews, and record review, the facility did not ensure that residents with pressure injuries received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 of 2 residents (R5 and R7) reviewed. * R5, who was assessed to be at risk for pressure injuries, developed a stage 3 ischium pressure injury identified on 11/21/24. R5's care plan was not updated with new offloading interventions after the development of the ischium pressure injury. On 11/21/24, Wound Doctor (WD)-H recommended to upgrade offloading chair cushion. This was not completed by the facility. WD-H's treatment orders were not initiated until 11/26/24. During the survey process, Surveyor observed R5 to not be repositioned at least every 2 hours and R5 was not wearing heel boots at all times per R5's plan of care. * R7 was admitted with a Deep Tissue Injury to the left heel. Registered Nurse (RN)-D had inaccurate staging of the pressure injury staging it a Stage I. The treatment to the left heel was not initiated until 10/18/2024, two days after R7's admission. No assessments were documented in R7's medical record after 11/5/2024 showing the area had healed. Observation on 11/26/2024 showed R7 had a dark area to the left heel that was not documented. Findings include: The facility's policy Pressure Injuries implemented 8/2/21 and last revised on 7/20/22 documents: Policy: .This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measure intended to achieve the goal of prevention of pressure injuries in our Residents. For those Residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. Examples of impaired skin integrity include, but not limited to, pressure injuries, venous (stasis) ulcers, arterial (ischemic) ulcers, diabetic (neuropathic) ulcers, surgical wounds, skin tears, and rashes. The staging of pressure injury is consistent with recommendation of National Pressure Injury Advisory Panel (NPIAP) and RAI Manual, Section M. Policy Explanation and Compliance Guideline: b. Assess current wounds at least every 7 days, or more frequently as needed. If a wound fails to show some evidence of progress towards healing within 2-4 weeks, the area and the Resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions. Results may vary depending on the Resident's overall condition and interventions/treatments used. The complexity of the Resident's condition may limit responsiveness to treatment or tolerance for certain treatment modalities. The clinicians, if deciding to retain the current regimen, should document the rational for continuing the present treatment to explain why some, or all, of the plan's interventions remain relevant despite little or no apparent healing. Care Planning: A comprehensive skin integrity care plan is based on Resident history, review of skin assessment, braden scale scoring, nutritional assessment, Resident and family interviews, and staff observations. Consider the areas of risk, as well as overall risk assessment score braden scale. Communicate identified risk factors and interventions to direct care staff. 2. Develop interventions based on individual risk factors including, but not limited to, weight, presence of edema, overall health status/comorbidities, use of medical devices, presence of acute infection, end of life/hospice, Resident preferences/choices, or medications that may impact healing. a. In the context of the Resident's choices, clinical condition, and physician input, the Resident's care plan should establish relevant goals and approaches to stabilize or improve co-morbidities, such as attempts to minimize clinically significant blood sugar fluctuations, and other interventions aimed at limiting the effects of risk factors associated with pressure injuries. Alternatively, center staff and practitioners, should document clinically valid reasons why such interventions were not appropriate or feasible. For a Resident to exercise his/her right appropriately to make informed choices about care and treatment, to decline treatment, the center and the Resident (or if applicable, the Resident representative) must discuss the Resident's condition, treatment options, expected outcomes, and consequences of declining treatment or interventions. Centers should document this discussion in the Risk vs. Benefit UDA in the electronic medical record. The care plan should be updated to reflect the Resident's choice and what interventions will be in place to minimize risk to the Resident. 1.) R5 was admitted to the facility on [DATE] and has diagnoses that include Dementia with Mood Disturbance, Adult Failure to Thrive, Atherosclerotic Heart Disease of Native Coronary Artery, Severe Protein-Calorie Malnutrition, Unspecified Psychosis, and Anxiety Disorder. R5 was admitted into Hospice on 5/5/2023 with a diagnosis of severe protein calorie malnutrition and was discharged from hospice on 6/17/24. R5's Quarterly Minimum Data Set (MDS) dated [DATE], documents that R5 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0. The MDS documents that the facility assessed R5 as needing total assistance with activities of daily living (ADLs) with one staff member. R5 has no impairment to her upper extremities and impairment to her bilateral lower extremities and uses a wheelchair. R5 is dependent for assistance with showers, upper and lower body dressing, and transfers. R5 requires substantial/maximum assistance for mobility. The Quarterly MDS also documents that R5 is always incontinent of urine and bowel and wears an adult brief. R5 needs assistance with meal set up and there are no concerns with loss of liquids, holding food, choking, or swallowing difficulties when eating. R5's MDS documents R5 is at risk for developing a pressure injury. At the time of assessment, R5 had 1 stage 1 pressure injury that was unhealed. R5's Pressure Ulcer Care Area Assessment (CAA) completed 7/8/24 documents R5 has an existing pressure ulcer/injury. Extrinsic risk factors include pressure requiring special mattress or seat cushion to reduce or relieve pressure, maceration due to moisture associated skin damage. Intrinsic risk factors include altered mental status, cognitive loss, incontinence, poor nutrition, antipsychotics and antidepressants, diagnoses of chronic or end-stage renal disease, malnutrition, other dementia, and depression. R5's CAA summary documents, R5 is at risk for developing pressure ulcer due to needing of extensive assistance with bed mobility and is frequent incontinent of bladder and bowel. Goal is to ensure R5 maintains current clean and intact skin free of pressure ulcer. Will proceed plan of care. On 8/13/24 and 11/21/24, R5's skin assessments document a score of 14.0, indicating R5 is at moderate risk for pressure injuries. R5's Bedside Kardex Report as of 11/26/24, instructs staff to avoid positioning R5 on left side, monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested, float heels when able, requires low air mattress on bed and cushion to chair and treatments as ordered. R5's open areas with start date: Stage 3 pressure wound on left ischium-11/21/24 1st right toe-arterial wound-11/14/24 2nd right toe-unstageable due to necrosis-11/14/24 Right inner ankle-6/11/24-healed Inner left thigh-10/3/24-healed Left outer ankle-11/5/24-healed Below left pinky toe-11/5/24-healed R5's comprehensive care plan documents: -Stage 3 pressure ulcer to left ischium-initiated on 11/25/24 Original focused problem was initiated on 10/30/24 for an actual open area to left inner peri area due to impaired mobility, incontinence, nutritional deficit Interventions initiated 10/30/24 with no revisions -Administer analgesia per MD (medical doctor) orders -Administer treatment per MD orders -Diet and supplements per MD orders -Encourage and assist as needed to turn and reposition; use assistive devices as needed -Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain. Notify MD PRN (as needed). -Special mattress/cushion on bed/wheelchair -Toileting program as indicated -R5 has unstageable pressure ulcer to the right 2nd hammer toe-initiated 11/25/24 Interventions initiated: -Administer treatments as ordered and monitor for effectiveness -Avoid positioning R5 on left side-revised 11/25/24 -Follow facility policies/protocols for the prevention/treatment of skin breakdown. -If R5 refuses treatment, confer with R5, team and family to determine why and try alternative methods to gain compliance. Document alternative methods. -Monitor nutritional status. Serve diet as ordered, monitor intake and record. -Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length x width x depth), stage. -R5 needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. -R5 requires low air loss mattress on bed and cushion to wheelchair. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue. Surveyor noted that the interventions for R5's open areas were initiated on the first day of the survey process on 11/25/24 and no new interventions have been implemented at the time the pressure injuries were discovered. The open areas on R5's 2nd toe were identified on 11/14/24, but a care plan was not initiated until 11/25/24. R5's stage 3 pressure wound on ischium was identified on 11/21/24, but a care plan was not initiated until 11/25/24. R5 was evaluated and treated by wound doctor (WD)-H on 11/21/24. WD-H documents: 2. Stage 3 pressure wound of the left ischium, 2 x 1.5 x 0.1. Moderate Sero-sanguinous, 70% devitalized necrotic tissue, 20% slough, 10% granulation. Leptospermum honey apply once daily with foam silicone border once daily. Recommendations: cleanse with wound cleanser at time of dressing change. Limit sitting to 60 minutes. Upgrade offloading chair cushion. Identified 11/21/24 3. Unstageable pressure (due to necrosis) of the right 2nd hammer toe. 1.0 x 0.8 x not measurable. Depth is unmeasurable due to presence of nonviable tissue and necrosis. 100% devitalized necrotic tissue. Betadine apply once daily. Recommendations: Pressure Off-loading Boot when in bed, recliner. Identified 11/14/24 R5's current physician orders for wound care were initiated on 11/25/24 with a start date of 11/26/24 and document: -Cleanse left ischium wound with wound cleanser, apply medi honey to the wound bed and cover with a border gauze daily every day shift for pressure wound. -Cleanse right 2nd toe, hammer toe with wound cleanser. Apply betadine to calloused area daily every day for pressure wound. Both physician orders were added to the Treatment Administration Record on 11/26/24 at 6:00 AM. Surveyor noted that WD-H initiated the physician orders on 11/21/24, however, the facility did not implement both wound treatment orders until 11/25/24. R5's physician orders also document that R5 should be wearing off-loading bilateral boots at all times every shift for pressure relief effective 11/1/24. On 11/25/24 at 10:15 AM, Surveyor observed R5 up in wheelchair with a cushion in the chair. Surveyor observed an air mattress on the bed. Surveyor observed 2 heel boots on top of the dresser. On 11/25/24 at 11:22 AM, Surveyor observed R5 in the same position in wheelchair and not wearing heel boots. On 11/25/24 at 12:55 PM, Surveyor observed R5 in wheelchair eating lunch and not wearing heel boots. On 11/25/24 at 2:39 PM, Surveyor observed R5 in bed on R5's left side, facing window. R5 has heel boots on. Surveyor noted that R5 had not been repositioned to relief pressure on R5's left ischium pressure injury as documented in R5's pressure injury plan of care. Surveyor noted that R5 did not have her heel boots on to relief pressure per R5's pressure injury plan of care. On 11/26/24 at 7:35 AM, Surveyor observed R5's treatments being completed by Director of Nursing (DON)-B. Surveyor observed medi-honey applied with border gauze placed on the stage 3 ischium pressure wound. DON-B applied skin prep to the 1st and 2nd right toes. Surveyor noted that DON-B completed the wrong treatment to the 2nd hammer toe. On 11/26/24 at 9:10 AM, Surveyor observed R5 in wheelchair, eating breakfast. R5 did not have heel boots on. On 11/26/24 at 10:28 AM, Surveyor observed R5 in wheelchair, no heel boots on, in common area in front of the television. On 11/26/24 at 11:15 AM, Surveyor observed R5 in wheelchair, no heel boots on, in common area in front of the television. On 11/26/24 at 12:10 PM, Surveyor observed R5 in wheelchair, no heel boots on, in common area in front of the television. On 11/26/24 at 12:56 PM, Surveyor observed R5 in wheelchair, no heel boots on, eating lunch in the dining room. Surveyor has not observed R5 to be repositioned at least every 2 hours during the survey process. On 11/26/24 at 9:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F. CNA-F stated that R5 wears heel boots when in bed. CNA-F knows this because I usually take the heel boots off in the morning. On 11/26/24 at 10:20 AM, Surveyor interviewed WD-H. WD-H explained that the left inner thigh area that is healed started as a scratch. WD-H stated that the left ischium is a stage 3 pressure ulcer, and that bone can be felt. WD-H stated the left inner thigh and the left ischium are considered 2 different areas. WD-H explained that WD-H's company policy does not allow for staff to leave the facility until all documentation including orders are completed and communicated with the facility. WD-H usually rounds with DON-B but did not on 11/21/24. However, WD-H cannot remember who WD-H rounded with on that date. WD-H confirmed there is a problem in the treatment of a pressure injury when there is a delay of treatment. On 11/26/24 at 10:38 AM, DON-B informed Surveyor that Licensed Practical Nurse (LPN)-C was the LPN that rounded with WD-H. Surveyor interviewed LPN-C. LPN-C explained it was LPN-C's first time rounding with WD-H. LPN-C stated that WD-H enters the information into WD-H's computer. WD-H assesses the wound and completes the treatment. LPN-C stated that the particular bandage WD-H wanted for R5 was on order at this time. LPN-C stated LPN-C did not take any verbal orders from WD-H because it was LPN-C's first time rounding. On 11/26/24 at 11:37 AM, Surveyor interviewed DON-B regarding R5's current open wounds. Surveyor and DON-B reviewed R5's comprehensive care plan addressing R5's open areas. Surveyor shared the concern that R5's care plan was revised on 11/25/24 and has no new interventions with the development of the 3 open areas. DON-B agreed R5's care plan should have been updated with new person-centered interventions when first identified. Surveyor shared that a documented root cause analysis of the open areas is not in R5's EMR. DON-B stated she is not sure completely how R5 developed the open areas. DON-B stated that WD-H does not verbally give treatment orders. The facility gets a print out on the rounding. DON-B confirmed DON-B did not do the rounding with WD-H on 11/21/24. DON-B stated the floor nurse does not know how to put in the treatment orders and that DON-B is the only person who puts in new treatment orders. DON-B stated that is the disconnect. DON-B agreed that R5's treatment orders from 11/21/24 did not get processed by the facility and DON-B realized it when Surveyor brought it to the facility's attention. Surveyor discussed with DON-B that a surveyor from the team observed DON-B complete the wrong treatment on the second hammer toe in which DON-B applied skin prep instead of betadine. DON-B confirmed DON-B put the wrong treatment on R5's second hammer toe pressure injury and forgot the treatment order had been switched. DON-B informed Surveyor that DON-B believes that the left inner thigh wound identified on 10/30/24 started as a scratch and is now currently healed. DON-B believes the left inner thigh open area is the same area of the stage 3 left ischium pressure area. Surveyor informed DON-B that no new interventions have been put in place once the stage 3 pressure wound was identified on the left ischium. Surveyor informed DON-B that Surveyor has observed R5 to not have bilateral heel boots on at all times per R5's physician orders during the survey. DON-B stated that R5 sometimes doesn't keep the boots on, but agreed this is not addressed in R5's care plan and that R5's care plan did not include interventions on how staff can reapproach R5 with encouragement to wear the bilateral heel boots. Surveyor informed DON-B that Surveyor has had observations of R5 not being repositioned during the survey process. Surveyor shared with DON-B that WD-H requested an upgrade to R5's off loading chair cushion. DON-B informed Surveyor that R5 has not received a new off loading chair cushion and has not followed up with therapy regarding R5 getting a new chair cushion. DON-B stated it was discussed that R5 needed a spare chair cushion because R5 soils the chair cushion. DON-B was unaware that WD-H recommended a new upgrade off loading chair cushion. On 11/26/24 at 1:30 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R5 has had new open areas identified with no root cause analysis. Surveyor informed NHA-A that R5's person-centered care plan focus for the new areas on the toes and ischium was not initiated until 11/25/24 and contained no new interventions. Surveyor shared with NHA-A that R5 has not had R5's bilateral heel boots on at all times and has not been repositioned every 2 hours during the survey process per physician orders and R5's care plan. Surveyor shared that WD-H recommended a new off loading chair cushion appropriate for R5's stage 3 ischium which has not been implemented by the facility. NHA-A informed Surveyor that NHA-A understood the concerns and had no further information at this time. On 11/26/24 at 1:55 PM, Surveyor spoke with Rehabilitation Director (RD)-I regarding R5's chair cushion. RD-I stated that R5 is not on current caseload. RD-I was asked to get a new cushion because R5 had soiled R5's current chair cushion. RD-I informed Surveyor that R5 currently has a Stage 2 Comfort Support Pro 16x16 wheelchair cushion. RD-I confirmed RD-I did not receive a referral for an upgrade for an off loading cushion for R5 and was not aware that WD-H had recommended the upgrade. RD-I stated that R5's current cushion is not appropriate for a Stage 3 pressure wound on the ischium. No additional information was provided as to why the facility did not ensure that R5 received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing. 38253 2.) R7 was admitted to the facility on [DATE] with diagnoses of open wound to the left lower leg, morbid obesity, diabetes, lymphedema, unstageable pressure ulcer of the left heel, cellulitis of the left lower leg, and anxiety. R7's Admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and impairment to the lower extremity. The assessment documented R7 had a Stage I pressure injury, one venous or arterial ulcer, and a surgical wound. The Pressure Ulcer/Injury Care Area Assessment (CAA) that is associated with this MDS assessment documented R7 had a potential for pressure ulcers. The CAA did not document where the current Stage I pressure injury was located or the individualized characteristics of R7 to help develop a Care Plan to address R7's needs. R7's discharge paperwork from the long-term acute care facility dated 10/16/2024 had orders to treat the left heel pressure injury with skin prep daily. Wound notes were included in the discharge paperwork. The wound note dated 9/23/2024 documented the left heel pressure injury developed on 8/26/2024 and was a Deep Tissue Injury (DTI) that measured 3.2 cm x 3.7 cm with no visible necrotic tissue and a distinct outline of the wound. The wound was being treated at that time with betadine and open to the air daily. On 10/16/2024 on the Admission Evaluation form, nursing documented R7 had a pressure injury to the left heel that measured 6 cm x 3 cm. No staging or description of the pressure injury were documented on the form. On 10/16/2024 at 8:46 PM, in the progress notes, a Registered Nurse (RN) documented R7 had a DTI to the heel that was not open. R7's Skin Integrity Care Plan for the DTI to the left heel was initiated on 10/16/2024. On 10/18/2024, an order was initiated to treat the deep tissue injury to the left heel: wash area with soap and water, pat dry, apply skin prep to area daily and as needed. Surveyor noted the treatment order was not started until two days after R7 was admitted to the facility. On 10/22/2024 at 9:49 AM, in the progress notes, the Registered Dietician documented R7 had a DTI to the left heel and recommended protein liquid 30 ml twice daily for wound healing. Surveyor noted that the order was initiated. On 10/23/2024 on the Skin Review-Weekly form, nursing documented R7 had yeast under the abdominal fold with a current order for antifungal in place. R7's Pressure Injury Weekly Tracker dated 10/16/2024 signed by RN-D on 10/23/2024, RN-D documented the left heel Stage I pressure injury measured 6 cm x 3 cm with 100% epithelial tissue. Surveyor noted the pressure injury was now classified as a Stage I pressure injury rather than following the previous documentation of a DTI. RN-D documented on the Pressure Injury Weekly Tracker form assessments on 10/22/204 signed 10/23/2024, 10/29/2024 signed 10/30/2024, and 11/5/2024 signed 11/6/2024. Each assessment documented the Stage I pressure injury to the left heel was improving with the measurements on 10/29/2024 and 11/5/2024 having the same measurements of 3.3 cm x 2.7 cm closed with 100% skin. No other documentation was found of the pressure injury after 11/5/2024. On 11/26/2024, Surveyor requested from Director of Nursing (DON)-B all of R7's wound documentation for review. DON-B provided the Pressure Injury Weekly Tracker assessments dated 10/16/2024, 10/22/2024, 10/29/2024, 11/5/2024, and 11/14/2024. Surveyor noted the 11/14/2024 assessment had not previously been in R7's medical record. The 11/14/2024 Pressure Injury Weekly Tracker form was completed by DON-B and signed on 11/26/2024 documenting R7's Stage I pressure injury had healed. On 11/20/2024 on the Skin Review-Weekly form, Licensed Practical Nurse (LPN)-C documented R7 had a pressure injury. Surveyor noted DON-B had documented R7's pressure injury had healed on 11/14/2024. On 11/26/2024 at 10:36 AM, Surveyor observed R7 eating breakfast in bed. R7 had an air mattress in place and the left leg/foot was elevated on pillows. R7 stated the dressing to the left lower leg and left heel were done every day. R7 said the left lower leg wound had previously had a wound vacuum in place but R7 was sensitive to the adhesive and so the wound vac was discontinued, and a daily dressing is done. Surveyor asked R7 if R7 would agree to have Surveyor observe the dressing change to the left lower leg and left heel. R7 agreed. In an interview on 11/26/2024 at 11:30 AM, Surveyor asked RN-D why the pressure injury to R7's left heel had changed from a DTI to a Stage I pressure injury. RN-D stated RN-D did not do the initial assessment of R7's left heel so did not know why it was changed to a Stage I. RN-D had completed the Pressure Injury Weekly Tracker forms and Surveyor noted RN-D documented on the 10/16/2024 initial assessment form the left heel pressure injury to be a Stage I. RN-D stated RN-D did the weekly wound rounds but left the facility two weeks prior to work at a different facility so did not know anything currently about R7's heel wound. On 11/26/2024 at 2:01 PM, Surveyor observed R7's left heel with LPN-C. R7's left leg and heel were elevated on pillows. The left leg had a stretchy gauze wrap around the leg holding the dressing in place. No dressing was on the left heel. The left heel had a small black/purple area that measured approximately 0.75 cm x 0.75 cm to the lateral aspect of the heel that was not open and flush with the surrounding skin. LPN-C agreed there was discoloration to the area. LPN-C stated the heel had originally been completely open with red tissue that needed to be measured with a cotton-tipped swab, so the dark area looked much better than what had been there. LPN-C stated the treatment to the left heel had recently been discontinued. On 11/26/2024 at 2:24 PM, Surveyor shared with DON-B the concerns observed during R7's treatment to the left leg. Surveyor shared a dark area was observed on R7's left lateral heel and LPN-C had stated R7's left heel had been open and deep that they had to use a cotton-tipped swab to measure the wound. DON-B stated the wound had never been open. Surveyor shared the conflicting documentation of the pressure injury to be a DTI prior to and at admission and the staging got changed to a Stage I. Surveyor shared with DON-B that RN-D had changed the staging and then stated the wound had always been a DTI when that was not what RN-D had documented. Surveyor shared with DON-B the treatment to R7's left heel did not start until two days after admission and no assessment was documented after 11/5/2024 until Surveyor asked for the wound documentation. DON-B stated DON-B saw R7's left heel on 11/14/2024 and it was healed at that time; DON-B had not documented it until today, 11/26/2024 after realizing the assessment was not in R7's medical record. No additional information was provided at that time.

Based on interview and record review, the facility did not ensure 1 (R5) of 7 residents reviewed were notified when there was a change in condition and a need to alter treatment. * R5's representative was not notified when R5 developed an open area below the left pinky toes on 11/5/24 and when R5 developed an area on the left outer ankle on 11/5/24. Findings Include: On 11/26/24, at 1:01 PM, Director of Nursing(DON) DON-B notified Surveyor there is no facility policy for notification. The facility's policy Pressure Injuries and Non pressure Injuries implemented 8/2/21 and last revised on 7/20/22 documents: .Resident/Responsible Party Education 1. Provide Residents/responsible parties education regarding risk of pressure injuries based on the overall Resident risk. 2. Inform Residents/responsible parties on the presence of wounds. 3. Inform Residents/responsible parties on the status of wound progression. R5 was admitted to the facility on [DATE] has diagnoses that include Dementia with Mood Disturbance, Adult Failure to Thrive, Severe Protein-Calorie Malnutrition, Major Depressive Disorder, Unspecified Psychosis, and Anxiety Disorder. R5 was admitted into Hospice on 5/5/2023 with a diagnosis of severe protein calorie malnutrition and was discharged from hospice on 6/17/24. R5 has an activated health care power of attorney (HCPOA) effective 1/15/24. R5's quarterly minimum data set (MDS) dated [DATE] indicated R5 had severely impaired cognition with a brief interview of mental status (BIMS) score of 0 and the facility assessed R5 needing total assistance with activities of daily living (ADLs) with one staff member. R5 has no impairment to her upper extremities and impairment to her bilateral lower extremities and uses a wheelchair. R5 is dependent assistance for showers, upper and lower body dressing and transfers. R5 requires substantial/maximum assistance for mobility. R5 is always incontinent of urine and bowel and wears an adult brief. R5 needs assistance with meal set up and there are no concerns with loss of liquids, holding food, choking, or swallowing difficulties when eating. On 11/25/24, at 3:09 PM, Surveyor spoke with R5's HCPOA who informed Surveyor that HCPOA was not informed of R5 having open areas to the toe or the ankle. HCPOA was notified by Wound Doctor (WD-H) last week of the status of all of R5's pressure areas and open areas. On 11/25/24, at 3:40 PM, Surveyor requested from Director of Nursing(DON) DON-B a timeline of R5's wounds: when the wounds started, when they healed, and when the HCPOA was notified. On 11/26/24, at 7:47 AM, Surveyor received a list of R5's wounds and when R5's HCPOA was notified. Surveyor reviewed R5's progress notes, WD-H documented notes, and facility assessments for notification of HCPOA located in R5's electronic medical record(EMR). Surveyor noted of all wounds, R5's HCPOA was not notified of the 11/5/24 area below left pinky toe and left outer ankle. The facility wound tracker documents representative was notified but not who was notified or the date the representative was notified. These boxes on the wound tracker document are blank. On 11/26/24, at 10:11 AM, Surveyor reviewed R5's EMR again. Surveyor notes that the effective on 11/5/24 weekly tracker was signed and locked by Registered Nurse(RN) on 11/5/24- RN- D. The date of the notification and specific name of who was notified is blank. On 11/26/24, at 10:51 AM, Surveyor notes that R5's weekly wound assessments for 11/5/25, have now been locked with a date of 11/25/24, the day Surveyors started the survey process at the facility. On 11/26/24, at 11:37 AM, Surveyor interviewed DON-B in regards to R5's HCPOA not being notified of the new open areas on of R5's 11/5/24 wounds on the left pinky toe and left outer ankle. DON-B informed Surveyor that the expectation is that the representative is notified immediately and that the section who is specifically updated with date should be filled out. On 11/26/24, at 12:00 PM, Surveyor interviewed RN-D in regards to the notification of R5's open areas. RN-D stated RN-D would typically put the name of who notified and the date on the weekly wound tracker. RN-D stated when the weekly wound tracker is completed, it is always locked the day of the assessment. On 11/26/24, at 12:05 PM, Surveyor reviewed R5's weekly wound tracker assessments in R5's EMR. Surveyor notes that now R5's weekly wound tracker contains documentation that R5's HCPOA was notified of the open areas on 11/5/24. Surveyor notes this document has been now locked on 11/26/24 at 11:59 AM. On 11/26/24, at 1:30 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that documentation is reflective that R5's HCPOA was notified of R5's 11/5/24 open areas. NHA-A agreed notification should be done right away, but there may be some slack possibly. No additional information was provided as to why the facility did not ensure that R5's activated HCPOA was notified of R5's open areas with a change of treatment.

Based on observation, interview, and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 1(R5) of 4 residents reviewed. * R5's current physician orders, Certified Nursing Assistant (CNA) bedside kardex, and comprehensive care plan document R5 is to wear size D double tubigrips to bilateral lower extremities (BLEs), worn toes to knees 23 hours/day as tolerated. Surveyor observed R5 to not be wearing the tubigrips during the survey process. On 11/14/24 an arterial open area was identified on R5's right 1st toe. R5's person-centered care plan was not updated with new interventions as well as R5 was not wearing physician ordered off-loading bilateral heel boots during the survey process. Findings Include: The facility's policy Pressure Injuries and Non pressure Injuries implemented 8/2/21 and last revised on 7/20/22 documents: Policy: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measure intended to achieve the goal of prevention of pressure injuries in our Residents. For those Residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. Examples of impaired skin integrity include, but not limited to, pressure injuries, venous(stasis) ulcers, arterial(ischemic) ulcers, diabetic(neuropathic) ulcers, surgical wounds, skin tears, and rashes. The staging of pressure injury is consistent with recommendation of National Pressure Injury Advisory Panel (NPIAP) and RAI Manual, Section M. Policy Explanation and Compliance Guideline: b. Assess current wounds at least every 7 days, or more frequently as needed. If a wound fails to show some evidence of progress towards healing within 2-4 weeks, the area and the Resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions. Results may vary depending on the Resident's overall condition and interventions/treatments used. The complexity of the Resident's condition may limit responsiveness to treatment or tolerance for certain treatment modalities. The clinicians, if deciding to retain the current regimen, should document the rational for continuing the present treatment to explain why some, or all, of the plan's interventions remain relevant despite little or no apparent healing. Care Planning: A comprehensive skin integrity care plan is based on Resident history, review of skin assessment, braden scale scoring, nutritional assessment, Resident and family interviews, and staff observations. Consider the areas of risk, as well as overall risk assessment score braden scale. Communicate identified risk factors and interventions to direct care staff. 2. Develop interventions based on individual risk factors including, but not limited to, weight, presence of edema, overall health status/comorbidities, use of medical devices, presence of acute infection, end of life/hospice, Resident preferences/choices, or medications that may impact healing. a. In the context of the Resident's choices, clinical condition, and physician input, the Resident's care plan should establish relevant goals and approaches to stabilize or improve co-morbidities, such as attempts to minimize clinically significant blood sugar fluctuations, and other interventions aimed at limiting the effects of risk factors associated with pressure injuries. Alternatively, center staff and practitioners, should document clinically valid reasons why such interventions were not appropriate or feasible. For a Resident to exercise his/her right appropriately to make informed choices about care and treatment, to decline treatment, the center and the Resident (or if applicable, the Resident representative) must discuss the Resident's condition, treatment options, expected outcomes, and consequences of declining treatment or interventions. Centers should document this discussion in the Risk vs. Benefit UDA in the electronic medical record. The care plan should be updated to reflect the Resident's choice and what interventions will be in place to minimize risk to the Resident. R5 was admitted to the facility on [DATE] has diagnoses that include Dementia with Mood Disturbance, Adult Failure to Thrive, Atherosclerotic Heart Disease of Native Coronary Artery, Sensorineural Hearing Loss, Bilateral, Severe Protein-Calorie Malnutrition, Unspecified Psychosis, and Anxiety Disorder. R5 was admitted into Hospice on 5/5/2023 with a diagnosis of severe protein calorie malnutrition and was discharged from hospice on 6/17/24. R5 has an activated power of attorney (POA) effective 1/15/24. R5's quarterly minimum data set (MDS) dated [DATE] indicated R5 had severely impaired cognition with a brief interview of mental status (BIMS) score of 0 and the facility assessed R5 needing total assistance with activities of daily living (ADLs) with one staff member. R5 has no impairment to her upper extremities and impairment to her bilateral lower extremities and uses a wheelchair. R5 is dependent assistance for showers, upper and lower body dressing and transfers. R5 requires substantial/maximum assistance for mobility. R5 is always incontinent of urine and bowel and wears an adult brief. R5 needs assistance with meal set up and there are no concerns with loss of liquids, holding food, choking, or swallowing difficulties when eating. R5's MDS documents R5 is at risk for developing a pressure injury. At the time of assessment, R5 had 1 stage 1 pressure injury that was unhealed. R5's Care Area Assessment(CAA) completed 7/8/24 documents R5 has an existing pressure ulcer/injury. Extrinsic risk factors include pressure requiring special mattress or seat cushion to reduce or relieve pressure, maceration due to moisture associated skin damage. Intrinsic risk factors include altered mental status, cognitive loss, incontinence, poor nutrition, antipsychotics and antidepressants, diagnoses of chronic or end-stage renal disease, malnutrition, other dementia, and depression. R5's CAA summary documents R5 is at risk for developing pressure ulcer due to needing of extensive assistance with bed mobility and is frequent incontinent of bladder and bowel. Goal is to ensure R5 maintains current clean and intact skin free of pressure ulcer. Will proceed plan of care. R5's physician orders document as of 7/10/24: R5 is to wear size D double tubigrips to bilateral lower extremities(BLEs), worn toes to knees 23 hours/day as tolerated. Nursing to check skin integrity every shift for tolerance. Surveyor notes placement of the tubigrips was being monitored on R5's Treatment Administration Record (TARs). R5's Certified Nursing Assistant (CNA) bedside kardex effective 11/26/24 instructs R5 is to wear size D double tubigrips to bilateral lower extremities(BLEs), worn toes to knees 23 hours/day as tolerated. Nursing to check skin integrity every shift for tolerance. R5's Bedside Kardex Report as of 11/26/24, also instructs staff to avoid positioning R5 on left side, monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested, float heels when able, requires low air mattress on bed and cushion to chair and treatments as ordered. R5's comprehensive care plan initiated on 10/18/18 and revised 7/22/24 am Activities of Daily Living(ADL) self care deficit due to physical limitations, dementia, psychosis and depression. On 7/10/24, the intervention of R5 being dependent assistance of 1 to don/doff Bilateral Lower Extremity size D double tubigrips worm from toes to knees 23 hour/day as tolerated. Nursing to check skin integrity every shift for tolerance. R5's comprehensive care plan also documents: -Right arterial wound to 1st toe-initiated on 11/25/24 Interventions all initiated on 11/25/24: -Administer treatment per MD orders -Diet and supplements per MD orders -Encourage and assist as needed to turn and reposition; use assistive devices as needed -Float heels as able -Special mattress/cushion on bed and wheelchair -Use pillows and/or positioning devices as needed Surveyor notes that focused problems for R5's open area was initiated on the first day of the survey process on 11/25/24 and no new interventions have been implemented at time of identification. The open areas on R5's 1st toe was identified on 11/14/24, but a care plan was not initiated until 11/25/24. R5 was evaluated and treated by wound doctor (WD)-H. On 11/21/24, WD-H documents: 1. R5 has an arterial wound of the right plantar, 1st toe. 0.8 x 0.5 x not measurable. Depth is unmeasurable due to presence of nonviable tissue and necrosis. 100% black necrotic tissue. Skin prep once daily. Identified 11/14/24 R5's current physician orders for wound care were initiated on 11/25/24 with a start date of 11/26/24 -Cleanse right plantar, 1st toe with wound cleanser. Apply skin prep to the area daily until healed every day shift for arterial wound. This physician order was added to the Treatment Administration Record on 11/26/24 at 6:00 AM. R5's physician orders also document that R5 should be wearing off-loading bilateral boots at all times every shift for pressure wound effective 11/1/24. On 11/25/24, at 10:15 AM, Surveyor observed R5 up in wheelchair with a cushion in the chair, eating breakfast. Surveyor observed R5 with white ankle socks and red slippers on. Surveyor observed R5's bare legs with no bilateral tubigrips on. Surveyor also observed an air mattress on the bed. Surveyor observed 2 heel boots on top of the dresser. On 11/25/24, at 11:22 AM, Surveyor observed R5 in the same position in wheelchair, and no bilateral tubigrips were on. R5 is not wearing heel boots. On 11/25/24, at 12:55 PM, Surveyor observed R5 up in wheelchair, eating lunch and was not wearing bilateral tubigrips. R5 is not wearing heel boots. On 11/25/24, at 2:39 PM, Surveyor observed R5 in bed on R5's left side, facing window. R5 has heel boots on. On 11/26/24, at 7:35 AM, Surveyor from the team observed R5's lower legs. Surveyor describes R5's skin above the ankles to feet are dark with poor circulation, ankles are red/dark pink. On 11/26/24, at 9:10 AM, Surveyor observed R5 in wheelchair, eating breakfast and was not wearing bilateral tubigrips. R5 is not wearing heel boots. On 11/26/24, at 9:30 AM, Surveyor interviewed Certified Nursing Assistant(CNA) CNA-F who informed Surveyor that CNA-F has not seen R5 wearing bilateral tubigrips. CNA-F stated that R5 wears heel boots when in bed. CNA-F knows this because I usually take the heel boots off in the morning. On 11/26/24, at 9:32 AM, Surveyor interviewed Licensed Practical Nurse(LPN) LPN-G in regards to R5's bilateral tubigrips. LPN-G informed Surveyor that if it is part of R5's Medication or Treatment Administration Record, then LPN-G should be checking to see if it is completed and put on. Surveyor confirmed LPN-G administered medications to R5 prior to interview. Surveyor shared that R5 is not wearing bilateral tubigrips. LPN-G stated LPN-G was going to check if R5 was wearing bilateral tubigrips. On 11/26/24, at 10:28 AM, Surveyor observed R5 in wheelchair, no heel boots on, in common area in front of the television. R5 is now wearing bilateral tubigrips. On 11/26/24, at 11:15 AM, Surveyor observed R5 in wheelchair, no heel boots on, in common area in front of the television. On 11/26/24, at 12:10 PM, Surveyor observed R5 in wheelchair, no heel boots on, in common area in front of the television. On 11/26/24, at 12:56 PM, Surveyor observed R5 in wheelchair, no heel boots on, eating lunch in the dining room. Surveyor has not observed R5 to be repositioned at least every 2 hours during the survey process. On 11/26/24, at 10:30 AM, Surveyor interviewed LPN-G who informed Surveyor that R5 allowed LPN-G to put the bilateral tubigrips on with out any problem. On 11/26/24, at 11:37 AM, Surveyor shared that during the survey process, Surveyor has observed R5 to not have R5's bilateral tubigrips on with Director of Nursing(DON) DON-B. DON-B stated the expectation is that R5 should have been wearing the bilateral tubigrips. Surveyor and DON-B reviewed R5's comprehensive care plan addressing R5's open areas. Surveyor shared the concern that R5's care plan was revised on 11/25/24 and has no new interventions with the development of the 3 open areas. DON-B agreed R5's care plan should have been updated with new person-centered interventions when first identified. Surveyor shared that a documented root/cause analysis of the open areas is not in R5's EMR. DON-B stated she is not sure completely how R5 developed the open areas. DON-B stated that WD-H does not verbally give treatment orders. The facility gets a print out on the rounding. DON-B confirmed DON-B did not do the rounding with WD-H on 11/21/24. DON-B stated the floor nurse does not know how to put in the treatment orders and that DON-B is the only person who puts in new treatment orders. DON-B stated that is the disconnect. DON-B agreed that R5's treatment orders from 11/21/24 did not get processed by the facility and DON-B realized it when Surveyor was asking questions. Surveyor addressed the concern with DON-B that Surveyor has observed R5 to not have bilateral heel boots on at all times per physician orders during the survey process. DON-B stated that R5 sometimes doesn't keep them on, but agreed this is not addressed in R5's care plan and with interventions on how staff can re-approach R5 with encouragement to wear the bilateral heel boots. Surveyor also informed DON-B that Surveyor has had observations of R5 not being repositioned during the survey process. On 11/26/24, at 1:30 PM, Surveyor shared the concern with Nursing Home Administrator(NHA) that Surveyor observed R5 not wearing R5's bilateral tubigrips during the survey process. Surveyor also shared that R5 has had new open areas identified with no root/cause analysis. Surveyor shared R5's person-centered care plan focused problems for the new area on the 1st toe was not initiated until 11/25/24 and contained no new interventions. Surveyor shared with NHA-A that R5 has not had R5's bilateral heel boots on at all times and has not been repositioned every 2 hours during the survey process. No additional information was provided as to why the facility did not ensure that R5 received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new non-pressure injuries from developing.

Based on observation, interviews, and record review, the facility did not ensure a resident (R) with hearing and vision impairment received proper treatment and assistive devices including arrangements for an audiology (ear doctor) for 1 (R5) of 1 residents reviewed for hearing and eyesight loss. * Surveyor observed R5 to not be wearing R5's glasses and bilateral hearing aides during the survey process. R5's Medication Administration Record(MAR) documented in August 2024, R5 had a referral for audiology consultation to evaluate need for or appropriate type of treatment relating to hearing deficits or medical problems. A consult was not completed. Findings Include: The facility's policy Use of Assistive Devices implemented 9/19/22 documents: .The purpose of this policy is to provide a process for the proper and consistent use of assistive devices for those Residents requiring equipment to maintain or improve function and/or dignity. 1. Assistive devices are tools, products, types of equipment, or technology that help individuals perform tasks and activities. They may help the individual move around, see, communicate, eat, or get dressed. Assistive devices include: h. Sensory enhancements(i.e. hearing aids, glasses) 2. The use of assistive devices will be based on the Resident's comprehensive assessment, in accordance with the Resident's plan of care. 3. The facility will provide assistive devices or obtain referral to specialist, for Resident who need them. 4. Facility staff will provide appropriate assistance to ensure that the Resident can use the assistive devices. 5. Direct care staff will be trained on the use of devices as needed to carry out their roles and responsibilities regarding the devices. 6. A nurse with responsibility for the Resident will monitor for the consistent use of the device and safety use of the device. R5 was admitted to the facility on [DATE] has diagnoses that include Dementia with Mood Disturbance, Adult Failure to Thrive, Sensorineural Hearing Loss, Bilateral, Severe Protein-Calorie Malnutrition, Major Depressive Disorder, Unspecified Psychosis, and Anxiety Disorder. R5 was admitted into Hospice on 5/5/2023 with a diagnosis of severe protein calorie malnutrition and was discharged from hospice on 6/17/24. R5 has an activated power of attorney (POA) effective 1/15/24. R5's quarterly minimum data set (MDS) dated [DATE] indicated R5 had severely impaired cognition with a brief interview of mental status (BIMS) score of 0 and the facility assessed R5 needing total assistance with activities of daily living (ADLs) with one staff member. R5 has no impairment to her upper extremities and impairment to her bilateral lower extremities and uses a wheelchair. R5 is dependent assistance for showers, upper and lower body dressing and transfers. R5 requires substantial/maximum assistance for mobility. R5 is always incontinent of urine and bowel and wears an adult brief. R5 needs assistance with meal set up and there are no concerns with loss of liquids, holding food, choking, or swallowing difficulties when eating. R5's MDS documents that R5 has hearing aides and can hear adequately with them. R5's MDS also documents that R5 has glasses and can see adequately with them. R5's Certified Nursing Assistant(CNA) Bedside Kardex Report as of 11/26/24 documents to ensure bilateral hearing aids are in and functioning for R5. The Kardex also documents that R5 wears hearing aides left and right. To power on, push white button on the hearing aide. One flash indicates that it is on. 2 flashes indicate that it is off. Charging deck, hearing aides must be inserted at night. Flashing light indicates that they are charging. Solid light indicates that they are fully charged. Staff are to monitor eyeglasses. Ensure glasses are worn as appropriate. Ensure glasses are clean, in good repair, and within reach. R5's comprehensive care plan documents: -Alteration in visual acuity as evidence by: wears glasses-Initiated 9/5/18 Interventions: -Attempt to keep frequently used items within easy reach-Initiated 9/5/18, Revised 1/6/19 -Ensure glasses are worn as appropriate. Ensure glasses are clean, in good repair, and within reach.-Initiated 9/5/18, Revised 8/19/20 -Refer to optometry as necessary.-Initiated 2/27/23 -Difficulty communicating due to hearing loss/deafness-Initiated 8/19/20, Revised 7/22/24 Interventions: -Attempt to minimize excess noise-Initiated 8/19/20, Revised 2/25/23 -Gain individuals attention before beginning to converse-Initiated 8/19/20, Revised 2/25/23 -HEARING AIDES (FYI) (bilateral)-Initiated 8/19/20 -Involve in activities which don't depend on ability to communicate/hear parties, crafts, movies-Initiated 8/19/20 -Provide accommodation for hearing impairments for activity participation such as placing near speaker, written instructions, adaptive television-Initiated 8/19/20 -Provide reassurance and patience when communicating with R5. Repeat information as needed-Initiated 8/19/20 -When talking to R5, use gestures and simple sentences while maintaining eye contact-Initiated 8/19/20, Revised 2/25/23 R5's current physician orders document on 8/26/22 for R5 to have a referral for audiology consultation to evaluate need for or appropriate type of treatment relating to hearing deficits or medical problems. Record review of R5's electronic medical record(EMR) indicates there has not been an audiology consult since 3/13/24. Surveyor reviewed R5's EMR for optometry and audiology consults. On 9/29/22 the audiology consult documents has severe to profound mixed hearing loss of the right ear. Severe mixed hearing loss of left ear. With this hearing loss, R5 will not hear conversational speech for either ear. On 3/13/24, R5 was too belligerent to perform audiometric testing. Surveyor was not able to locate optometry consults. On 11/25/24, at 10:15 AM, Surveyor observed R5 in wheelchair, eating breakfast, facing the television that was on at medium volume. R5 was not wearing R5's glasses which were folded up to the right of R5's breakfast tray on the overbed table. Surveyor observed no hearing aides in R5's ears. On 11/25/24, at 11:22 AM, Surveyor observed R5 in same position, in front of TV with no glasses on and no hearing aides in. On 11/25/24, at 12:55 PM, Surveyor observed R5 in the dining room eating lunch with no glasses on or hearing aides in. R5's glasses are folded up on the table next to R5's lunch meal. On 11/26/24, at 9:10 AM, Surveyor observed R5 eating breakfast in the dining room. R5 has no glasses on and no hearing aides in. Surveyor does not observe R5's glasses within reach. On 11/26/24, at 9:30 AM, Surveyor interviewed Certified Nursing Assistant(CNA) CNA-F. CNA-F stated that R5 will take R5's glasses off at times and CNA-F try's to keep up with it. CNA-F stated that CNA-F has never seen R5 wear hearing aides since CNA-F started working in September. On 11/26/24, at 9:32 AM, Surveyor interviewed Licensed Practical Nurse(LPN)-G. LPN-G was unaware that R5 was to be wearing bilateral hearing aides and informed Surveyor, its not listed in the Medication Administration Record(MAR). On 11/26/24, at 10:28 AM, Surveyor observed R5 in wheelchair in common area in front of television that had a movie on at medium sound. Surveyor observed R5's glasses not on and no hearing aides in. On 11/26/24, at 10:30 AM, LPN-G informed Surveyor that LPN-G checked with Director of Nursing(DON)-B who had stated to LPN-G that R5's hearing aides were lost a long time ago. On 11/26/24, at 11:15 AM, Surveyor observed R5 in common area with movie on television and no glasses on. On 11/26/24, at 11:37 AM, Surveyor interviewed DON-B regarding R5's glasses and hearing aides. DON-B started working at the facility in January of 2024 and understood that R5's hearing aides were lost before then. DON-B recalls being told at the 11/20/24 care conference by the Health Care Power of Attorney(HCPOA) that R5's hearing aides were lost. DON-B stated the HCPOA had stated HCPOA was not going to schedule appointments anymore because R5 was never ready in time. DON-B acknowledged the hearing aides were still documented on R5's Kardex and comprehensive care plan and stated that R5 is due for a care plan update. DON-B stated that R5 will leave glasses everywhere, but around lunch time, R5 will wear. Surveyor notes R5 leaving glasses everywhere and wearing at lunch time is not documented on R5's comprehensive care plan or Kardex. On 11/26/24, at 12:56 PM, Surveyor observed R5 eating lunch in the dining room and is not wearing glasses. R5's glasses are not within reach. On 11/26/24, at 1:30 PM, Surveyor shared the concern with Nursing Home Administrator(NHA)-A that Surveyor observed R5 not wearing R5's glasses or hearing aides during the survey process. Surveyor shared that Surveyor had been informed that R5's hearing aides have been lost, however, there is no documentation that the facility has attempted to arrange an audiology consult to obtain new hearing aides. No additional information was provided as to why the facility did not ensure that R5 received the necessary treatment and services consistent with professional standards of practice to promote quality of life by making sure R5's glasses were on during the survey process and that an audiology consult was completed to obtain new bilateral hearing aides so R5 could hear daily conversations.

Based on interview and record review, the facility did not ensure medication administration records were complete and accurate for 2 (R1 and R3) of 5 residents reviewed for medication administration. * R1's Medication Administration Record (MAR) had empty signature boxes for multiple medications from 9/2024 through 11/2024. The signature boxes indicate the medication was administered by a nursing professional assigned to R1. * R3's MAR had empty signature boxes for multiple medications from 9/2024 through 11/2024. The signature boxes indicate if the medication was administered by a nursing professional assigned to R3. Findings include: The facility policy and procedure titled Medication Administration General Guidelines dated 1/2024 document: Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. 4. The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee signature log. 1.) R1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, diabetes, epilepsy, depression, and anxiety. R1's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented R1 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 1 and had hallucinations and delusions. R1 had a Guardian. R1's September 2024, October 2024, and November 2024 MARs were reviewed. R1's September 2024 MAR had the following medications not documented as administered at 7:00 AM on 9/1/2024, 9/3/2024, 9/15/2024, 9/19/2024, and 9/26/2024: -Amlodipine 5 mg for hypertension -Ferrous sulfate 325 mg for a supplement -Januvia 100 mg for diabetes -Omeprazole 20 mg for gastroesophageal reflux disorder -Polyethylene Glycol powder 17 Gm for constipation -Potassium 20 mEq for a supplement -Zoloft 100 mg for anxiety -Senna plus 8.6-50 mg for anal fissure -Topiramate 25 mg for seizures -Acetaminophen 650 mg for pain; the Noon dose was not documented as administered for the same dates and the 7:00 AM dose was not documented as administered on 9/29/2024. -Depakote sprinkles delayed release 250 mg for impulsive behaviors; additionally, the 7:00 AM dose was not documented as administered on 9/12/2024 and the Noon doses were not documented as administered on 9/1/2024, 9/3/2024, 9/15/2024, 9/17/2024, 9/19/2024, and 9/26/2024. Insulin Glargine 18 units was not documented as administered at 7:00 AM on 9/1/2024, 9/3/2024, and 9/9/2024 and blood sugar readings were not documented. The order was changed on 9/10/2024 to be administered in the evening rather than in the morning. Insulin lispro sliding scale and blood sugars were not documented as administered at 11:00 AM on 9/15/2024, at 7:30 AM and 11:00 AM on 9/17/2024, 9/19/2024, and 9/26/2024. R1's October 2024 MAR had the following medications not documented as administered at 7:00 AM on 10/1/2024, 10/9/2024, 10/10/2024, 10/12/2024, 10/23/2024 and 10/25/2024: -Amlodipine 5 mg for hypertension -Ferrous sulfate 325 mg for a supplement -Januvia 100 mg for diabetes -Omeprazole 20 mg for gastroesophageal reflux disorder -Polyethylene Glycol powder 17 Gm for constipation -Potassium 20 mEq for a supplement -Zoloft 100 mg for anxiety -Senna plus 8.6-50 mg for anal fissure -Topiramate 25 mg for seizures -Acetaminophen 650 mg for pain; the Noon dose was not documented as administered for the same dates. Depakote sprinkles 250 mg was not documented as administered at 7:30 AM and 11:00 AM on 10/1/2024 and 10/3/2024. The order was discontinued on 10/3/2024 and new order for valproic acid solution 250 mg three times daily for mood and impulsive behavior was initiated on 10/4/2024. The valproic acid solution was not documented as administered at 7:00 AM and Noon on 10/9/2024, 10/10/2024, 10/12/2024, 10/23/2024 and 10/25/2024. Insulin lispro sliding scale and blood sugars were not documented as administered at 7:30 AM and 11:00 AM on 10/1/2024, 10/9/2024, 10/10/2024, 10/11/2024, 10/12/2024, and 10/23/2024; and at 11:00 AM on 10/7/2024 and 10/25/2024. R1's November 2024 MAR had the following medications not documented as administered at 7:00 AM on 11/21/2024, 11/22/2024, and 11/24/2024: -Amlodipine 5 mg for hypertension -Ferrous sulfate 325 mg for a supplement -Januvia 100 mg for diabetes -Omeprazole 20 mg for gastroesophageal reflux disorder -Polyethylene Glycol powder 17 Gm for constipation -Potassium 20 mEq for a supplement -Zoloft 100 mg for anxiety -Senna plus 8.6-50 mg for anal fissure -Topiramate 25 mg for seizures -Acetaminophen 650 mg for pain; the Noon dose was not documented as administered for the same dates. -Valproic acid solution 250 mg for mood and impulsive behavior; the Noon dose was not documented as administered for the same dates and the 3:00 PM dose on 11/2/2024 was not documented as administered. Insulin glargine 22 units and blood sugars were not documented as administered at 7:00 PM on 11/2/2024, 11/7/2024, and 11/24/2024. Insulin lispro sliding scale and blood sugars were not documented as administered at 4:00 PM on 11/2/2024, 7:30 AM and 11:00 AM on 11/21/2024 and 11/22/2024, and 7:30 AM, 11:00 AM, and 4:00 PM on 11/24/2024. 2.) R3 was admitted to the facility on [DATE] with diagnoses of paralytic syndrome, diabetes, chronic obstructive pulmonary disease, morbid obesity, congestive hear failure, chronic kidney disease, anxiety, and depression. R3's Annual Minimum Data Set (MDS) assessment dated [DATE] documented R3 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and was administered anti-anxiety, antidepressant, diuretic, opioid, and hypoglycemic medications. R3's September 2024, October 2024, and November 2024 MARs were reviewed. R3's September 2024 MAR had the following medications not documented as administered at 7:00 AM on 9/15/2024 and 9/26/2024: -Metolazone 2.5 mg for congestive heart failure; additionally, the 7:00 AM dose was not documented as administered on 9/19/2024. -Metoprolol succinate extended release 75 mg for hypertension -Multivitamin for supplement -Vraylar 1.5 mg for depression -Bumex 3 mg for edema; additionally, the Noon dose was not documented as administered on 9/9/2024, 9/15/2024, 9/24/2024, and 9/26/2024. -Buspirone 10 mg for anxiety -Clonazepam 1 mg for anxiety; additionally, the 7:00 AM dose was not documented as administered on 9/9/2024. Advair diskus aerosol inhaler 100-50 mcg/act for shortness of breath was not documented as administered at 6:00 AM on 9/9/2024, 9/15/2024, and 9/26/2024. Lactobacillus capsule for probiotic was not documented as administered at 6:00 AM on 9/15/2024 and 9/26/2024. Sertraline 100 mg for depression was not documented as administered at 8:00 AM on 9/15/2024 and 9/26/2024. Lidocaine external cream 4% for shoulder pain was not documented as administered at 8:00 AM on 9/9/2024, 9/15/2024, 9/17/2024, and 9/26/2024. Methocarbamol 500 mg, a muscle relaxant, was not documented as administered at 8:00 AM on 9/9/2024, 9/15/2024, and 9/26/2024 and at Noon on 9/15/2024, 9/18/2024, 9/23/2024, 9/24/2024, and 9/26/2024. Pregabalin 75 mg for convulsions was not documented as administered at 8:00 AM on 9/9/2024 and 9/26/2024 and at 8:00 PM on 9/15/2024. Cholestyramine 4 gm packet for high cholesterol was not documented as administered at 8:30 AM on 9/9/2024, 9/15/2024, and 9/26/2024. Ciprofloxacin 500 mg for urinary tract infection was not documented as administered at 9:00 AM on 9/26/2024. Acetaminophen 1000 mg for pain was not documented as administered at 9:00 AM on 9/15/2024 and 9/26/2024 and at 2:00 PM on 9/15/2024. Insulin glargine 46 units for diabetes was not documented as administered at 7:00 PM on 9/26/2024. Insulin lispro sliding scale and blood sugars were not documented as administered at 7:30 AM and 11:00 AM on 9/15/2024, 9/17/2024, and 9/26/2024, and at 11:00 AM on 9/5/2024, 9/9/2024, 9/10/2024, 9/23/2024, and 9/30/2024. R3's October 2024 MAR had the following medications not documented as administered. Advair diskus aerosol inhaler 100-50 mcg/act for shortness of breath was not documented as administered at 6:00 AM on 10/9/2024, 10/12/2024, and 10/23/2024. Lactobacillus for probiotic was not documented as administered at 6:00 AM on 10/9/2024 and 10/12/2024. Bumex 3 mg for edema was not documented as administered at 7:00 AM and Noon on 10/3/2024. Metolazone 2.5 mg for congestive heart failure was not documented as administered at 7:00 AM on 10/9/2024. Metoprolol succinate extended release 75 mg was not documented as administered at 7:00 AM on 10/3/2024, and 50 mg was not documented as administered at 7:00 AM on 10/9/2024, 10/12/2024, 10/23/2024, and 10/25/2024. Multivitamin for supplement, clonazepam 1 mg for anxiety, and buspirone 10 mg for anxiety was not documented as administered at 7:00 AM on 10/9/2024, 10/12/2024, and 10/23/2024, buspirone 10 mg for anxiety was not documented as administered at Noon on 10/23/2024, 10/25/2024, and 10/26/2024, and clonazepam 1 mg for anxiety was not documented as administered at 7:00 PM on 10/9/2024. Cariprazine (Vrylar) 1.5 mg for depression was not documented as administered at 7:00 AM on 10/23/2024. Metformin 1000 mg for diabetes was not documented as administered at 7:30 AM on 10/23/2024. Insulin aspart sliding scale and blood sugars were not documented as administered at 7:30 AM on 10/8/2024, 10/12/2024, 10/23/2024 and 10/25/2024, and at 11:00 AM on 10/8/2024, 10/9/2024, 10/10/2024, 10/12/2024, 10/23/2024 and 10/25/2024. Lidocaine external cream 4% for shoulder pain was not documented as administered at 8:00 AM on 10/9/2024 and 10/12/2024. Bumetanide 2 mg for congestive heart failure, sertraline 100 mg for depression, methocarbamol 500 mg for muscle relaxant, and pregabalin 75 mg was not documented as administered at 8:00 AM on 10/9/2024, 10/12/2024, and 10/23/2024, methocarbamol 500 mg was not documented as administered at Noon on 10/9/2024, 10/10/2024, 10/23/2024, 10/25/2024, and 10/26/2024, and pregabalin 75 mg was not documented as administered at 8:00 PM on 10/9/2024. Acetaminophen 100 mg for pain was not documented as administered at 8:00 AM on 10/23/2024, 9:00 AM on 10/9/2024 and 10/12/2024, 1:00 PM on 10/23/2024, 10/25/2024, and 10/26/2024 and at 9:00 PM on 10/9/2024 and 10/10/2024. Potassium chloride extended release 20 mEq for supplement was not documented as administered at 8:00 AM on 10/12/2024 and 10/23/2024. Doxycycline hyclate 100 mg for skin infection and lactobacillus for supplement was not documented as administered at 8:00 AM on 10/23/2024. Insulin glargine 25 units for diabetes was not documented as administered at 8:00 AM on 10/8/2024, 10/9/2024, and 10/12/2024. Trulicity 3 mg injection for diabetes was not documented as administered at 8:00 AM on 10/8/2024. Vraylar 1.5 mg for depression was not documented as administered at 8:00 AM on 10/9/2024 and 10/12/2024. Cholestyramine packet 4 gm for high cholesterol was not documented as administered at 8:30 AM on 10/9/2024, 10/12/2024, and 10/23/2024. Cetirizine 10 mg for cold symptoms was not documented as administered at 7:00 PM on 10/13/2024. R3's November 2024 MAR had the following medications not documented. Bumetanide 2 mg for chronic kidney disease and cholestyramine 4 gm packet for cholesterol was not documented as administered at 6:00 AM on 11/19/2024, 11/21/2024, and 11/22/2024, and was not documented as administered at 3:00 PM on 11/7/2024 and 11/24/2024. Clonazepam 1 mg for anxiety was not documented as administered at 7:00 AM on 11/19/2024, 11/21/2024, and 11/22/2024, at 3:00 PM on 11/7/2024 and 11/24/2024, and at 7:00 PM on 11/7/2024 and 11/24/2024. Cariprazine (Vrylar) 1.5 mg for depression, metoprolol succinate extended release 50 mg, and multivitamin for supplement was not documented as administered at 7:00 AM on 11/19/2024, 11/21/2024, and 11/22/2024, and metoprolol succinate extended release 50 mg was not documented as administered at 7:00 AM on 11/24/2024. Advair diskus inhaler for chronic obstructive pulmonary disease (COPD) was not documented as administered at 7:00 AM on 11/19/2024, 11/21/2024, and 11/22/2024, and was not documented as administered at 3:00 PM on 11/7/2024 and 11/24/2024. Metolazone 2.5 mg for edema was not documented as administered at 7:00 AM on 11/19/2024 and 11/21/2024. Metformin 1000 mg for diabetes was not documented as administered at 7:30 AM on 11/19/2024 and at 4:00 PM on 11/24/2024. Insulin aspart sliding scale and blood sugars were not documented as administered at 7:30 AM on 11/18/2024, 11/19/2024, 11/22/2024 and 11/24/2024, and at 11:00 AM on 11/18/2024, 11/19/2024, and 11/2/2024, and at 4:00 PM on 11/6/2024, 11/7/2024, and 11/24/2024. Methocarbamol 500 mg for muscle relaxant was not documented as administered at 8:00 AM on 11/19/2024, at Noon on 11/19/2024 and 11/21/2024, at 4:00 PM on 11/24/2024, and at 8:00 PM on 11/7/2024 and 11/24/2024. Potassium chloride 20 mEq for heart failure and Trulicity 3 mg injection for diabetes was not documented as administered at 8:00 AM on 11/19/2024. Lactobacillus capsule for supplement, pregabalin 75 mg for pain, and sertraline 100 mg for depression was not documented as administered at 8:00 AM on 11/19/2024 and at 8:00 PM on 11/7/2024 and 11/24/2024. Buspirone 10 mg for anxiety was not documented as administered at 8:00 AM on 11/19/2024, at Noon on 11/19/2024, and at 4:00 PM on 11/24/2024. Acetaminophen 1000 mg for pain was not documented as administered at 8:00 AM on 11/19/2024, at 1:00PM on 11/19/2024 and 11/21/2024 and at 8:00 PM on 11/7/2024 and 11/24/2024. Dulaglutide 3 mg injection for weight loss was not documented as administered at 3:00 PM on 11/12/2024. Amitriptyline 25 mg for depression was not documented as administered at 7:00 PM on 11/7/2024. Insulin glargine 25 units for diabetes was not documented as administered at 7:00 PM on 11/7/2024 and 11/12/2024. On 11/25/2024 at 1:12 PM, Surveyor asked R3 if R3 had any concerns about getting medications late or not at all. R3 stated all medications and shots have been provided. On 11/25/2024 at 2:01 PM, Surveyor asked Licensed Practical Nurse (LPN)-C when nurses document medications and blood sugar results into the resident's MAR. LPN-C stated they should be put in the MAR right away, but that depends on what is going on in the facility at the time. LPN-C stated LPN-C will write down blood sugars on a piece of paper and then will chart when LPN-C has time if it was busy. LPN-C states LPN-C tries to write everything in the chart right when it happens, like passing meds and blood sugar results. On 11/25/2024 at 3:36 PM, Surveyor asked Director of Nursing (DON)-B what the expectation was for nurses documenting in the MAR medications being administered. DON-B stated the nurse should sign out the medication as soon as it is given and the same for when a blood sugar is obtained. Surveyor shared with DON-B the concern R1 and R3 had multiple medications and blood sugar results that were not documented as administered or obtained. DON-B stated audits are done daily by DON-B to make sure medications are signed out. No additional information was provided as to why the facility did not ensure that medication administration records were complete and accurate for R1 and R3.

Based on the comprehensive assessment of a resident, the facility did not ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and to ensure residents do not develop pressure injuries unless the individual's clinical condition demonstrates they were unavoidable; and residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (R5 and R26) of 2 residents reviewed for pressure injuries. R5 developed a facility acquired, stage 3, pressure injury. R26 developed a facility acquired stage 3 pressure injury on the coccyx on 4/4/24. This pressure injury was assessed on 4/5/24 as a Stage 2 pressure injury. A comprehensive assessment was not completed as there was no documentation of the percentage of the wound bed. The pressure injury was incorrectly staged as a Stage 2 as the coccyx pressure injury had granulation tissue. A stage 2 pressure injury does not have granulation tissue and should have been staged as a Stage 3. R26's care plan was not revised until three days later and the treatment was not started until the next day, 4/5/24. During wound rounds on 4/30/24 R26's pressure injury was not cleansed prior to the clean dressing being applied. CNA's informed Surveyor R26 developed this pressure injury due to not being changed properly and not being repositioned. Findings include: The facility policy titled Pressure Injuries and Non pressure Injuries revised 7/20/22 documents (in part) . .This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. 1. Upon admission: a. A head to toe body evaluation will be completed on every resident upon admission/readmission and will be documented on the Admission/Readmission Evaluation. b. Complete the Braden Scale to assess risk of developing a PI (pressure injury). It consists of six categories: Sensory perception, moisture, activity, mobility, nutrition and friction/shear. c. Initiate the baseline plan of care related to current skin status and skin risk level. When determining skin risk status and appropriate interventions, consider the following: Braden scale score, Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus, drugs such as steroids that may affect healing, impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency, resident declination of some aspects of care and treatment, cognitive impairment, the need or request to elevate the head of bed, exposure of skin to urinary and fecal incontinence, under nutrition, malnutrition and hydration deficits. 2. Weekly: a. Complete a head to toe skin check and document findings on the Skin Review - Weekly. b. Assess current wounds are least every 7 days, or more frequently as needed (e.g. decline in wound, presence of infection, wound healed). If a wound fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident's overall clinical condition should be reassessed. Care Planning: A comprehensive Skin Integrity Care Plan is based on resident history, review of Skin Assessment, Braden Scale scoring, Nutritional Assessments, resident and family interviews, and staff observations. Consider the areas of risk as well as overall risk assessment score of the Braden Scale. 1. Develop interventions based on subsets of Braden Scale that may include: Sensory Perception: Carefully assess ability to move in bed and supplement any deficit. Protect bony prominence's that are affected by sensory deficits. Moisture: Use moisture barrier. Use absorbent pads or incontinent products that wick and hold moisture. Address cause of moisture, if possible. Activity: If resident is chair bound or bed bound, provide good positioning, good support surface and scheduled repositioning in the plan (consider use of micro shifts to supplement routine repositioning for chair bound individuals). Mobility: As mobility scores decrease, concern about the adequacy of the support surface should increase - evaluate need for specialty wheelchair cushion and specialty mattress. Develop turning/repositioning schedule based on resident needs and risk factors. Nutrition: Refer each resident with nutritional risk and pressure injury risk to Dietician and other health care professionals as appropriate. Friction and Shear: Head of bed elevated no more than 30 degrees unless medically necessary, protect elbows and heels as appropriate, keep skin moisturized. 1.) R5 admitted to the facility on [DATE]. Diagnoses include: Type 2 Diabetes Mellitus with chronic Diabetic Neuropathy, Diabetic Retinopathy, Chronic Kidney Disease, Restless Leg Syndrome, Rheumatoid Arthritis, Spinal Stenosis lumbar region, Anemia, Atherosclerotic Heart Disease, Major Depressive Disorder and Hydronephrosis with renal and ureteral calculous obstruction and Clostridium Difficile (C-diff). R5's Admission Minimum Data Set (MDS) with an Annual Reference Date of 2/5/24 documents: Section GG0170 Mobility. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed: Partial/moderate assist. Bed mobility: partial/moderate assist. Section H0200 Urinary Toileting Program. Has a trial of a toileting program (scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? No. Urinary continence - Select the one category that best describes the resident: Always incontinent. Bowel continence. Select the one category that best describes the resident: Always incontinent. Is a toileting program currently being used to manage the resident's bowel continence? No. Section GG0130 Self-Care. Toileting hygiene - The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement: Dependent. R5's Braden dated 2/13/24 documented a score of 16 (At risk). R5's Braden dated 2/20/24 documented a score of 12 (High Risk). R5's Admission assessment dated [DATE] documents: Is Resident Continent of Bladder? No. How long has the resident been incontinent? Longer than 1 year. How often is the resident wet? Once or more per shift. Resident is wet during: Day and night time. Amount of urine: Large (puddles/soaks, clothes, bed, floor). Continent of Stool? No. Subsequent bladder/incontinence evaluations: 2/11/24: Incontinent of bladder. Clothes or incontinence pad wet. Impaired mobility/ambulation. Dependent transfer (2 persons). Leakage with cough, sneeze, physical activity. Incontinence without sensation of urine loss. Prolonged voiding. Nocturia greater than 2 times. Mixed incontinence (symptoms of both stress and urge). Not appropriate for toileting or retraining program. 4/1/24: Incontinent of bladder. Impaired mobility/ambulation. Dependent transfer (2 persons). Decreased manual dexterity. Urinary tract infection within 30 days. Mixed incontinence (symptoms of both stress and urge). Alzheimer's Disease/Dementia, Diabetes. R5's Admission skin assessment dated [DATE] documents: Right heel 3 x 3 x 0.1 cm press (pressure) vs Diabetic. Surveyor noted there was not a comprehensive assessment or staging of the wound. Treatment was ordered and implemented: Apply skin prep to right heel daily every evening shift for skin protection. Surveyor noted no further documentation, assessments or measurements of R5's right heel pressure injury. Surveyor asked the facility to print R5's care plan with revisions. The copy provided did not include revisions and was not the care plan viewed in Point Click Care (PCC). Director of Nursing (DON)-B reported she printed the wrong one and re-printed the care plan. The 2nd care plan provided to Surveyor did not match information viewed on R5's care plan in PCC, such as information about the pressure injury. The facility was advised and printed another copy for Surveyor. The 3rd copy still did not match all information on R5's care plan in PCC. Surveyor was advised the facility is having problems printing and the Care Plan provided is R5's current care plan. R5's care plan documented: At risk for alteration in skin integrity related to: (blank) - initiated 1/29/24. Interventions: Barrier cream to peri area/buttocks as needed. Encourage to reposition as needed; use assistive devices as needed. Use pillows/positioning devices as needed. Surveyor noted although R5 required assistance for bed mobility, the care plan was not personalized to include how often R5 should be repositioned. Actual unstageable pressure wound to the right heel related to diabetes, impaired mobility, incontinence - initiated 2/5/24, resolved 2/20/24. Interventions: Administer treatment per MD (Medical Doctor) orders, diet and supplements per MD orders, encourage and assist as needed to turn and reposition, use assistive devices as needed, float heels as able, Specialty mattress/cushion on bed/wheelchair, heel protectors while in bed. Surveyor noted although R5 required assistance for bed mobility, the care plan was not personalized to include how often R5 should be repositioned. At risk for nutritional status change related to obesity due to excess PO (by mouth) intake, sedentary lifestyle AEB (as evidenced by) BMI (body mass index) greater than 30. Potential for inadequate PO intake r/t (related to) recent C-diff, Covid+, increased nutrient needs, resident reporting she is a fussy eater AEB variable meal intake at times, altered skin integrity - initiated 1/29/24. Surveyor identified concern R5 sustained severe weight loss since admission to the facility (cross reference F692), this was not identified by the facility as a potential concern in pressure injury development and care planned accordingly. ADL (Activity of Daily Living) self-care deficit as evidenced by impaired mobility, C-diff, RLS (Restless Leg Syndrome), rheumatoid arthritis, spinal stenosis, cervical spondylosis - revised 2/5/24. Interventions: Gel cushion in wheelchair - implemented 3/8/24. Bed mobility/Positioning: Extensive assist of 1. Bilateral LE (lower extremity) elevation while in bed - implemented 2/2/24. Toileting: Extensive assist of 1, check and change PRN (as needed) implemented 2/2/24. Bowel Incontinence r/t impaired mobility - initiated 1/29/24. Goal: Will have no skin breakdown. Interventions: Record BM (bowel movement) and report any abnormalities. Report changes in bowel movement frequency, consistency, control, etc. (etcetera). Surveyor noted the care plan was not personalized to include R5 had C-diff with frequent/multiple loose stools per day. R5's care plan indicated check and change PRN. R5 is not aware of incontinence and dependent on staff for incontinence care. The care plan did not specify how often R5 should be checked and changed. Actual stage 3 pressure wound to sacrum posteriorly r/t impaired mobility, incontinence, nutritional deficit - initiated 2/20/24. Interventions: Encourage and assist as needed to turn and reposition, use assistive devices as needed, float heels as able, specialty mattress/cushion on bed/wheelchair. Surveyor noted R5's care plan was not revised after the stage 3 pressure injury was identified. The interventions (including specialty mattress/cushion on bed/wheelchair) were not new and had been implemented on 2/5/24. Review of R5's medical record revealed a Physician's order dated 4/11/24 - Air Mattress: Check function and settings every shift. Every shift for Pressure Reduction. On 4/28/24 at 9:30 AM Surveyor observed R5 lying in bed on her back. Surveyor noted R5 has an alternating pressure air mattress. Surveyor noted the call light pinned to her sheet and asked if she uses it. R5 stated: Yes, but they don't answer it, then I scream for help. R5 reported she very rarely gets out of bed, They don't let me get up in my wheelchair. I screamed enough because I had a burning butt and they finally looked at it. I told them it was their fault, they were letting me sit in feces because they don't answer my light. R5 reported she is able to turn herself herself in bed and demonstrated by grabbing the right grab bar to turn herself halfway onto her right side. R5 reported she would very much prefer to sit up in the chair, but they rarely get me up anymore. This is me, lying in bed all the time. On 4/29/24 at 10:10 AM Surveyor observed R5 lying in bed on her back wearing a gown and pink robe. R5 did not remember Surveyor from previous day. Surveyor asked R5 if she was getting out of bed today. R5 laughed, stating: They never get me out of this bed. Surveyor noted R5 did not get out of bed prior to Surveyor leaving the building at 4:00 PM. On 4/29/24 at 11:53 AM Surveyor spoke with Certified Nursing Assistant (CNA)-K. CNA-K reported she usually works the other side, but does work with R5. Surveyor asked if R5 gets out of bed. CNA-K stated: Yes, it depends on her cognition, if she's really confused we worry she might be flailing or try to get out of her wheelchair, so we might wait awhile, but therapy gave orders that she is supposed to be up for 2 hours each shift. On 4/30/24 at 9:36 AM Surveyor spoke with Therapy Director-L who reported R5 does get out of bed, But it's on her terms, we can't force her but we strongly encourage. On 4/30/24 at 11:29 AM Surveyor spoke with CNA-M and CNA-N. Surveyor asked how they thought R5's pressure injury developed. CNA-M stated: When she (R5) first came she was more alert. She admitted with C-diff and that never stopped. At first she would use the call light to let us know she needed to be changed, but now we just check and change her. Her stool is always loose, watery and mucous - it has been since she came here, so we're supposed to check her every 2 hours, but we check her more often because literally, every time you change her she is incontinent of that watery stool and her butt has always been really red. CNA-M added: Sometimes if she starts yelling out and praying, you know she might be incontinent and uncomfortable, so we go check on her. CNA-N agreed, If she starts yelling, it's usually because she's incontinent, and her stool has always been loose/watery and her butt was red and raw. Surveyor asked if R5 gets out of bed. CNA-M stated: Yeah sometimes, night shift usually gets her up in the chair because she can be behavioral on nights. I know she gets up for therapy. Surveyor asked both CNA's if they have reported R5's loose, watery mucous stools to anyone. CNA-N reported R5's stools have always been that way since she got here, and the nurses know. CNA-M agreed. Surveyor noted the facility identified R5 to be incontinent of bowel and bladder with large amount of urine during day and night time and is dependent on staff for incontinence care. In addition, R5 had a diagnosis of C-diff with frequent loose, watery stools reported by staff. R5's care plan indicates R5 is to be checked and changed as needed. The facility did not complete a comprehensive bowel and bladder assessment to determine a pattern or if R5 needed to be changed more frequently to prevent skin breakdown and pressure injury. R5's Skin Review Weekly dated 2/14/24 documents: Select all impairments that are present: None. Are any new skin impairments present? No. R5's Daily Skilled Observation dated 2/20/24 at 4:14 AM documents: Skin conditions (Check all that apply). Surveyor noted a check mark next to bruises. Any skin treatment/dressing? No. Skin Integrity/Positioning Devices: Heel Relief/Protector/Lift, Chair/Seat Cushion, Alternating Pressure Mattress in bed, Other - please describe. Surveyor noted a check mark next to None of the above. Review of R5's medical record revealed a stage 3 pressure injury was identified on 2/20/24. Surveyor was advised the pressure injury was identified during the Physician and nurse weekly wound rounds. Director of Nursing (DON)-B advised Surveyor she goes around with the physician every week for wound rounds and measure wounds together, so the Physician and facility measurements should be the same. The (name of wound clinic) wound physician notes document: 2/20/24 Stage 3 pressure wound Sacrum full thickness. 1.8 x 5.2 x 0.1 cm (centimeters). Cluster wound open ulceration area of 5.63 cm. 10% slough, 50% granulation, 40% skin. Light serosanguineous exudate. Appropriate treatment was implemented. 2/27/24 visit rescheduled. The facility documentation of wound: Sacrum stage 3. 1.6 x 5.2 x 0.1. 45% granulation, 15% slough, 40% skin. 3/5/24 Stage 3 pressure wound Sacrum full thickness. 1.6 x 5.2 x 0.1 cm. Cluster wound open ulceration area of 4.99 cm. 15% slough, 45% granulation, 40% skin. Moderate serosanguineous exudate. Improved evidenced by decreased surface area. 3/12/24 Stage 3 pressure wound Sacrum full thickness. 1.6 x 3.8 x. 0.1 cm. 40% slough, 60% granulation. Moderate serosanguineous exudate. Improved evidenced by decreased surface area. Stage 3 pressure wound of the left buttock full thickness. 1 x 1 x 0.1 cm. 100% granulation tissue. Moderate serosanguineous drainage. Clustered wound from other listed pressure injury - now being tracked as separate wound instead of clustered. 3/19/24 Patient not seen due to a non-wound related hospitalization . 3/26/24 Stage 3 pressure wound Sacrum full thickness. 1 x 2 x 0.1 cm. 100% granulation. Moderate serosanguineous exudate. Improved evidenced by decreased surface area. Stage 3 pressure wound of the left buttock - Resolved. Surveyor noted the sacrum pressure injury continued to be followed weekly by the wound physician. Surveyor identified no concerns with treatment and the wound continued to improve. On 4/23/24 the measurements documented: 0.4 x 0.8 x 0.1 cm. 20% slough, 80% granulation tissue. Moderate serosanguineous exudate. Improved evidenced by decreased surface area. On 4/30/24 at 2:28 PM Surveyor attended wound rounds for R5 with Wound Physician-O and a facility nurse. Upon entering R5's room Surveyor noted R5 was sitting up in her wheelchair, dressed. This was the first time Surveyor observed R5 out of bed on survey. On 4/30/24 at 3:00 PM Surveyor, Wound Physician-O and facility nurse returned to R5's room where she was lying in bed. R5 was rolled onto her left side. Surveyor observed a heart shaped Mepilix dressing covering her coccyx/buttock area dated 4/29/24. Wound Physician-O removed the old dressing revealing intact pink skin. Wound Physician-O stated It's healed and advised the resident. Wound Physician-O showed Surveyor where the previous Stage 3 pressure injury was located by pointing to the area. No open skin was observed. Wound Physician-O recommended keeping a Meplix dressing on for protection for at least another week, and the nurse applied a new dressing. Surveyor asked to view R5's heels. Surveyor observed no open areas or signs of skin breakdown. On 4/30/24 at 12:49 PM Surveyor spoke with Director of Nursing (DON)-B about R5's facility acquired Stage 3 pressure injury. DON-B reported the wound was identified during wound rounds for her heel which was healed the same day. Surveyor advised there is no evidence of comprehensive assessments and measurements of R5's right heel wound in the medical record. DON-B reported she will look for the information. No evidence was provided. Surveyor advised DON-B of concern the facility identified a stage 3 pressure injury to R5's coccyx and the care plan was not revised. DON-B reported R5 was given an air mattress that day (2/20/24). Surveyor asked DON-B if she had a work order or delivery slip to confirm when the mattress was placed. DON-B reported she will provide evidence (No evidence was provided). Surveyor advised R5's care plan indicated Specialty mattress/cushion on bed/wheelchair which was implemented on 2/5/24. The care plan does not document an APM air mattress was implemented. In addition, Physician's orders documented an order for air mattress, check function and settings every shift for pressure reduction on 4/11/24. DON-B maintains the air mattress was put on R5's bed on 2/20/24. Surveyor advised DON-B of concern R5 admitted to the facility with C-diff, is incontinent of bowel and bladder and dependent on staff for incontinence care. R5's care plan indicates check and change as needed only. There is no evidence the facility recognized the increased risk for skin breakdown r/t urine and stool incontinence and did not complete a comprehensive bowel and bladder assessment to determine if there was a need for increased turning, checking and changing. In addition, staff report R5 has had loose, watery stools since admission, and currently with every check and change. DON-B reported she was not aware R5 was still having loose stools and staff is not documenting loose stools in Point of Care (POC). Surveyor asked if R5 was having multiple loose stools per day related to C-diff, did the facility do further assessment to determine if there was a need for increased check and change versus just as needed. DON-B stated: Not that I can see. Surveyor asked DON-B if she thought incontinence was a factor in R5's stage 3 pressure injury development. DON-B stated: Probably. I understand what your saying. The care plan should have been updated to check and change her more frequently because of her incontinence. No additional information was provided. On 5/1/24 at 12:04 PM Surveyor asked VP Clinical Services if the facility has evidence of a comprehensive bowel assessment for R5. VP Clinical Services stated: If it's not under assessments, then we don't have. We haven't been able to find any. No additional information was provided. 20483 2.) R26's diagnoses includes chronic kidney disease stage 5, diabetes mellitus, lymphedema, and epilepsy. The actual skin impairment care plan initiated 11/3/22 & revised 4/22/24 documents interventions of * Barrier cream to peri area. Initiated 11/3/22 & revised 4/22/24. * Encourage to reposition as needed with staff assistance. Initiated 11/3/22 & revised 4/22/24. * Float heels as able. Initiated 11/3/22. * Observe skin condition with ADL (activities daily living) care daily; report abnormalities. Initiated 11/3/22. * Pressure redistributing device on chair. Initiated 11/3/23 & revised 1/23/23. * Therapy eval (evaluate) and treat as ordered. Initiated 11/3/22. * Diabetic nail care weekly by licensed nurse. Initiated 1/16/24. * Licensed nurse to complete diabetic foot checks nightly. Initiated 1/16/24. * Podiatric care as needed. Initiated 1/16/24. * Weekly skin assessment done by licensed nurse. Initiated 1/16/24. * Pressure redistributing mattress. Initiated & revised 4/7/24. * Remind resident to turn and reposition frequently. Educate on the importance of skin health. Initiated 4/28/24. The CNA (Certified Nursing Assistant) kardex as of 4/29/24 under skin section documents * diabetic nail care weekly by licensed nurse. * Float heels as able. * Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. * Licensed nurse to complete diabetic foot checks nightly. * Pressure redistributing mattress . * Remind resident to turn and reposition frequently. Educate on the importance of skin health. * Weekly skin assessment done by licensed nurse. APNP (Advanced Practice Nurse Prescriber)-CC note dated 3/28/24 under chief complaint documents CKD-5 (chronic kidney disease-Stage 5) and goals of care. Under subjective documents Nursing reports that patient has been more lethargic at times and refusing pain medications and not eating as well lately. Overall, patient has had a functional decline in health. Last creatinine with CKD 4 was 4.09 on 3/21/2024. Increase in BLE (bilateral lower extremity) edema despite BLE compression wraps and diuretics. Patient reports increase in bilateral lower extremity pain as well and limited relief with acetaminophen. She is seen sitting in her wheelchair and reports that her bilateral feet pain makes her cry especially at night, 5/10, throbbing, chronic and disruptive to her sleep. Labs ordered for follow up. Goals of care discussion done- please see below. Has a follow-up with nephrology next week Tuesday. No fever, chills, cough, sob (shortness of breath), cp (chest pain) or bowel/bladder concerns. Under Goals documents Recommendation given for hospice, end-stage renal disease,and overall function decline. Patient wants to remain a DNR (do not resuscitate). Wishes to be started on low dose oxycodone for comfort despite potential side effects with renal failure. Wishes for no more hospitalization s. Agreeable to hospice consult- would like to wait til next week to discuss matter over with her grand-daughter and family with a care conference. I also updated the grand-daughter, [name] via phone per patients wishes about conversation. DON (Director of Nursing) updated. The order administration note dated 4/2/24 at 13:36 (1:36 p.m.) documents Weekly skin review every day shift every Tue (Tuesday). If new skin area is identified follow protocol for SBAR (situation, background, assessment, and recommendation), MD (medical doctor) update and risk management. Only able to assess BLE's (bilateral lower extremities) and BUE's (bilateral upper extremities). Resident out for appointment most of the day. This note was written by RN (Registered Nurse)-H. The nurses note dated 4/4/24 at 23:04 (11:04 p.m.) documents F/U (follow up) pressure injury to the buttock, new dressing applied. This nurses note was written by RN-BB. The physician order with a start date of 4/5/24 documents Wound care to coccyx: remove old dressing and discard. Using clean technique, cleanse wound with normal saline or wound cleanser. Pat dry. Apply skin prep to peri wound skin. Apply thin layer of medihoney to wound. Cover area with bordered foam dressing. Change dressing daily and PRN ( as needed) if soiled or dislodged. every evening shift for wound care. This order was discontinued on 4/23/24. The physician order dated 4/5/24 documents Consult [Name] Wound Care for pressure injury to coccyx. The pressure injury weekly tracker dated 4/5/24 documents for date acquired 4/4/24. The site documents coccyx and type is pressure. The length is documented as 4 cm (centimeters), width 1 cm, and depth 0.1. The Stage is documented as II (2). The tissue type documents granulation tissue. The percentage of the wound bed was not completed. The drainage is serosanguineous. This assessment was completed by RN-H. Surveyor noted this is not a comprehensive assessment as the percentage of wound bed was not completed and the pressure injury was incorrectly staged as a Stage 2 pressure injury does not have granulation tissue. The pressure injury should have been staged as a Stage 3. There were no revisions in R26's care plan until 4/7/24 three days later. The pressure injury weekly tracker dated 4/9/24 documents for date acquired 4/4/24. The site documents coccyx and type is pressure. The length is documented as 5 cm, width 2 cm, and depth 0.1. The Stage is documented as III (3). The tissue type documents granulation tissue. The percentage of the wound bed is 100% granulation. The drainage is serosanguineous, moderate drainage. This assessment was completed by DON-B. R26 started receiving hospice services on 4/9/24. The nurses note dated 4/10/24 at 11:14 (11:14 a.m.) documents F/U O/A (open area) at the buttock, new dressing applied, encourage to change position and staff will continue to monitor. This nurses note was written by RN-BB. The nurses note dated 4/11/24 at 23:16 (11:16 p.m.) documents F/U O/A to the coccyx, dressing intact, repositioned and staff will continue to monitor. This nurses note was written by RN-BB. The significant change MDS (minimum data set) with an assessment reference date of 4/15/24 has a BIMS score of 5 which indicates severe cognitive impairment. R26 is assessed as requiring partial/moderate assistance for toileting hygiene, supervision or touching assistance for chair/bed to chair transfer & toilet transfer and independent with rolling left and right. R26 is assessed as being frequently incontinent of urine and always incontinent of bowel. R26 is assessed as being at risk for pressure injury development and is assessed as not having a pressure injury. Surveyor noted the assessment of rolling left and right is inaccurate as during the month of April for bed mobility the CNAs did not check independent. Bed mobility is checked as being extensive assistance - Resident involved inactivity, staff provide weight-bearing support or total dependence - Full staff performance. The pressure injury section is also inaccurate as R26 developed a Stage 3 pressure injury on the coccyx on 4/4/24. The pressure injury CAA (care area assessment) dated 4/24/24 under analysis of findings for nature of problem/condition documents CAA triggered r/t (related to) increased risk for skin impairment related to increased need for help with ADL such as bed mobility which can decrease blood flow and increase pressure leading to wounds. Under care plan considerations documents Pressure Ulcers CAA triggered secondary to potential for pressure ulcers. Contributing factors include ADL (activity daily living)/functional/mobility impairment and incontinence. Risk factors include pain, development of PU (pressure ulcer)/skin condition, and fluid deficit risk. Nurse assesses skin each week and provides interventions to prevent skin breakdown. Skin is also assessed by caregivers with each bathing and dressing. The physician is to be notified of any abnormal findings and treatment orders are obtained. The dietitian is monitoring intake, and implementing dietary interventions Caregivers assist with repositioning frequently and as needed for comfort. Care plan will be initiated or reviewed to improve or maintain current ADL status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer/fluid deficit risk. Location of documentation: see NN (nurses notes)/Braden/TAR (treatment administration record) for the look back period. The pressure injury weekly tracker dated 4/17/24 documents for date acquired 4/4/24. The site documents coccyx and type is pressure. The length is documented as 3.3 cm, width 1 cm, and depth 0.1. The Stage is documented as III (3). The tissue type documents granulation tissue. The percentage of the wound bed is 80% granulation and 20% slough. The drainage is serosanguineous, moderate drainage. This assessment was completed by DON-B. The pressure injury weekly tracker dated 4/23/24 documents for date acquired 4/4/24. The site documents coccyx and type is pressure. The length is documented as 2.5 cm, width 1 cm, and depth 0.1. The Stage is documented as III (3). The tissue type documents granulation tissue. The percentage of the wound bed is 100% granulation. The drainage is serosanguineous, moderate drainage. This assessment was completed by RN-H. The physician order dated 4/23/24 documents Wound care to coccyx: remove old dressing and discard. Using clean technique, cleanse wound with normal saline or wound cleanser. Pat dry. Apply skin prep to peri wound skin. Apply thin layer of medihoney to wound. Cover area with bordered foam dressing. Change dressing 3 [TRUNCATED]

Based on interview and record review the Facility did not ensure each Resident received adequate supervision and assistance devices to prevent accidents for 2 (R21 & R19) of 4 Residents. R21 is being cited as actual harm/isolated. * R21's falls on 10/1/23 & 10/23/23 were not thoroughly investigated & root cause not determined to help prevent future falls. On 10/28/23 the Certified Nursing Assistant (CNA) did not use a gait belt & R21 fell in the bathroom. On 11/14/23 R21 sustained another fall. This fall was not thoroughly investigated, root cause not determined and there were no revisions in the care plan or indications the interventions remain appropriate. On 11/19/23 R21 was left alone in the bathroom fell and sustained a hip fracture. On 1/7/24 R21 fell . The facility did not conduct a thorough investigation, determine a root cause to help prevent future falls and did nor revise the care plan or indicate the interventions are appropriate. On 1/18/24 R21 fell . The facility did not conduct a thorough investigation and did not revise the care plan to include the intervention to call for assistance to adjust the bedding. R21 was observed in bed without the bed being at the lowest level and was not wearing gripper socks in bed according to R21's plan of care. * R19 was not supervised while smoking according to R19's plan of care. Findings include: The Fall Prevention and Management Guidelines policy last reviewed/revised 11/8/22 under Policy Explanation and Compliance Guidelines includes documentation of: 8. Review each fall/fall investigation during the next morning meeting/clinical meeting with the interdisciplinary team (IDT). Actions of the IDT may include: a. Review of investigation and determination of potential root cause of fall. b. Review of fall risk care plan and any updates to plan of care completed post fall. c. Additional revisions to the plan of care including any physical adaptation to room, furniture, wheelchair, and/or assistive devices. d. Education of staff as to any care plan revisions. e. Scheduling resident/family conferences. f. Verification of timely notification of physician and responsibly part of the fall. Note: If after IDT review, it is determined that existing interventions in the care plan are most appropriate, document rationale and describe any additional actions taken. 1.) R21's diagnoses includes diabetes mellitus, congestive heart failure, atrial fibrillation, anxiety disorder, and depressive disorder. The at risk for falls care plan initiated 1/31/22 & revised 12/28/23 documents the following interventions: * Bed in low position. Initiated 1/31/22. * Encourage to transfer and change position slowly. Initiated 1/31/22. * Fall Risk (FYI) (for your information). Initiated 1/31/22. * Have commonly used articles within easy reach. Initiated 1/31/22. * Medication as ordered 1/31/22. * Provide assist to transfer and ambulate as needed. Initiated 1/31/22. * Reinforce need to call for assistance. Initiated 1/31/22. * Reinforce w/c safety as needed such as locking brakes. Initiated 1/31/22 * Report development of pain, bruises, change in mental status, ADL (activities daily living) function, appetite, or neurological status post fall. Initiated 1/31/22. * Therapy eval (evaluate) and treat as ordered. Initiated 1/31/22. * Increase rounding at night and offer toileting while awake. Initiated 6/29/22 & revised 7/7/22. * Encourage resident to wear non skid footwear at all times even while in bed. Initiated & revised 3/13/23. * Sign was placed in resident's room to remind her to use the call light for assistance. Initiated 3/16/23. * Frequent reminders to use call light prior to unassisted ambulation/transfers as needed. Initiated 3/13/23. * Anti-tippers to w/c (wheelchair). Initiated 4/24/23. * Offer/toilet every hour between the hours of 12 am - 5 am as needed. Initiated 5/12/23. * Resident has anti-roll back brakes. Initiated 10/24/23 & revised 11/9/23. * Anti-rollbacks to wheelchair. Initiated 12/1/23. * Scoop mattress. Initiated 12/1/23. * Fall mat beside bed. Initiated 12/1/23. The CNA (Certified Nursing Assistant) kardex as of 5/1/24 under the safety section documents * Anti-tippers to w/c (wheelchair). * Anti-rollbacks to wheelchair. * At moderate risk for elopement. * Bed in low position. * Educate resident on need to lock brakes on wc when it is not in motion and to call for assistance for safety. * Encourage resident to wear non skid footwear at all times even while in bed. * Fall mat bedside bed. * Fall Risk (FYI) (for your information). * Frequent reminders to use call light prior to unassisted ambulation/transfers as needed. * Increase rounding at night and offer toileting while awake. * Resident has anti-roll back brakes. * Scoop mattress. The nurses note dated 10/2/23 at 03:02 (3:02 a.m.) documents Resident was calling writers name and writer heard her as writer was walking out of resident room on (name of unit). Writer followed her voice to find her by the front entrance on the floor sitting on her butt. Resident had on a long winter goldish-green coat that went down to her ankles and was way to big on her. Resident stated she was looking for her mother and father and thought they were calling to her from up there. Resident then stated she slid out of her wheelchair onto the floor because of the coat. VSS (vital signs stable), ROM WNL (range of motion within normal limits), Neuro (neurological) checks negative. Assessment was positive for bruising in L (left) Thigh, otherwise negative for any other noted injuries. Resident stated she did not hit her head. Writer and Med Tech [initials] assisted resident off floor and back into chair c sic (with) mechanical lift. [medical group] On Call MD (medical doctor) updated. Nephew [name] updated as well. DON (Director of Nursing) updated. This nurses note was written by RN (Registered Nurse)-R. The incident report dated 10/1/23 under incident description for nursing description documents Resident was calling writers name and writer heard her as writer was walking out of resident room on (name of unit). Writer followed her voice to find her by the front entrance on the floor sitting on her butt. Resident had on a long winter goldish-green coat that went down to her ankles and was way to big on her. Resident stated she was looking for her mother and father and thought they were calling to her from up there. Resident then stated she slid out of her wheelchair onto the floor because of the coat. VSS, ROM WNL, Neuro checks negative. Assessment was positive for bruising in L Thigh, otherwise negative for any other noted injuries. Resident stated she did not hit her head. Writer and Med Tech [initials] assisted resident off floor and back into chair c sic (with) mech lift. [medical group] On Call MD updated. Nephew [name] updated as well. DON updated. Under resident description documents Resident had on a long winter goldish-green coat that went down to her ankles and was way to big on her. Resident stated she was looking for her mother and father and thought they were calling to her from up there. Resident then stated she slid out of wheelchair onto the floor because of the coat. Under notes dated 10/4/23 documents On 10/01 resident was observed on floor near business office door, Pt was observed wearing oversized jacket that was too long for her. Pt stated she was looking for her parents. Resident stated she slipped out of her chair due to oversized jackets. Resident called out to Nurse for help. Nurse and MT (med tech) used mechanical lift to place back in chair. Resident appeared more confused than usual but no other changes noted. Resident currently has a wander guard but it was placed on her w/c due to the resident not wanting it on her person per the staff. Intervention Resident reports will wear wander guard if it can be bedazzled (Activities Director will handle) Educate staff and let them know all wander guard bracelets are to be placed on resident; not on their assistive device. Surveyor noted the Facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R21, what was R21 doing, etc. The Facility did not determine a root cause and did not revise R21's care plan to include bedazzling R21's wanderguard, although this would not prevent R21 from falling in the future. The fall assessment dated [DATE] has a score of 5 which indicates low risk. The nurses note dated 10/24/23 at 00:00 (12:00 a.m.) documents Writer and Med Tech/CNA-[initials] charting at nurses station and heard a crash. [Initials] went down the hallway to check on residents and found resident in front of her closet with back towards closet and resident on floor in sitting position in front of closet. Resident stated she was trying to get briefs from closet and lost her balance. Resident stated she did hit her head, but on the closet as she slid down. Writer was called down by [initials] and upon performing physical assessment, writer noted a large 9 x 2 x 0.2 abrasion/scrape-mid back-just barely off to the right of the spine. Resident states that the abrasion is painful. The rest of physical assessment is negative and resident was assisted off the floor via lift and 2 staff. Resident was brought to the nurses station. Acetaminophen administered for pain. Neuro checks negative, VSS, ROM WNL. Area on back cleansed c sic (with) NS (normal saline), TAO applied and covered c sic (with) border gauze. MD Updated. [name] called and updated. This nurses note was written by RN-R. Incident report dated 10/23/23 under incident description for nursing description documents Writer and Med Tech/CNA-[initials] charting at nurses station and heard a crash. [initials] went down the hallway to check on residents and found resident in front of her closet with back towards closet and resident on floor in sitting position in front of closet. Resident stated she was trying to get briefs from closet and lost her balance. Resident stated she did hit her head, but on the closet as she slid down. Writer was called down by [initials] and upon performing physical assessment, writer noted a large 9 x 2 x 0.2 abrasion/scrape-mid back-just barely off to the right of the spine. Resident states that the abrasion is painful. The rest of physical assessment is negative and resident was assisted off the floor via lift and 2 staff. Resident was brought to the nurses station. Acetaminophen administered for pain. Neuro checks negative, VSS, ROM WNL. Area on back cleansed c NS, TAO (topical antibiotic ointment) applied and covered c (with) border gauze. MD Updated. [name] called and updated. Resident description documents Resident stated she was trying to get briefs from closet and lost her balance. Resident stated she did hit her head and her back but on the closet as she slid down. Under notes dated 11/9/23 On 10/23 approx 2345 (11:45 p.m.) resident had a fall in room during a self-attempt to stand from w/c d/t (due to) trying to retrieve a brief from closet. Resident is a repeat faller (sic) and has poor safety awareness. Resident acquired a skin tear to mid spine. Neuro check initiated. MD and POA (power of attorney) notified. Intervention: Treatment to back in place; wound consult ordered. On 10/24 anti-rollback brakes were placed on the residents w/c. Care plan updated. Surveyor noted the Facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R21, when was R21 last toileted. The Facility did not determine a root cause. The order note dated 10/28/23 at 20:31 (8:31 p.m.) documents Writer was in room [number] giving meds to resident when CNA [initials] came in thru the [NAME] n [NAME] bathroom and informed writer that resident fell during the transfer to toilet to wheelchair. Writer went into bathroom with CNA [initials] to see the resident laying on the floor, face up, depends at knees, shoes on. Writer did not see a gait belt. CNA stated resident was standing up at the bar, holding onto the bar. CNA [initials] stated she was standing behind the resident and attempted to catch resident as she fell to the left. Writer performed a physical assessment on resident. Resident stated she did not hit her head, she stated her hip and butt hurt. Writer noted some scratches and bruising on left and right hips and left upper thigh, left leg. Neuro check was negative, ROM was WNL, VSS. [Name]-Nephew and On call [medical group] update c sic (with) NOR (new order received). This order note was written by RN-R. The incident report dated 10/28/23 under incident description for nursing description documents Writer was in room [number] giving meds to resident when CNA [initials] came in thru the [NAME] n [NAME] bathroom and informed writer that resident fell during the transfer to toilet to wheelchair. Writer went into bathroom with CNA [initials] to see the resident laying on the floor, face up, depends at knees, shoes on. Writer did not see a gait belt. CNA stated resident was standing up at the bar, holding onto the bar. CNA [initials] stated she was standing behind the resident and attempted to catch resident as she fell to the left. Writer performed a physical assessment on resident. Resident stated she did not hit her head, she stated her hip and butt hurt. Writer noted some scratches and bruising on left and right hips and left upper thigh, left leg. Neuro check was negative, ROM was WNL, VSS. [Name]-Nephew and On call [medical group] update c sic (with) NOR. Resident description documents Resident stated she lost her balance. Under notes dated 11/2/23 documents Resident had a witnessed fall while in the bathroom with the CNA. Resident was not wearing a gait belt and fell during transfer from toilet to w/c. CNA was not positioned correctly during transfer. CNA was attempting to assist with transfer from behind the w/c during transfer. Upon resident standing, the CNA was unable to catch the resident and the resident fell . No injuries noted but resident reported pain. Pain meds given. MD notified and POA made aware. Intervention CNA transfer education provided PT OT to screen eval and treat as indicated. Surveyor noted the Facility's investigation revealed the CNA was did not use a gait belt as required. The fall assessment dated [DATE] has a score of 7 which indicates low risk. The quarterly MDS (minimum data set) with an assessment reference date of 10/31/23 has a BIMS (brief interview mental status) score of 10 which indicates moderate cognitive impairment. R21 is assessed as requiring partial/moderate assistance for toileting hygiene, chair/bed to chair transfer and toilet transfer and is independent with wheeling the wheelchair. R21 has fallen since the prior assessment with one fall no injury and 1 fall with injury except major. The nurses note dated 11/14/23 at 18:30 (6:30 p.m.) documents Writer was called to residents room due to resident being found sitting on floor. Upon entering the residents room, writer found resident sitting on her buttocks with her back against her nightstand, her bed on her left, wheelchair on her right, and tray table in front of her. Resident was holding onto her bed and chair. When writer asked resident what she was doing prior to falling. Resident stated she was trying to get into her wheelchair from her bed. Resident bed was down too low for resident to be able to transfer, resident call light was within reach. wheelchair wheels were locked, resident was barefoot. Writer performed physical assessment with negative results. Resident states she did not hit her head, and does not hurt anywhere not, but will feel it tomorrow. Writer expects some bruising on resident buttocks. Writer and Executive Director [initials] assisted resident off the floor with Hoyer. Resident assisted back into wheelchair. Writer updated nephew [name], on call [medical group] [name], and DON [initials]. This nurses note was written by RN-R. Surveyor was not provided with an investigation regarding R21's fall on 11/14/23 and no revisions were made to R21's fall care plan or have evidence the care plan was reviewed and all interventions remain appropriate. The fall assessment dated [DATE] has score of 11 which indicates moderate risk. The nurses note dated 11/19/23 at 21:45 (9:25 p.m.) documents Resident is being transferred to the hospital by Menomonee Falls 911 EMT's (emergency medical technicians). This nurses note was written by LPN (Licensed Practical Nurse)-U. The nurses note dated 11/19/23 at 22:06 (10:06 p.m.) documents Called to resident room and observed resident on the floor in the bathroom. Resident was lying on her back with her head by the opposite door and her feet by the toilet. This nurses note was written by LPN (Licensed Practical Nurse)-U. The incident report dated 11/19/23 Under incident description for nursing description documents At 2055 (8:55 p.m.) I was called to resident room while in the hallway and observed resident on the floor in the bathroom. Toilet (sic) resident was lying on her back with her head by the opposite door and her feet by the toilet. Urine and bowel movement noted in toilet resident dry and shoes on feet. While doing neuro check resident complaint of pain to left and unable to have range of motion to leg. Resident description: I had to get up. My back and legs were starting to hurt. Under immediate action taken documents Assessment and vitals done. Placed a call to the MD orders obtained and 911 called to transfer resident to the hospital. Under notes dated 11/26/23 documents On 11/19 approx 2055 resident was noted to have a fall due to self attempt to transfer from toilet to w/c. Resident was assisted to toilet by med tech. Med tech checked on resident times 2 while on toilet and handed resident call light in in bathroom stating to put on call light when ready. Within approx 5 min med tech heard resident yelling and found resident on the floor laying on back side in bathroom. Med tech asked resident why did she not use her call light and resident was noted saying My back and legs were starting to hurt. I had to get up During neuro checks resident complaint of pain to left leg without ROM (range of motion). Resident last fall was on 11/14 due to self transfer. MD and RP made aware. Intervention Resident sent out to eval and treatment. Resident to not be left alone while being toileted. R21's previous fall was 5 days prior when according to this incident fall R21 had self transferred. There was no revision in R21's care plan for the previous fall nor was the care plan revised to include not being left alone on the toilet following this fall. R21's care plan was not revised until 12/1/23 R21 sustained a left femur fracture and was hospitalized until 11/29/23 when R21 returned to the Facility. The fall assessment dated [DATE] has a score of 8 which indicates low risk. The significant change MDS with an assessment reference date of 12/6/23 has a BIMS score of 3 which indicates severe cognitive impairment. R21 is assessed as substantial/maximal assistance for toileting hygiene, chair/bed to chair transfer and toilet transfer. R21 is assessed as partial/moderate assistance to wheel the wheelchair 50 feet and substantial/maximal assistance to wheel the wheelchair 150 feet. R21 is assessed as not having any falls since prior assessment period. The fall assessment dated [DATE] has a score of 11 which indicates moderate risk. The nurses note dated 1/7/24 at 22:13 (10:13 p.m.) documents Writer was at nurses station speaking with CNA [initials] when [initials] noted that resident was on floor in front of her doorway. Writer and other staff went down to assess resident and to assist off the floor. Resident stated she was looking for her yellow stick but could not find it. So she was coming back to talk to writer at the nurses station. Resident stated she slid out of her chair onto her butt and hit her head. Resident states she has a headache. Report given to [name] RN at [hospital initials] ER (emergency room ). [Name of ambulance] called for Transport. Resident is on eliquis. Writer examined resident and assessment was negative. No red marks, bruises, or lumps on head or thru out body that could be attributed to fall. ROM WNL, Neuro checks negative. BP (blood pressure) high- On call NP (Nurse Practitioner) [Name] informed and gave new orders to send out due to resident being on blood thinner. Writer called and informed POA Nephew [Name]. Writer updated resident as well to let her know what was going on. Report given to [Name] RN at [hospital initials] ER. (name of ambulance) called for Transport. This nurses note was written by RN-R. The incident report dated 1/7/24 for Incident description under nursing description documents Writer was at nurses station speaking with CNA [initials] when [initials] noted that resident was on floor in front of her doorway. Writer and other staff went down to assess resident and to assist off the floor. Resident stated she was looking for her yellow stick but could not find it. So she was coming back to talk to writer at the nurses station. Resident stated she slid out of her chair onto her butt and hit her head. Resident states she has a headache. Report given to [Name] RN at [hospital initials] ER. [Ambulance name] called for Transport. Resident is on eliquis. Writer examined resident and assessment was negative. No red marks, bruises, or lumps on head or thru out body that could be attributed to fall. ROM WNL, Neuro checks negative. BP high- On call NP [Name] informed and gave new orders to send out due to resident being on blood thinner. Writer called and informed POA Nephew [Name]. Writer updated resident as well to let her know what was going on. Report given to [Name] RN at [Hospital initials] ER. [Ambulance name] called for Transport. Under Resident description documents Resident stated she was looking for her yellow stick but could not find it. So she was coming back to talk to writer at the nurses station. Resident stated she slid out of her chair onto her butt and hit her head. Resident states she has a headache. The nurses note dated 1/8/24 at 01:00 (1:00 a.m.) documents returned from hospital with NNOR (no new orders received). Negative CT and negative hip Xray. Resident at baseline, awake alert and cooperative upon arrival via [ambulance name]. This nurses note was written by RN-R. Surveyor noted the Facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R21, when was R21 last toileted, what was R21 doing. The Facility did not determine a root cause and did not revise the care plan or have evidence the care plan was reviewed and all interventions remain appropriate. The nurses note dated 1/18/24 at 06:37 (6:37 a.m.) documents Resident found on the floor in front of wheelchair at bedside. Resident stated I was fixing my bed so that I could get in it and fell out on wheelchair. Resident vitals taken and given PRN (as needed) Tylenol for comfort. Resident Neuro check negative. This nurses note was written by LPN-U. The incident report dated 1/18/24 under incident description for Nursing description documents Resident found on the floor in front of wheelchair at bedside. Resident description documents I was fixing my bed sheets and fell out of the chair. Under notes dated 1/18/24 Root cause: Resident was fixing sheets on her bed and leaned to far forward sliding out of the chair. Intervention Reminders to call for assistance from staff to adjust her bedding. Surveyor noted the Facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R21, when was R21 transferred out of bed and how was R21's bed when R21 was transferred out. R21's care plan was not revised to include the intervention to call for assistance to adjust the bedding. The fall assessment dated [DATE] has a score of 7 which indicates low risk. The nurses note dated 1/19/23 at 10:59 (10:59 a.m.) documents Resident is on follow up for: On 1/18/24 resident was found on the floor in front of wheelchair at bedside. Resident stated I was fixing my bed so that I could get in it and fell out on wheelchair. The current status is Resident is alert. No s/s (signs/symptoms) of pain noted. No changes in ROM noted. Skin remains free from any injuries This nurses note was written by RN-H. On 4/29/24 at 7:05 a.m. Surveyor observed R21 in bed on the right side. R21's bed is in the low position, there is a mat on the floor on the right side of R21's bed and there are two transfer bars up. There is a glass of water on the over bed table not within R21's reach. On 4/29/24 at 7:34 a.m. Surveyor observed CNA (Certified Nursing Assistant)-M in R21's room. CNA-M washed her hands, placed gloves on, removed clothing from the closet and removed the gait belt from the back of R21's room door. CNA-M raised the height of the bed and removed the bedding off R21. Surveyor observed R21 has bare feet and is not wearing gripper socks according to the plan of care. CNA-M placed gripper socks on R21, swung R21's legs so R21 was sitting on the edge of the bed and placed the gait belt around R21. R21 placed shoes on R21, told R21 she was going to go to the rest room and assisted R21 with standing up and transferring into the wheelchair. CNA-M wheeled R21 into the bathroom, assisted R21 with standing up and then step backwards to the toilet having R21 sit on the toilet. At 7:47 a.m. CNA-M removed her gloves, washed her hands, removed the wheelchair from the bathroom and placed gloves on telling R21 she was going to wash her face & get her dressed. CNA-M washed R21's face & upper body and placed a dress & sweater on R21. CNA-M placed a brief on R21 and the gait belt around R21. At 7:54 a.m. CNA-M asked R21 if she was ready and stood R21 up. R21 stated she can't and R21 was sat back on the toilet. CNA-M removed her gloves, stated sometimes she does that and exited the bathroom and closed the bathroom door. Surveyor noted R21 was left alone in the bathroom. At 7:56 a.m. CNA-M left R21's room and returned back at 7:59 a.m. While CNA-M was washing her hands, CNA-K entered R21's room, washed her hands and staff placed gloves on. At 8:01 a.m. CNA-K stood R21 up and CNA-M washed R21's frontal perineal area and buttocks. CNA-K & CNA-M pulled up and refastened the incontinence product and transferred R21 into the wheelchair. On 4/30/24 at 7:18 a.m. Surveyor observed R21 in bed on the left side. R21's call light is within reach & there is a mat on the floor on the right side. Surveyor observed R21's bed is not in a low position. On 4/30/24 at 8:21 a.m. Surveyor asked CNA-N if she could show Surveyor R21's feet. R21 was observed in bed on her back, head of the bed elevated and R21's bed is not in a low position. CNA-N removed the bedding off R21's feet. Surveyor observed R21 is not wearing gripper socks according to her plan of care. On 4/30/24 at 9:10 a.m. Surveyor observed R21 continues to be in bed with the head of the bed elevated. Surveyor observed R21's bed is not at a low position. On 4/30/24 at 10:45 a.m. Surveyor observed R21 continues to be in bed on her back. Surveyor observed R21's bed is now in a low position. On 4/30/24 at 4:06 p.m. during the end of the day meeting Surveyor asked NH (Nursing Home Administrator)-A, DON (Director of Nursing)-B and Regional VP (Vice President)-E if there is any additional information as Surveyor needs the Facility's complete fall investigation for R21's falls starting in October to present. On 5/1/24 at 6:59 a.m. Surveyor observed R21 in bed on the right side holding on to the transfer bar on the right side. Surveyor observed there is a mat on the floor on the right side and R21's bed is not in the low position. On 5/1/24 at 9:38 a.m. Surveyor asked DON-B if there is any additional information regarding R21's falls. DON-B informed Surveyor there is nothing else. Surveyor went over R21's falls and concerns with the not a thorough investigation, root cause not determined to help prevent further falls and R21's care plan not always revised. Surveyor also informed DON-B of R21 not wearing gripper socks in bed and the bed not being in the low position according to the plan of care. On 5/1/24 at 9:43 a.m. Surveyor asked CNA-M if R21 should wear gripper socks in bed. CNA-M replied yes. Surveyor then asked if R21's bed should be in the low position. CNA-M replied yes. 47094 2.) The facility policy entitled Smoking Policy revised 7/14/2022 states: To identify factors that may put residents at risk for smoking or nicotine use independently and to provide appropriate supervision/approaches for safety. This center shall establish and maintain a safe resident environment, while maintain resident rights, smoking or nicotine use will be limited to designated areas, supervision, and safety plans. Those residents who wish to engage in these practices will be educated, assessed, and provided with appropriate supervision to safely do so. Policy Explanation and Compliance Guidelines . 2. Risk factors identified through the assessment process shall be used in the development of the plan of care. 5. If a resident is deemed to be unsafe, they will be required to use a smoking apron, extender, or gloves and they may be required to smoke with supervision only. 9. Residents who are assessed to require supervised smoking will have nicotine materials secured in a container that is maintained by the licensed nurse. R19 was admitted to the facility on [DATE] and has diagnoses that include rheumatoid arthritis, schizophrenia, major depressive disorder, lymphedema, and restless leg syndrome. R19's quarterly minimum data set (MDS) dated [DATE] indicated R19 had intact cognition with a brief interview for mental status (BIMS) score of 15 and the facility assessed R19 having no impairments to R19's upper extremities, having impairments to lower extremities and modified independent with transfers and repositioning with assistive devices. R19's at risk for smoking related injury due r/t (related to) poor decision making, memory loss care plan initiated 1/30/2023 has the following interventions: - Assure smoking material is extinguished prior to resident leaving smoking area. - Complete nicotine assessment per facility policy. - Observe resident for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management of concerns. - Resident not to have cigarettes or smoking material on person. (Initiated 2/27/2024) R19's care Kardex has the following interventions for safety as of 4/29/2024: -Resident not to have cigarettes or smoking material on person. On 4/28/2024 at 1:42 PM Surveyor spoke with R19 who stated R19 smoked cigarettes outside. Surveyor asked if R19 held onto R19's smoking materials. R19 stated R19 had own smoking materials in R19's bedroom and sometimes has to get from nursing. Surveyor asked R19 if R19 can smoke outside alone or if R19 needed to have someone when R19 smoked. R19 stated R19 goes outside and smokes alone. Surveyor reviewed R19's last Nicotine assessment that was completed on 2/27/2024, based on the assessment staff determined that R19 was AT RISK: requires staff, family, or friend for physical support or supervision with tobacco/nicotine products. Smoking materials will be kept under control of center staff. On 4/30/2024 at 2:04 PM Surveyor interviewed registered nurse (RN)-H who stated R19 was supposed to give staff back R19's smoking supplies when R19 was done with them. Surveyor asked if R19 required supervision when smoking. RN-H stated R19 can go outside alone to smoke and does not require supervision. Surveyor asked RN-H how often R19 goes outside to smoke. RN-H stated that some days R29 never goes out and other days R19 goes out several times, but nothing consistent. On 4/30/2024 at 2:04 [TRUNCATED]

Based on observation, 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. Residents expressed concerns to surveyors that the facility does not have sufficient staff, resulting in delayed call light responses. This deficient practice has the potential to affect all 30 residents residing in the facility at the time of the survey. Findings include: The facility is composed of 3 units and had a census of 30 residents on 4/28/24. On 4/30/24 at 8:17 am, Surveyor interviewed Director of Nursing (DON)-B regarding the facility staffing levels and triggering for low weekend staffing on the Payroll Based Journal (PBJ) report for Fiscal Year 2023 (October 1 - December 31). Surveyor asked DON-B how the facility determines the amount of staffing needed to meet resident's needs. DON-B notified Surveyor that the facility determines the amount of staffing needed to meet resident's needs based on the total number of residents in the facility and acuity care needs of the residents. DON-B stated staffing does not change for the weekends and requires the same number of staff. DON-B indicates the facility uses a scheduling program called Smart Linx which creates an ideal schedule based on the number and acuity of residents residing in the facility. Surveyor reviewed the Facility assessment dated [DATE], which states the following: ~ Average daily census is 28 - 32 residents. ~ 5 Licensed Nursed providing direct care are needed ~ 8 Nurses Aides (CNA) are needed ~ 1 Registered Nurse (RN) or Licensed Practical Nurse (LPN) needed for each shift ~ 1 RN or LPN needed per 20 residents on days and PM shift. ~ 1 RN or LPN needed per 30 residents on night (NOC) shift ~ 1 CNA needed per 12 residents on day and PM shift ~ 1 CNA needed per 20 residents on NOC shift Surveyor reviewed the staffing from 4/1/24 to 4/29/24. Based on the staffing levels provided by the Facility Assessment, Surveyor noted the facility was short of staff the following days: 4/7/24 - Census 29 - Facility short staffed on NOC shift with 1 CNA 4/8/24 - Census 30 - Facility short staffed on NOC shift with 1 CNA 4/22/24 - Census 32 - Facility short staffed on NOC shift with 1 nurse and 1 CNA Surveyor reviewed the weekend staffing from 10/1/23 to 12/31/23. Based on the staffing levels provided by the Facility Assessment, Surveyor noted the facility was short of staff the following days: 10/7/23 - Census 27 - Facility short staffed on NOC shift with 1 CNA. Surveyor notes there are no CNA timecard punches for NOC shift. 10/8/23 - Census 27 - Facility short staffed on NOC shift with 1 CNA. Surveyor notes there are no CNA timecard punches for NOC shift. 10/14/23 - Census 27 - Facility short staffed on PM shift with 1 CNA. Facility short staffed on NOC shift with 1 CNA. 10/15/23 - Census 27 - Facility short staffed on NOC shift with 1 CNA. 10/21/23 - Census 26 - Facility short staffed on NOC shift with 1 nurse and 0 CNA. Surveyor notes the daily schedule indicates 2 CNAs called in. Surveyor notes there are no CNA timecard punches on NOC shift for CNAs. 10/22/23 - Census 26 - Facility short staffed with 1 nurse and 0 CNAs. Surveyor notes there are no timecard punches for the nurses or CNAs on NOC shift 10/28/23 - Census 27 - Facility short staffed on NOC shift with 1 CNA. 10/29/23 - Census 27 - Facility short staffed on NOC shift with 1 CNA. 11/4/23 - Census 24 - Facility short staffed on NOC shift with 1 CNA. 11/5/23 - Census 24 - Facility short staffed on NOC shift with 1 CNA. 11/11/23 - Census 23 - Facility short staffed on NOC shift with 1 CNA. Surveyor notes there are no timecard punches for CNAs on NOC shift. 11/12/23 - Census 23 - Facility short staffed on NOC shift with 1 CNA. Surveyor notes there are no timecard punches for CNAs on NOC shift. 11/18/23 - Census 23 - Facility short staffed on NOC shift with 1 CNA. 11/19/23 - Census 23 - Facility short staffed on NOC shift with 1 CNA. 11/25/23 - Census 20 - Facility short staffed on NOC shift with 1 CNA. 11/26/23 - Census 20 - Facility short staffed on NOC shift with 1 CNA. Surveyor notes there are no timecard punches for CNAs on NOC shift. 12/2/23 - Census 25 - Facility short staffed on NOC shift with 1 CNA. 12/3/23 - Census 25 - Facility short staffed on NOC shift with 1 CNA. 12/9/23 - Census 26 - Facility short staffed on NOC shift with 1 CNA. 12/10/23 - Census 26 - Facility short staffed on NOC shift with 1 CNA. 12/16/23 - Census 24 - Facility short staffed on NOC shift with 1 CNA. 12/17/23 - Census 24 - Facility short staffed on NOC shift with 1 CNA. 12/23/23 - Census 22 - Facility short staffed on NOC shift with 1 CNA. 12/24/23 - Census 22 - Facility short staffed on NOC shift with 1 CNA. 12/30/23 - Census 24 - Facility short staffed on NOC shift with 1 CNA. 12/31/23 - Census 24 - Facility short staffed on NOC shift with 1 CNA. Surveyor notes a discrepancy with daily schedules and timecard punches. Surveyor notes the facility does not have an accurate record of staff who have worked every shift. On 4/30/24 at 1:38 pm, Surveyor conducted Resident Council during the facility recertification survey. Residents expressed concerns with long call wait times and the facility being short staffed. Residents expressed concerns with requiring additional assistance after having procedures/surgeries and long call wait times. Residents stated this concerns them if they have medical changes and/or procedures that require them to press their call light more frequently. R2 described the call light wait time as horrible. R24 states R2 resides close to her and R24 will notice R2's call light on for long periods of time. R24 stated she will personally ask R2 if she needs assistance and check on her when she notices long call light wait times. Residents in Resident Council state, they have previously brought up long call light wait time concerns and low staffing concerns with the facility and have not been updated on a resolution or progress by the facility. On 5/1/24 at 9:02 am, Surveyor notified DON-B of concerns with the above findings. No further information was provided as to why the facility did not ensure that sufficient staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries, and with pressure injuries, were comprehensively assessed with an individualized plan of care. This was observed with 2 (R1, R2) of 3 residents reviewed with pressure injuries, and at risk for pressure injury. *R1 was assessed at high risk for pressure injuries. The facility did not initiate a turning or repositioning schedule for R1. On 10/10/23, R1 was noted with an unstageable necrotic pressure injury to their sacrum. The facility did not individualize R1's care plan related to their pressure injury or discuss risks versus benefits related to repositioning with R1 or R1's representative. *R2 was assessed at risk for pressure injuries. The facility did not ensure R2's pressure relieving interventions were in place in accordance with R2's comprehensive care plan. Findings include: 1. R1 was admitted to the facility on [DATE] with diagnoses of hemiplegia, vascular dementia, and malnutrition. R1's admission assessment dated [DATE] documented R1 had a Braden score of 12, indicating R1 was at high risk for pressure injuries. R1's Admission MDS (Minimum Data Set) assessment dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 02, indicating R1 was noted with severe cognitive impairment related to daily decision making. R1's MDS indicated that R1 was dependent upon staff for bed mobility and the ability to reposition. R1's MDS indicated the facility did not initiate a repositioning or turning schedule upon R1's admission to the facility. R1's admission MDS assessment did not indicate R1 had pressure injuries upon admission to the facility on [DATE] or refusal or inconsistency with repositioning or off-loading. R1 was discharged from the facility on 11/22/23 for debridement of their pressure injury. Surveyor reviewed R1's closed medical record including physician orders, progress notes, and care plans. Surveyor noted skin integrity care plan with initiation date of 9/26/23 reading, At risk for alteration in skin integrity related to: impaired mobility, incontinence. Care plan interventions included: Barrier cream to peri area/buttocks as needed, encourage to reposition as needed, use assistive devices as needed, float heels or use heel protector boots as resident allows. On 10/10/23, R1 was noted with an unstageable necrotic pressure injury (referencing the sacrum area) measuring 2.5 x 1.7 x 0.1 cm with 70% granulation tissue and 30% thick adherent devitalized necrotic tissue. On 12/13/23, Surveyor reviewed a facility document titled Incident description dated 11/29/23. Surveyor noted the documentation included the following: .It is reasonable to conclude that the area developed was unavoidable and as a result of the resident's co-morbidities, inconsistency with allowing repositioning and off-loading . Surveyor noted that R1's care plan interventions for encourage to reposition as needed, barrier cream to peri area/buttock, use assistive devices as needed, float heels or use heel protector boots as resident allows were not updated to reflect the need for the facility to establish an increased need for a routine repositioning program upon discovery of R1's sacral pressure injury on 10/10/23. Surveyor noted that there was no indication in R1's care plan that R1's mattress was appropriate for an unstageable pressure injury. R1's care plan was not updated when the facility documented an Incident description on 11/29/23 which determined R1's pressure injury was unavoidable as a result of co-morbidities and inconsistencies or resistance with allowing repositioning and off-loading. On 12/14/23 at 11:18 AM, Surveyor conducted a telephone interview with Certified Nursing Assistant (CNA)-E. Surveyor asked CNA-E if they had ever had concerns with R1 being resistive with cares or positioning. CNA-E responded that they never had any issues with R1 being resistive or uncooperative with repositioning. CNA-E added that R1 needed a lot of help because of the inability to reposition independently. Surveyor asked CNA-E if a resident or their representative are resistive to cares including repositioning or refusing treatment, should that be reflected in a resident's care plan. CNA-E responded that they would assume that any refusals of care would be reflected in a resident's care plan. On 12/14/23 at 10:44 AM, Surveyor conducted a telephone interview with Wound MD-F. Wound MD-F is no longer conducting wound rounds at the facility. Surveyor asked Wound MD-F if they had ever had concerns with R1 being resistive with cares or positioning. Wound MD-F recalled that R1's daughter had once refused debriding of R1's unstageable pressure injury but later agreed to have debriding performed by Wound MD-F at the facility. Surveyor asked Wound MD-F if a resident or their representative are resistive to cares including repositioning or refusing treatment should that be reflected in a resident's care plan. Wound MD-F responded that they would think that any refusals of care should be reflected in a resident's comprehensive care plan. Surveyor asked Wound MD-F if residents with unstageable pressure injuries should be on a turning and repositioning schedule. Wound MD-F responded, Yes. On 12/14/23 at 10:44 AM, Surveyor conducted telephone interview with Wound MD-G. Wound MD-G is the facility's current wound physician and conducts weekly rounds at the facility. Surveyor asked Wound MD-G if they had ever had concerns with R1 being resistive with cares or positioning. Wound MD-G told Surveyor that they had only seen R1 a few times before they were discharged from the facility and they didn't remember R1 that well. Surveyor asked Wound MD-G if they recalled R1 ever being resistive to care including repositioning. Wound MD-G responded that they did not recall R1 being resistive to cares or repositioning while they conducted weekly wound rounds. Surveyor asked Wound MD-G if a resident or their representative are resistive to cares including repositioning or refusing treatment, should that be reflected in a resident's care plan. Wound MD-G responded that they would expect that any refusals of care should be reflected in a resident's comprehensive care plan. Surveyor asked Wound MD-G if residents with unstageable pressure injuries should be on a turning and repositioning schedule. Wound MD-G responded that they would have the expectation for any resident either at risk for pressure injuries or with any current pressure injury should be on a repositioning schedule. On 12/14/23 at 2:10 PM, Surveyor conducted interview with DON-B (Director of Nursing.) DON-B told Surveyor that R1's representative was very challenging throughout R1's stay at the facility. Surveyor asked DON-B to elaborate. DON-B told Surveyor that R1's representative had often refused or changed her mind frequently throughout R1's overall treatment including being resistive or refusing immunizations, medications ordered by physicians, and pressure injury treatments including offloading, repositioning, and debridement of R1's sacral pressure injury. Surveyor asked DON-B if a resident or their representative is resistive to care or recommendations made by a physician, should that be reflected in the resident's comprehensive care plan. DON-B nodded their head yes at this time. Surveyor asked DON-B if there had ever been discussion with R1's representative regarding risk versus benefits of not repositioning R1 on a scheduled basis. DON-B told Surveyor that they would check with Social Services Director-H for more information. On 12/18/23 at 10:30 AM, Surveyor reviewed Social Services documentation including care conference documentation. Surveyor could not identify any documentation related to discussion with R1's representative related to risk versus benefit of not repositioning R1 on a scheduled basis due to their unstageable pressure injury. Surveyor conducted interview with Social Services Director-H. Social Services Director-H did not recall ever discussing any risk versus benefit related to R1's unstageable pressure injury because that would be a more clinical thing that would involve nursing rather than social services. Surveyor asked Social Services Director-H if a resident or their representative is resistive to care or recommendations, should that be reflected on a resident's care plan. Social Services Director-H responded that they would think that any refusals by residents or their representative should be documented and reflected on the resident's care plan. On 12/18/23 at 11:10 AM, Surveyor shared concerns with NHA (Nursing Home Administrator)-A, DON-B, VP (Vice President) of Operations-C and Interim DON-D related to R1's development of a facility acquired unstageable pressure injury, lack of repositioning schedule, lack of care plan update and lack of documentation related to alleged refusals of repositioning and treatment from R1's representative. The facility submitted additional information after the facility exit which was written by MD-F documenting the following: MD-F saw R1 for the first time on 10/10/23 as a new patient with a pressure wound to her sacrum. During the course of treatment, the patient used to resist reposition during my wound rounds. The healing process was slow because of non-repositioning as the DON-B used to tell me, the patient also has low albumin level which is indicator for protein level. The patient's daughter (POA) refused the debridement in the beginning which also delay wound healing and increase risk of infection. Even after healing, the area will be weaker than normal skin and reopening is easier through the new scar, which means if the patient after wound healing is not off loading the area, the wound will happen again. With all these factors and the patient is not following the wound care prevention recommendations the wound will take longer time of healing or non-healing and reopening is expected. Surveyor reviewed the above information however, the facility did not update R1's care plan when R1 was observed to have an unstagable pressure injury on 10/10/23, did not update the care plan after the 11/29/23 Incident description which indicated R1's inconsistencies or resistance with allowing repositioning and off-loading, R1's care plan did not reflect R1's refusals for repositioning and off-loading, and there was no evidence that the risks and benefit's of not repositioning was discussed with R1 and their POA. 16584 2. R2 was originally admitted to the facility on [DATE]. R2 has diagnosis that includes; Charcot's joint left foot and ankle (syndrome in patients who have peripheral neuropathy or loss of sensation in the foot and ankle) Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic kidney disease, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side. R2 has a history of a sacral pressure ulcer and cellulitis to the right lower limb. The most recent quarterly MDS (Minimum Data Set), dated 9/22/23 indicates that R2 has a BIMS (brief interview for mental status) score of 15 - cognitively intact. R2 is said to be at risk for pressure injuries and at the time of the assessment has an unstageable deep tissue injury. Interventions included pressure relief for the bed and chair. Physical Therapy treatment encounter note, dated 9/18/23, states; during session, noticed left lower leg has small red mark, is slightly swollen. RN made aware and RN looking at R2's left lower extremity during physical therapy session. Also, during session, socks taken off and a large amount of dry/dead skin in socks and falling off feet. Much old dry skin sticking to feet. Left heel dark in color. Director of Nursing (DON) made aware. Repositioned lower extremity on the bed with left foot boot on for heel protection. Surveyor conducted further medical record review for R2, and it was noted that the skin review- weekly note, dated 9/18/23 states that R2 has a pressure injury to the left heel, suspected deep tissue injury measuring 2 centimeters by 1.7 centimeters and no depth. R2 was assessed by the Wound Physician on 9/19/23. Chief complaint- R2 had a wound on her left heel. Unstageable deep tissue injury within and around wound. Measures 1.9 centimeters by 0.9 centimeters by 0.1 centimeters. Surface area is 1.71 centimeters, 100% granulation tissue. Duration: less than 1 day. Treatment: Leptospermum honey apply three times per week for 30 days; Xeroform gauze apply once daily for 30 days. Recommendations: off- load wound; float heels in bed. A review of the plan of care for R2 indicated that R2 is at risk for skin integrity condition, or pressure sores due to impaired mobility and preferring to sleep in wheelchair, incontinence. This plan of care was initiated on 10/4/21 and last revised on 1/25/23. Interventions included apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. A revision was made on 11/10/21 for R2 to be encouraged to wear left heel lift boots at all times to offload pressure. Prevalon boots while in bed. Appropriate to remove for cares. Further review of the plan of care did not show that R2 was resistive to wearing the Prevalon boots in bed. On 12/12/23, Surveyor conducted a review of the most current wound assessment for R2 that was conducted on 12/5/23. R2 remains with the pressure injury to left heel, Stage 3. Measures 0.8 centimeters by 0.8 centimeters by 0.1 centimeters. Wound progress- not at goal, objective healing/ maintain healing. Duration R2 has had the area is 76 days. On 12/12/23 at 12:10 p.m., Surveyor made observations of Licensed Practical Nurse (LPN)- I conducting the treatment on R2's left heel. The Wound Physician was also present for an assessment of the wound. MD states that the area is making progress and will be changing the treatment to everyday. LPN- I then applied latex gloves, cleansed the area to the left heel and applied the treatment. R2 is laying in bed during the treatment with a pillow under her knees lifting up her leg. Surveyor asked R2 about the area to her left heel. R2 stated that she had a sore to her heel over a year ago and it re-opened. R2 stated that she got new diabetic shoes and wore them for just 1 day as she sat in her chair. R2 stated that the left shoe was much too tight and said this caused the sore to her left heel. Surveyor asked R2 if staff check her feet daily and R2 responded no they do not. LPN- I continued to apply the treatment and applied the foam dressing. LPN- I did not provide any additional of R2's left review toes or the right foot. On 12/14/22 at 8:52 a.m., Surveyor interviewed DON- B regarding R2's left heel pressure injury. DON- B stated that she had conducted an assessment, on 9/18/23, on R2's lower extremity because her leg and foot were warm to touch. As she was assessing her leg, she noted that the left heel had a deep tissue injury. DON- B stated that she believed the area developed because R2 was wearing her diabetic shoes even when she was in bed. Surveyor confirmed with DON- B that R2 is unable to ambulate and is either in her bed or up in a Broda chair. DON- B stated yes, but R2 wanted to wear the new shoes as she had worn diabetic shoes in the past. Surveyor asked DON- B why R2 would be wearing the diabetic shoe in bed and not the Prevalon Boots as per the plan of care. DON- B stated she was not aware she was wearing the shoe while in bed, but she was aware she would wear it while up in the chair. Surveyor shared that during the interview with R2 that R2 said she wore the shoe once and it was not fitting correctly. Surveyor asked DON- B if anyone had explained the risks of R2 continuing to wear the diabetic shoe instead of the pressure relief boots while in the chair or bed. DON- B stated she could not recall. DON- B was asked if the diabetic shoe was part of R2's plan of care. DON- B verified that it was not an intervention. DON- B was able to confirm that R2 had received the diabetic shoes on 8/31/23. On 12/18/23 the facility submitted additional information to indicate the area on R2's heel was unavoidable as a result of wearing diabetic shoes. Surveyor noted the diabetic shoes were not noted to be part of R2's plan of care to specify when to wear and to monitor for fit. Additionally, the plan of care continued to indicate R2 was at risk for pressure injuries and continued to have a plan of care to off load the foot/heels. R2 developed an unstageable/deep tissue injury as a result of not having a clear plan of care to address R2's risk factors for developing pressure injuries.

Based on interview and record review, the Facility did not immediately consult with a physician from general surgery when ordered and did not inform the resident's representative of the condition change and need for surgical consult for 1 (R5) of 6 Residents reviewed for notification. On 9/20/20 facility staff identified a mass on R5's left thigh. The physician gave orders for a consult with a physician from general surgery. The facility did not consult with a general surgeon and get an appointment. The facility did not inform the Health Care Power of Attorney, who is actively involved in her brother's care, about the left thigh mass and the order for a consult for general surgery. On 3/15/21 the facility again identified the left thigh mass when doing a skin sweep. The physician again gave orders for a general surgery consult. The facility did not consult with a general surgeon and obtain an appointment and did not inform the resident's Health Care Power of Attorney. One year later, when a consult was finally obtained, results confirmed the mass was a high grade sarcoma. The Facility's failure to consult with a physician from general surgery regarding the left thigh mass and to arrange for R5 to see a general surgeon and its failure to notify R5's Health Care Power of Attorney about R5's left thigh mass and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator-A and Corporate RN (Registered Nurse)-H were notified of the Immediate Jeopardy on 10/11/21 at 11:40 a.m. The immediate jeopardy was removed on 10/11/21. The deficient practice continues at a scope and severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: R5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 has an activated Health Care Power of Attorney (HCPOA). The order administration note dated 9/29/20 documents, Consult to general surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Will obtain. Surveyor noted there was no follow up consultation with the physician from general surgery regarding R5's left thigh mass. Surveyor noted there is no documentation R5's HCPOA was informed of the left high mass and general surgery consult. The care conference note dated 10/1/20 documents, Care conference held today with POA attending via phone. Resident remains in the facility for LTC (long term care), he is a DNR (do not resuscitate), no changes made to code status. Plan of care reviewed with no changes. Resident's vitals and BS (blood sugar) reviewed, at times resident refuses medication/treatment however with re-approach 10-15 minutes later he accepts cares/treatment. Should resident refuse after reapproach, POA would like to be notified, care plan continues to reflect this request. POA brought in special orthopedic boot that she ordered for resident on the recommendation of specialist MD (medical doctor), he has been agreeable to wearing it as per POA's request. POA will also purchase closed toe shoes for resident as the weather is getting colder. Therapy discharge summary reviewed, resident is back to PLOF (previous level of function). Resident's cognitive status discussed, no changes he remains stable and alert. Nutrition assessment reviewed with POA. POA denies concerns, she may set up outdoor visit, she understands to call facility in advance to arrange. IDT (interdisciplinary team) to continue to follow. Surveyor noted there is no documentation R5's POA was informed of the left high mass and general surgery consult. Surveyor noted there was no follow up consultation with the physician from general surgery regarding R5's left thigh mass. The nurses note dated 3/15/21 documents Skin sweep and assessment completed. OA (open area) to L (left) ball of foot medial side tx (treatment) CDI (clean dry intact) followed by wound clinic goes q (every) week. L hip/thigh large solid mass skin intact. The nurses note dated 3/15/21 documents Writer updated [name of doctor] and NP (Nurse Practitioner) [name] regarding mass to resident L upper thigh. Awaiting response. The nurses note dated 3/15/21 documents MD called back regarding L upper thigh mass. NOR (new order received) for general surgery, order transcribed. Surveyor was unable to locate any information the Facility consulted with a physician from general surgery and there is no documentation R5's HCPOA was informed of the left thigh mass or need for a general surgery consult. The progress note dated 9/2/21 documents Spoke with sister who states she is working on changing cardiologist and will let the staff know when she arranges the appointment. Writer also reviewed recent NP appointment and expressed findings related to the Lt (left) leg lipoma which has been there over a year as sister indicates she was not aware of it. Appointment is pending to f/u (follow up) on area as the size has changed per NP since onset. No pain or discomfort, no warmth or pain no changes in skin color. Resident currently in room awaiting lunch. The nurses note dated 9/10/21 documents Appointment for surgical consult made for [R5] on 9/14/21 re left thigh lipoma. [Name of POA] aware and pleased. Transportation set up. On 9/14/21 the report of consultation under findings documents 10 x 13 cm (centimeter) Mass (L) (left) thigh 30# (pound) wt (weight) loss. Suspicious. Needs MRI of (L) thigh & then possible referral to sarcoma team @ (at) [name of hospital]. On 9/20/21 at 1:34 p.m. Surveyor informed Corporate RN (Registered Nurse)-H Surveyor was unable to locate when R5's HCPOA was informed of the left thigh mass identified on 9/29/20 and consult for general surgery. On 9/21/21 at 10:10 a.m. Surveyor spoke with R5's HCPOA on the telephone. During this conversation R5's HCPOA informed Surveyor she was not informed of the mass on R5's left thigh. R5's HCPOA stated, This could have been looked at .No way this would have been ignored with me. I've been taking care of [R5] since 2006 .Would of never let it go like that. R5's HCPOA informed Surveyor first time she became aware of the mass on her brother's thigh was on 9/10/21. R5's HCPOA informed Surveyor she received two phone calls from [name of hospital] to set up surgical consult. On 9/21/21 11:55 a.m. Corporate RN-H informed Surveyor she was unable to locate any information. On 10/6/21 the Facility emailed to the Division of Quality Assurance, R5's [MEDICATION(S)] radiology biopsy dated 10/1/21 for cytologic interpretation under preliminary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's condition went undiagnosed for over a year, creating an opportunity for cancerous cells to spread if the mass was cancerous. According to Is the Lump Sarcoma? Lipoma? Learn the Difference, lipomas are fatty non-cancerous tumors (which tend to be squishy, non-tender and <2 inches) while sarcomas are cancerous tumors and tend to be firm, tender and >5 inches. The earlier a sarcoma is found, the less likely it has spread, and the better the outcome. https://www.premierhealth.com/your-health/articles/health-topics/is-this-lump-a-sarcoma-lipoma-learn-the-difference. Similarly, United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States notes, For high-grade soft tissue sarcomas, the most important prognostic factor is the stage at which the tumor is identified. Staging criteria for soft tissue sarcomas are primarily determined by whether the tumor has metastasized or spread elsewhere in the body . Using the staging criteria of soft tissue sarcomas of the American Joint Committee on Cancer (AJCC) produces similar results for sarcomas found in the limbs (arms or legs): 90% 5-year survival rate for Stage 1 sarcomas; 81% for Stage 2; and 56% for Stage 3. Sarcomas identified as Stage 4 have a very low 5-year survival rate . http://www.boneandjointburden.org. Failure to consult with a physician from general surgery as ordered by the attending physician prevented early diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This led to a finding of immediate jeopardy. Cross reference F684. The immediate jeopardy was removed on 10/11/21 when the facility implemented the following action plan: * Notification to MD and Resident's HCPOA of any abnormal findings if noted. * The Facility completed a follow up call to the Resident's HCPOA to review current care planning and review related to any additional surgical follow up appointments that may be scheduled. * Facility initiated training with Licensed Nursing Staff on documenting and reporting Changes of Condition at the time of time of observation to the Physician and the Resident's responsible party participating in care planning for the identified Resident. * Reviewed the policy and procedure for changes of condition F580. * Re-educated Licensed Nursing Staff on identifying and reporting of changes of condition when newly identified changes in health status are identified. * Re-educated Licensed Nursing Staff on completing a notification to the MD, RP (responsible party) and or Guardian at the time of identification. * The Facility will review Point Click Care (PCC) daily during morning meeting to identify changes of condition and ensure notifications/consultations were completed. Follow up will be completed if indicated based on the outcome of the audit. * The Facility will complete random audits 3x weekly on scheduling of appointments to ensure notifications were completed to the Responsible Party and to ensure notifications of MD orders were completed. * The Facility will complete random audits 3x weekly to ensure skin events with a change in clinical presentation are reported at the time of identification to the MD and Responsible Party. * The Facility will ensure Residents with growths have a focused routine assessment that identifies changes in dimensions, color, shape, presentation and overall decline and or improvement in characteristics and reported to the MD and RP and Guardian at the time of identification.

Based on interview and record review the facility did not ensure 1 (R5) of 6 Residents reviewed received care and treatment in accordance with their physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Nurse Practitioner (NP) note dated 9/29/20 documents under assessment and plan, Left Thigh Mass - patient notes duration is 8 months - non-tender, non-mobile. firm -will refer to general surgery. Under physical exam for extremities documents, No [CONDITION(S)] noted. Not cyanotic. left thigh mass. There are no measurements of the left thigh mass and no revisions in R5's skin integrity care plan. The order administration note dated 9/29/20 documents, Consult to general surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Will obtain. There is no information regarding an appointment being made or R5 having a general surgery consult. There are no subsequent measurements of the thigh mass by facility staff. On 3/15/21 a skin sweep was conducted and LPN-CC identified the left thigh mass. R5's physician was notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There are no subsequent measurements by facility staff. On 8/31/21 the NP note documents under assessment and plan, Left Thigh Mass -has been present over 1 year - may be limpoma (fatty lump) or something more - non-tender, non-mobile firm - referred to general surgery back in [DATE] however no follow up arranged - reorder general surgery consult today as staff note increase in size. Under physical exam for extremities documents No [CONDITION(S)] noted. Not cyanotic. firm left thigh mass. Surveyor noted there were no measurements of the left thigh mass until 9/13/21 when the non pressure weekly tracker documents for site, .left thigh (rear) and under description Intact attached Lipoma. Circumference 7 cm (centimeters). Protrudes off thigh 3 cm in height. Surveyor noted this is the only measurement taken by Facility staff that Surveyor was able to locate. An appointment was made for general surgery consult on 9/14/21. The report of consultation dated 9/14/21 under findings documents, 10 x 13 cm (centimeter) Mass (L) (left) thigh 30# (pound) wt (weight) loss. Suspicious. Needs MRI of (L) thigh & then possible referral to sarcoma team @ (at) [name of hospital]. The [MEDICATION(S)] radiology biopsy dated 10/1/21 for cytologic interpretation under preliminary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility's failure to routinely monitor and assess R5's left thigh mass until 9/13/21, to document at least monthly on its size, and to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This created a finding of Immediate Jeopardy (IJ) which began on 9/29/20. Administrator-A and Corporate RN (Registered Nurse)-H were informed on 10/11/21 at 11:40 a.m. The immediate jeopardy was removed on 10/11/21. The deficient practice continues at a scope and severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: R5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 has an activated power of attorney. The MD (Medical Doctor) note dated 7/12/20 does not have any documentation regarding a left thigh mass. The NP (Nurse Practitioner) notes dated 7/13/20, 7/20/20, 7/23/20, 8/7/20, and 8/11/20 do not have any documentation regarding a left thigh mass. The MD note dated 9/1/20 does not have any documentation regarding a left thigh mass. The NP note dated 9/29/20 documents under assessment and plan Left Thigh Mass - patient notes duration is 8 months - non-tender, non-mobile. firm -will refer to general surgery. Under physical exam for extremities documents No [CONDITION(S)] noted. Not cyanotic. left thigh mass. Surveyor noted there are no measurements of the left thigh mass. The order administration note dated 9/29/20 documents Consult to general surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Will obtain. Surveyor was unable to locate any information regarding an appointment being made or R5 having a general surgery consult. On 9/21/21 at 9:57 a.m. Surveyor informed LPN (Licensed Practical Nurse)-Y she had written an order administration note for R5 dated 9/29/20 for a general surgery consult. Surveyor asked if she could remember making this appointment. LPN-Y informed Surveyor she doesn't recall anything about this. The NP note dated 10/14/20 documents under assessment and plan: Left Thigh Mass - patient notes duration is 8 months - non-tender, non-mobile, firm -referral placed to general surgery Sept (September) 2020. Under physical exam for extremities documents No [CONDITION(S)] noted. Not cyanotic. left thigh mass. Surveyor noted there are no measurements of the left thigh mass. The NP note dated 10/23/20 documents under assessment and plan: Left Thigh Mass - patient notes duration is 8 months - non-tender, non-mobile. firm -referral placed to general surgery [DATE]. Under physical exam for extremities documents No [CONDITION(S)] noted. Not cyanotic. left thigh mass. Surveyor noted there are no measurements of the left thigh mass. The NP note dated 10/27/20 documents under assessment and plan: Left Thigh Mass - patient notes duration is 8 months - non-tender, non-mobile. firm -referral placed to general surgery [DATE]. Under physical exam for extremities documents No [CONDITION(S)] noted. Not cyanotic. left thigh mass. Surveyor noted there are no measurements of the left thigh mass. The MD note dated 1/13/21 documents under assessment and plan Left Thigh Mass - patient notes duration is 8 months - non-tender, non-mobile. firm -referral placed to general surgery [DATE]. Under physical exam for extremities documents No [CONDITION(S)] noted. Not cyanotic. Surveyor noted there are no measurements of the left thigh mass and there have been no ongoing measurements by facility staff. The NP note dated 3/3/21 does not have any documentation regarding a left thigh mass. The MD note dated 3/14/21 does not have any documentation regarding a left thigh mass. The nurses note dated 3/15/21 documents Skin sweep and assessment completed. OA (open area) to L (left) ball of foot medial side tx (treatment) CDI (clean dry intact) followed by wound clinic goes q (every) week. L hip/thigh large solid mass skin intact. The nurses note dated 3/15/21 documents Writer updated [name of doctor] and NP (Nurse Practitioner) [name] regarding mass to resident L upper thigh. Awaiting response. The nurses note dated 3/15/21 documents MD called back regarding L upper thigh mass. NOR (new order received) for general surgery, order transcribed. Surveyor was unable to locate any information regarding an appointment being made or R5 having a general surgery consult. The NP note dated 4/13/21 under physical exam for extremities documents No [CONDITION(S)] noted. Not cyanotic. Left thigh soft tissue mass. The MD note dated 5/24/21 does not have any documentation regarding a left thigh mass. The NP notes dated 6/2/21 and 8/11/21 do not have any documentation regarding a left thigh mass. The NP note dated 8/31/21 documents under assessment and plan Left Thigh Mass -has been present over 1 year - may be limpoma (fatty lump) or something more - non-tender, non-mobile firm - referred to general surgery back in [DATE] however no follow up arranged - reorder general surgery consult today as staff note increase in size. Under physical exam for extremities documents No [CONDITION(S)] noted. Not cyanotic. firm left thigh mass. Surveyor noted there are no measurements of the left thigh mass and there have been no measurements by facility staff since the mass was first discovered on 9/29/20. The progress note dated 9/2/21 documents, Spoke with sister who states she is working on changing cardiologist and will let the staff know when she arranges the appointment. Writer also reviewed recent NP appointment and expressed findings related to the Lt (left) leg lipoma which has been there over a year as sister indicates she was not aware of it. Appointment is pending to f/u (follow up) on area as the size has changed per NP since onset. No pain or discomfort, no warmth or pain no changes in skin color. Resident currently in room awaiting lunch. The nurses note dated 9/10/21 documents, Appointment for surgical consult made for [R5] on 9/14/21 re left thigh lipoma. [Name of POA] aware and pleased. Transportation set up. The non pressure weekly tracker with an effective date of 9/13/21 documents for site 36) left thigh (rear) and under description Intact attached Lipoma. Circumference 7 cm (centimeters). Protrudes off thigh 3 cm in height. Surveyor noted this is the only measurement taken by Facility staff that Surveyor was able to locate. On 9/14/21 the report of consultation under findings documents 10 x 13 cm (centimeter) Mass (L) (left) thigh 30# (pound) wt (weight) loss. Suspicious. Needs MRI of (L) thigh & then possible referral to sarcoma team @ (at) [name of hospital]. On 9/20/21 at 12:16 p.m. Surveyor asked LPN (Licensed Practical Nurse)-CC who is responsible for making consult appointments. LPN-CC informed Surveyor the nurses are. LPN-CC explained after they get an order, the doctors office is called and then they make transportation. LPN-CC informed Surveyor sometimes it can take a couple days to make the appointment. Surveyor asked if a progress note would be written regarding the appointment. LPN-CC replied, Yes, should make a note. On 9/20/21 at 1:19 p.m. Surveyor asked LPN-CC if R5 was one of her Residents. LPN-CC informed Surveyor she is not on that side. Surveyor informed LPN-CC Surveyor had noted three nurses notes on 3/15/21 regarding a skin sweep for R5. LPN-CC informed Surveyor Administrator-A asked her to do a skin sweep of all the Residents in the building at this time and she gave all the sheets to Administrator-A. Surveyor informed LPN-CC one of the notes indicated a new order was received for general surgery and the order was transcribed. Surveyor asked LPN-CC if she made the appointment for this consult. LPN-CC informed Surveyor she would not have made the appointment as she was not the nurse. LPN-CC informed Surveyor she knows she updated the Director of Nursing at that time and spoke with LPN-Y the nurse on that side. On 9/21/21 at 9:54 a.m. Surveyor informed LPN-Y, LPN-CC had conducted a skin sweep on 3/15/21, noted R5 had a left thigh mass, and that LPN-CC had informed her that R5's physician had ordered a general surgery consult. Surveyor asked LPN-Y if she made the general surgery appointment for R5 which was ordered on 3/15/21. LPN-Y informed Surveyor she doesn't recall if an appointment was made. Surveyor asked who would be responsible to ensure an appointment was made. LPN-Y informed Surveyor she doesn't recall who would be responsible. On 9/21/21 at approximately 2:10 p.m. Corporate RN-H informed Surveyor she wasn't able to find the general surgery consults for 9/29/20 and 3/15/21. Administrator-A informed Surveyor R5's POA would sometimes cancel R5's appointments. Surveyor informed Administrator-A and Corporate RN-H there is no evidence Facility staff made these appointments and there is no documentation in R5's medical record R5's POA canceled appointments. On 10/5/21 at 1:25 p.m. Surveyor spoke with Physician-DD on the telephone regarding R5's left thigh mass. Surveyor asked Physician-DD if he saw R5's left thigh mass. Physician-DD replied yes and explained on 9/1/20 did not see a mass and on 9/29/20 the NP did see it, patient notes (it was) there for 8 months and refer to general surgery. Physician-DD informed Surveyor for a couple month they noted the mass and also in January and then lost follow up. Physician-DD informed Surveyor more recently the mass grew in size. On 8/31/21 the NP saw R5 and she reordered a general surgery consult as staff said it has increased in size. Physician-DD informed Surveyor he was looking at his & the NP's documentation and does not have any of the Facility's documentation. Surveyor asked Physician-DD if he actually saw the mass on R5' left thigh. Physician-DD informed Surveyor he must have but is not visualizing and not picturing the mass. Physician-DD indicated his partner saw R5 on 9/20/21 and R5 was going to see the surgeon the next day. Surveyor asked Physician-DD what his expectations are for staff monitoring R5's left thigh mass. Physician-DD informed Surveyor he doesn't know how to answer this, he does know the Facility does regular skin checks and doesn't know who first noticed the mass, was it the patient asking about it or did staff. Surveyor asked Physician-DD if he would expect staff to measure R5's left thigh mass. Physician-DD replied I would. Surveyor asked if staff should be measuring the mass weekly. Physician-DD informed Surveyor he didn't think it would have to be measured weekly as it's not an active wound but should be measured monthly. Surveyor asked Physician-DD if he was aware R5 did not see the general surgeon which was ordered on 9/29/20. Physician-DD informed Surveyor their notes mention the general surgeon the first month or two and after that point doesn't know if the consult got lost. Surveyor asked Physician-DD if he was aware there was another general surgery consult ordered on 3/15/21. Physician-DD informed Surveyor he was personally not aware. Surveyor then informed Physician-DD of the nurses notes dated 3/15/21 regarding a skin sweep, a call being placed to himself and the NP awaiting a call back and the MD calling back and ordering a general surgery consult. Physician-DD informed Surveyor he has no recollection of that but it's a plausible story. Surveyor asked Physician-DD if there is any impact on R5 with the delay in the general surgery consult. Physician-DD informed Surveyor he can't answer that. He knows a biopsy was recently done and they are waiting for the results. On 10/6/21 the Facility emailed to the Division of Quality Assurance R5's [MEDICATION(S)] radiology biopsy report. The [MEDICATION(S)] radiology biopsy report, dated 10/1/21, for cytologic interpretation under preliminary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's condition went undiagnosed for over a year, creating an opportunity for cancerous cells to spread if the mass was cancerous. According to Is the Lump Sarcoma? Lipoma? Learn the Difference, lipomas are fatty non-cancerous tumors (which tend to be squishy, non-tender and <2 inches) while sarcomas are cancerous tumors and tend to be firm, tender and >5 inches. The earlier a sarcoma is found, the less likely it has spread, and the better the outcome. https://www.premierhealth.com/your-health/articles/health-topics/is-this-lump-a-sarcoma-lipoma-learn-the-difference. Similarly, United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States notes, For high-grade soft tissue sarcomas, the most important prognostic factor is the stage at which the tumor is identified. Staging criteria for soft tissue sarcomas are primarily determined by whether the tumor has metastasized or spread elsewhere in the body . Using the staging criteria of soft tissue sarcomas of the American Joint Committee on Cancer (AJCC) produces similar results for sarcomas found in the limbs (arms or legs): 90% 5-year survival rate for Stage 1 sarcomas; 81% for Stage 2; and 56% for Stage 3. Sarcomas identified as Stage 4 have a very low 5-year survival rate . http://www.boneandjointburden.org. The Facility's failure to ensure R5 received appropriate care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The immediate jeopardy was removed on 10/11/21 when the facility implemented the following action plan: * The Facility reviewed the care plan of R5 to identify and complete follow up, if indicated, on any outstanding orders pertaining to consultations for specialty provider services. * The Facility performed and updated complete head to toe skin assessment of R5 to identify any abnormal findings. * The Facility reviewed the care planning of R5 to ensure monitoring orders related to the left thigh mass are in place. The Facility will monitor the dimensions, skin type of actual growth, skin type of surrounding tissue, new onset pain or worsening pain and opening or reopening of identified area. * The Facility reviewed the details of the care planning related to R5 with the Medical Director who is also resident's attending physician. * The Facility initiated a review of each Resident currently admitted to identify any possible similar events related to abnormal findings related to the skin review. * The Facility initiated a review of each Resident with an identified growth on the skin for new orders related to care planning and on going observation of the identified area. * The Facility initiated a review of each Resident currently admitted to identify and complete follow up on any identified growths on the skin for additional care planning and observation to the identified area. * The Facility completed a review with each current attending physician in relation to outstanding consultation orders and initiate follow up if indicated. * The Facility reviewed the policy and procedures for Physician Services F684. * Re-educated all Licensed Nursing Staff on identifying changes in health status. * Re-educated all Licensed Nursing Staff on completion of a comprehensive assessment on all skin events with a noted change in size, shape, and clinical presentation at the time of discovery. * Re-educated all Licensed Nursing Staff on the importance of following up on identified changes to the skin upon notification by the Certified Nursing Assistant. * Re-educated all Licensed Nursing Staff on completing a detailed or comprehensive assessment on identified growths that have changed in size or clinical presentation. * Re-educated all Licensed Nursing Staff on following up on all abnormal findings during the weekly skin review process. * The Facility reviewed the appointment scheduling process to ensure consistency in scheduling and follow up. * The Facility will review orders to identify and ensure follow upon recommendations for consultations during daily morning meeting. * The Facility will review Point Click Care (PCC) daily during morning meetings to identify changes of condition. Follow up will be completed if indicated based on the outcome of the audit. * The Facility will complete random audits 3x weekly with Licensed Nurses to gauge understanding related to completion of changes of condition. Remedial education will be provided at the time of completion of audits if indicated. * The Facility will review orders to identify and ensure follow up on recommendations for consultations daily during morning meeting. The Facility will ensure Residents with growths have a focused routine assessment that identifies changes in dimensions, color, shape, presentation and overall decline and or improvement in characteristics.

Based on interview, record review and observation, the facility did not ensure that a resident who entered the facility without a Pressure Injury (PI) did not develop a PI and received appropriate care, treatment and preventative measures to promote healing for 2 (R3 & R6) of 3 Residents reviewed for pressure injuries. R3 was admitted to the facility on [DATE] for short term rehab without any pressure injuries. On 2/7/21, R3 was identified with a small open area. There was no assessment of this open area. The weekly skin review dated 2/11/21 noted R3 had a previously existing pressure injury to the coccyx but no other open areas. There was no assessment of R3's pressure injury on 2/11/21. On 2/15/21, 8 days later, NP (Nurse Practitioner)- K was made aware of coccyx open area and a nurses notes indicates NP-K would refer to wound team and wound doctor. There was no weekly skin review completed during the week of 2/14/21 through 2/20/21. A wound assessment was not completed by Facility staff or WD (Wound Doctor)-M until 2/26/21 at which time R3's pressure injury was unstageable and had a foul odor. This assessment was 19 days after being identified as a small open area. WD-M informed Surveyor it was a significant injury when he saw the pressure injury on 2/26/21 and was not aware of R3's pressure injury until 2/26/21. R3's pressure injury declined and on 3/5/21 the Facility's wound evaluation documented Stage 4. WD-M's wound assessment on 3/8/21 documents R3's sacrum pressure injury as Stage 4. R3's skin integrity care plan was not revised when the pressure injury was identified and when there was a decline in the pressure injury. R3's nurses note dated 3/10/21 documents R3 was placed on antibiotic therapy for the coccyx wound. On 3/20/21 R3's lab showed R3 was positive for C-diff and was started on [MEDICATION(S)]. The Facility's failure to assess R3's small open area for 19 days, at which time it was assessed as unstageable with 5% slough and 55% necrotic wound bed and a foul odor, failure to implement appropriate interventions to facilitate healing and prevent further deterioration of the pressure injury, and the failure to consult with the Physician when the pressure injury was first identified, created a finding of Immediate Jeopardy (IJ) which began on 2/7/21. The Surveyor notified Administrator-A, Interim DON (Director of Nursing)-B, and Corporate RN (Registered Nurse)-H on 7/21/21 at 11:30 a.m. The immediate jeopardy was removed on 7/23/21. The deficient practice continues at a scope and severity of a G (harm/isolated) as the facility continues to implement its action plan and as evidenced by; * R6 developed a left heel pressure injury on 4/22/20. The facility did not assess R6's left heel Stage 4 pressure injury from 4/30/21 to 5/14/21, during which time the left heel pressure injury increased in size and went from an unstageable pressure injury to a Stage 4 pressure injury. The Wound Evaluation Tracker assessment dated [DATE] did not document the amount of Granulation or Slough in the wound bed. The facility did not assess R6's left heel during the week of 7/11/21 - 7/17/21. * R3 developed a blister to the right heel on 6/22/21. There was no description or measurement of the wound until 6/25/21. On that date, the wound nurse (LPN-G) incorrectly described the wound as unstageable. The facility did not assess the left heel from 7/11/21 - 7/17/21. Findings include: The Pressure Ulcer/Injury, Prevention of policy and procedure with an original effective date of June 2017 under the section documentation guidelines indicates; Documentation may include: * Date, time, approaches to prevent pressure ulcer/injury development. * Prevention equipment used. * Condition of the resident's skin. * Physician notification when change in skin condition is observed. * If a pressure ulcer/injury is present, the Licensed Nurse is responsible to record condition of the skin, including stage, size, site, depth, color drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure ulcer/injury is identified as well as when treatment is not effective. * Signature and title. 1. R3 was admitted to the facility on [DATE] for short term rehab without any pressure injuries. R3 does not have an activated power of attorney. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission evaluation dated 1/21/21 includes a Braden assessment with a score of 14. A score of 13-14 indicates moderate risk. Under the skin integrity section there is no documentation of any skin impairments. The admission MDS (Minimum Data Set) with an assessment reference date of 1/26/21 documents a BIMS (Brief Interview Mental Status) score of 15 which indicates cognitively intact. R3 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfer, is dependent with one person physical assist for toilet use, and does not ambulate. R3 is coded as having an indwelling catheter and is always incontinent of bowel. R3 is at risk for pressure injury development and is coded as not having any pressure injuries. The admission pressure injury CAA (Care Area Assessment) under analysis of findings documents; Skin is checked upon admission during cares, toileting and bathing. Skin audit upon admission shows no skin concerns. [R3] admitted to facility for therapy after recent hospitalization for CHF (congestive heart failure). Therapy is in place and [R3] plans to return to previous living arrangements upon completion. Extensive to total assistance with ADL's (activities daily living) as per POC (plan of care) documentation. [R3] remains at risk for development of pressure area due to his dependency on staff for cares. [R3] continues to have a Foley catheter in place and is incontinent of bowel. A toileting program has been implemented. Skin prevention interventions are currently in place. The weekly skin review dated 1/28/21 is checked for skin intact. The At risk for Skin Integrity Condition or Pressure Sores r/t (related to) Impaired mobility, Incontinence Care Plan initiated & revised 2/1/21 documents the following interventions: * Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. Initiated 2/1/21. * Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately. Initiated 2/1/21. * Avoid friction/shearing while repositioning: if Resident is unable to assist, use at least two staff members, use lift sheet, bed should be as flat as possible with lifting. Initiated 2/1/21 & revised 7/2/21. * Conduct pressure injury skin assessments (i.e. Braden scale) as indicated. Initiated 2/1/21. * Frequent repositioning in bed. Initiated 2/1/21 & revised 7/2/21. * Head to toe assessment by Licensed Nurse performed weekly at minimum. Initiated 2/1/21. * Keep Resident clean and dry. Use barrier cream after good peri-care. Apply proper incontinent products as indicated. Initiated 2/1/21 and revised 7/2/21. * Labs and antibiotics as ordered. Initiated 3/10/21. * Provide treatments as ordered. Initiated 3/10/21. * Encourage the use of pressure relieving boots while in bed. Initiated 5/6/21 & revised 7/2/21. The weekly skin review dated 2/4/21 includes documentation of no new open areas noted. The Braden assessment dated [DATE] has a score of 16 which indicates is at risk for pressure injury development. The daily skilled note by LPN-F dated 2/7/21 under summary documents, Resident is doing well. A small open area was found on the resident coccyx this AM (morning) it was cleansed and dressed. There was no assessment, including an RN (Registered Nurse) assessment, of the small open area including measurements and description of wound bed. R3's skin integrity care plan was not revised and there is no notification to the physician. On 7/21/21 at 7:47 a.m. Surveyor asked LPN-F what type of dressing did she apply on 2/7/21. LPN-F informed Surveyor if she was to guess just a bordered gauze at the time or foamy kind of. Surveyor asked if she notified anyone of the pressure injury. LPN-F replied, I'm sure I must have. I don't remember. Surveyor asked how she became aware of the pressure injury. LPN-F replied, I don't remember and then informed Surveyor she probably would have told the DON but doesn't remember what she did back in February. The nurses note dated 2/8/21 documents, Isolation maintained throughout first and second shift as a covid precaution no fever cough or shortness of breath. Dressing on coccyx is CDI (clean dry intact). The nurses note dated 2/10/21 documents, Isolation precautions maintained during shift, no respiratory distress. Coccyx wound has no drainage during night, resident repositioned off coccyx. The NP progress note dated 2/10/21 under physical exam for skin documents, no rashes or [CONDITION(S)] noted. This NP progress note does not address R3's pressure injury. The Braden assessment dated [DATE] has a score of 11 which indicates high risk for pressure injury development. The weekly skin review dated 2/11/21 documents, no new open areas aside from coccyx that is being treated. OA (open areas) and pre existing are checked. The nurses note dated 2/12/21 documents, Repositioned as PPOC (personal plan of care). Excoriation remains to buttocks. Incontinent care provided. [NAME] barrier cream applied f/b (followed by) abd (abdominal) pad. The nurses note dated 2/14/21 documents, Barrier cream applied to coccyx. Repositioned per protocol. The nurses note dated 2/15/21 documents, Writer spoke with NP -K regarding Dx. (diagnosis) for Foley cath (catheter), NP made aware of coccyx open area, will refer to wound team and wound Dr. NOR (new order received) for Tylenol 650 mg (milligram) PRN (as needed) pain/fever. Surveyor noted this notification is 8 days after R3 was identified as having a small open area. The daily skilled note dated 2/17/21 includes documentation of Skin turgor: Extremely dry - tenting 4+ (plus) sec. (seconds). Skin conditions: Pressure area(s). open area on coccyx. order was given to dress with hydra blue, abd (abdominal) and tape until the resident sees the wound Dr. on Friday Skin integrity/positioning devices: Heel Relief/Protector/Lift Chair/Seat Cushion. open area on coccyx. The nurses note dated 2/17/21 documents, Dressing was changed today per order from NP-K wound was cleansed with dakins and dressed with hydra blue, abd (abdominal) pads and tap (tape). dressing to remain in place until Friday when resident will be seen by wound Dr. The NP progress note dated 2/17/21 under new orders documents, 1. Labs order for tomorrow. 2. Wound care consult. Under physical exam for skin documents No rashes or [CONDITION(S)] noted. This progress note does not include an assessment of R3's pressure injury. There was no weekly skin review dated 2/18/21 or at any other time during this week. The nurses note dated 2/18/21 documents, NP updated on labs. Cleansed coccyx area and applied dry bandage. Turned and repositioned from side to side. The nurses noted dated 2/19/21 documents, Dressing on coccyx was CDI throughout first and second shift wound Dr. will be here Monday to see resident. The nurses note dated 2/23/21 documents, Dressing on coccyx is clean dry and intact. No complaints of pain related to fall, MD (Medical Doctor) notified. The NP progress note dated 2/24/21 documents under physical exam for skin no rashes or [CONDITION(S)]. This NP progress note does not address R3's pressure injury. The nurses note dated 2/25/21 documents, Necrosis noted coccyx open wound. Repositioned side to side. wet to dry dressing applied. Surveyor reviewed the February 2021 TAR (Treatment Administration Record) and noted a treatment with a start date of 2/26/21 and discontinued on 3/3/21 for the PM (evening) shift of Coccyx OA (open area) Remove packing material Skin prep peri wound, pack wound with Dakins' soaked gauze, cover with Bordered gauze, change q (every) day until healed. One time a day for wound healing. The next treatment listed on the February 2021 TAR with a start date of 2/27/21 and discontinued on 3/8/21 for the AM (morning) shift of Santyl Ointment 250 unit/gm (gram) ([MEDICATION(S)]) Apply to Coccyx topically one time a day for wound healing. Coccyx: Cleanse with Dakins', pat dry, skin prep peri wound, apply Santyl to wound base, pack wound with Dakins' soaked gauze, cover with Bordered gauze change q day until healed. Surveyor noted there are no other treatments on the February 2021 TAR. The wound evaluation for date of wound data collection is documented as 2/26/21. Site is documented as; 53) sacrum, type pressure, length 4.91, width 4.52, depth 2 and Stage is documented as Unstageable. For the question when was the wound identified documents 02/26/2021. Under the exudate section for color/type documents, seropurulent, consistency Thin, watery, Amount Large/copious, and Odor Foul. The Wound bed is 40% granulation, 5% slough and 55% necrotic. Date of treatment ordered documents 02/26/2021. Under current wound status/additional comments documents, debrided by wound MD (Medical Doctor) this shift. This assessment was signed on 4/27/21 by LPN (Licensed Practical Nurse)-G. Surveyor noted this is the first assessment (2/26/21) of R3's pressure injury, and this assessment did not occur until 19 days after it was identified as a small open area on 2/7/21. There was no revision of R3's skin integrity care plan during that time period. The wound evaluation for date of wound data collection 03/05/2021 documents, length 6.33, width 7.85, and depth 3.3. Under staging documents, IV (4). Under the exudate section for color/type documents serous, consistency Thin, watery, Amount moderate, and Odor not present. The Wound bed is 45% granulation, 15% slough and 40% necrotic. Date of treatment ordered documents 02/26/2021. Under current wound status/additional comments is blank. This assessment was signed on 4/27/21 by an RN (Registered Nurse) who is no longer employed by the Facility. Although the measurements of R3's pressure injury have increased and is now a Stage 4, Surveyor noted there were no revisions in R3's skin integrity care plan. The Facility's next wound evaluation is dated 4/9/21. The Facility provided Surveyor with WD (wound doctor)-M's assessments dated 2/26/21, 3/8/21, 3/19/21 (11 days), 3/26/21, 4/2/21, 4/9/21, 4/16/21, 4/30/21 (14 days), 5/14/21 (14 days), 5/21/21, 5/28/21, 6/4/21 6/18/21, 6/25/21, and 7/9/21. Starting 3/8/21, WD-M began classifying R3's pressure injury as a Stage 4. The nurses note dated 3/8/21 documents, wound was cleaned by wound MD, IV (intravenous) started in L (left) hand for [MEDICATION(S)] (antibiotic), IV to be started in AM (morning). The nurses note dated 3/10/21 documents, Abt (antibiotic) therapy for coccyx wound prophylactic. PIV (peripheral intravenous line) left outer hand. Coccyx wound without odor. The nurses note dated 3/11/21 documents, Abt therapy prophylactic for coccyx wound. No redness or odor noted @ (at) site. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses note dated 3/16/21 documents, Treatment to coccyx wound con't (continued). Positioned side to side in bed. IV abt therapy con't for coccyx wound. The nurses note dated 3/18/21 documents, Coccyx wound dressing changed per orders, IV antibiotics completed today no9 [sic] (no) adverse reaction to antibiotics. The nurses note dated 3/19/21 documents, Post antibiotic therapy loose stool have obtained an order to collect a stool sample to test for c-diff ([CONDITION(S)]). The nurses note dated 3/20/21 documents, Writer received confirmation from Wisconsin diagnostic laboratories of resident being positive for C Diff. [Physician-L] paged at this time to update on the positive result to receive ABT order awaiting return call to facility. The nurses note dated 3/20/21 documents, Coccyx wound, wound vac to be started today. Resident is positive for C-diff and will be started on Vanco ([MEDICATION(S)] - antibiotic) and probiotics. Surveyor compared LPN-G's wound evaluation with WD-M's wound evaluation dated 4/9/21. Surveyor noted the measurements are the same with Length 4.39, width 4.61, and depth 2.20 with the exception of undermining. LPN-G documents undermining at 9-3 o'clock 1.4 cm and MD-M documents undermining 0 cm (centimeters). LPN-G documents the wound bed as 100% granulation while WD-M documents the wound bed as 83% red tissue and 16% black tissue. Surveyor noted weekly Facility wound evaluations dated 4/16/21, 4/23/21, 4/30/21 and 5/7/21. The wound evaluation dated 5/7/21 shows R3's Stage 4 pressure injury declined with length documented, 7.6 (previous week 5.93), width 6.4 (previous week 3.66) and depth 2(previous week 1.2). The wound bed is 76% granulation, 20% slough, and 4% necrotic. The previous week the wound bed was 10% epithelial and 90% granulation. Surveyor noted there was no revision in R3's plan of care. Surveyor noted weekly Facility wound evaluations for R3's stage 4 sacrum pressure injury dated 5/14/21, 5/21/21, 5/28/21, 6/4/21, 6/11/21, 6/18/21, 6/25/21, 7/2/21, and 7/9/21. Surveyor noted there are no assessments documented for the week of 7/11/21 through 7/17/21. Surveyor also noted the facility is now interchangeably referencing the coccyx pressure injury as the sacrum pressure injury. The nurses note dated 4/30/21 documents, Resident monitored for coccyx and buttocks open areas. Dressing remains clean and intact. Resident repositioned during the night. No complaints of pain noted will continue to monitor. Surveyor noted this is the first nurses note regarding a buttocks open area. The nurses note dated 5/13/21 documents, Resident monitored for coccyx and right buttocks wound. The nurses note dated 5/17/21 documents, Resident monitored for coccyx and right buttocks wound. The nurses note dated 5/20/21 documents, Resident monitored for coccyx and right buttock wounds. Dressing remains clean and intact. Resident position on side to side. Encouraged to stay off back to improve wound healing. Foley catheter patent with yellow urine in tubing and bag. Resident denies pain or discomfort. Will continue to monitor. The nurses note dated 5/26/21 documents, Resident monitored for coccyx and right buttock wounds. Dressing remains clean and intact. Resident position on side to side. Encouraged to stay off back to improve wound healing. Foley catheter changed prior shift due to no output and complaints of abdomen discomfort. Resident denies pain or discomfort. Will continue to monitor. The nurses note dated 5/31/21 documents, Resident monitored for coccyx and right buttock wounds. Dressing remains clean and intact. Resident position on side to side. Encouraged to stay off back to improve wound healing. Foley catheter patent with yellow urine in tubing and bag. Resident denies pain or discomfort. Will continue to monitor. Surveyor noted this is the last nurses note regarding right buttock wound and did not note any wound assessment for R3's right buttocks. Surveyor was unable to locate any weekly skin reviews completed in May 2021. The weekly skin review dated 6/9/21 under other documents, bilateral feet dryness lotioned daily. Surveyor was unable to locate any further weekly skin reviews in June 2021. On 7/20/21 at 11:03 a.m., Surveyor spoke with R3 who informed Surveyor they told him he needs to go to the hospital and have a new catheter put in. Surveyor observed R3 was on his left side in bed laying on an air mattress and wearing bilateral pressure relieving boots. Surveyor asked R3 if he has any open areas on his buttocks. R3 informed Surveyor he does and the nurse makes sure it is medicated. Surveyor asked R3 how he developed the open area on his buttocks. R3 informed Surveyor the reason they said was because he is on his back side. R3 informed Surveyor the reason he is on his back side is because he is in bed and if someone doesn't move him he can't move himself. Surveyor asked R3 if staff moves him around in bed. R3 replied, just from one side to the other. Surveyor asked R3 how often staff moves him from side to side. R3 replied, I'd say three times a day. Surveyor asked R3 why he wears the boots on his feet. R3 replied, They insisted I wear them because I have a sore on my leg. Surveyor asked if the pressure injuries on his buttocks or heel hurts. R3 informed Surveyor sometimes they put spray on them which irritates the skin. On 7/20/21 at 12:15 p.m., Surveyor observed R3 on a stretcher being wheeled out of his room by ambulance staff. On 7/20/21 at 1:54 p.m., Surveyor asked CNA (Certified Nursing Assistant)-J if she has provided cares to R3. CNA-J replied, yes. Surveyor asked CNA-J if she had any idea how R3 developed the pressure injury on his buttocks. CNA-J replied, no. Surveyor asked CNA-J if R3 would allow staff to reposition him. CNA-J replied, yes and he is turned from one side to the other. Surveyor asked how long R3 has had the air mattress. CNA-J informed Surveyor R3 had the air mattress since he was on another unit. On 7/20/21 at 3:04 p.m. Surveyor spoke with LPN-G to inquire about pressure injury assessments. LPN-G informed Surveyor she assesses Residents every week on Friday. Surveyor asked what should happen if a CNA reports a pressure injury. LPN-G informed Surveyor the nurse should be going in measuring the area, notify the doctor, get orders and open up a wound tracker. LPN-G informed Surveyor the nurses were also letting her know and notify the family. LPN-G informed Surveyor WD-M comes in the Facility once a week and she does rounds with him. Surveyor asked if the assessments are completed with WD-M. LPN-G informed Surveyor sometimes she'll get a head start before he comes in or if WD-M can't come then she will do the wound rounds herself. Surveyor asked if she completes the assessments herself does she review the assessments with anyone. LPN-G informed Surveyor she'll talk with RN (Registered Nurse)-N who is the night nurse but mostly updates RN Corporate-H. LPN-G informed Surveyor she will call or email RN Corporate-H. LPN-G informed Surveyor she places the information into a flow sheet for RN Corporate-H so she will know who has pressure injuries in the building. Surveyor asked how would RN-N or RN Corporate-H verify the assessment is correct. LPN-G informed Surveyor they could come in and measure to double check. Surveyor asked LPN-G if she knows how R3 developed the pressure injury on his sacrum. LPN-G replied No, that was before I was here. Surveyor asked LPN-G if she knew why R3 was placed on an antibiotic in March. LPN-G replied no. Surveyor asked who is responsible for revising the care plan. LPN-G replied, DON (Director of Nursing) unless she told me to. On 7/21/21 at 8:26 a.m. Surveyor asked Corporate RN (Registered Nurse)-H why R3 was started on an antibiotic IV in March and if there was any lab work. At 8:28 a.m. RN-H informed Surveyor she was unable to locate any lab work for the antibiotic and thinks R3 was placed on an antibiotic for his CRP (C-Reactive Protein) levels. Corporate RN-H also informed Surveyor there is a MD progress note dated 3/14/21 which references coccyx wound infection. On 7/21/21 at 9:01 a.m., Surveyor spoke with WD -M on the telephone regarding R3's sacrum pressure injury. Surveyor informed WD-M according to his & the Facility's assessment R3's pressure injury on 2/26/21 was identified as unstageable. Surveyor informed WD-M this is the first assessment Surveyor located. WD-J replied 2/26 was when I was informed of the wound. Surveyor informed WD-M the next assessment dated [DATE] by the Facility and his assessment 3/8/21 documents the pressure injury is now a Stage 4. Surveyor asked how the pressure injury declined to a Stage 4. WD-M informed Surveyor looking at his notes the depth was 2 cm (centimeters) and there was a lot of necrotic tissue on 2/26/21. WD-M informed Surveyor on 2/26 he wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . WD-M informed Surveyor when he saw the pressure injury on 3/8 it was mostly cleaned out and post debridement the depth was 3.3 cm. WD-M explained R3 doesn't have much meat on his backside and it was past the fascia at that point and opted to call the pressure injury a Stage 4. WD-M explained to Surveyor there were a few challenges here and there but the wound is doing better. At this point believes the depth is 1 cm and is not as deep as before. WD-M informed Surveyor he did have a wound vac on for a short period but the wound vac was challenging depending on the skill of the nurses and he was worried R3 might develop [CONDITION(S)]. WD-M informed Surveyor he was having CRP levels done as he was concerned for [CONDITION(S)]. WD-M informed Surveyor It was a significant injury when I saw it on 2/26. WD-M informed Surveyor there were a lot of challenges with staffing and the Facility tried to get staff. On 7/21/21 at 12:51 p.m., Surveyor asked LPN-G if she was working at the Facility last week (7/11/21 to 7/17/21). LPN-G replied no and explained she was on vacation. Surveyor informed LPN-G of not being able to locate any skin assessments when she was on vacation. On 7/23/21 Surveyor received an email from Administrator-A with the additional information: * Director of Nursing timeline * Critical event dated 3/8/21 which Surveyor had previously reviewed * Training log/inservice sheet dated 3/9/21 which documents for objectives Review wound policy and sign that you understand. If you have any questions see DON. Surveyor noted there are 4 LPN (Licensed Practical Nurse) signatures and 13 CNA (Certified Nursing Assistant) signatures. * Pressure Ulcer/Injury, prevention of policy and procedure which Surveyor had previously reviewed. * Skin sweep dated 3/8/21 & 3/9/21. * A quality team visit summary not dated. * Emails dated 6/8/21 & 6/9/21 between Corporate RN-H and Previous DON-R * Approximately 43 Resident shower/bath check sheets dated 6/8/21 & 6/9/21. Surveyor noted R3 is included with a shower/bath check. The facility submitted a skin review for R3 dated 7/14/21 and signed on 7/22/21. Under site documents 53 sacrum and under description documents, Peri wound skin appears macerated c (with) small skin tear like spots. No odor noticed, tissue is pink with small areas of yellow. Measures 7 x 5 x . (sic) Surveyor noted this is not a comprehensive assessment as there there is no percentage of slough and does not include the depth of the pressure injury. There is no documentation of exudate. The facility's failure to ensure R3 received care consistenent with professional standards of practice to prevent pressure injuries, to promote healing and to provide appropriate care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The immediate jeopardy was removed on 7/23/21 when the facility implemented the following action plan: * Initiated a review of care planning on all Residents with pressure injuries to ensure appropriate interventions were in place to decrease the risk of pressure injuries based on the risk assessment and scoring. * Initiated a review of current weekly skin assessments to ensure an accurate comprehensive wound assessments completed by a Registered Nurse. * Initiated a review of all other Residents to ensure at risk care planning is in place based on risk assessment and scoring. * Initiated full house skin review audit on all Residents. * Re-educated all licensed and non licensed staff on the policy and procedure for intervention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] * All licensed staff will complete return demonstration training on completion of the skin assessment and review upon admission. * All licensed staff were be re-educated on the process of timely notification to the physician when a new skin injury event is identified. * All licensed staff were re-educated on the process of timely treatment and care planning when a new skin injury is identified. * All certified nursing assistants received re-education on the policy and procedure related to prevention for pressure related skin injuries. * Reviewed the Policy and Procedure on Pressure Ulcer care and intervention. * DON and/or designee will review progress notes daily during morning meeting to identify new skin events. The IDT will ensure a comprehensive assessment and care plan review is completed at that time of identification to ensure appropriate interventions and orders for treatment are in place. * DON and/or designee will conduct 5 random audits of wound documentation weekly to treatments and interventions are completed per the recommended plan of care. * The center will conduct a monthly QAPI (Quality Assessment Perfomance Improvement) meeting to review findings with any additional recommendations. Following the implementation of their action plan, the deficient practice continues as evidenced by the following two examples. R6 is being cited at a scope and severity level of G (harm/isolated). 2. R6 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Quarterly MDS (Minimum Data Set) dated 3/30/21 documents a BIMS (Brief Interview of Mental Status) score of six, indicating that R6 is severely cognitively impaired. Due to R6's mental status, Surveyor was unable to interview R6. The MDS Section G (Functional Status) documents that R6 requires extensive assistance and two person physical assist for his bed mobility needs. Section G also documents that R6 has total dependence on staff and requires a two person physical assist for his transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R6 has impairment to one of both his upper and lower extremities. Section M (Skin Conditions) documents that R6 had one unhealed unstageable pressure injury at the time of the MDS. Section M also documents that R6 is at risk for the development of pressure injuries. Surveyor reviewed R6's left heel pressure injury documentation and noted that a pressure injury on the left heel was first discovered on 4/22/20 and that the area was followed by the wound physician and that the following interventions were in place since 2020: Offloading heels, turning and repositioning every 2 hours, the implementation of an air mattress and wearing of heel boots. R6's Pressure Injury CAA (Care Area Assessment) dated 7/27/20 documents under the Care Plans considerations section, Resident has actual wound, unstageable pressure area to plantar foot near heel, measuring 5.0 x 2.2 x 0 cm (centimeters) with 40 % necrosis and 60% epithelial skin. Wound care is performed daily as ordered. Wound MD (Medical Doctor) making virtual visits every 2-3 weeks. Wound is much improved in last 30 days. Remains at risk for impaired skin integrity r/t impaired mobility, incontinence. Bed and WC (wheelchair) are fitted with pressure relieving devices. Staff provide assistance with frequent repositioning and provide incontinence cares prn (as needed). Skin is monitored daily and assessed weekly. Will continue to care plan. R6's Tissue Analytics wound assessment completed by the [TRUNCATED]

Based on interviews and closed record review, the facility did not ensure that residents with an indwelling catheter were assessed for removal of the catheter and received appropriate treatment and services to prevent urinary tract infections for 1 (R2) of 1 residents reviewed for catheters. R2 had a Foley catheter placed in October 2019 with no subsequent attempts at removal. The care plan was not revised to ensure proper care and treatment of [REDACTED]. The facility did not accurately monitor or record R2's urine output and flush the catheter as ordered on [DATE] and 3/30/20. R2 developed penile erosion (12/18/19) from the catheter, recurrent urinary tract infections and/[MEDICAL CONDITION] resulting in hospitalization (UTIs 11/6/19, 1/30/20, 3/30/20 catheter associated UTI and [MEDICAL CONDITION]). Two separate physician orders [REDACTED]. On 3/4/20 the physician discontinued the urology consult secondary to R2's hospice status. Findings include: The Facility policy and procedure titled: Catheter Care, Indwelling Catheter dated June 2017 documented: Purpose: To prevent infection. To reduce irritation. Procedure: .Wash perineum well with soap and warm water, taking care to wash from front to back. .Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra. .All debris must be removed from catheter at insertion site. Assessment guidelines may include, but are not limited to: .Color, consistency, amount of urine. .Condition of skin at site of insertion. .Pain, burning, discomfort. .Hydration and fluid balance status. Documentation may include: .Date, time, procedure, condition of the perineum and catheter insertion site. .Any unusual condition or change in condition. .Color, amount, consistency and odor of urine. .Notification of the physician of any condition or change. .Intake and output and evaluation of intake and output per facility procedure. Care Plan Documentation Guidelines: Enter the catheter care as an approach under the appropriate underlying problem on the resident's care plan. Identifying the underlying problem will assist the nursing staff to develop an individualized care plan. The use of an indwelling catheter is an approach to a specific problem. Develop a care plan with the objective of removing the catheter when the problem is resolved, whenever possible. R2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. R2 did not have a catheter upon admission to the facility. R2's Care Plan Focus area Urinary incontinence/bowel incontinence related to functional incontinence, cognition dated revised on 6/24/19 listed interventions that include: Catheter per MD (Medical Doctor) orders - revised on 10/25/19. Report changes in amount, frequency, color or odor of urine - date initiated 6/24/19. Surveyor noted R2's care plan did not include individualized interventions that were implemented regarding catheter care or potential for infection related to the catheter. R2's Minimum Data Set (MDS) significant change in status assessment dated [DATE] section G, Functional Status indicated total dependence 2 person physical assist with toileting. Section H, Bladder and Bowel indicated indwelling catheter. Surveyor's review of the Facility progress notes revealed no documentation of antibiotic use for treatment of [REDACTED]. Progress note dated 10/22/19 documented: Phone call to resident's daughter and POA (Power of Attorney) regarding resident being more sleepy and unable to participate in therapy and cares. Nurse Practitioner (NP) here on rounds and orders for labs received. Resident straight cath'd (catherized) for urinalysis with large amount of urine return. Placed drainage bag for further draining of urine > (greater than) 1000 cc urine returned, clear amber. Physician's Telephone orders dated 10/23/19 documented: Keflex (antibiotic) 250 po (by mouth) BID (twice daily) x 5 days. Monitor urine output PRN (as needed). Call if < (less than) 400 / shift. Surveyor noted R2 was not placed on intake or output monitoring, thus the facility had no consistent accurate record of R2's urine output. Progress note dated 10/30/19 documented: Spoke with NP about indwelling Foley cath. New order to add dx (diagnosis) of [MEDICAL CONDITION]. Surveyor noted there was no documentation to indicate the facility attempted a trial removal of the catheter or had a plan in place for removal of the catheter. There were no appointments with urology documented. On 11/6/19 at 4:39 PM Progress notes documented .resident had emesis during lunch and cloudy urine noted in Foley. Normal saline intravenously at 100 cc/hour was ordered in addition to [MEDICATION NAME] (antibiotic) 2 mg (milligrams) ordered daily. Stat (immediate) labs were ordered and a new Foley was inserted. Urine output of 600 cc after insertion of new Foley. On 11/6/19 at 10:01 PM Progress notes documented .Foley catheter draining thick urine, whitish in color. Stat lab results received. WBC (white blood cells) elevated at 16.6, urine indicates UTI. Call out to MD. On 11/10/19 NP was updated on lab results, new order received to discontinue IV (intravenous) antibiotic and start [MEDICATION NAME] (antibiotic) 500 mg twice daily for 7 days. On 12/16/19 an open area was noted to R2's penis. Progress notes documented .Resident has an open area to penis foreskin with noted discharge. Area cleansed and dried. Resident showed signs of discomfort but refused pain medication. Surveyor noted there was no indication the physician was updated at this time. On 12/18/19 the Physician wrote an order for [REDACTED]. Wound evaluation and treatment for [REDACTED]. Progress note dated 12/18/19 documented: Resident seen by NP. New orders received for urology consult for suprapubic catheter, [MEDICATION NAME] gel BID for penile pain and a wound evaluation for penile erosion. Orders transcribed and appointments in binder. Surveyor located no evidence the facility followed the 12/18/19 physician's orders [REDACTED]. There was no evidence in R2's medical record that R2 was seen by urology. Progress note dated 12/27/19 documented .Resident seen by Dr .wound doctor today at facility. New order received for stat lock to be put on alternating upper inner thigh to hold catheter in place to keep secure and prevent any injury. DON-B provided Surveyor R2's Wound Evaluation Tracker which documented: Date of wound data collection 1/8/20. Site: Tip of penis. Type: Pressure. Length 0.5 cm (centimeters). Width 1.0 cm. Depth 0.1 cm. Stage 2. When was the wound identified: 12/23/19. (Progress notes indicate wound was identified on 12/18/19). Wound type: Pressure ulcer in house acquired. Current treatment: Zinc oxide every shift and PRN (as needed). Facility records indicated the open area/penile erosion healed as of 1/22/20. On 1/29/20 at 12:42 PM Progress notes indicate the MD was notified about no urine output in R2's Foley bag. Orders received to change the Foley due to no urine output. R2 refused to lay down to have Foley changed. Subsequently, an order was obtained to send the resident to the ER for Foley insert and evaluation. Progress note dated 1/30/20 at 10:22 AM documented: Resident admitted to CMH (Community Memorial Hospital) with dx (diagnosis) [MEDICAL CONDITION] and UTI (Urinary Tract Infection). Surveyor's review of the Hospital record date of service 1/30/20 documented: Chief complaint: No urine output. History of present illness: .was sent to the ED (emergency department) given no urine output for 24 hours and inability to replace the Foley catheter. The patient has chronic indwelling Foley catheter. History of penile drainage per nursing staff. Here in the ED forceps was used to separate the foreskin and the meatus was identified by ED provider following which a Foley catheter was placed, which drained 1 liter of purulent yellow urine. The patient was given IV [MEDICATION NAME]. Assessment and plan: .[MEDICAL CONDITION] secondary to CAUTI (Catheter Associated UTI) present on admission. Facility unable to replace catheter. Received IV [MEDICATION NAME] and a dose of oral Fluconazole in the ED. Culture pending. Continue IV [MEDICATION NAME]. Focus ID (Infectious Disease) note 2/3/20: Discharge antibiotic recommendation: Ertapenem 1 gram IV every 24 hours x 10 days at discharge. Progress note dated 2/3/20 documented .Patient arrived via ambulance from CMH. [MEDICAL CONDITION] secondary to UTI. IV PICC (peripherally inserted central catheter) in right AC (antecubital). Surveyor located a physician's orders [REDACTED]. Physician note dated 2/10/20 at 10:22 AM documented: .Patient was recently hospitalized at Froedtert 1/30-2/3/20 [MEDICAL CONDITION]/UTI. Started [MEDICATION NAME] total of 14 days. Recommend urology consult for SPC placement after completed antibiotic. Surveyor noted there were now 2 separate Physician orders [REDACTED]. There was no evidence the facility followed these orders to have R2 seen by the urologist as ordered by the Physician. Progress note dated 2/17/20 at 5:11 PM .Resident was transferred to hospital due to abnormal creatinine and BUN (blood, urea, nitrogen), significant increase from last week. MD updated and gave order to transfer to hospital due to possible acute kidney failure. Surveyor review of the Hospital record dated 2/21/20 documented: .In the ED he was found to be afebrile (without fever) and elevated creatinine was thought to be an error. UA (urinalysis) was negative and the PICC line was removed. During this hospitalization , the residents' daughter /HCPOA decided on hospice care and was subsequently readmitted to the facility on hospice. Physicians order dated 3/4/20 documented: Discontinue urology consult secondary to hospice status. Progress note dated 3/25/20 5:36 PM documented: .Green, milky discharge noted from penis. Foley intact, patent, draining. Urine tea colored, cloudy, malodorous. Resident assessed by MD, ordered [MEDICATION NAME] (antifungal) 200 mg by mouth x 1. May transport resident to ER in AM 3/26/20 for Foley catheter replacement. R2 was subsequently admitted to the hospital following the ER visit on 3/26/20. The Hospital Discharge Summary dated 3/30/20 documented: Reason for hospitalization : UTI and change of Foley catheter. Principal problem: UTI due to urinary indwelling catheter. Hospital course: Catheter associated UTI and [MEDICAL CONDITION] (inflammation of the kidney). Completed 5 days of [MEDICATION NAME] (antibiotic), discharged with [MEDICATION NAME] (antibiotic) twice daily for 5 days. Recommend Foley flushing/irrigation every other day and PRN as needed. Surveyor review of R2's TAR (Treatment Administration Records) did not indicate the order to flush/irrigate R2's Foley catheter every other day (as ordered) as having been completed. Surveyor's interview with R2's daughter who was the AHCPO (Activated Healthcare Power of Attorney) indicated she was never advised the MD recommended a urology consult or SPC (Suprapubic Catheter) placement. She stated she did ask the facility about SPC placement and was told regardless if he had a SPC or Foley, it's still a route for bacteria and risk for infection. On 7/29/20 at 1:30 PM Surveyor met with Director of Nursing (DON)-B to discuss the above concerns. Surveyor and DON-B viewed the (2) Physician orders [REDACTED]. DON-B reported she was not able to find anything in R2's medical record indicating he was seen by urology as ordered by the physician. DON-B could not find notes or evidence the resident was seen by urology. She could not find evidence of any conversation regarding the urology consult or suprapubic placement with the HCPOA. DON-B informed Surveyor: That was before my time when I started in April. DON-B was not able to provide any information about why the facility did not follow the physician orders [REDACTED]. Surveyor asked DON-B what system the facility had in place to monitor R2's urine output. DON-B stated the facility was not recording R2's urine output. DON-B and Surveyor viewed R2's November and December 2019 TAR which documented: Monitor void output every shift. Call MD if < (less than) 400 ml/shift. Surveyor noted staff to be initialing as completed, but there was no urine output recorded. DON-B reported she presumed staff would contact the MD if the output was less than 400. Surveyor asked what her expectation would be regarding urine output, to which DON-B stated: I would expect the urine output to be recorded in amount so you have an accurate number to report to the physician. It would be the best way to make sure you're compliant with the order. Surveyor reviewed R2's care plan with DON-B. Surveyor reviewed the facility catheter care policy, specific to care plan documentation. Surveyor advised DON-B the care plan was not individualized for R2. There was no evidence the facility made any attempt to remove the catheter and no revisions were made to the care plan related to catheter care. In addition, R2 had multiple recurrent UTI's and hospitalization s with no revisions to his care plan. There was no indication as to what the facility did to prevent infections. DON-B stated: I agree. It appears they did nothing. That was before my time. On 7/29/20 at 4:15 PM Surveyor met with Nursing Home Administrator (NHA)-A and DON-B. Surveyor advised of concerns including, but not limited to: R2 having a Foley catheter placed in October 2019 with no subsequent attempts at removal. R2 developing penile erosion from the catheter and recurrent UTI's and/[MEDICAL CONDITION] resulting in hospitalization . Two separate physician's orders [REDACTED]. The facility did not accurately monitor or record the R2's urine output and flush the catheter as ordered. The care plan was not revised to ensure proper care and treatment of [REDACTED]. No additional information was provided.

Based on interview and record review the facility did not provided adequate supervision and assistive devices to prevent accidents for 2 (R491 and R19) of 2 residents reviewed with falls. R491 had a fall on 3/22/18 while attempting to transfer into a family member's car. The family member was providing transport to a doctor's appointment. The fall occurred outside, in the facility parking lot and no facility staff were witness to the fall. The facility initially documented that R491 did not suffer any injuries after the fall but a week later on 3/29/18 it was discovered that R491 had a right femur fracture. The facility did not train R491's family regarding how to safely transfer R491. (The resident's mother thought R491 could walk.) The facility did not complete a comprehensive fall investigation, post fall assessment or update the plan of care related to the fall or implement interventions that would prevent future falls. On 2/25/18 R19 was not transferred correctly according her care plan resulting in her legs hitting the commode. There was no staff training implemented regarding safe transfers with the sit to stand lift following the incident. On 6/16/18 R19 was again not transferred correctly according to her care plan causing a fall that resulted in no injuries. Findings include: 1.) Facility policy, entitled Fall Prevention and Management Guidelines, dated 2/2017, states, .Key elements to the Fall Prevention and Management Program: .8. Environmental Assessment: completed by the maintenance staff, nursing, housekeeping and other members of the safety committee; . b. assess condition of equipment and assistive devices and the ability of the resident to use them properly. B. Dynamic treatment plan: [REDACTED]. The interdisciplinary team members must address: a. Resident, staff and family teaching; .e. Physical limitations: 1. Activities of Daily Living (ADL) skills; f. Pain; . i. Consistent appropriate and proper uses of assistive or protective devices, electric scooters, etc. based on assessment. 2. As information is updated, it needs to be communicated to the staff, residents and family. Staff: 1. Identify the residents' fall potential; 2. Summarize assessment and changes needed in services; 3. Individual care plan developed, communicated with staff and implemented.b. Residents: One to one individualized education and review on the level the resident can understand; c. Families: Discuss assessment findings, the resident's risk for falling and the care plan for their participation. C. Evaluation: 1. Complete a post fall evaluation after every fall or near fall or assisted fall. a. A fall Investigation and Post Fall Assessment must be completed. These need to include: 1. Physical assessment; 2. All contributing factors to the fall; 3. Medication changes (new or discontinued); 4. Mental status changes; 5. New diagnosis. 2. Active reporting mechanism/tracking of falls within the facility. a. A facility Fall log needs to be completed. Each fall needs to be tracked. b. Actions of the interdisciplinary team. 1. Timely modifications to the treatment plan and re-inservising of staff; 2. Family/resident conferences: timely notification of family of an incident; 3. Timely notification of physical of fall; 4. Physical adaptation to the room, wheelchair, and/or walking devices. c. Collective review, identification, and analysis of trends in resident falls throughout the facility. The facility does not have an official policy addressing residents going out on pass with family providing transport or family members assisting with transfers. However on 8/6/18 at 11:03 am, Physical Therapist-G stated the therapy department recommends that families obtain therapy training before families ambulate or transfer residents; there is no documentation in R491's medical recorded that therapy staff provided training to R491's family prior to the fall on 3/22/18. Physical Therapist -G was one of the therapists actively involved in R491's treatment. R491 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R491's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/14/18, documents a Brief Interview of Mental Status (BIMS) score of 15, indicating that R491 is cognitively intact. The MDS also documents that R491 requires extensive assist of 2 staff persons for transfers and required assist of 1 staff person for walking off the unit but did not walk on the unit or in the corridors. R491's Care Plan, dated 12/24/17, with a target date of 5/11/18, states: Limited physical mobility R/T (related to) hx (history) of MVA (Motor Vehicle Accident) with fractures, hx of non-Hodgkin [MEDICAL CONDITION]. Interventions include: Nursing will provide assistance as needed for transfers via Hoyer lift; PT (Physical Therapy)/OT (Occupational Therapy) screen/evaluation for positioning, transfers, mobility, device aids, etc. R491 was seen by Physical Therapist (PT)-G on 3/21/18 (the day prior to the fall). PT-G's therapy note dated 3/21/18 documents: . Patient does not have pain. Pt (Patient), staff able to verbalized understanding of shifting weight forward and return demonstration 100% of the time.Remaining barriers to progress include limitations in balance, weakness of LEs (Lower Extremities) , and need for training in safe gait techniques. R491 seen by Physical Therapy Assistant (PTA) on 3/22/18, prior to fall. Therapy progress note documents: Gait training to improve stride length, weight acceptance on RLE (Right Lower Extremity) to facilitate improved gait for safe ambulation. Patient ambulates with 2 ww (wheeled walker), 22 feet and 26 feet with CGA (Contact Guard Assist), demonstrating improved stride and cadence today, wheelchair in tow, as patient continues to be anxious and wanting to sit very quickly. On 3/22/18 R491 was transferring into a family member's car from a wheelchair when R491 fell in the facility parking lot. The family members were the only witnesses to the fall, no facility staff were present. On 8/06/18 at 11:54 AM, Surveyor interviewed Therapy Director-I, who stated he assisted LPN (licensed practical nurse)-H with a hoyer transfer of R491 off the ground in the parking lot the day of the fall on 3/22/18. Therapy Director-I could not recall if there were any other staff present outside after R491's fall but only he and LPN-H completed the hoyer lift transfer. Therapy Director-I provided Surveyor with a written statement of what was witnessed on 3/22/18. Therapy Director-I's statement documents the only detailed description of R491 immediately after the fall. The statement dated 3/22/18, documents: .Upon initial observation R491 was sitting on the parking lot with BLE extended outwards with manual transport w/c (wheelchair) closely behind and with family standing around her. The car's passenger front door was open at least 8 feet away . While LPN-H attended, a women-possibly (R491's) mother, who was unknown to writer said that someone (unspecified) told her that (R491) could walk. Writer advised that (R491) was to only walk with therapy and that such a recommendation to do so with family would only occur following PT (Physical Therapy) and family education. A hoyer lift was brought out and past the car being moved forward. LPN-H and writer provided a hoyer lift assist of 2 from parking lot back into w/c, leg rests used. R491 was returned into SNF (Skilled Nursing Facility) to complete additional care. Therapy Director-I does not have documentation of the therapy staff providing education to R491's family on R491's ability to transfer or ambulate. There is no care plan related to R491's fall on 3/22/18. (Cross Reference F656) R491's Fall Investigation Report, dated 3/22/18, is incomplete. No information is documented as to the position R491 was found, how the fall occurred, if assistitive devices were needed and/or used, who assessed R491 after the fall or how staff assisted R491 from the ground. The staff person completing the assessment is a LPN (Licensed Practical Nurse). The assessment was not completed per facility policy. (Cross Reference F684) R491's Post Fall Assessment, dated 3/22/18, is incomplete. The areas of falls history, physical status, medication status, care plan, mental/behavior status and environment were not complete. The assessment does not provide a description of how the fall occurred, who assessed the resident and what interventions were put into place to prevent future falls. The staff person completing the assessment is a LPN (Licensed Practical Nurse). The assessment was not completed per facility policy. (Cross Reference F684) There is no documentation that R491 was assessed after the fall by an RN (Registered Nurse). (Cross Reference F684) PTA progress note, dated 3/23/18, after the fall, documents: Patient had a fall yesterday when out with parents. No injury noted, but patient is complaining of pain in RLE (right lower extremity), is not allowing weight on leg during stance, is unable to advance leg during attempts to gait train or transfer. Sit to stand with max (maximum) assistance to facilitate weight shifting over BOS (Base of Support). Patient is able to come to a stand, but starts to sit very quickly. Patient able to stand with max assist of 2 to allow for change of briefs and clothing. Patient required multiple attempts to perform cares, having to sit multiple times throughout the process. Reported pain to the nurse, asked about possible x-ray to R (right) leg. PTA progress note, dated 3/26/18, documents: Seated AROM (Active Range of Motion) exercises with LLE (left lower extremity) x10 (10 times), x3, patient complained of pain with all RLE movement, in particular knee flection. No complaints of pain with palpating, no increase in swelling or bruising noted. Patient did have a fall 4 days ago, nursing has been using a hoyer lift for transfers due to patient increase in assistance required. Attempted to come to a stand with max assistance, patient resisting to come to a stand, unable to facilitate weight bearing. Attempting standing at standing table, patient cried out in pain with start of weight bearing, unable to come to a stand due to patient pain. Reported pain, inability of patient to bear weight to nurse. Requested x-ray of RLE to rule out fracture, to allow for safe progression to PLOF (Prior Level of Function). On 3/29/19, R491's medical record documents: Resident up in wheelchair via hoyer lift has had a recent hip and pelvic xray that were negative but this am her right knee was more swollen called MD .order for knee xray today, abnormal xray, ok to send to ER (emergency room ) to treat and evaluate POA (Power of Attorney) ok to cancel today's appointment also had POA write statement on recent lower to the ground, sent disc images along with POA, asked that she bring them back, ER informed to use lift for transport . (Cross reference F684.) Right Knee x-ray results, dated 3/29/18, documented: Acute impacted angulated displace complex distal right femoral fracture; [MEDICAL CONDITION]; marked [MEDICAL CONDITION]; peripheral vascular calcification. R491 was transported to the hospital on [DATE] for further evaluation and did not return to the facility. On 8/06/18 at 12:10, Surveyor informed Director of Clinical Services (DCS)-C of the concern the facility did not have a comprehensive fall investigation, comprehensive post fall assessment, no care plan addressing R491's fall or interventions put into place to prevent future falls. There is no documentation that R491's family was informed of the level of care required to transfer R491 in and out of a vehicle. DCS-C confirmed that facility did not address R491's fall appropriately and did not complete a comprehensive fall investigation or post fall assessment. DCS-C stated the facility did not have the correct staff in place at the time of the fall to address the fall appropriately. DCS-C stated the facility response to R491's fall was not what it should have been and confirmed the facility did not follow correct protocol for investigation and follow up post fall. On 8/7/18 at 8:25 am, DCS-C and Administrator-A informed Surveyor the facility did not respond to R491's fall appropriately. The leadership at the facility was broken at the time of the fall and it is now back on track. DCS-C stated that an RN should have assessed R491 after the fall, a comprehensive fall investigation and post fall assessment should have been completed and a care plan should have been created to address R491's fall and interventions to prevent future falls. DON-B stated the facility does not have a policy and procedure addressing residents going out on pass. DCS-C stated the facility is aware a policy and procedure for alerting families of the responsibility and liability of taking a resident out on pass is important and the facility will be working on that. Administrator-A provided Surveyor with a letter that will be sent to current residents' family members and will be given to any newly admitted residents offering the services of facility staff to train family members on how to transfer their resident to and from a vehicle. 2.) On 2/25/18 R19 was not transferred correctly according her care plan resulting in her legs hitting the commode. There was no staff training implemented regarding safe transfers with the sit to stand lift following the incident. On 6/16/18 R19 was again not transferred correctly according to her care plan causing a fall that resulted in no injuries. R19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor review of the Nursing Progress note admission summary dated 1/17/2018 at 8:18 PM documented: Resident admitted to room [ROOM NUMBER] via stretcher attended by Paratech staff x 2. Transfers are done using sit to stand with assist of two staff members. R19's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/24/18 section for Transfer - how resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet) documented R19 as needing extensive assist with two person assist. Surveyor review of R19's Care plan dated as initiated 3/20/18 documented: Resident has impaired functional mobility as evidenced by: Altered gait or balance, chronic condition. Needs extensive assist with dressing bathing and grooming as evidenced by bilateral [MEDICAL CONDITION] of the knees. Interventions: Nursing will provide assistance as needed for transfers - sit to stand. Resident requires 2 STAFF ASSIST TO TRANSFER sit to stand machine (non ambulatory). 08/02/18 at 12:55 PM Surveyor spoke with Director of Clinical Services (DCS)-C and asked for R19's care plan that was in place in (MONTH) (YEAR) at the time of the incident. DCS-C reported the facility was having issues with the computer carry over with care plans, therefore the R19's care plan needed to be re-entered in (MONTH) (YEAR). DCS-C confirmed to Surveyor R19's care plan with the date initiated 3/20/18 is the care plan that was in place back to the resident's admission. Surveyor review of the facility self report documented: Resident statement 2/26/18: When Certified Nursing Assistant (CNA) got her on the sit to stand lift to get ready to transfer her to the commode, she slung her legs around so fast that her legs hit the commode during the transfer. Resident stated her legs were hit so hard against the commode that the commode went into the wall and she yelled out because it hurt her legs. Resident stated the CNA used the sit to stand lift by herself, no one came into the room to assist her. The Facility investigation documented abuse was not substantiated, but documented the CNA did transfer R19 alone when there should be 2 people for sit to stand lift. Surveyor noted there was no indication of staff training for safe transfers using the sit to stand lift following the incident involving R19 on 2/26/18. R19's Quarterly MDS with an ARD of 6/8/18 section for Transfer - how resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet) documented R19 as extensive assist with two person assist. 07/31/18 at 2:59 PM Surveyor spoke with R19 who stated on 6/16/18 between 7-8 AM she fell out of bed while the CNA was working with her. R19 reported she was sitting on the edge of the bed in the morning, and the CNA sat her up too close to the edge. R19 reported the sit to stand lift was in front of her, but not close enough for her to grab when she fell . R19 stated: The CNA went to the foot of the bed to do something with the blankets or something and I yelled because I felt like I was sliding. R19 reported the CNA said: Don't get excited, you're fine. R19 reported the CNA didn't do anything until she saw her sliding, and landed on the floor. Reported she had to tell the CNA 3 times to call for help. R19 stated the CNA was alone and believes she is supposed to have 2 people to transfer with the sit to stand. Surveyor review of the Witness Fall Report dated 6/16/18 incident description: CNA came to nurses and stated to writer; I need some help, I had to lower R19 to the floor. Upon arrival of writer, second nurse and another CNA, noted resident on floor in upward sitting position against bed frame. Questioned resident as to whether or not she was hurt stated: No, but I did hit my back on the bed rail as I was sliding out of bed but otherwise I'm OK. Resident described incident as stated above. Other information section documented: Resident stated: I was sitting on the edge of the bed and I started sliding off. CNA stated; I slid her down to the floor to keep her from hurting herself. No injuries or bruising noted at this time. Surveyor review of the fall report notes section dated 6/18/18 document: Patient requires 1 person assist with ADL's and 2 person assist with transfers via sit to stand and non ambulatory. ROOT CAUSE: Assigned CNA was preparing patient to transfer from bed to wheelchair. When sat up patient in bed and patient started to reposition self to the edge of the bed which caused the patient to slide out of bed. CNA assisted patient to floor. No apparent injuries noted. Surveyor noted facility staff did not follow R19's care plan which resulted in R19's fall. R19's care plan documented she was to be transferred utilizing the stand up lift with 2 persons. On 08/06/18 at 11:13 AM Surveyor spoke with Director of Nursing (DON)-B who reported there is no documentation of staff training on stand up lift transfers following the (MONTH) incident involving R19. DON-B reported training was just completed in (MONTH) (YEAR) and stated inservice training was completed by CNA's on 6/17/18 regarding care delivery guides to provide safe cares for residents, transfer of patients, and 2 staff to be present when using sit to stand and hoyer.

Based on observation, record review and interview, the facility did not ensure that 2 (Resident #8 & Resident #10) of 4 residents at risk for the development of pressure injuries received consistent measures to prevent the development of pressure injuries. * Resident #8 developed two avoidable pressure injuries to her left foot. Resident #8's pressure injury care plan did not reflect the identified intervention of floating heels prior to Resident #8 developing two unstageable pressure injuries to her left foot. Resident #8 was observed not to have her heels floated per her plan of care. * Resident #10 was observed to not have her heels floated per her plan of care. Findings include: 1. Surveyor # reviewed Resident #8's medical record from 9/26/16 to 9/28/16. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's admission MDS (Minimum Data Set) dated 6/23/16 documents under Section C1000 that Resident #8's cognitive skills for daily decision making are severely impaired. Section M0150 documents that Resident #8 is at risk for developing pressure injuries. Resident #8's Pressure ulcer (injuries) CAA (Care Area Assessment) signed as completed on 6/24/16 documents under the Care Plans Considerations section, At risk for pressure ulcers (injuries) and falls related to impaired mobility, incontinence, impaired cognition, potential pain, hx (history) of falling and routine [MEDICAL CONDITION] medication use. Refer to skin POC (Plan of Care) for interventions to prevent pressure ulcers (injuries). Resident #8's initial Care Delivery Guide dated 6/16/16 documented under the Skin Care section Float Heels. Resident #8's Braden Risk Assessment Scale dated 6/30/16 documents a score of 14 indicating that Resident #8 is at moderate risk of developing pressure ulcers/injuries. Resident #8's quarterly MDS (Minimum Data Set) dated 8/14/16 documents under Section C1000 that Resident #8's cognitive skills for daily decision remain severely impaired. Section M0150 documents that Resident #8 continues to be at risk for developing pressure ulcers (injuries). Left Heel Pressure Injury: Resident #8's nursing SBAR (Situation, Background, Assessment, Recommendation) Communication form dated 8/2/16 documents under the Situation section, Left heel and Left Ball of foot SDTI (Suspected Deep Tissue Injury) see attached pink sheets. Resident #8's Skin grid dated 8/2/16 documents two unstageable pressure injuries to Resident #8's left foot. Resident #8's Skin grid documents that the physician was notified on 8/2/16. Surveyor # was not provided or was able to locate any documentation from 8/2/16 that provided measurements or a description of Resident #8's pressure injuries to her left foot on 8/2/16 other than reference to two unstageable pressure injuries. Resident #8's Skin grid dated 8/8/16 documents an unstageable pressure injury to Resident #8's left heel measuring 8 cm (centimeters) in length and 6 cm in width. Resident #8's Skin grid documents under the comments section Moderate amount of sero (serous) drainage. 75% slough, 25% non-granulated tissue, edges macerated from drainage. Mild odor present. No pain. Heels floated. Resident #8's Skin grid dated 8/15/16 documents an unstageable pressure injury to Resident #8's left heel measuring 7.2 cm in length and 5 cm in width. Resident #8's Skin grid documents under the comments section Moderate amount of sero (serous) drainage. Black eschar to heel, no complaints of pain. Resident #8's Nurse Practitioner Progress note dated 8/15/16 documents under Objective section Wound #1 Left Heel is a chronic Stage 3 Pressure Ulcer (Injury) and has received a status of Not healed. Initial wound encounter measurements are 7.2 cm in length by 5 cm width and 0.1 cm depth. No undermining has been noted. Wound bed is 1-25% [MEDICATION NAME], 26-50% adherent, yellow slough, 1-25% granulation. Periwound skin does not exhibit signs or symptoms of infection. Under the Assessment section, Resident #8 was diagnosed with [REDACTED]. Resident #8's Nurse Practitioner Progress note dated 8/22/16 documents under Objective section Wound #1 Left Heel is a chronic Unstageable Pressure (ulcer) Injury Obscured full-thickness skin and tissue loss Pressure Ulcer (injury) and has received a status of Not Healed. Subsequent wound encounter measurements are 3.5 cm length and 4.2 cm width and 0.1 cm depth. No undermining noted. Wound bed is 26-50% adherent, yellow slough, 26-50% granulation. Ball of Left Foot (mid) Pressure Injury Resident #8's Skin grid dated 8/8/16 documents an unstageable pressure injury to the ball of Resident #8's left foot measuring 3 cm in length and 2 cm in width. Resident #8's Skin grid documents under the comments section Dry black hard eschar, intact. No signs or symptoms of infection, wound edges dry/normal No pain will continue current treatment. Resident #8's Skin grid dated 8/15/16 documents an unstageable pressure injury to the ball of Resident #8's left foot measuring 2.7 cm in length and 3.5 cm in width. Resident #8's Skin grid documents under the comments section Dry hard black eschar intact. No signs of infection or pain. Resident #8's Nurse Practitioner Progress note dated 8/15/16 documents under Objective section Wound #2 Left Foot (Mid) is a chronic Stage 3 Pressure Ulcer (Injury) and has received a status of Not healed. Initial wound encounter measurements are 2.7 cm in length by 3.5 cm width and 0.1 cm depth. No undermining has been noted. Wound bed is 51-75% adherent, yellow slough, 1-25% granulation. Under the Assessment section, Resident #8 was diagnosed with [REDACTED]. Resident #8's Nurse Practitioner Progress note dated 8/22/16 documents under Objective section Wound #2 Left Foot (mid) is a chronic Unstageable Pressure Ulcer (Injury) Obscured full-thickness skin and tissue loss Pressure Ulcer (injury) and has received a status of Not Healed. Subsequent wound encounter measurements are 2.5 cm length and 2.4 cm width and 0.1 cm depth. No undermining noted. Wound bed is 76-100% dry black eschar. Resident #8's Nurse Practitioner Progress note dated 9/12/16 documents under Objective section Wound #2 Left Foot (mid) is a chronic Unstageable Pressure Ulcer (Injury) Obscured full-thickness skin and tissue loss Pressure Ulcer (injury) and has received a status of Not Healed. Subsequent wound encounter measurements are 0.5 cm length and 1 cm width and 0.1 cm depth. No undermining noted. Wound bed is 76-100% dry black eschar. Resident #8's Skin grid dated 9/26/16 documents an unstageable pressure injury to the ball of Resident #8's left foot measuring 0.5 cm in length and 0.8 cm in width. Resident #8's Skin grid documents under the comments section 100% slough remains with min (minimal) sero (serous) drainage from wound. No complaints of pain with treatment. No signs of infection. Will continue with POC (plan of care) and current tx (treatment). Left Heel Pressure Injury/Pressure Injury on Sole of Left Foot: Resident #8's Skin grid dated 8/29/16 documents two unstageable pressure injuries to Resident #8's left heel as a result of pink, new tissue forming between the total area of the original unstageable pressure injury. An unstageable pressure injury to Resident #8's left heel measures 1.5 cm in length and 1.0 cm in width. An unstageable pressure injury to Resident #8's sole measures 2.0 cm in length and 3.0 cm in width. Resident #8's Skin grid documents under the comments section Two areas remain black with pink new tissue between. Eschar starting to lift at edges. Surveyor # noted that the pressure injury to Resident #8's heel had split into two areas as a result of the development of new tissue dividing the pressure injury into two separate parts. Resident #8's Nurse Practitioner Progress note dated 9/12/16 documents under Objective section Wound #1 Left Heel is a chronic Unstageable Pressure Ulcer (Injury) Obscured full-thickness skin and tissue loss Pressure Ulcer (injury) and has received a status of Not Healed. Subsequent wound encounter measurements are 1.5 cm length and 4 cm width and 0.1 cm depth. No undermining noted. Wound bed is 51-75% adherent, yellow slough, 1-25% granulation. Resident #8's Nurse Practitioner Progress note dated 9/12/16 documents under Objective section Wound #3 Left Distal Foot Heel is a chronic Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 0.5 cm length and 1.0 cm in width and 0.1 cm depth. No undermining noted. Wound bed is 51-75% adherent, yellow slough, 1-25% granulation. Resident #8's Skin grid dated 9/26/16 documents two unstageable pressure injuries to Resident #8's left heel as a result of new tissue forming between the total area of the original unstageable pressure injury. Documentation includes an unstageable pressure ulcer (injury) to Resident #8's left heel measuring 1.0 cm in length and 0.5 cm in width. An unstageable pressure ulcer (injury) to Resident #8's sole measures 1.0 cm in length and 2.5 cm in width. Resident #8's Skin grid documents under the comments section Skin area between 2 areas (pressure injuries) remain intact with new tissue. Heel remains 100% slough with not (sic) pain to site. Area to sole 100% eschar, soften but intact, edges lifting. On 9/27/16 at 1:03 p.m., Surveyor # reviewed Resident #8's Skin Integrity Care plan dated 8/2016 and noted that the intervention of elevating Resident #8's heels off of the bed for pressure relief was not listed as a current intervention to prevent pressure injuries to Resident #8's heels although it was listed on the care delivery guide dated 6/16/16. Surveyor # noted that the intervention of floating Resident #8's heels originally listed on the 6/16/16 care deliver guide did not get carried over to Resident #8's plan of care despite being at risk for pressure injuries. Resident #8's CNA (Certified Nursing Assistant) Care Card dated 7/29/16, prior to Resident #8 developing the two pressure injuries to her left foot, does not list the intervention of elevating Resident #8's heels off of the bed as an intervention to prevent pressure injuries to Resident #8's heels. Resident #8's nursing notes prior to 8/2/16, when Resident #8 developed two pressure injuries to her left foot, does not document any instances when Resident #8's heels were floated off of the bed to prevent pressure injuries to Resident #8's heels. On 9/28/16 at 8:00 a.m., Surveyor # informed DON (Director of Nursing)-B of the above findings. Surveyor # asked DON-B if there were any documented interventions of Resident #8's heels being floated as identified on Resident #8's initial care delivery guide dated 6/16/16, prior to Resident #8 developing two pressure injuries to her left foot on 8/2/16. DON-B informed Surveyor # that she had initially identified the floating of Resident #8's heels during her initial care delivery guide on 6/16/16 but did not know why the intervention was not listed on the Skin Integrity Care plan prior to 9/27/16. DON-B informed Surveyor # that she would look to see if the floating of Resident #8's heels off of the bed was documented prior to 8/2/16 when Resident #8 developed two pressure injuries to her left foot. On 9/28/16 at 8:20 a.m., Surveyor # informed Administrator-A of the above findings. On 9/28/16 at 10:04 a.m., DON-B informed Surveyor # that she could not provide any documentation that the intervention of floating of Resident #8's heels off of the bed was in place prior to 8/2/16 when Resident #8 developed two pressure injuries to her left foot. Surveyor # asked DON-B about the use of the term chronic in the description of Resident #8's pressure injuries by the Nurse Practitioner. DON-B informed Surveyor # Resident #8's pressure injuries were not chronic and had not been present prior to 8/2/16. DON-B informed Surveyor # that the documentation program inserts that words as a description but that Resident #8 did not have pressure injuries to her left foot prior to 8/2/16. DON-B informed Surveyor # that although Resident #8's heels were identified as at risk during admission, the intervention of floating Resident #8's heels off of the bed was not documented on the Skin Integrity care plan or CNA Care Card prior to Resident #8 developing two pressure injuries to her left foot on 8/2/16. No further information was provided as to why the facility did not have interventions in place to prevent the development of pressure injuries to Resident #8's left foot prior to 8/2/16. Resident #8's current CNA Care Card provided on 9/26/16 documents under the Skin section FLOAT HEELS AT ALL TIMES. Observations of heels not floated: On 9/28/16 at 4:01 a.m., Surveyor # observed Resident #8 lying supine in bed. Surveyor # observed Resident #8 to have both of her heels resting directly on the mattress and not have her heels floated while in bed to provide pressure relief to her heels per her plan of care. On 9/28/16 at 4:32 a.m., Surveyor # observed Resident #8 lying in bed yelling loudly. Surveyor # observed Resident #8 to have her left heel resting directly on the mattress and not have her left heel floated while in bed to provide pressure relief to her heels per her plan of care. On 9/28/16 at 4:50 a.m., Surveyor # observed Resident #8 sleeping in bed. Surveyor # observed Resident #8 to have her left heel resting directly on the mattress and not have her left heel floated while in bed to provide pressure relief to her heels per her plan of care. On 9/28/16 at 5:07 a.m., Surveyor # observed Resident #8 sleeping in bed. Surveyor # observed Resident #8 to have her left heel resting directly on the mattress and not have her left heel floated while in bed to provide pressure relief to her heels per her plan of care. On 9/28/16 at 6:10 a.m., Surveyor # observed Resident #8 sleeping in bed. Surveyor # observed Resident #8 to have her left heel resting directly on the mattress and not have her left heel floated while in bed to provide pressure relief to her heels per her plan of care. On 9/28/16 at 6:35 a.m., Surveyor # observed Resident #8 sleeping in bed. Surveyor # observed Resident #8 to have both her heels resting directly on the mattress and not have her heels floated while in bed to provide pressure relief to her heels per her plan of care. On 9/28/16 at 8:00 a.m., Surveyor # informed DON (Director of Nursing)-B of the above findings. Surveyor # asked DON-B if Resident #8 should have her heels floated per her plan of care to prevent pressure ulcers. DON-B informed Surveyor # that Resident #8 should have her heels floated per her plan of care to prevent pressure ulcers. On 9/28/16 at 8:20 a.m., Surveyor # notified Administrator-A of the above findings. No further information was provided as to why the facility did not provide Resident #8 with consistent measures to prevent the development of pressure injuries or to promote the healing of existing pressure injuries. 2. Surveyor # reviewed Resident #10's medical record on 9/26/16 to 9/28/16. Resident #10 has a [DIAGNOSES REDACTED]. The skin integrity plan of care initiated 2/16 includes an intervention dated 2/2/16 of float heels with heels off cushion. The quarterly MDS (minimum data set) with an assessment reference date of 8/3/16 and signed as complete on 8/4/16 documents Resident #10 has short term memory problems, long term memory is ok, and is severely impaired for cognitive skills for daily decision making. Resident #10 requires extensive assistance with two plus persons physical assist for bed mobility & transfer, and does not ambulate. Resident #10 is at risk for developing pressure injuries and is coded as not having any pressure injuries. The Braden assessment dated [DATE] has a score of 13. A score of 13-14 indicates moderate risk for developing pressure injuries. The physician order's signed on 9/9/16 documents under treatment orders Float heels on heels off cushion. The CNA (Certified Nursing Assistant) Care Delivery Guide provided to Surveyor # on 9/26/16 under the section skin documents, Float Heels with heels off cushion. On 9/27/16 at 7:02 a.m., Surveyor # observed Resident #10 in bed on his back. Surveyor # observed there is a heel lift cushion at the end of the bed by the footboard but observed that Resident #10's heels are resting directly on the mattress and are not being offloaded. On 9/27/16 at 8:00 a.m., Surveyor # observed Resident #10 awake in bed on his back making nonsensical sounds. Resident #10 is wearing a gown, incontinence product and has blue gripper socks on his feet. Surveyor # observed that Resident #10's heels are resting directly on the mattress and are not being offloaded on the heel lift cushion. On 9/27/16 at 8:30 a.m., Surveyor # observed LPN (Licensed Practical Nurse)-D enter Resident #10's room informing Resident #10 that she was going to give Resident #10 Tylenol. Surveyor # observed that Resident #10 continues to be in bed on his back. Surveyor # observed there is a heel lift cushion at the end of the bed by the footboard but observed that Resident #10's heels are resting directly on the mattress and are not being offloaded. On 9/28/16 at 4:09 a.m., Surveyor # observed Resident #10 in bed on his back. Surveyor # observed Resident #10 has blue gripper socks on and Resident #10's heels are resting directly on the mattress and are not being offloaded. Surveyor # observed the heel lift cushion is on top of the heater. On 9/28/16 at 5:02 a.m., Surveyor # observed Resident #10 in bed on his back making nonsensical sounds. Surveyor # observed the heel lift cushion is now at the foot of the bed but Resident #10's heels are resting directly on the mattress and are not being offloaded on the heel lift cushion. On 9/28/16 at 5:53 a.m., Surveyor # observed Resident #10 awake in bed on his back. Surveyor # observed Resident #10 is wearing blue gripper socks and his heels are resting directly on the mattress and are not being offloaded on the heel lift cushion. On 9/28/16 at 10:00 a.m., Surveyor # informed DON (Director of Nursing)-B that Surveyor # noted Resident #10's plan of care documents that Resident #10 should have his heels offloaded on a heel lift cushion. Surveyor # informed DON-B of the observations of Resident #10's heels not being offloaded. DON-B informed Surveyor # that she placed the heel lift cushion under Resident #10's legs around 6:00 a.m.

Based on record review and interview the Facility did not ensure that the physician was consulted with regarding of a significant change in condition for 3 (Resident #25, #27, & #24) of 9 sampled Residents. * Resident #25 was admitted to the facility on [DATE] for short term rehabilitation with [DIAGNOSES REDACTED]. Resident #25's admission medication included [MEDICATION NAME] ([MEDICATION NAME]) 2 mg at hour of sleep, a medication that can thin the blood and reduce the chances for clots occurring. Other medications included [MEDICATION NAME] (an antibiotic) 250 mg (milligrams) twice a day through 12/28/14, aspirin 81 mg every day, and Levothyroxicine 88 mcg (micrograms) every day, all of which can potentate the effects of the [MEDICATION NAME]. The hospital discharge summary dated 12/24/14 documents that Resident #25 has been maintained on long-term anticoagulation on [MEDICATION NAME] and would be discharged on her prior-to-admission dose of [MEDICATION NAME] 2 mg once a day with [MEDICATION NAME]/INR ([MEDICATION NAME] time/International Normalized Ratio) approximately 48-72 hours (to measure the blood's ability to clot). A PT/INR was drawn on 12/29/14. The APNP who had not cared for Resident #25 gave a verbal telephone order to increase the [MEDICATION NAME] to 3 mg but did not order a follow up PT/INR. Facility staff did not inquire about a follow up PT/INR during Resident #25's stay at the Facility. On 1/12/15 Resident #25 had an emesis of approximately 30 ml of blood. Tums (antacid) were administered and Resident #25 was placed on the 24 hour report board. On 1/13/15 Resident #25 had dark red emesis. Resident #25's physician was contacted and an order was received to transfer to the hospital. The emergency department record for labs document [MEDICATION NAME] > (greater than) 120 (reference range is 10.1-12.9) and INR (International Normalized Ratio) > 10.0 (reference range is .9-1.1) and a [DIAGNOSES REDACTED]. * Resident #27 has been residing in the Facility for the past four years. Resident #27 has a history of [MEDICAL CONDITION] frequently, often from Urinary Tract Infections, and had been hospitalized three times [MEDICAL CONDITION] prior to November 2014. On 11/5/14 at 5:00 a.m. Resident #27 developed a temperature of 101.6 degrees. Staff administered Tylenol but at 1:00 p.m. Resident #27's temperature was 100 degrees. Staff notified Resident #27's physician who instructed staff to monitor Resident #27 and to notify him if Resident #27 developed another high temperature as he might want to order labs. The evening of 11/6/14 Resident #27's temperature was 99 degrees, at 3:00 a.m. 100 degrees, Tylenol was administered and Resident #27's temperature came down to 99.7 degrees. On 11/6/14 at 7:20 p.m. Resident #27's temperature was 99.6 degrees. Facility staff did not notify Resident #27's physician of his elevated temperatures. On 11/7/14 Resident #27's temperature was 101.2 and 100.3. Facility staff did not notify Resident #27's physician of his elevated temperatures. On 11/9/14 Resident #27's temperature was 100.7 degrees axillary, which would translate to an oral temperature of 101.7 degrees. Facility staff did not notify Resident #27's physician of his elevated temperature. On 11/10/14 Resident #27 had a temperature of 100.8 degrees. Facility staff did not notify Resident #27's physician of his elevated temperature. On 11/11/14 Resident #27 had a temperature of 103.3 degrees. Facility staff contacted Resident #27's physician and an order was received to transfer Resident #27 to the hospital. Resident #27 was admitted to the hospital with [REDACTED]. The failure to notify the physician for both Resident #25 and #27 created a finding of Immediate Jeopardy on 11/6/14 regarding Resident #27. The facility's recertification survey concluded on 12/8/14 making the 11/6/14 date prior to the facility's recertification survey. Due to this, the start date for the Immediate Jeopardy is 12/8/14 which is the recertification survey exit date. On 1/15/15 at 11:05 a.m. the Administrator, Director of Nursing and Corporate RN (Registered Nurse)-I were informed of the finding of Immediate Jeopardy for Resident #25. On 1/21/15 at 3:00 p.m. the Administrator and Corporate RN-I were informed of the finding of Immediate Jeopardy for Resident #27. The Immediate Jeopardy was removed on 1/27/15 for Resident #25 & #27 but continues at a severity/scope level of E (potential for harm that is not immediate Jeopardy/pattern) until all inservices are completed, the revised system is completely implemented and for current non compliance for Resident #24. * Resident #24 had low blood sugars of less than 60 on 1/10/15, 1/23/15, & 1/24/15. According to the physician order's licensed staff is to notify the physician if the blood sugar is less than 60. Licensed staff did not notify Resident's #24's physician of the low blood sugar on 1/10/15, 1/23/15, & 1/24/15. Findings include: The Facility's Notification of Resident Change in Condition policy and procedure revised July 2014 under procedure documents 1. "Notify the Physician and family or legal representative at the earliest possible time, during waking hours, if there is a non critical change in condition (unless requested to do otherwise)." 2. "Notify the physician and family or legal representative immediately, if there is a significant change in condition, regardless of the time. a. If the nurse responsible for the care of the resident is remaining with the resident and is unable to place the telephone calls, another clinician will place the calls. b. Contact the Medical Director if unable to contact attending physician or on call physician. c. If an emergency call area emergency number e.g., 911." 3. Document in the Nurses Notes the times notification was made and the names of the person(s) to whom you spoke. Sign the entry. The nurse may use the Interact-SBAR (Situation, Background, Assessment, Request) Communication Tool and Progress Note as a physician notification and as a Nurses Note." The Interact Change in Condition: When to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant) documents: "Immediate Notification: Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A Marked Change (i.e. more severe) in relation to usual symptoms and signs, or Unrelieved by measures already prescribed." 1.) Surveyor # reviewed Resident #25's medical record on 1/13/15 to 1/1/15/15. Resident #25 was admitted to the facility on [DATE] for short-term rehabilitation. [DIAGNOSES REDACTED]. Admitting medication included [MEDICATION NAME] ([MEDICATION NAME]) 2 mg at hour of sleep. [MEDICATION NAME] reduces the ability of the blood to clot by blocking the formation of vitamin K-dependent clotting factors. Other medications include [MEDICATION NAME] (an antibiotic) 250 mg (milligrams) twice a day through 12/28/14, aspirin 81 mg every day, and Levothyroxicine 88 mcg (micrograms) every day. These medications can potentate the effects of the [MEDICATION NAME]. The hospital discharge summary dated 12/24/14 documents under hospital course "[MEDICAL CONDITION], chronic, managed and monitored by Physician-MM. In addition, she has a known history of [MEDICAL CONDITION] thrombus and has been maintained on long-term anticoagulation on [MEDICATION NAME]. On admission INR upper end therapeutic at 3.0 with need for urgent surgery, anticoagulation reversed, receiving vitamin K and within 36 hours pro time/INR 1.2, safe for surgery. Subsequently, she underwent open reduction and fixation distal femur fracture. Postoperatively, she was restarted back on [MEDICATION NAME], managed by pharmacy, and felt not requiring bridging. She will be discharged on her prior to admission dose of [MEDICATION NAME] 2 mg once a day with pro time/INR approximately 48-72 hours. Regarding [MEDICAL CONDITION], she remains rate controlled, on no rate limiting medication at this time, with ventricular response 65-80." Under discharge instructions document "[MEDICATION NAME]/INR ([MEDICATION NAME] time/International Normalized Ratio) approximately 72 hours." The admitting physician orders [REDACTED]. PT/INR test measures the ability of the blood to clot. The lab drew the PT/INR on 12/29/14 as the nurse mistakenly wrote 12/29/14 instead of 12/27/14 on the lab slip. The lab results on 12/29/14 documents [MEDICATION NAME] high 18.2 (reference range 9.7-11.6) and INR 1.7 (2.0 to 3.0). The physician telephone order dated 12/29/14 documents:(1) D/C (discontinue) [MEDICATION NAME] 2 mg po (by mouth q (every) HS (hour sleep). (2) Start [MEDICATION NAME] 3 mg po q HS 12/29/14. The telephone order does not document when the next PT/INR should be drawn. The admission MDS (minimum data set) signed as completed on 1/5/15 documents a BIMS (brief interview mental status) total score of 15 which indicates cognitively intact, is checked as having a UTI (urinary tract infection) and has received anticoagulant medication 7 times & an antibiotic 5 times The physician orders [REDACTED]. (sodium) 3 mg tablet. Give 1 tablet by mouth once daily for [MEDICAL CONDITION] fib (fibrillation). and [MEDICATION NAME] Sod. 3 mg tablet Nurse must check PT/INR results prior to administering dose. On 1/8/14 Resident #25's physician examined Resident #25 at the Facility and ordered to recheck CBC (complete blood count) and BMP (basic metabolic panel). The CBC and BMP were drawn on 1/9/15 which revealed the white blood cells were high at 22.9 (reference range 4.2-11.0), red blood cells were low at 3.14 (reference range 4.0-5.2), Hemoglobin low at 7.2 (reference range 12.0-15.5), Hematocrit low at 26.5 (reference range 36-46.5) and platelet high at 914 (reference range 140-450)." On 1/9/15 at 2:40 p.m. a message was left at Resident #25's physician's office. On 1/10/15 the on call physician order [REDACTED]. (culture and sensitivity). The nurse's note dated 1/12/15 at 1400 (2:00 p.m.) documents: IDT met & discussed labs from 1/9/15 NOR'D (new order received) to enc. (encourage) fluids & U/A still pending @ (at) this time. Ortho consult needs to be clarified as to WB (weight bearing) status will follow up. The nurse's note dated 1/12/15 at 1600 (4:00 p.m.) documents: alert/responsive able to make needs know. lungs CTA (clear to auscultation) without SOB (shortness of breath) @ this time. UA pending. Writer enc. fluids without c/o (complaint of) pain. The nurse's note dated 1/12/15 at 2300 (11:00 p.m.) documents: UA pending. Pt. (patient) complains of heartburn at HS (hour of sleep). Emesis basin found at bedside with ~ (approximately) 30 ml (milliliters) of bright red, clear emesis. Pt. stated she threw that up. Pt. given Tums. Will continue to monitor. Put on 24 hr. board. There is no documentation that Resident #25's physician was notified of the bright red emesis. The SBAR (situation, background, assessment, request) dated 1/13/15 documents: Per 1/12/15 report resident had bright red emesis 30 ml then on 1/13/15 resident had dark emesis. Received order to send to ED (emergency department) for eval (evaluation) and tx (treatment) due to recent labs and emesis. The nurse's note dated 1/13/15 at 1300 (1:00 p.m.) Res. (Resident) being admitted to CMH (Community Memorial Hospital) still doing work up. Will call back for admitting dx. (diagnosis). On 1/13/15 at 10:22 a.m. Surveyor # observed an ambulance stretcher outside Resident #25's room. Surveyor # asked LPN (Licensed Practical Nurse)-DD if Resident #25 was going to the hospital. LPN-DD replied, "Yes." Surveyor # asked LPN-DD if she knew why Resident #25 was going to the hospital. LPN-DD replied "possible GI (gastrointestinal) bleed." The physician telephone orders dated 1/13/15 documents under [DIAGNOSES REDACTED]. On 1/14/15 at 10:16 a.m. Surveyor # reviewed the Facility's 24 hour report board for Resident #25. On 1/12/15 nights document: UA (urinalysis) pending. Days document: 144/78, 79, 90, 22 enc. (encourage) fluids. PM's document: UA pending Bloody emesis. On 1/13/15 nights document: Without complaints of GI issue. Days documents: Hospital. There is no documentation on the 24 hour report board that Resident #25's physician was notified regarding the bloody emesis on 1/12/15. On 1/14/15 at 10:28 a.m. Surveyor # spoke with RN (Registered Nurse)-NN regarding Resident #25 and the note she wrote on 1/12/15 at 11:00 p.m. Surveyor # inquired if she notified Resident #25's physician that Resident #25 had an emesis of bright red blood. RN-NN replied "no." Surveyor # asked if the only thing she did was give Resident #25 Tums and place her on the 24 hour report board. RN-NN informed Surveyor # that it was pretty late at night. Surveyor # informed RN-NN that Surveyor didn't know what she meant by it was pretty late at night. RN-NN replied "I don't know I guess I should have called the doctor." Surveyor # inquired if she had taken care of Resident #25 prior. RN-NN replied, "Yes." Surveyor # asked RN-NN if she was aware that Resident #25 was on [MEDICATION NAME]. RN-NN replied, "Yes." Surveyor # asked RN-NN if she administered [MEDICATION NAME] to Resident #25. RN-NN replied, "Yes." On 1/14/15 at 11:40 a.m. Surveyor # reviewed the Emergency Department hospital records dated 1/13/15. Surveyor # noted under chief complaint documents "vomiting blood." Under ED course documents "Pt. (patient) has Hb (hemoglobin) < (less than) 7.0g/dl and hx (history) suggestive of GI bleed. 2 units PRBCs (packed red blood cells) ordered, [MEDICATION NAME] 80 mg, followed by 8mg/hr (milligram per hour) drip ordered." Under ED labs document "[MEDICATION NAME] > (greater than) 120" (reference range is 10.1-12.9) and "International Normalized Ratio > 10.0"(reference range is .9-1.1). Under [DIAGNOSES REDACTED]." According to an American Heart Association article, The Patient's Guide to Taking [MEDICATION NAME]/[MEDICATION NAME], "The major complications associated with [MEDICATION NAME] are clotting due to underdosing or bleeding due to excessive anticoagulation. The most serious bleeding is gastrointestinal or [MEDICATION NAME] you experience the following signs of bleeding, you should call 911 or your healthcare provider immediately: ...Coughing up large amounts of bright red blood ... "<http://circ.ahajournals.org/content/119/8/e220.full> The failure to immediately consult with the physician when Resident #25 had an emesis of bright red blood created a finding of immediate jeopardy. The Facility removed the Immediate Jeopardy on 1/27/15 when the Facility: 1. RN-NN received 1:1 education for notification of MD. 2. Licensed nurses were educated on timely notification of MD for a change of condition. 3. Licensed nurses were educated to call the primary physician first and if a delay then call the medical director. 2. Cross reference F309. Resident #27 has resided at the facility for several years. Resident #27 has major [DIAGNOSES REDACTED]. Surveyor # reviewed Resident #27's closed medical record after receiving a complaint about his care at the facility. Resident #27 was discharged from the facility on 11/11/14 and has not returned. Resident #27 was hospitalized and diagnosed with [REDACTED]. The August 30, 2014 hospital discharge summary includes "Discharge Diagnoses: [REDACTED].#27 was placed on an eight-week IV antibiotic regimen when discharged from the hospital. The IV antibiotics were completed in the nursing home on October 25, 2014. Surveyor # obtained UTI (Urinary Tract Infection) Surveillance Worksheets from Infection Preventionist RN (Registered Nurse)-GG. The Worksheets show Resident #27, who has an indwelling urinary catheter, was treated for [REDACTED].#27 did not always meet the criteria for UTI as defined on the facility worksheets. Staff report that is because Resident #27 gets septic very quickly. Resident #27's UTIs include: 3/30/14-hospitalized in April [MEDICAL CONDITION]; 5/23/14, 5/29/14-hospitalized in June [MEDICAL CONDITION]; 8/13/14 UTI and positive blood cultures-hospitalized [MEDICAL CONDITION]. Corporate RN-I and ADON (Assistant Director of Nursing)-C informed Surveyor # that Resident #27 is quickly treated with antibiotics even before his urine or blood cultures show final results or the lab doesn't meet the typical criteria for ABT (antibiotic) treatment because Resident #27 gets septic so fast, they must act quickly. Surveyor # interviewed Director of Nursing (DON)-B who stated they use the Interact Tool as their policy regarding how to respond to a change of condition. Surveyor # reviewed the Interact Care Path-Fever which states: Fever Definition: -One temp >100 degrees F; -Two temps >99 degrees F; -Increase in temp of 2 degrees over baseline. If a Resident meets the definition of fever, staff are directed to take vital signs. If any of the vital signs meet criteria, staff should call the doctor, nurse practitioner of physician's assistant. The criteria for Temperature is a Temperature of >100.5 degrees. Resident #27's Nurses' Notes include: 11/4/14 8:00 p.m. Flu shot given in left deltoid. No signs/symptoms of adverse reaction noted thus far. 11/5/14 at 12:30 a.m. T (temperature) 101.6 had flu shot on 11/4/14. Given Tylenol 325 mg. (2)- 650 mg. (milligrams). 11/5/14 1:30 a.m. T 100.1... 11/5/14 1:00 p.m. T99.9 Resident given Tylenol. Rechecked T 99.9...MD called and updated. Monitor. If temp continues call back may order labs. Resident able to hold a conversation with nurse. Meds taken. Requested to stay in bed... 11/5/14 8:00 p.m. T99.1 11/6/14 3:30 a.m. At 1:00 a.m. T 101.0. PRN (as needed) Tylenol was given and helpful, Resident's temp down to 99.7. No adverse effects noted from flu vaccine, no redness to site... 11/6/14 7:20 p.m. T99.6 Gave PRN Tylenol, effective T97.2. Left deltoid no redness, no complaint of pain.. 11/7/14 2:30 a.m. T101.2 Given PRN Tylenol. No redness or swelling noted to flu injection site... 11/7/14 8:15 p.m. T100.3 Gave PRN Tylenol T98.4... (24 Hour Board shows follow up T on night shift T99.0; T100.4 on evening shift). 11/8/14 9:30 p.m. Speech is slow, must give patient extra time to respond to questions... (Note: No elevated temperatures are recorded in the Nurses' Notes on 11/8/14. Resident #27 does receive scheduled aspirin each morning.) 11/9/14 4:40 a.m. T100.7 axillary (Note: this translates to 101.7 orally). Given Tylenol 650 mg. 11/10/14 3:35 a.m. T100.8 axillary (101.8 orally). Given 650 mg. Tylenol. Will continue to monitor. 11/10/14 4:30 a.m. T down to 98.8 axillary (99.9 orally)... 11/10/14 1:00 p.m. Resident alert, responsive. Skin warm/moist. T99.6...Cool compress applied...Will monitor. 11/10/14 3:30 p.m. Writer called MD/APNP (Advanced Practice Nurse Practitioner) to update...Resident has had increased temps and increased lethargy. APNP order to obtain labs CBC, CMP and blood cultures MD specific to draw 11/11/14... 11/10/14 7:15 p.m. ...No temp this shift but increased lethargy... 11/11/14 2:55 p.m. At 2:30 p.m., Resident's temp 103.3 oral PRN Tylenol given cool compresses applied to forehead and neck. MD called and updated. Orders to sent to hospital... Surveyor # asked DON-B why Resident #27's physician was not called back after 11/5/14 as requested by the MD when Resident #27 continued to have elevated temperatures meeting the criteria to call the MD. The Nurses' Notes and 24 Hour Report document temperatures >100.5 (meeting Interact criteria to call MD) on 11/6/14, 11/7/14, 11/9/14 and night shift on 11/10/14 but the MD was not called until the evening shift on 11/10/14. DON-B had no information why nurses did not contact Resident #27's MD. On 1/15/15 at approximately 2:30 p.m., Surveyor # interviewed LPN (Licensed Practical Nurse)-SS, who documented elevated temperatures for Resident #27 in the Nurses' Notes on 11/6/14 and 11/7/14, and documented a call to Nurse Practitioner (NP)-CC on 11/10/14 at 3:30 p.m. informing her Resident #27 had increased temperatures and increased lethargy. Surveyor # asked why she did not call Resident #27's physician sooner considering staff report of Resident #27's recurrent UTIs and quickly getting septic. LPN-SS stated she thought Resident #27's elevated temperatures were due to his receiving the flu shot on 11/4/14. Surveyor # asked if she reported the temperatures to a RN. LPN-SS stated she did not specifically recall reporting the elevated temperatures to a RN, but Resident #27 was on the 24-hour board and the temperatures are usually recorded there for others to see. LPN-SS stated in response to Resident #27's temperature, she gave Resident #27 Tylenol and would ask how he was feeling. The CDC (Centers for Disease Control and Prevention) states side effects of the flu shot may include: Soreness, redness, or swelling where the shot was given, Fever (low grade), and Aches. The intradermal flu shot may cause other additional mild side effects including: Toughness and itching where the shot was given. If these problems occur, they begin soon after the shot and usually last one to two days... Rarely, people who get the flu shot have fever, muscle pain, and feelings of discomfort or weakness. If experienced at all, these effects usually last 1-2 days after vaccination and are much less severe than actual flu illness. http://www.cdc.gov/flu/about/qa/flushot.htm Surveyor # reviewed Resident #27's "Actual/Potential for Infection Plan of Care" rewritten 9/18/13 and most recently updated 9/2014. The "Problem" states Actual/potential for Infection related to: -UTI 11/6/13, 12/3/13, possibly 8/14/15; -history of UTI; -history [MEDICAL CONDITION]; -URI (upper respiratory infection) 12/2013; -F/C (fever/chills); -skin breakdown; -IV access; -wound-right hip abscess; -Bacteremia 6/24/14; -positive blood cultures 12/5/13; -[MEDICAL CONDITION] 4/2014; -positive blood cultures 5/29/14. The "Goal" states -Will be free from s/s (signs/symptoms) of infection (redness, pain, [MEDICAL CONDITION], foul odor or drainage) ongoing; -Temperature will be at baseline, plus or minus 1 degree. (Note: facility staff does not obtain nor record baseline temperatures.) Interventions include: monitor labs/diagnostics; medications as ordered; catheter care per protocol; encourage fluids unless contraindicated; flu and pneumonia vaccines; update physician and family as needed; temperature per protocol; monitor for s/s of infection. At the daily exit meeting on 1/15/15, Surveyor # shared the above information and asked for any additional information regarding notification to Resident #27's physician of his ongoing elevated temperature after initial notification on 11/5/14. On 1/20/15, Surveyor # reviewed Resident #27's hospital record. The Hospital Discharge [DIAGNOSES REDACTED]. The Infectious Disease consultation notes positive blood cultures from 11/11/14 Staph aureus, PICC line catheter tip culture positive for Staph aureus, positive urine culture. Assessment: 1.[MEDICAL CONDITION] secondary to staph Bacteremia and UTI. 2. Catheter related UTI present on admission. 3. Staph aureus bacteremia, probably due to PICC line infection or due to deep focus. Has history of right psoas abscess. 4. [MEDICAL CONDITIONS]. On 1/20/15 at 2:10 p.m., Surveyor # interviewed DON-B and Corporate RN-I, asking if there was any additional information regarding notification of Resident #27's physician of the ongoing elevated temperatures. DON-B stated "You have what we have, there is really nothing new." Surveyor # asked if there was any evidence of Resident #27's physician being called. DON-B indicated: No, the only additional information they located were their "Clinical Meeting Follow Up Tool" sheets they use in their daily meetings that ADON-C keeps. DON-B stated Resident #27 was listed on 11/5, 11/8 and 11/11. DON-B provided Surveyor # with Follow Up Tools dated 11/5/14, 11/8/14 and 11/11/14. Surveyor # reviewed the Clinical Meeting Follow Up Tool dated 11/5/14 and noted Resident #27's name on the list. "Reason for Review" states "temp 101, blood in catheter bag, IV antibiotic dc'd (discontinued) 10/25/14, cultures,[MEDICAL CONDITION]? - no labs". No Follow Up Tools were provided for 11/6/14 or 11/7/14 when Resident #27 had documented temperatures of 101 and 101.2 degrees. The Tool for 11/8/14 states Resident #27 "How's temp, butt, urine- temperature at NOC (night), 99.6 on days." No Tools were provided for 11/9/14 when Resident #27 had a temperature of 100.7 axillary (101.7 orally), or for 11/10/14 when Resident #27's temperature was recorded as 100.8 axillary (101.8 orally). The Tool for 11/11/14 notes Resident #27 was admitted to the hospital with [REDACTED]. These Follow-up Tools did not indicate Resident #27's physician was contacted when his fever persisted. DON-B had no further information. The facility's failure to consult with Resident #27's physician regarding his recurrent elevated temperatures given his known history [MEDICAL CONDITION] created a situation of Immediate Jeopardy for Resident #27. The facility removed the Immediate Jeopardy on 1/27/15 when the facility implemented the following: ~The facility reviewed their policy and procedure related to changes in condition and provided training to nursing staff ~The facility completed a sweep of all current residents reviewing for appropriate physician notification. ~The facility established a monitoring system to ensure that nursing staff have responded appropriately to Resident needs and contacted the physician as indicated by policy. 3.) Resident #24 has [DIAGNOSES REDACTED]. Resident #24 was readmitted to the facility 10/21/14. Resident #24's readmission orders [REDACTED] -Blood glucose monitoring: Use as directed. Check blood glucose four times daily. Call MD if <60 or >301. -Humalog ([MEDICATION NAME]) (insulin) inject 4 units subcutaneously before breakfast, lunch and supper. -Humalog ([MEDICATION NAME]) insulin subcutaneously per sliding scale three times a day... -"Per facility protocol: If Resident does not respond to second carbohydrate feeding or no IV access, give [MEDICATION NAME] 1 mg. (milligram) IM (intramuscularly)." (Note: Resident #24's orders do not include when to give first or second carbohydrate feeding- the order starts with "If Resident does not respond to second carbohydrate feeding...). (Note: there are no orders to hold the insulin if Resident #24's blood sugar is less than 60; the nurse is to call the MD for further instructions.) Surveyor # reviewed Resident #24's Diabetes Plan of Care originally dated 4/2014 and most recently updated 10/2014 stating Resident #24 has potential for Alteration in blood glucose levels related to [DIAGNOSES REDACTED]. The Goal is Resident #24 will have no episodes of symptomatic [MEDICAL CONDITION] or [DIAGNOSES REDACTED] through the next review; resident will comply with dietary restrictions; resident will alert staff if signs of hyper or [DIAGNOSES REDACTED], numbness/tingling in extremities, or changes in vision are present; resident will comply with taking medication. The checked Interventions include: -Administer 1/2 cup or 4 ounces of juice, 1 cup skim milk, 3 glucose tablets, 4 sugar cubes, 5 to 6 pieces of hard candy if resident able to swallow. -Administer [MEDICATION NAME] 1 mg. (milligram) subcutaneously or IM (intramuscularly) if resident cannot ingest per physician order. -Administer [DIAGNOSES REDACTED] measures with 15-20 grams of fast acting carbohydrate; -Administer hypoglycemic medications per MD order; -Administer oral hypoglycemics as ordered; -Assess and document any signs/symptoms of hypo/hyper glycemia; -Document actions taken for hyper/[DIAGNOSES REDACTED]; -Follow up with physician as needed; -Follow with protein snack such as peanut butter or cheese sandwich, diabetic nutrition bar, milk; -Monitor for signs of [DIAGNOSES REDACTED]-sweating, tremor, nervousness, [MEDICAL CONDITION] light-headedness, confusion; -Report abnormal results to physician for follow up; -Report blood glucose results that exceed low and high parameters to physician Surveyor # reviewed Resident #24's medical record. Resident #24's MAR (Medication Administration Record) for January, 2015 shows RN (Registered Nurse) -WW documented Resident #24's blood sugar was 52 at noon on 1/10/15 and she held Resident #24's scheduled insulin. Before supper on 1/10/15, RN-WW documented Resident #24's blood glucose was 62 and again her insulin was held. RN-M documented on the January MAR that Resident #24's blood glucose was 63 before breakfast on 1/20/15 and she gave the 4 units insulin as ordered. RN-M documented on the MAR on 1/23/15 that Resident #24's blood glucose was 64 before breakfast, but the morning insulin was held. RN-M documented on 1/24/15 that Resident #24's blood glucose was 53 before breakfast and the insulin was held. RN-WW documented on the MAR that Resident #24's blood glucose was 48 before supper on 1/25/15 and the insulin was held. Surveyor # reviewed Resident #24's Nurses' Notes and observed no documentation at all from 1/8/15 until 1/17/15 (neither note pertained to Resident #24's blood sugar readings.) There is no documentation indicating RN-WW called Resident #24's physician on 1/10/15 when her blood glucose was 52 at noon. There is no documentation RN-WW obtained an order to hold Resident #24's insulin before lunch and supper, as she did. Nurses' Notes dated 1/20/15 indicate Resident #24's physician was in the facility and reviewed Resident #24's weekly blood sugar report (1/12/15 thru 1/18/15); no new orders. The note states "...stable blood glucose when she eats meals. Daily BM..." (Note: no "Blood Glucose Weekly Monitoring Record" was located for 1/5/15 through 1/11/15). The next Nurses' Note is dated 1/22/15 but does not address blood sugars. The next note is dated 1/25/15 at 5:00 p.m. by RN-WW stating "Called MD for (down arrow-decreased) blood sugar, no new orders." There is no documentation pertaining to RN-M holding Resident #24's insulin on 1/23/15 before breakfast when her blood sugar was 64. Nor was there any documentation on 1/24/15 when her blood sugar was 53 before breakfast and MD orders direct staff to call the MD if the blood sugar is less than 60. No orders were observed to hold Resident #24's insulin on any dates. RN-WW's Note on 1/25/15 at 5:00 p.m. does not include orders to hold Resident #24's insulin; it states "no new orders" but the insulin was held. The note does not include any further documentation regarding an assessment of Resident #24 or signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar). As of 1/26/15 at 8:45 a.m., that was the last Nurses' Note in Resident #24's medical record. On 1/26/14 at 8:50 a.m., Surveyor # interviewed RN Manger-N, asking about any further assessment or information regarding Resident #24's low blood sugar of 53, whether or not the MD was called per orders, and why the insulin was held if the notes states "no new orders". RN-N stated she had not had a chance to review the 24 hour report yet,

This deficiency is uncorrected at the verification visit. Based on record review and interview, facility staff did not provide appropriate care for 4 of 9 sampled Residents: one of one Residents with elevated fever (#27); 2 of 2 Residents with skin impairments (#21 and #22); 1 of 1 Residents with low blood sugar (Resident #24). * Resident #27, who has a history of [MEDICAL CONDITION], had an elevated temperature on 11/5/14. Resident #27's physician instructed staff on 11/5/14 to monitor Resident #27's temperature, and call back if it continued and he may order lab work. Resident #27 had elevated temperatures on 11/6/14, 11/7/14, 11/9/14 and 11/10/14, yet Resident #27's physician was not contacted until the afternoon of 11/10/14. No RN (Registered Nurse) assessment was completed for Resident #27. Resident #27 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The facility's failure to provide care to Resident #27 based upon his individualized needs and in accordance with standards of care for a change of condition created a situation of Immediate Jeopardy for Resident #27 on 11/6/15. The facility's recertification survey concluded on 12/8/14 making the 11/6/14 date prior to the facility's recertification survey. Due to this, the start date for the Immediate Jeopardy is 12/8/14, which is the recertification survey exit date. On 1/21/15 at 3:00 p.m. the Administrator and Corporate RN-I were informed of the finding of Immediate Jeopardy for Resident #27. The Immediate Jeopardy was removed on 1/27/15 for Resident #27 but continues at a severity/scope level of E (potential for harm that is not immediate Jeopardy/pattern) until all inservices are completed, the revised system is completely implemented and for current non compliance for Resident's #21, #22 and #24. * Resident #24 is diabetic and has orders for four times a day blood glucose monitoring. If Resident #24's blood sugar is less than 60 or greater than 300, the nurse is to call Resident #24's physician. Resident #24 had blood glucose reading less than 60 on 1/10/15, 1/23/15 and 1/24/15. Resident #24's physician was not called, nor is there any documentation in the Resident's record of what actions staff took to address the low blood sugar. * Resident #22 has a venous stasis ulcer on her left lateral malleous which the physician ordered a treatment of [REDACTED]. Staff did not do this treatment on 1/12/15. * Resident #21 was observed with open areas on her right and left buttocks on 1/13/15 & 1/14/15. There is no documentation regarding these open areas or treatment obtained until these areas were brought to the Facility's attention by the State Surveyor. Findings include: 1. Resident #27 has resided at the facility for several years. Resident #27 has major [DIAGNOSES REDACTED]. Surveyor # reviewed Resident #27's closed medical record after receiving a complaint about his care at the facility. Resident #27 was discharged from the facility on 11/11/14 and has not returned. Resident #27 was hospitalized and diagnosed with [REDACTED]. The August 30, 2014 hospital discharge summary includes "Discharge Diagnoses: [REDACTED].#27 was placed on an eight-week IV antibiotic regimen when discharged from the hospital. The IV antibiotics were completed in the nursing home on October 25, 2014. Surveyor # obtained UTI (Urinary Tract Infection) Surveillance Worksheets from Infection Preventionist RN (Registered Nurse)-GG. The Worksheets show Resident #27, who has an indwelling urinary catheter, was treated for [REDACTED].#27 did not always meet the criteria for UTI as defined on the facility worksheets. For example: -3/30/14 Resident #27 had purulent discharge from around the catheter, but did not have the lab results to support [DIAGNOSES REDACTED].>100,000 cfu/mL (colony-forming units/milliliter) of any organism). The final lab results dated 4/1/14 state: "60,000 to 100,000 cfu/mL multiple organisms isolated with no predominant type. Consistent with contamination. Consider recollection." The Worksheet notes Resident #27 was treated with IV antibiotics starting on 4/8/14 to 5/2/14 when staphylococcus was isolated. (That lab was not attached and RN-GG was not the Infection Control Nurse at that time). (hospitalized in April [MEDICAL CONDITION]). -5/23/14 Started on [MEDICATION NAME] for UTI, though lab results state ">100,000 cfu/mL multiple organism isolated with no predominant type, consistent with contamination. Consider recollection". There is no evidence attached indicating another specimen was obtained. -5/29/14 IV [MEDICATION NAME] for UTI and positive blood culture showing gram stain positive cocci clusters. (hospitalized in June [MEDICAL CONDITION]). -8/13/14 UTI and positive blood cultures. (hospitalized [MEDICAL CONDITION].) Corporate RN-I and ADON (Assistant Director of Nursing)-C informed Surveyor # that Resident #27 is quickly treated with antibiotics even before his urine or blood cultures show final results or the lab doesn't meet the typical criteria for ABT (antibiotic) treatment because Resident #27 gets septic so fast, they must act quickly. Surveyor # interviewed Director of Nursing (DON)-B who stated they use the Interact Tool as their policy regarding how to respond to a change of condition. Surveyor # reviewed the Interact Care Path-Fever which states: Fever Definition: -One temp >100 degrees F; -Two temps >99 degrees F; -Increase in temp of 2 degrees over baseline. If a Resident meets the definition of fever, staff are directed to take vital signs. If any of the vital signs meet criteria, staff should call the doctor, nurse practitioner of physician's assistant. The criteria for Temperature is a Temperature of >100.5 degrees. Resident #27's Nurses' Notes include: 11/4/14 8:00 p.m. Flu shot given in left deltoid. No signs/symptoms of adverse reaction noted thus far. 11/5/14 at 12:30 a.m. "T (temperature) 101.6 had flu shot on 11/4/14. Given Tylenol 325 mg. (2)- 650 mg. (milligrams). 11/5/14 1:30 a.m. T 100.1... 11/5/14 1:00 p.m. T99.9 Resident given Tylenol. Rechecked T 99.9...MD called and updated. Monitor. If temp continues call back may order labs. Resident able to hold a conversation with nurse. Meds taken. Requested to stay in bed... 11/5/14 8:00 p.m. T99.1 11/6/14 3:30 a.m. At 1:00 a.m. T 101.0. PRN (as needed) Tylenol was given and helpful, Resident's temp down to 99.7. No adverse effects noted from flu vaccine, no redness to site... 11/6/14 7:20 p.m. T99.6 Gave PRN Tylenol, effective T97.2. Left deltoid no redness, no complaint of pain.. 11/7/14 2:30 a.m. T101.2 Given PRN Tylenol. No redness or swelling noted to flu injection site... 11/7/14 8:15 p.m. T100.3 Gave PRN Tylenol T98.4... (24 Hour Board shows follow up T on night shift T99.0; T100.4 on evening shift). 11/8/14 9:30 p.m. Speech is slow, must give patient extra time to respond to questions... (Note: No elevated temperatures are recorded in the Nurses' Notes on 11/8/14. Resident #27 does receive scheduled aspirin each morning.) 11/9/14 4:40 a.m. T100.7 axillary (Note: this translates to 101.7 orally). Given Tylenol 650 mg. 11/10/14 3:35 a.m. T100.8 axillary (101.8 orally). Given 650 mg. Tylenol. Will continue to monitor. 11/10/14 4:30 a.m. T down to 98.8 axillary (99.9 orally)... 11/10/14 1:00 p.m. Resident alert, responsive. Skin warm/moist. T99.6...Cool compress applied...Will monitor. 11/10/14 3:30 p.m. Writer called MD/APNP (Advanced Practice Nurse Practitioner) to update...Resident has had increased temps and increased lethargy. APNP order to obtain labs CBC, CMP and blood cultures MD specific to draw 11/11/14... 11/10/14 7:15 p.m. ...No temp this shift but increased lethargy... 11/11/14 2:55 p.m. At 2:30 p.m., Resident's temp 103.3 oral PRN Tylenol given cool compresses applied to forehead and neck. MD called and updated. Orders to sent to hospital... On 1/15/14, at 9:28 a.m., after reviewing the Nurses' Notes documentation, Surveyor # asked DON-B if any of the nurses' signatures were RNs (Registered Nurses). By the State of Wisconsin Nurse Practice Act, LPNs (Licensed Practical Nurses) may collect data regarding a resident, but they cannot conduct a full assessment. DON-B stated all the signatures on the documentation in Resident #27's medical record from 11/5/14 through discharge on 11/11/14 were from LPNs- no RN documented in Resident #27's medical record during that time. DON-B stated "I know we were in there. They (the LPNs) frequently come and get us to look at Residents." When asked if she recalled assessing Resident #27 from 11/5/14-11/11/14, DON-B replied "No". Surveyor # asked if an RN did assess Resident #27, should the assessment be documented in the Nurses' Notes. DON-B stated all assessments should be documented. Surveyor # asked DON-B why Resident #27's physician was not called back after 11/5/14 as requested by the MD when Resident #27 continued to have elevated temperatures meeting the criteria to call the MD. The Nurses' Notes and 24 Hour Report document temperatures >100.5 (meeting Interact criteria to call MD) on 11/6/14, 11/7/14, 11/9/14 and night shift on 11/10/14 but the MD was not called until the evening shift on 11/10/14. DON-B had no information why nurses did not contact Resident #27's MD. Surveyor # asked if staff obtain and document baseline temperatures for Residents. DON-B stated they do not to that at this facility. Surveyor # reviewed a facility procedure titled Episodic Documentation revised July, 2012, that states "Note: Permanently maintain "Vital Signs-Individual Resident Flow Sheet" with baseline body temperature and date in the medical record." Surveyor # reviewed a "Vital Signs-Individual Resident Flow Sheet" for Resident #27 with data from 9/4/14 through 10/11/14 and the "Baseline Body Temperature" section is blank. Of the 50 entries, only 8 temperature readings are 98.6 or higher. 33 temperature readings are less than or equal to 98.2, and 27 of those are less than 98.0. From that information though it is unknown if Resident #27 had received any medication affecting temperature prior to obtaining those temperatures. Research has shown older people tend to have lower baseline temperatures. The Hartford Institute for Geriatric Nursing article "Age-related changes in health- Geriatric Nursing Protocol: Age-related changes in health" states "Baseline oral temperature in older adults is 97.4 °F (36.3 °C) versus 98.6 °F (37 °C) in younger adults", citing: Lu, S.H., Leasure, A.R., & Dai, Y.T. (2010). A systematic review of body temperature variations in older people. Journal of Clinical Nursing, 19(1-2), 4-16. http://consultgerirn.org/topics/normal_aging_changes/want_to_know_more On 1/15/15 at approximately 2:30 p.m., Surveyor # interviewed LPN (Licensed Practical Nurse)-SS, who documented elevated temperatures for Resident #27 in the Nurses' Notes on 11/6/14 and 11/7/14, and documented a call to Nurse Practitioner (NP)-CC on 11/10/14 at 3:30 p.m. informing her Resident #27 had increased temperatures and increased lethargy. Surveyor # asked why she did not call Resident #27's physician sooner considering Resident #27's recurrent UTIs and quickly getting septic. LPN-SS stated she thought Resident #27's elevated temperatures were due to his receiving the flu shot on 11/4/14. Surveyor # asked if she reported the temperatures to a RN. LPN-SS stated she did not specifically recall reporting the elevated temperatures to a RN, but Resident #27 was on the 24 hour board and the temperatures are usually recorded there for others to see. LPN-SS stated in response to Resident #27's temperature, she gave Resident #27 Tylenol and would ask how he was feeling. The CDC (Centers for Disease Control and Prevention) states side effects of the flu shot may include: Soreness, redness, or swelling where the shot was given, Fever (low grade), and Aches. The intradermal flu shot may cause other additional mild side effects including: Toughness and itching where the shot was given. If these problems occur, they begin soon after the shot and usually last one to two days... Rarely, people who get the flu shot have fever, muscle pain, and feelings of discomfort or weakness. If experienced at all, these effects usually last 1-2 days after vaccination and are much less severe than actual flu illness. http://www.cdc.gov/flu/about/qa/flushot.htm Surveyor # reviewed Resident #27's "Actual/Potential for Infection Plan of Care" rewritten 9/18/13 and most recently updated 9/2014. The "Problem" states Actual/potential for Infection related to: -UTI 11/6/13, 12/3/13, possibly 8/14/15; -history of UTI; -history [MEDICAL CONDITION]; -URI (upper respiratory infection) 12/2013; -F/C (fever/chills); -skin breakdown; -IV access; -wound-right hip abscess; -Bacteremia 6/24/14; -positive blood cultures 12/5/13; -[MEDICAL CONDITION] 4/2014; -positive blood cultures 5/29/14. The "Goal" states -Will be free from s/s (signs/symptoms) of infection (redness, pain, [MEDICAL CONDITION], foul odor or drainage) ongoing; -Temperature will be at baseline, plus or minus 1 degree. (Note: facility staff does not obtain nor record baseline temperatures.) Interventions include: monitor labs/diagnostics; medications as ordered; catheter care per protocol; encourage fluids unless contraindicated; flu and pneumonia vaccines; update physician and family as needed; temperature per protocol; monitor for s/s of infection. At the daily exit meeting on 1/15/15, Surveyor # shared the above information and asked for any additional information regarding a RN assessment of Resident #27 from 11/5/14 through 11/11/14; notification to Resident #27's physician of his ongoing elevated temperature after initial notification on 11/5/14; any other interventions performed regarding Resident #27's ongoing elevated temperature other than administering Tylenol (cool compress only documented on evening of 11/10/14 and early morning on 11/11/14 before he was sent to the hospital), for a Resident known to staff to get septic quickly. Surveyor # also noted Resident #27's Care Plan Goal #2 is his temperature will be at baseline, plus or minus one degree, but they have not obtained Resident #27's baseline temperature (or those of any other resident). On 1/20/15, Surveyor # reviewed Resident #27's hospital record. The Hospital Discharge [DIAGNOSES REDACTED]. The Infectious Disease consultation notes positive blood cultures from 11/11/14 Staph aureus, PICC line catheter tip culture positive for Staph aureus, positive urine culture. Assessment: 1.[MEDICAL CONDITION] secondary to staph Bacteremia and UTI. 2. Catheter related UTI present on admission. 3. Staph aureus bacteremia, probably due to PICC line infection or due to deep focus. Has history of right psoas abscess. 4. [MEDICAL CONDITIONS]. On 1/20/15 at 2:10 p.m., Surveyor # interviewed DON-B and Corporate RN-I, asking if there was any additional information regarding Resident #27's care from 11/5/14 to 11/11/14. DON-B stated "You have what we have, there is really nothing new." Surveyor # asked if there was any evidence of an RN assessment or Resident #27's physician being called. DON-B stated: No, the only other information they located were their "Clinical Meeting Follow Up Tool" sheets they use in their daily meetings that ADON-C keeps. DON-B stated Resident #27 was listed on 11/5, 11/8 and 11/11. DON-B provided Surveyor # with Follow Up Tools dated 11/5/14, 11/8/14 and 11/11/14. Surveyor # reviewed the Clinical Meeting Follow Up Tool dated 11/5/14 and noted Resident #27's name on the list. "Reason for Review" states "temp 101, blood in catheter bag, IV antibiotic dc'd (discontinued) 10/25/14, cultures,[MEDICAL CONDITION]? - no labs". No Follow Up Tools were provided for 11/6/14 or 11/7/14 when Resident #27 had documented temperatures of 101 and 101.2 degrees. The Tool for 11/8/14 states Resident #27 "How's temp, butt, urine- temperature at NOC (night), 99.6 on days." No Tools were provided for 11/9/14 when Resident #27 had a temperature of 100.7 axillary (101.7 orally), or for 11/10/14 when Resident #27's temperature was recorded as 100.8 axillary (101.8 orally). The Tool for 11/11/14 notes Resident #27 was admitted to the hospital with [REDACTED]. Surveyor # asked DON-B if they had evidence of any follow up on 11/6 or 11/7 after the 11/5/14 Clinical Meeting Follow Up Tool [MEDICAL CONDITION] and notes no labs. Did they discuss this on 11/6 or 11/7? If they were concerned Resident #27 gets septic very quickly, why would no further follow-up have taken place. The Tool on 11/8/14 notes "Temp at NOC, 99.6 on days". DON-B stated ADON-C brought the day shift temperature with her to the meeting, as she did with the information "No labs" noted on the 11/5/14 Tool. Surveyor # asked if additional follow up was done other than noting Resident #27's temperature of 99.6. DON-B had no further information. Surveyor # then interviewed ADON-C, asking why Resident #27 was not on the Follow-up Tools for 11/6, 11/7, 11/9 or 11/10. ADON-C stated she could not find those sheets- he may have been on them but they cannot find them. Surveyor # noted ADON-C was informed by the hospital that Resident #27 was admitted to the hospital with [REDACTED]. Knowing Resident #27 gets septic quickly as ADON-C informed Surveyor # earlier, was any review of Resident #27's care conducted after learning Resident #27's was hospitalized . ADON-C stated no review was conducted. This lead to the finding of immediate jeopardy for Resident #27. The Immediate Jeopardy was removed on 1/27/15 when nursing management provided education to staff nurses on appropriate care and treatment of [REDACTED]. Nursing management established an audit system to review each resident's medical record to ensure appropriate assessment, follow through and documentation of resident care, along with review of MARs and TARs (Medication Administration Record and Treatment Administration Record) daily to ensure appropriate care is provided. 2.) Resident #24 has [DIAGNOSES REDACTED]. Resident #24 was readmitted to the facility 10/21/14. Resident #24's readmission orders [REDACTED] -Blood glucose monitoring: Use as directed. Check blood glucose four times daily. Call MD if <60 or >301. -Humalog ([MEDICATION NAME]) (insulin) inject 4 units subcutaneously before breakfast, lunch and supper. -Humalog ([MEDICATION NAME]) insulin subcutaneously per sliding scale three times a day... -"Per facility protocol: If Resident does not respond to second carbohydrate feeding or no IV access, give [MEDICATION NAME] 1 mg. (milligram) IM (intramuscularly)." (Note: Resident #24's orders do not include when to give first or second carbohydrate feeding- the order starts with "If Resident does not respond to second carbohydrate feeding...). (Note: there are no orders to hold the insulin if Resident #24's blood sugar is less than 60; the nurse is to call the MD for further instructions.) Surveyor # reviewed Resident #24's Diabetes Plan of Care originally dated 4/2014 and most recently updated 10/2014 stating Resident #24 has potential for Alteration in blood glucose levels related to [DIAGNOSES REDACTED]. The Goal is Resident #24 will have no episodes of symptomatic [MEDICAL CONDITION] or [DIAGNOSES REDACTED] through the next review; resident will comply with dietary restrictions; resident will alert staff if signs of hyper or [DIAGNOSES REDACTED], numbness/tingling in extremities, or changes in vision are present; resident will comply with taking medication. The checked Interventions include: -Administer 1/2 cup or 4 ounces of juice, 1 cup skim milk, 3 glucose tablets, 4 sugar cubes, 5 to 6 pieces of hard candy if resident able to swallow. -Administer [MEDICATION NAME] 1 mg. (milligram) subcutaneously or IM (intramuscularly) if resident cannot ingest per physician order. -Administer [DIAGNOSES REDACTED] measures with 15-20 grams of fast acting carbohydrate; -Administer hypoglycemic medications per MD order; -Administer oral hypoglycemics as ordered; -Assess and document any signs/symptoms of hypo/hyper glycemia; -Document actions taken for hyper/[DIAGNOSES REDACTED]; -Follow up with physician as needed; -Follow with protein snack such as peanut butter or cheese sandwich, diabetic nutrition bar, milk; -Monitor for signs of [DIAGNOSES REDACTED]-sweating, tremor, nervousness, [MEDICAL CONDITION] light-headedness, confusion; -Report abnormal results to physician for follow up; -Report blood glucose results that exceed low and high parameters to physician Surveyor # reviewed Resident #24's medical record. Resident #24's MAR (Medication Administration Record) for January, 2015 shows RN (Registered Nurse) -WW documented Resident #24's blood sugar was 52 at noon on 1/10/15 and she held Resident #24's scheduled insulin. Before supper on 1/10/15, RN-WW documented Resident #24's blood glucose was 62 and again her insulin was held. RN-M documented on the January MAR that Resident #24's blood glucose was 63 before breakfast on 1/20/15 and she gave the 4 units insulin as ordered. RN-M documented on the MAR on 1/23/15 that Resident #24's blood glucose was 64 before breakfast, but the morning insulin was held. RN-M documented on 1/24/15 that Resident #24's blood glucose was 53 before breakfast and the insulin was held. RN-WW documented on the MAR that Resident #24's blood glucose was 48 before supper on 1/25/15 and the insulin was held. Surveyor # reviewed Resident #24's Nurses' Notes and observed no documentation at all from 1/8/15 until 1/17/15 (neither note pertained to Resident #24's blood sugar readings.) There is no documentation indicating RN-WW called Resident #24's physician on 1/10/15 when her blood glucose was 52 at noon. There is no documentation RN-WW obtained an order to hold Resident #24's insulin before lunch and supper, as she did. Nurses' Notes dated 1/20/15 indicate Resident #24's physician was in the facility and reviewed Resident #24's weekly blood sugar report (1/12/15 thru 1/18/15); no new orders. The note states "...stable blood glucose when she eats meals. Daily BM..." (Note: no "Blood Glucose Weekly Monitoring Record" was located for 1/5/15 through 1/11/15). The next Nurses' Note is dated 1/22/15 but does not address blood sugars. The next note is dated 1/25/15 at 5:00 p.m. by RN-WW stating "Called MD for (down arrow-decreased) blood sugar, no new orders." There is no documentation pertaining to RN-M holding Resident #24's insulin on 1/23/15 before breakfast when her blood sugar was 64. Nor was there any documentation on 1/24/15 when her blood sugar was 53 before breakfast and MD orders direct staff to call the MD if the blood sugar is less than 60. No orders were observed to hold Resident #24's insulin on any dates. RN-WW's Note on 1/25/15 at 5:00 p.m. does not include orders to hold Resident #24's insulin; it states "no new orders" but the insulin was held. The note does not include any further documentation regarding an assessment of Resident #24 or signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar). As of 1/26/15 at 8:45 a.m., that was the last Nurses' Note in Resident #24's medical record. On 1/26/14 at 8:50 a.m., Surveyor # interviewed RN Manger-N, asking about any further assessment or information regarding Resident #24's low blood sugar of 53, whether or not the MD was called per orders, and why the insulin was held if the notes states "no new orders". RN-N stated she had not had a chance to review the 24 hour report yet, so was not aware of Resident #24's low blood sugar, but she would look into it. Surveyor # reviewed the 24 hour report with RN-N but Resident #24 was not on the 24 hour report on 1/23/15, 1/24/15, 1/25/15 or 1/26/15. Surveyor # reviewed Resident #24's Nurses' Notes with RN-N and both observed RN-WW's note on 1/25/15 at 5:00 p.m. was the last note documented. After reviewing the MAR for 1/25/15 and observing the blood sugar of 48 , RN-N stated RN-WW should have performed and documented an assessment regarding whether or not Resident #24 exhibited any signs or symptoms of [DIAGNOSES REDACTED], and called Resident #24's physician. On 1/26/15 at 9:00 a.m., RN-N brought RN-XX to speak with Surveyor # . RN-XX worked night shift (shift ended at 6:00 a.m.) but he was still finishing up his work. RN-XX informed Surveyor # that RN-WW verbally reported to him at shift change that Resident #24 had a low blood sugar before supper, but had no signs of [DIAGNOSES REDACTED]. RN-XX stated he assessed Resident #24 and she was not having any signs or symptoms of hyper or [DIAGNOSES REDACTED]. (Because Resident #24 did not receive her pre-supper insulin, then ate supper, her bedtime blood glucose level was 300). RN-XX stated RN-WW reported after the blood glucose level of 48, Resident #24 ate most of her supper. RN-XX then documented that information in Resident #24's Nurses' Notes, indicating it was documented at 3:00 a.m. Surveyor # interviewed RN-GG, nurse educator. RN-GG informed Surveyor # they did not have any policy and procedure pertaining to insulin administration or how to treat hypo or [MEDICAL CONDITION], but she did have training materials regarding treatment of [REDACTED].# with copies of slides for a presentation titled "Clinical Education Diabetes Level One". On page 13, a slide states "treatment for [REDACTED]. Rule of 15. If blood sugar is less than 70 give 15 grams of carbohydrate. Wait 15 minutes. Re-test, if still less than 70, give 15 grams of carbohydrate. Wait 15 minutes, re-test. When above 70, give snack or meal." Another slide defines severe [DIAGNOSES REDACTED] as when an individual cannot be treated with oral glucose due to confusion or unconsciousness. Requires [MEDICATION NAME] injection. RN-GG also had materials describing Symptoms of low blood sugar/[DIAGNOSES REDACTED] and Symptoms of high blood sugar/[MEDICAL CONDITION]. Surveyor # then interviewed RN-M. RN-M stated she did not call Resident #24's physician on 1/24/15 when her blood sugar was 53. RN-M acknowledged Resident #24's physician orders [REDACTED].#24's blood glucose is <60. RN-M stated "a person is more than a number", and that she knows Resident #24 very well and Resident #24 did not exhibit any signs or symptoms of [DIAGNOSES REDACTED]. Surveyor # asked why RN-M did not document an assessment of Resident #24 and call the MD. RN-M stated "I should have." Surveyor # shared the above information with DON (Director of Nursing)-B and Corporate RN-I. On 1/26/15 neither had any additional information regarding the lack of documentation indicating Resident #24's physician was contacted regarding [DIAGNOSES REDACTED] on 1/10/15, 1/23/14, and 1/24/15. On 1/28/15, DON-B provided Surveyors with a root cause analysis including a statement from RN-XX that says she was just doing what she saw other nurses do. Later, Surveyor # observed a Late Entry Physician Telephone Order showing RN-XX wrote out telephone orders on 1/27/15 for 1/10/15 and 1/25/15 to hold the insulin. DON-B stated RN-XX kept notes at the facility of what happens each shift and saw in her notes that she called the MD and obtained orders to hold the insulin but did not document it. This conflicts with her statement in the root cause analysis that she did not call the MD (on 1/10/15) because others do not call when Resident #24's blood glucose is less than 60, and it conflicts with her documentation on 1/25/15 stating "No new orders". 3.) Surveyor # reviewed Resident #22's medical record on 1/13/15 to 1/15/15. Resident #22 was admitted to the Facility with a venous stasis ulcer on her left lateral malleous. The physician orders [REDACTED]. On 1/13/15 at 10:27 a.m. Surveyor # observed Resident #22 dressed for the day lying in bed. Surveyor # observed there was gauze stuck to the wound bed on Resident #22's left lateral malleous (ankle) gauze. The Kerlix wrap was not over the wound bed but up on the shin area. Surveyor # asked Resident #22 if she could move her leg so Surveyor # could see the date on the dressing. Resident #22 was able to move her left leg and stated, "it's dated the 11th" and informed Surveyor # that the dressing is done every day "so today is the 12th." On 1/13/15 at 10:55 a.m. Surveyor # reviewed Resident #22's TAR (treatment administration record) and noted the treatment is not initialed as being completed on 1/12/15. On 1/13/15 at 11:50 a.m. Surveyor # entered Resident #22's room with ADON (Assistant Director of Nursing)-C and RN (Registered Nurse)-GG to observe Resident #22's treatment. Surveyor # noted the treatment supplies were already set up on top of a towel on the over bed table. ADON-C and RN-GG washed their hands and placed gloves on. ADON-C cleaned her scissors with an alcohol pad, removed her gloves, and cleansed her hands. At 11:54 a.m. Surveyor # verified with ADON-C that the dressing on Resident #22's left lateral malleous is dated 1/11. ADON-C sprayed normal saline on the gauze that was stuck to the left lateral malleous wound bed. While ADON-C was attempting to remove the gauze, Resident #22 stated "ow". ADON-C replied, "I know I'm sorry. Going to get it wet a little more." ADON-C sprayed more normal saline on the gauze while removing the gauze from the wound bed. ADON-C removed the gauze, removed her gloves stating, "I got her" and cleansed her hands. ADON-C measured the left lateral malleous obtaining measurements of 3.3 cm (centimeters) length by 2.0 cm width. ADON-C cleansed the left lateral malleous with normal saline and placed skin prep around the wound. ADON-C removed her gloves, cleansed her hands, and measured the lower wound obtaining measurements of 4.0 cm length by 0.9 width. ADON-C cleansed the wound with normal saline, applied skin prep around the wound, removed her gloves, cleansed her hands and placed new gloves on. ADON-C placed Santyl ointment on a 4 by 4 gauze and placed this gauze over the left lateral malleous wound. ADON-C placed Santyl ointment on another 4 by 4 gauze and placed this gauze over the wound. RN-GG held up Resident #22's left leg while ADON-C wrapped the dressing with Kerlix. ADON-C and RN-GG removed their gloves and washed their hands. On 1/13/15 at 12:15 p.m. Surveyor # informed ADON-C that the dressing was dated 1/11 and the treatment administration record was not initialed as being completed on the 12th and asked why the dressing wasn't done on 1/12/15. ADON-C informed Surveyor # that she would have to look into it as she was off 1/12/15 as she worked the night shift Sunday night. On 1/15/15 at 9:14 a.m. Surveyor # asked the Director of Nursing if there was any information as to why Resident #22's left lateral malleous treatment was not done on 1/12/15. The Director of Nursing informed Surveyor # that the day shift didn't do it and they passed it on to the evening shift to do. The evening shift passed it on to the night shift to do and the night shift didn't do it because they knew that the day shift would be doing it. Surveyor # asked if anyone in nursin

Based on observation, interview and record review, the facility did not ensure that each resident receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility did not ensure this for 2 (Resident #6 & #5) of 14 residents included in the sample. Resident #6 receives the antipsychotic medication [MEDICATION NAME] in the treatment of [REDACTED]. Resident #5 was observed to express pain during an observation of a pressure ulcer treatment; the resident was administered pain medication at the end of the treatment. Findings include: 1.) Resident #6 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident #6 has been receiving [MEDICATION NAME] since before his admission to the facility and was initially receiving 25 mg in the morning and 50 mg at bedtime, the facility did however, consult with the resident's physician to discontinue the morning dose on 7-28-14, the bedtime dose continues at this time. The initial MDS dated [DATE] indicates Resident #6 has short and long-term memory problems, and the staff assessed the resident to be severely cognitively impaired, requires extensive to total assistance to complete his activities of daily (ADLs). The initial MDS does not identify Resident #6's behavioral symptoms, but does indicate the resident has mild depression. The [MEDICAL CONDITION] drug use and cognitive loss/ dementia care area assessments (CAAs), dated 7-30-14, also do not identify targeted symptoms, and does not include input from family or representatives concerning the resident's behavioral symptoms, even though the resident's clinical record notes his brother is named as his health care power of attorney (HCPOA). The falls CAA indicates Resident #6 has [MEDICAL CONDITION] disorder. The 9-19-14 quarterly update to the MDS assessment indicates Resident #6's mental state has improved, such that the resident is cognitively intact, though remains mildly depressed, but this assessment does not identify psychiatric or behavioral symptoms. According to PDR.net 2011 (Physician's drug reference) [MEDICATION NAME] contains a "boxed warning" due a serious side effect than can occur in some individuals, i.e., severe agranulocytosis (decreased [DIAGNOSES REDACTED]s - a component of white blood cells) that can lead to serious infection and death, and that persons who are prescribed this medication must have regular laboratory measurements of their white blood cells. Resident #6's clinical record does contain evidence of weekly to bi-weekly blood values, however, there is no evidence of a discussion either with the resident or his HCPOA about the risks and benefits to the use of the [MEDICATION NAME] to treat dementia or psychiatric symptoms. On 12-3-14 at 2:30 PM, Surveyor # conducted interviews with RN-D, MDS coordinator, and SSD-BB, social services director. Surveyor # asked RN-D about the [MEDICAL CONDITION] disorder [DIAGNOSES REDACTED]. RN-D indicated that notation in the falls CAA was erroneous, as she was not sure where that came from. Surveyor # also asked RN-D and SSD-BB, to identify the behavioral symptoms for which the [MEDICATION NAME] is being used to treat. SSD-BB indicated the medication is treating the resident's agitation and anxiety; both staff were not able to identify the kind and intensity of Resident #6's agitation or anxiety. On 12-8-14 at 8:15 AM, Surveyor # conducted an interview with RN-B, director of nurses, and asked for further information concerning the use of the [MEDICATION NAME]. RN-B indicated the medication is being used to treat the resident's visual hallucinations of "seeing silhouettes of children". RN-B does not indicate if these hallucinations are distressing to the resident or whether the hallucinations are enough to cause the resident to become agitated or anxious. Resident #6's clinical record contains no evidence of this hallucination. On 12-8-14 at approximately 10:00 AM, RN-C, assistant director of nurses, presented Surveyor # with a psychiatric consultation progress note, wherein Resident #6 was diagnosed with [REDACTED]. 2.) Resident #5 has [DIAGNOSES REDACTED]. The 5-23-14 annual MDS assessment indicates Resident #5 reports pain at pain level "6" ( 1 - 10 pain scale), and the 11-20-14 quarterly update to the MDS assessment indicates the resident did not answer when asked, but had rare pain. Resident #5's clinical record indicates the resident receives [MEDICATION NAME] 25 mcg (narcotic) via a skin patch, that is replaced every 72 hours, in addition to [MEDICATION NAME] 200 mg twice a day for the nerve pain, and [MEDICATION NAME] 20 mg four times a day for the muscle spasms/pain; the resident can also have [MEDICATION NAME] 650 mg as four times a day as needed (PRN). The facility conducted a pain data and collection assessment on 11-17-14 that indicates Resident #5 expresses pain verbally at times but also exhibits non-verbal expressions of pain via facial (grimacing), breathing and tense body language. This same assessment notes the above medications as well as repositioning the resident and an air mattress to be effective interventions in assisting to relieve the resident's pain. On 12-3-14 at 9:41 AM, Surveyor # observed RN-C and RN-GG perform a pressure ulcer treatment to Resident #5's right ischial (buttock) area and a treatment to a lesion on the resident's outer thigh. Upon entering the resident's room, Resident #5 was observed in bed, positioned on his left side with pillows and other positioning devices. Both staff were observed to remove the pillow and positioning device while the resident was observed to call out "Ow!" RN-GG asked the resident if he was having pain and Resident #5 responded "that's a big OW!" Resident #5 was observed to moan throughout the duration of the treatment which lasted approximately 20 minutes; RN-C intermittently stated 'we're almost done'. The staff were observed to replace the positioning devices, RN-GG again asked the resident if he was in pain, the resident did not respond. After both staff left the resident's room, Surveyor # asked LPN-T at 10:10 AM, if she had given the resident something for pain before the resident's pressure ulcer treatment. LPN-T indicated she was on her way to administer some Tylenol to Resident #5, and was not able to get there earlier.

Based on record review and interview the Facility did not ensure there was adequate monitoring and that Resident's were free from unnecessary drugs for 3 (Resident #2, #6, & #7) of 14 sampled Residents. Resident #2's blood pressure and heart rate was not obtained prior to receiving [MEDICATION NAME] Tart. 25 mg per physician order. Resident #6 receives [MEDICATION NAME] 50 mg, an antipsychotic, without adequate monitoring. Resident #7 receives [MEDICATION NAME] ([MEDICATION NAME]), 25 mg. As of 12/8/14, no dose reductions have been attempted. Findings include: 1.) Surveyor # reviewed Resident #2's medical record on 12/2/14 to 12/8/14. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].=12.5 mg) by mouth twice daily [MEDICAL CONDITION](hypertension) (Hold if SBP (systolic blood pressure) < (less than) 100 and HR (heart rate) < 50)." This order is dated 6/26/14. On 12/3/14 at 11:17 a.m. Surveyor # reviewed Resident #2's December 2014 MAR (medication administration record) which documents "[MEDICATION NAME] Tart. 25 mg tablet 6/26/14 Give 1/2 tablet (=12.5 mg) by mouth twice daily [MEDICAL CONDITION](Hold if SBP <100 and HR <50)." Surveyor # noted that this medication is signed as being administered twice a day on 12/1/14 & 12/2/14 and once on 12/3/14. Surveyor # did not note Resident #2's blood pressure or heart rate documented on the December 2014 MAR. On 12/3/14 at 11:23 a.m. Surveyor # asked LPN (Licensed Practical Nurse)-T where Surveyor # would be able to locate vital signs. LPN-T informed Surveyor # that they are in the chart or if they are weekly they would be in the TAR (treatment administration record). Surveyor # asked if vital signs are to be taken before administering a medication where would they be located. LPN-T informed Surveyor # that they may be in the MAR (medication administration record). LPN-T then informed Surveyor # that about a year ago there were about 22 of the 26 Residents who resided on the Deerpath unit who required daily blood pressures so the medical director had them do a three month study of their blood pressures. After the study they no longer had to take some Residents blood pressure daily and these Residents were change to weekly with their shower day. Surveyor # informed LPN-T that Resident #2's physician orders [REDACTED].# is unable to locate vital signs prior to this medication being administrator. LPN-T informed Surveyor # that she didn't have an answer for Surveyor # . On 12/3/14 at 11:31 a.m. Surveyor # reviewed Resident #2's November MAR and noted [MEDICATION NAME] Tart 25 mg is signed as being administered twice a day from 11/1/14 through 11/20/14. Surveyor # did not note Resident #2's blood pressure or heart rate documented on the November 2014 MAR. On 12/3/14 at 2:15 p.m. during the exit conference the Administrator and Director of Nursing were informed of the above. As of the exit on 12/8/14 no information was provided to Surveyor # . 2.) Resident #6 has been receiving [MEDICATION NAME] 50 mg at bedtime since 7-28-14; the resident was admitted to the facility on [DATE] initially prescribed with [MEDICATION NAME] 25 mg in the morning (which discontinued on 7-28-14) in addition the bedtime dose. The resident's clinical record indicates Resident #6 receives the above antipsychotic medication to treat anxiety and agitation. On 12-3-14 at 2:30 PM, Surveyor # interviewed RN-D and SSD-BB about the nature of Resident #6's behavioral symptoms for the use of the medication. SSD-BB indicated the resident has anxious behaviors and agitation with no elaboration on how these symptoms are distressing to the resident or other. On 12--8-14 at 8:15 AM, RN-B presented additional information concerning the resident's symptoms, and stated the medication was being used to treat Resident #6's visual hallucinations of "seeing silhouettes of children". The resident's clinical record contains no documented evidence of the visual hallucinations, it does not indicated the intensity of the resident's anxiety or agitation, and/or whether these symptoms are detrimental to the resident or disruptive to others. 3.) Resident #7 was admitted to the facility in September 13, 2013 with physician orders [REDACTED]. (milligrams) three times a day. In June, 2014, [MEDICATION NAME] (mirtazepine, an antidepressant) 15 mg. a day was added. Federal regulations require staff to attempt a gradual dose reduction (GDR) twice within the first year, in two separate quarters, one month apart. As of 12/8/14, no dose reductions have been attempted. Surveyor # reviewed monthly Pharmacy Medication Regimen Reviews for Resident #7. On 4/3/14, the pharmacist wrote "R/B (risk benefits) taper [MEDICATION NAME]". On 12/1/14, the pharmacist wrote "GDR [MEDICATION NAME] or [MEDICATION NAME]. Seen by (psychiatry) on 11/6/14. No changes made dose (down arrow). Review in 6 months." The typed Pharmacy Consultation report dated 11/6/14 states "try dose reduction in December". Surveyor # reviewed an Initial Evaluation dated 6/2/14 from the psychiatrist. The note indicates Resident #7 has advanced senile dementia and is on [MEDICATION NAME] 25 mg. TID (three times a day). Resident #7 has experienced dysphoria, anhedonia and melancholia with no interests in any activities, including TV, music and any kinds of activities. She appears profoundly depressed..." [MEDICATION NAME] 15 mg. was added to Resident #7's drug regimen. Psychiatry Notes dated 8/11/14 and 11/6/14 both state Resident #7's "agitation, confusion, dysphoria, anhedonia, melancholia, mood lability and anxiety are all under good control...Mood is stable, euthymic and well modulated...Continue active care and treatment plan." Neither follow up note discusses a dose reduction for [MEDICATION NAME], which should have been evaluated for a dose reduction twice, in two separate quarters, before September 13, 2014. Surveyor # reviewed Social Service notes which include acknowledging Resident #7 seen by psychiatrist 8/11/14 and 11/6/14 with no new orders written. None of the Social Service notes from September 2013 to September 2014 discussed dose reduction of the [MEDICATION NAME]. The first mention of a dose reduction is dated 12/1/14 stating "Mind over meds meeting held. Discussed GDR, but psych does not want to decrease behaviors have been stable..." This note does not include justification of why the psychiatrics does not feel a dose reduction is appropriate. On 12/8/14, Surveyor # interviewed Social Service Director (SSD)-BB, who did not have any information regarding why two dose reductions were not attempted between September, 2013 and September 2014. Surveyor # shared this information with Director of Nursing-B, RN consultant-I, and Nursing Home Administrator-A on 12/8/14. No further information was provided.

Based on observation, staff interview and record review, the Facility did not ensure that the Resident environment remained as free of accident hazards as is possible; and each Resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 4 Residents reviewed who were at risk for falls. The Facility did not consistently assess behavior/fall trends and identify root causes for unwanted self-transfers, did not consistently implement new interventions to prevent falls when past interventions had proven ineffective, and did not consistently implement care-planned approaches for preventing falls. Resident #2 has had 13 falls since his admission on 5/14/14. During 6 of the falls, the bed &/or chair alarm was disconnected or not functioning. Staff continued to rely on alarm even though this fall intervention proved to be ineffective because Resident #2 could disconnect them. On 6/14/14 Resident #2 had two falls. Following the 2nd fall Resident #2 complained of pain, and x-rays revealed right rib fractures. Staff did not implemented the care plan intervention of 30 minute checks and Resident #2 was observed transferring himself while staff observed. Staff did not attempt to place a gait belt on Resident #2. Findings include: Surveyor # reviewed Resident #2's medical record on 12/2/14 to 12/4/14. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (minimum data set) signed as complete on 5/27/14 documents that Resident #2 has short and long term memory loss, is severely impaired for cognitive skills for daily decision making, does not ambulate, requires extensive assistance with two plus persons for transfers and toilet use, and is frequently incontinent of bowel & bladder. Resident #2 has fallen in the last 2 to 6 months prior to admission and has fallen twice with no injury since admission. The care delivery guide updated 11/20/14 is checked for assist transfer with one. Under special transfer aids documents "gait belt pivot transfer." Under comments/special needs document "30 minute checks and 1 hour toileting." Fall risk is also checked. The Resident Incident report for incident date of 5/15/14 at 10:30 p.m. documents, "Called to resident room observed resident sitting on floor in doorway of bathroom. Right leg bent on floor and left leg bent with only foot on floor clothes and shoes on holding onto sink with his left hand grabbing the sink. denies hitting head no injuries noted. Had a second fall at 0625 this am attempting to self transfer from wheelchair into bed. Found sitting on floor mat." The Facility obtained witness investigation statements from staff on duty but the statements only address Resident #2 after his fall. There is no information whether Resident #2 was sleeping or awake prior, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. The Facility instituted a new intervention of bed & chair alarm. The Resident Incident report for incident date of 5/17/14 at 8:28 a.m. documents, "Resident was found on the floor next to his bed. Resident was able to hand gesture what had happened. Moved resident to bed, took a set of vitals ad explained to the resident that it is important that he has a nurse or CNA (Certified Nursing Assistant) with him when he wants to transfer. Resident was shown call light and asked if he understood. He shook his head yes. Family was notified and updated on the incident and were informed of the interventions in place to keep their family member safe. MD was notified and no new orders were received." Staff statements indicate that the alarm was not sounding. The Facility obtained witness investigation statements from staff on duty but the statements only address Resident #2 after his fall. There is no information whether Resident #2 was sleeping or awake prior, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. The Facility implemented an intervention of stop sign in room. The Resident Incident report for incident date of 5/21/14 at 9:55 a.m. documents, "residents alarm sounding and cna called for help as resident was on the floor in the bathroom. Resident attempted to self transfer to the toilet resident was holding the arm handles for the riser seat and was under by the sink area. Resident assisted by RN (Registered Nurse) (after her assessment of the resident) and cna up from the floor and into his wheelchair when asked if in pain he stated no along with using profanity." The Facility instituted an intervention of placing a stop sign on the bathroom door to aid resident in asking for help to the toilet. The Facility obtained witness investigation statements from staff on duty but the statements only address Resident #2 after his fall. There is no information what Resident #2 was doing prior, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. The Resident Incident report for incident date of 5/25/14 at 3:50 p.m. documents, "Resident was found on the floor in his bathroom. Chair alarm was turned off. Resident was lying in front of the toilet with his pants down on his right side." The Facility implemented an intervention of 15 minute checks for 48 hours but continued with the alarms and stop sign on bathroom door. The Facility obtained witness investigation statements from staff on duty but the statements only address Resident #2 after his fall. There is no information what Resident #2 was doing prior, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. The Resident Incident report for incident date of 6/4/14 at 7:50 a.m. documents, "Resident found on floor mat next to bed in front of wheelchair." The Facility added an intervention of body pillow but continued with the alarms and stop sign on bathroom door. The Facility's incident report does not address if the alarms were on. The Facility obtained witness investigation statements from staff on duty but the statements only address Resident #2 after his fall. There is no information what Resident #2 was doing prior, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. The Resident Incident report for incident date of 6/8/14 at 4:45 p.m. documents, "Residents alarm was heard. nurse came and told me that resident fell in his bathroom. found resident on the floor in his bathroom. he said he bumped his head on the sink. no injuries noted. range of motion at baseline." The Facility implemented intervention of remind patient to use call light and one to one checks for 24 hours. The Facility also placed a message in the CNA's caretracker which documents, "This resident is on specific fall interventions that require 15 minute checks, and scheduled toileting every two hours. He has had at least 5 falls related to attempting to self transfer to the toilet. There must be monitoring and documentation of assist with toileting interventions. If you are following the careplan and it is not appropriate, please follow up with your nurse supervisor and/or the nursing management team for review. We need to assist with keeping him safe and meeting his needs. If there are any questions and/or concerns please follow up with me." This message was written by the former Director of Nursing who is no longer employed at the Facility. The Facility obtained witness investigation statements from staff on duty but the statements only address Resident #2 after his fall. There is no information what Resident #2 was doing prior, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. The Resident Incident report for incident date of 6/14/14 at 1:30 p.m. documents, "Resident was trying to self transfer to his bed from his wheelchair CNA had toileted him prior to her lunch and ask him if he wanted to lay down he said no also CNA had informed other CNAs she was going to lunch and to keep an eye out for this resident. This resident also constantly turns off his own alarm on the chair even when it is moved out of his reach. MD updated family updated." CNA-KK statement documents, "I was called into Resident #2's room by CNA-JJ. Resident #2 was on the floor and CNA - JJ needed the nurse. He said he was trying to get into bed. CNA-JJ saw him on the floor and called for help. His alarm didn't go off. Nobody heard it. He turned his alarm off." Facility continued with their current interventions even though the intervention of the alarm was ineffective. The Facility obtained witness investigation statements from staff on duty but the statements only address Resident #2 after his fall. There is no information what Resident #2 was doing prior, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. The Resident Incident report for incident date of 6/14/14 at 5:50 p.m. documents, "Res. (Resident) laying on the bathroom floor on his right side next to the toilet, pants down around his knees." Under final outcome documents, "Resident to ER (emergency room ) after fall with c/o (complain of) pain to R (right) shoulder. X-ray performed and showed no sign of fx (fracture) and/or dislocation. resident with care plan changed to not be left in room unattended when up out of bed. resident with follow up assessment and X-ray if no improvement of pain and/or ROM (range of motion)." Staff statements obtain do not indicate if the alarm was on or had been turned off/removed. Also staff statements only address Resident #2 after his fall. Resident #2 continued to complain of pain following his return from the emergency room and obtained X-ray which revealed right rib fracture. The Resident Incident report for incident date of 6/28/14 at 9:30 a.m. documents, "Resident was found on the floor brushing his teeth. No complaints of pain or noted injury. Resident right ear was bleeding from old scab." Also documented is "Resident was combative and aggressive. Resident threw chair and bed alarm at aide." Surveyor # noted that the Facility continued with their current intervention of alarms even though it had been ineffective in the past. No staff statements were provided to Surveyor # . On 6/30/14 the alarms were discontinued for Resident #2. The Resident Incident report for incident date of 7/6/14 at 6:45 a.m. documents, "Resident found on floor in his room on his buttocks, w/c (wheelchair) on its side next to him." The Facility obtained witness investigation statements from staff on duty but the statements only address Resident #2 after his fall. There is no information what Resident #2 was doing prior, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. The Facility implemented an intervention of one to one until 7/22/14 when one to one was changed to day and evening shifts only. The nurses note dated 7/22/14 documents that Resident #2 was found on the floor in his room at 6:45 a.m. Surveyor # was not provided with a Resident Incident report or staff statements for this fall. The Resident Incident report dated 8/11/14 at 11:51 p.m. documents, "Called into resident room to find resident sitting on the bathroom floor." The Facility implemented an intervention of to keep the wheelchair out of the room on nights. There were no staff statements obtained and there is no information whether Resident #2 was sleeping or awake prior, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. The nurses notes dated 9/25/14 documents, "CNA-R reported to writer resident was sitting on floor in his room between bed and w/c. Writer went to room and found resident sitting on floor next to bed, in between bed and w/c. Resident stated he did not hit his head. He did not have any pain or any injuries. Neuro checks negative and VS (vital signs) stable. Neuro checks initiated. MD updated and call placed to family. Initiation of a daily after nap was implemented on care card, staff made aware." There were no staff statements obtained and there is no information who last saw Resident #2, where was Resident #2 prior to the fall, if he had been agitated, when Resident #2 was last toileted, whether he was continent or incontinent. This information is critical to developing appropriate interventions to prevent further falls. On 12/2/14 at 11:51 a.m. Surveyor # observed Resident #2 wheel himself into the bathroom. On 12/2/14 at 12:02 p.m. Surveyor # entered Resident #2's room with CNA-R. Resident #2 was observed sitting on the toilet in the bathroom with his wheelchair in the bathroom. CNA-R informed Surveyor # that Resident #2 likes to do his own thing. CNA-R told Resident #2 to let her know if he wanted help. Surveyor # observed Resident #2 stand up, wiped him, and pull up his product and pants. After pulling up his pants, Resident #2 sat himself in the wheelchair. Surveyor # noted that Resident #2's care delivery guides indicates that Resident #2 should be assisted with transfers with one assist and a gait belt. Surveyor # did not observe CNA-R ask Resident #2 if she could place a gait belt on him and assist him. CNA-R stood in the doorway of the bathroom next to Surveyor # and just watched Resident #2. On 12/3/14 at 9:44 a.m. Surveyor # reviewed the 30 minute checks located in a binder at the nurses station. Surveyor # noted on 12/3/14 the last 30 minute check was completed at 9:00 a.m. On 12/2/14 the 30 minute checks were completed. On 12/1/14 the 30 minute checks were blank from 0630 (6:30 a.m.) to 2200 (10:00 p.m.). On 11/30/14 the 30 minute checks were completed. On 11/29/14 the 30 minute checks were blank from 2400 (12:00 a.m.) to 05:30 (5:30 a.m.) and 1430 (2:30 p.m.) to 2130 (9:30 p.m.). On 11/28/14 the 30 minute checks were blank from 0630 (6:30 a.m.) to 1330 (1:30 p.m.). On 11/27/14 the 30 minute checks were blank from 2400 (12:00 a.m.) to 0530 (5:30 a.m.) and 18:30 (6:30 p.m.) to 2330 (11:30 p.m.). On 11/26/14 the 30 minute checks were blank from 2400 (12:00 a.m.) to 0530 (5:30 a.m.) and 2230 (10:30 p.m.) to 2330 (11:30 p.m.). On 12/4/14 at 4:30 p.m. Surveyor # met with the Director of Nursing and Corporate RN-I regarding Resident #2's falls. Surveyor # asked who Surveyor # should speak to as Surveyor # knew that the Director of Nursing has only been employed at the Facility a couple of months. The Director of Nursing stated that Surveyor # could speak with her and Corporate RN-I. Surveyor # informed the Director of Nursing and Corporate RN-I that the Facility obtained staff statements but the statements only addressed Resident #2 after the falls and not what Resident #2 was doing prior, who saw him, was he agitated, was he awake or sleeping, etc. Also the Facility continued with the intervention of chair/bed alarms which were ineffective as Resident #2 removed and or shut off the alarms. Surveyor # asked for the fifteen minute checks and one to one that were implemented. Surveyor # also informed the Director of Nursing and Corporate RN-I that the care delivery guide documents that Resident #2 should be an assist of one with a gait belt and Surveyor # has an observation of staff watching Resident #2 transfer himself and did not ask about placing a gait belt or assisting him. On 12/8/14 at 7:18 a.m. Surveyor # asked the Director of Nursing for a copy of Resident #2's 30 minute checks for November and December. On 12/8/14 Corporate RN-I provided Surveyor # with a time line of Resident #2's falls. The timeline indicates the root cause for Resident #2's falls is self transfers without using the call light. Surveyor # noted that Corporate RN-I timeline does not include fall on 7/22/14. On 12/8/14 at 1:42 p.m. Surveyor # informed the Director of Nursing that Surveyor # had reviewed the 30 minute checks for December and November and had noted that the 30 minute checks now had the forms completed and inquired about this. The Director of Nursing informed Surveyor # that she spoke with staff and filled out the information but Corporate RN-I told her she couldn't do this. Surveyor # informed the Director of Nursing that there were two forms for 11/24/14 with different information as to where Resident #2 was on each of the forms. On 12/8/14 at 3:36 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. As of the exit on 12/8/14 Surveyor # was not provided with any 15 minute checks or one to one checks.

Based on record review and observations, the facility did not provide the necessary care and services to attain the highest practicable physical well-being for 1 (Resident #5) of 9 sampled residents. Resident #5, who has a history [MEDICAL CONDITION] having been hospitalized in April 2014 [MEDICAL CONDITION] related to a urinary tract infection, has a non-pressure wound on the left thigh that started as a skin tear in April 2014. On 8/14/14, Resident #5 was noted with foul smelling drainage from the left thigh wound. The physician was notified on 8/19/14, and a culture was ordered to be done with the next dressing change on 8/21/14. On 8/21/14, nursing staff could not obtain the culture because the facility did not have the correct culture kit available. The culture was not obtained until 8/24/14, then another 24 hour delay occurred when the laboratory did not pick up the culture tube until 8/25/14. The culture was positive for Proteus mirabilis. Resident #5 was treated with a one-time injection of [MEDICATION NAME] on 8/28/14, 14 days after the foul smelling drainage began. Resident #5 has foul smelling drainage from the left thigh wound as noted on 9/2/14, and no further physician contact has occurred. The facility did not obtain the wound culture when ordered on [DATE], did not notify the physician when the culture was delayed, and did not complete the wound culture until three days later when the wound was noted to have increased foul smelling drainage. Resident #5 has a history [MEDICAL CONDITION] and failure to act upon physician orders [REDACTED].#5 at risk [MEDICAL CONDITION] and its life threatening complications. This resulted in a finding of immediate jeopardy, which began on 8/21/14. The Administrator and Director of Nursing were informed of this finding on 9/4/14 at 11:15am. The immediate jeopardy was removed on 9/4/14, however, the deficient practice continues at a scope and severity level of a D (potential for harm/isolated). The facility continues to educate nursing staff on changes in protocols to ensure availability of culture supplies and appropriate follow-up care for residents with infections. Findings include: Surveyor # reviewed Resident #5's record from 8/28 - 9/4/14. Resident #5 was hospitalized from 4/25-4/28/14. According to the hospital discharge summary dated 4/28/14, Resident #5's discharge [DIAGNOSES REDACTED]. Sepsis occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] has a high death rate of 20% and over 60% for those who develop septic shock. According to the article,[MEDICAL CONDITION] (Blood Infection) and Septic Shock <http://www.webmd.com/a-to-z-guides/sepsis-[MEDICAL CONDITION]-blood-infection>, "Sepsis is a serious medical condition caused by an overwhelming immune response to infection. Chemicals released into the blood to fight infection trigger widespread inflammation. Inflammation may result in organ damage. Blood clotting [MEDICAL CONDITION] reduces blood flow to limbs and internal organs, depriving them of nutrients and oxygen. In severe cases, one or more organs fail. In the worst cases, infection leads to a life-threatening drop in blood pressure, called septic shock. This can quickly lead to the failure of several organs -- lungs, kidneys and liver --causing death. " According to an incident report dated 4/21/14, Resident #5 sustained a 3cm x 2.9cm skin tear on the left posterior thigh on 4/18/14. This area eventually deteriorated and Resident #5 was seen in the Wound Clinic. On 8/6/14, the Wound Clinic Advanced Practice Nurse Prescriber (APNP) noted a decline in the left lateral thigh wound, requiring [MEDICATION NAME]. The recommended treatment for [REDACTED]. On 8/14/14, Resident #5 was noted to have foul smelling drainage from the left thigh wound. RN-K was notified, and the finding was placed on the Physician Call Board. On 8/15/14, documentation indicates Resident #5's dressing was saturated with foul smelling drainage. Resident #5 was placed on the Physician Call Board to request some bloodwork due to increased drainage and foul odor. On 8/17/14, documentation indicates the Nurse Practitioner (NP) was notified about the increased foul smelling drainage, which resulted in an order for [REDACTED]. On 8/19/14, nurse's notes indicate a contact was made with the nurse at the Wound Clinic regarding a decline in the left thigh wound, increased foul odor and increased purulent drainage. A new order was received for a wound culture, and new appointment time. The order indicated the culture could be done with the next dressing change due on 8/21/14. A skin grid form was initiated on 8/19/14, and indicated the left lateral thigh wound was 6.8cm x 3cm x 2.9cm with 30% slough and foul odor. On 8/20/14 at 3:15am, nursing documented a slight odor noted from just standing by Resident #5. On 8/20/14 at 10:00pm, nursing documented the dressing to the left lateral thigh wound was saturated, with slight foul odor. On 8/21/14, nursing documented a dressing change to the left lateral thigh wound. The dressing was saturated, with slight odor detected. Nursing did not obtain a wound culture because the facility did not have the appropriate swab/materials to collect a culture. Lab was contacted and culture supplies ordered. A culture will be obtained when supplies arrive. On 8/22/14 at 4:30am, nursing documented the dressing to the left thigh was saturated, leaking through. A new dressing was applied. On 8/24/14, nursing documented Resident #5 was being monitored for left thigh wound, increased foul odor. Culture was obtained today at 3:30pm. Lab was called for pick up of culture at 4:30pm. On 8/25/14 at 11:30am, nursing documented a 3rd call to lab for pick up of the culture. On 8/25/14 at 2:00pm, nursing faxed another lab order and requisition for the left thigh culture. Lab made arrangements for a STAT (immediate) pick up. Resident #5 was seen again in Wound Clinic on 8/26/14. The left thigh wound was deemed unstageable, measuring 6.6cm x 3.5cm x 2.5cm with 80% slough. Three streaks of nonblanchable [DIAGNOSES REDACTED] (redness) are noted around the edge of the wound. The plan from the Wound Clinic was to wait for the culture results. On 8/28/14, the culture results were obtained and showed Proteus mirabilis. A one-time order for [MEDICATION NAME] was obtained. Nursing documentation indicates the [MEDICATION NAME] ([MEDICATION NAME]) could not be given because there was no [MEDICATION NAME] to mix with the [MEDICATION NAME] as ordered. On 8/29/14, nursing documentation indicates the [MEDICATION NAME] was given late pm on 8/28/14. On 8/31/14, nursing documented that Resident #5 was to be seen in Wound Clinic on 9/10/14. On 9/2/14 at 2:00pm, Surveyor # observed the treatment to Resident #5's left thigh wound. Surveyor # observed that instead of an Allevyn dressing as ordered, Resident #5 had an ABD dressing over the left thigh wound. The ABD was removed by Licensed Practical Nurse (LPN)-M. There was a large amount of malodorous drainage on the dressing. LPN-M cleansed the wound with NS, and measured the wound (6.6cm x 4.0cm x 2.4cm). The wound bed was approximately 50% slough. Documentation on the Skin Grid sheet for 9/2/14, indicates "excessive drainage of purulent foul smelling." Documentation through 9/4/14 at 5:00am, reveals no mention of physician and/or Wound Clinic notification of the "excessive drainage of purulent foul smelling" noted on 9/2/14. The facility's failure to provide necessary wound care and treatment in accordance with the comprehensive assessment when the facility did not assess Resident #5's risk [MEDICAL CONDITION] in the infected wound and did not complete wound cultures in a timely fashion as ordered, created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 9/4/14 when: * An audit of in-house lab supplies was completed on 9/4/14. * The facility Wound nurse or designee will audit supplies on a weekly basis and call the lab immediately if shortage of supply is noted. If a staff nurse recognizes a shortage of supply, they are to notify the ADON immediately. *ACL lab was contacted on 9/3/14, regarding the timeliness of culture pick up and have implemented systemic changes. * Resident #5's primary physician was contacted on 9/4/14 and ordered another wound culture. The Wound Clinic was contacted to provide an update on wound status and to request an earlier than previously scheduled appointment. The Wound Clinic increased the frequency of dressing changes to daily until Resident #4 is seen in clinic on 9/10/14. * Nursing education on culture supply was started on 9/4/14 dayshift with all nurses receiving the education. PM and NOC shift will receive the education on 9/4/14 at the start of their shifts. Nurses not on duty will receive the education prior to their next shift.

Based on observations, record reviews and interviews, the facility did not ensure that residents with pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 3 of 3 sampled residents with pressure ulcers (Residents #4, #5 & #6). * Resident #4 was found with a dark fluid filled blister on the right heel on 6/20/14. The facility did not describe the pressure ulcer accurately with the initial documentation but, instead, documented Resident #4 with an area of black eschar on the right heel. Resident #4's nutritional status was reviewed by the dietician who recommended Prostat 1 ounce twice daily for wound healing. Resident #4 received the Prostat from 6/25-6/30/14. The Prostat was not written on the July or August 2014 Medication Administration Records (MAR's), therefore, Resident #4 did not receive the Prostat after 6/30/14. Certified Nursing Assistant (CNA)-L stated Resident #4 had bilateral lower extremity contractures and would flex his knees causing his heels to be resting on the calf buddy insert on his wheel chair leg rests. There was no evidence the facility attempted to provide additional pressure relief while Resident #4 was up in his wheelchair, after the development of the right heel pressure ulcer. The facility received an order for [REDACTED]. On 6/25/14, the Santyl treatment was discontinued and skin prep was ordered. The facility completed weekly assessments of the right heel. There was little change in the size or appearance of the right heel through the 7/29/14 assessment. On 7/30/14, nurses' note documentation indicates the Nurse Practitioner was notified of Resident #4 experiencing an elevated temperature, confusion and a deep tissue injury to the right foot. There was no assessment or documentation of the exact location, size or appearance of the new pressure ulcer. There is a note written on the physician communication board dated 7/31/14, which indicates a request for skin prep to blisters on the left foot top, sides and plantar surface, and 4th toe. There is no documentation in the clinical record regarding new pressure ulcers to the left foot. On 7/29/14, the dietician documents Resident #4 has experienced a significant weight loss, and recommended an increase in Med Pass from once daily to three times daily. This recommendation was not initiated. On 8/2/14, Resident #4 was observed with a moderate amount of foul, purulent drainage from the right foot. During the evening of 8/2/14, Resident #4 received a skin check with his bath. The right heel had deteriorated, and multiple new pressure areas were identified. The physician was not notified of the new areas until the evening of 8/3/14. On 8/4/14, documentation indicates there were new orders for strict input recording and suggested a family meeting to discuss decreased intake. On 8/5/14, Resident #4 was sent to the hospital after a coffee ground emesis. The Emergency Department (ED) staff determined Resident #4 was septic from an infection to the right heel ulcer, and noted multiple other pressure ulcers to the right and left feet, coccyx and scrotum. During the hospitalization , Resident #4 required an amputation of the lower right leg. The failure to (a) initiate pressure relief interventions for the wheelchair, (b) administer recommended nutritional supplements and protein supplements, and (c) document and provide treatment as recommended by the NPUAP guidelines resulted in a finding of immediate jeopardy, which began on 6/20/14. The Administrator and Director of Nursing were notified of this finding on 9/4/14, at 11:15am. The immediate jeopardy was removed on 9/4/14, however, the deficient practice continues at a scope and severity level of a D (potential for harm that is not immediate jeopardy/isolated), as evidenced by the following two examples and by the fact that the facility is continuing to re-educate nursing staff on pressure ulcer prevention, treatment and documentation. * Resident #5, who has multiple pressure ulcers did not receive the prescribed treatments for pressure ulcers on the left ischium as observed on 9/2/14, and the right lateral foot on 9/2 & 9/3/14. On 9/3/14, Licensed Practical Nurse (LPN)-E did not wash her hands after removing gloves, while treating the wounds on the ischium and right lateral foot. Resident #5 has a pressure ulcer on the left 5th metatarsal that is being treated, but there are no weekly pressure ulcer assessments documented. Measurements obtained on 9/2/13 were incorrectly documented on the Skin Grid sheets. There is no evidence the pressure ulcers have deteriorated. * Resident #6 has a right ischial pressure ulcer. There was no weekly assessment of the pressure ulcer on 8/26/14, and during observations of wound care on 8/28/14, Registered Nurse (RN)-F removed her gloves, but re-gloved without washing her hands after removing the soiled dressing. Findings include: A review of the facility Wound Prevention and Treatment procedure last revised in April 2009, reveals the facility's prevention and treatment protocols are based on best nursing practice including that of the Wound, Ostomy, and Continence Nurses Society (WOCN) and the NPUAP. NPUAP 2009 practice guidelines indicate all skin assessment must be documented. "Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals." NPAUP 2009 practice guidelines indicate debridement should not be initiated on intact skin on ischemic limbs. 1.) Surveyor # reviewed Resident #4's record from 8/28/14 through 9/4/14 as part of a complaint investigation. Resident #4 was admitted in November 2013, with [DIAGNOSES REDACTED]. On 5/9/14, nurses' note documentation indicates Resident #4 had a reddened right hip and his bilateral heels were reddened. The physician was notified and skin prep was ordered for the right hip and bilateral heels. A heels-up cushion was initiated to keep Resident #4's heels elevated while in bed. The heels-up cushion was added to the skin-at-risk care plan. Resident #4 was seen by a podiatrist on 6/10/14. The report indicates Resident #4 has a history of [MEDICAL CONDITION], and was noted to have peeling skin on the plantar surface of the right foot. No ulcerations were noted. On 6/20/14, the nurses' notes indicate a Certified Nursing Assistant (CNA) reported an area of concern on the right inner heel. The area was described as 2.2cm x 2.4cm area of eschar with white macerated skin surrounding the eschar. A call was placed to the physician with an order received to cleanse the ulcer, apply Santyl and cover with an Allevyn dressing. The note indicated the Registered Nurse (RN)-F should look at the pressure ulcer. (RN-F monitors wounds in the facility). When interviewed on 9/2/14 at 10:55am, RN Consultant-J told Surveyor # that the pressure ulcer first noted on 6/20/14 did not present as an area of eschar; rather, it presented as a fluid-filled blister. This had been confirmed by RNs F & K. The initial documentation had been done by a facility Licensed Practical Nurse (LPN). RN Consultant-J concurred that the treatment of [REDACTED]. On 6/25/14, there is a physician's orders [REDACTED]. This treatment continued until 8/3/14. On 6/24/14, Resident #4 was evaluated by Registered Dietician (RD)-G. RD-G indicates Resident #4 has a new open area to the right inner heel and indicates she will start Prostat 1 ounce twice daily for extra protein for wound healing. A review of the MARs (where nurses document the administration of nutritional supplements) for June, July and August 2014 reveals the Prostat 1 ounce twice daily was given to Resident #4 from June 25 through June 30, 2014, but was not transcribed on to the July or August 2014 MAR's. On 9/4/14 at 9:30am, RN Consultant-J told Surveyor # that the Prostat had not been given as ordered for the months of July and August 2014. On 7/15/14, RD-G documents that Resident #4 has had a non-significant weight loss of 4.3% in one month. The note indicates Resident #4 is taking Prostat for 200 calories... with a recommendation to start Med Pass 120cc daily for extra calories. A review of the July 2014, MAR indicated [REDACTED]. On 7/29/14, RD-G documents that Resident #4 has had a significant weight loss of 14 pounds in 1 months or a 6% loss. Intakes were down to 66%. RD-G recommended an increase in Med Pass to 120cc three times daily. The July and August 2014 MARs and physician orders [REDACTED]. (Cross reference F325) A review of the pressure ulcer care plan reveals there were no changes in pressure reduction interventions after the blister was noted on Resident #4's right heel on 6/20/14. On 9/4/14 at 8:30am, RN Consultant-J told Surveyor # that RN-K stated boots were not in use because Resident #4 used his feet to self-propel, and would be unable to self-propel with protective boots in place. This, however, is not corroborated by staff who worked directly with Resident #4. * On 9/4/14 at 9:32am Surveyor # spoke with CNA-D. CNA-D stated she started working in the facility on June 3, 2014. CNA-D stated she was familiar with Resident #4 and stated she had never seen him using his feet to self-propel his wheelchair. * On 9/4/14 at 9:30am, CNA-I told Surveyor # that Resident #4 was not using his feet to self- propel prior to his discharge to hospital in August 2014. * On 9/2/14 at 12:10pm, Surveyor # spoke with Therapy Director-H. Therapy Director-H stated that on 6/24/14, a calf buddy was added to Resident #4's wheelchair leg rests to help with lower extremity positioning. On 9/4/14 at 9:40am, Therapy Director-H told Surveyor # that Resident #4 was using his hands to self-propel his wheelchair. The use of the calf buddy would have impeded the use of his legs for self-propulsion. On 9/2/14 at 2:45pm, CNA-L told Surveyor # that Resident #4 would draw his legs up until his heels or feet rested on the calf buddy. CNA-L stated that with cueing, Resident #4 could straighten his legs a bit. CNA-L stated she tried to use a pillow on the calf buddy for padding. CNA-L stated she had not seen Resident #4 wearing boots. Surveyor # reviewed the weekly pressure ulcer assessments for Resident #4's right inner heel ulcer which revealed: On 6/20/14, unstageable, 2.2cm x 2.4cm, black On 6/24/14, 3.2cm x 2.8cm, eschar center with pink dry skin surrounding On 7/1/14, unstageable, 2cm x 3cm, eschar center with dry peeling sin surrounding. No drainage or odor. On 7/8/14, unstageable, 2.9cm x 3.1cm, eschar center, surrounding skin dry, no drainage, no odor. On 7/15/14, unstageable, 2.8cm x 1.8cm, eschar center, surrounding skin dry, mild serosanguinous drainage, eschar beginning to lift around edges. No odor, no pain. On 7/22/14, unstageable, 3cm x 2.6cm, eschar center, surrounding skin dry. Edges lifting. No drainage. No odor. No pain. On 7/29/14, unstageable, 3cm x 2.6cm, eschar center, edges lifting, surrounding skin dry, mild amount of serosanguinous drainage, mild odor, no pain. On 7/30/14, nursing documents the Advanced Practice Nurse Practitioner (APNP) was notified regarding a Deep Tissue Injury (DTI) to the right foot, elevated temperature and confusion. A Complete Blood Count (CBC), Urinalysis (UA) and Chest X-ray (CXR) were ordered. Blood cultures x2 were also ordered on [DATE]. Of note, there was no Skin Grid sheet initiated for the DTI. Therefore, there is no further description of size or exact location of the DTI on the right foot. The facility provided Surveyor # with a copy of the Physician's "Call Board" form. This is a form that facility nurses use to document concerns that need to be communicated with the physician. There is a column to initial after the physician is notified of the concern. There is an entry on the physician's call board regarding Resident #4, dated 7/31/14. The issue is, "skin prep to blisters left foot top, sides and plantar and 4th toe." A review of nurses' notes and Resident #4's skin grid sheets reveal no documentation of any skin changes to Resident #4's left foot. On 7/31/14, nursing documents that the UA was negative, blood cultures were drawn and awaiting results. Resident #4 was up in his wheelchair most of the dayshift. White Blood Count (WBC) is 11.9. No fever or other signs and symptoms of infection. On 8/2 at 11:00am, Resident #4's niece visited and the nurse discussed the niece's concerns regarding right foot wound, weight loss and pending urine results. On 8/2/14 at 3:00pm, nursing documents, "dressings to right foot done with moderate amount of foul purulent drainage noted to previous dressings." There is no documentation that nurses attempted to contact the physician regarding the change in drainage to right heel on 8/2/14. LPN-E told Surveyor # on 9/3/14 at 1:05pm, that she had attempted to call the physician on 8/2/14, but was unsuccessful. LPN-E stated she told the night shift that the physician needed to be contacted, and when she arrived for work on the afternoon shift of 8/3/14, noted there had been no physician contact. LPN-E stated she called the physician/APNP on 8/3/14 at 5:20pm. There was no mention of the need to contact the physician on the physician call board. Nurses' note documentation on 8/3/14 at 4:00pm, indicates Resident #4 has increased lethargy and confusion. "Hold [MEDICATION NAME] until speak with MD." The Skin Grid sheets for Resident #4 dated 8/2/14 and completed by LPN-E indicate the following. - The right heel is described as having a moderate amount of purulent foul smelling drainage, and was measured at 8cm x 9cm with 80% black and 20% eschar. - The right lateral foot is described as having a DTI, 2.6cm x 3cm, with a scant amount of purulent drainage, and was 50% black, 20% slough and 30% red. - The right medial/top is described as having a DTI, 6cm x 2.5cm, with scant serosanguinous drainage and 60% red, 20% slough and 20% black. On 8/3/14 at 8:10pm, LPN-E documents the following: "MD/APNP updated at 7:20pm regarding new skin areas noted on resident writer found when completing a skin check assessment. Right heel wound: Measuring 8cm length x 9cm width, necrotic, spongy with purulent, foul drainage. New Tx (treatment) order: wash with NS (normal saline), pat dry, skin prep around necrotic area, [MEDICATION NAME] to wound bed, cover with non ad. (adherent dressing), wrap with Kerlix, change every three days. Right lateral foot and right medial wounds measuring 2.6cm x 3cm and 6cm x 2.5cm. respectively. New Tx order: Wash with NS, pat dry, skin prep around necrotic areas, paint necrotic area with [MEDICATION NAME], cover with non ad, wrap with Kerlix, change every day. Right 4th toe: Wash with NS, apply [MEDICATION NAME] to red/necrotic area. Orders faxed to pharmacy, on TX record, completed at 7:30pm." There is no documentation, either in the nurses' notes or on the skin grid sheet, regarding an area on the right 4th toe. The size, specific location and appearance of the right 4th toe is not described in the clinical record. On 8/3/14 at 8:20pm, LPN-E documents that Resident #4 is being monitored for new meds. ([MEDICATION NAME] and [MEDICATION NAME]). Resident has increased confusion, increased lethargy, and having trouble arousing from sleep. Resident #4 needs assistance with eating and drinking which is a change as the resident had previously been independent with food and fluids. Vital signs were stable. The MD/APNP was updated with orders received to hold [MEDICATION NAME] on 8/4 & 8/5/14. Resume [MEDICATION NAME] on 8/4/14. Update MD/APNP on 8/6/14. Turn/reposition and float heels every hour. Resident is to be sent to wound care clinic for foot wounds. Additional physician's orders [REDACTED]. - [MEDICATION NAME] to buttocks/under scrotum twice daily till healed. - Skin prep to left foot blisters (top, sides, plantar and 4th toe). There is no documentation in the clinical record, either in nurses' notes or on skin grid sheets, regarding the condition of Resident #4's buttocks and scrotum necessitating the use of [MEDICATION NAME], or the presence of blisters on the left foot. When interviewed on 9/3/14 at 1:05pm, LPN-E told Surveyor # that the order for skin prep to the left foot areas was obtained because of the note written on the Physician Call Board form on 7/31/14, to request the skin prep. LPN-E stated she noted the request had not been initialed as done, so she obtained the order on 8/3/14. LPN-E stated Resident #4 had a reddened area on his scrotum on 8/3/14. A Shower and Weekly Skin Assessment completed on 8/2/14 noted only new areas on the right foot. On 8/4/14 at 3:45pm, nursing documents Resident #4 has increased lethargy and continues to need assistance eating. On 8/4/14 at 6:00pm, the APNP was updated on lab results; Heme profile, BMP (Basic Metabolic Panel), and blood cultures. Resident #4 was placed on strict input recording. Management is to meet tomorrow to discuss further options for resident and update family on resident's declining state. Drank 50cc for nurse, ate 50% of meal. Resident #4's speech was described as unclear and confusing. Vital signs are stable. On 8/5/14 at 5:30am, night shift documents that Resident #4 was moaning during his sleep. He was awakened and denied having pain. On 8/5/14 at 2:00pm, nursing documents NP was notified of lab results with no new orders. NP suggests hospice or PEG tube. On 8/5/14 at 5:15pm, nursing documents Resident #4 was found with vomited blood on his face, shirt and bed. Resident #4 was moaning but unable to answer questions. BP 92/38, Pulse oximetry 62%, elevated pulse at 106, elevated respirations at 30. Resident #4's skin was cold to touch. Orders were received to send Resident #4 to hospital. 911 called. Surveyor # reviewed Resident #4's hospital record on 9/2/14. The ED physician described Resident #4's right heel as having necrotic, black malodorous ulcer with surrounding [DIAGNOSES REDACTED]. Initial [DIAGNOSES REDACTED]. Multiple pressure areas were noted on both feet, and on Resident #4's coccyx and scrotum. Measurements obtained on 8/5/14 by the ICU RN revealed: - Right outer foot 6cm x 5cm deep purple. - Right outer 2 toes with deep purple coloration. - Right foot plantar surface with 1cm x 0.5cm eschar. - Right heel eschar 5cm x 5.5cm. - Right arch medial/distal with 7.5cm x 2cm deep purple/Stage 2. - Left lateral arch with 3cm x 0.5cm deep purple - Left medial arch with 2cm x 4cm reddened, non-blanchable. - Left heel abrasion 1cm x 1.5cm - Coccyx-Stage 3, 6cm x 5.5cm - Scrotum-Stage 2, 5cm x 2cm Hospital narrative notes indicate that deep tissue injuries bilateral medial and lateral feet are possible due to wheelchair pedals. An orthopedic consultation completed on 8/6/14, concluded the "eschar and ulcer appear to be pressure ulcers and not vascular in nature, however the heel is very hard to get skin coverage over and it is large enough that once debrided healing by secondary intention may not be possible, and aggressive flap surgery is not indicted, amputation may be needed." On 8/8/14, Resident #4 had a [MEDICAL CONDITION] of the right leg. The facility's failure to (a) initiate pressure relief interventions for the wheelchair, (b) administer recommended nutritional supplements and protein supplements, and (c) document and provide treatment as recommended by the NPUAP guidelines resulted in a finding of immediate jeopardy. The facility removed the immediate jeopardy on 9/4/15 when: * On 9/2 & 9/3/14, the facility completed a house sweep of nutritional supplements to verify all recommended supplements are on the included on the MAR's. * A new procedure was initiated in which the dietician will provide the clinical team a list of the residents she has reviewed during her visit. The clinical team will verify during the daily clinical meeting that physician orders [REDACTED]. * Education regarding the change in procedure was provided to the entire clinical management team on 9/3/14. * On 9/3 & 9/4/14, a review was completed to ensure residents at risk for breakdown have appropriate pressure relief devices in place. * If residents are unsuccessful with various measures additional attempts and interventions will be made to relieve pressure from affected areas. * Wound status and interventions will be reviewed weekly at clinical meeting to ensure proper treatment is in place and effective. * Wound education including prevention and interventions began on 9/4/14. All dayshift nurses have received the training. PM and NOC shift nurses will receive education at the start of their shifts on 9/4/14. Nurses not on duty 9/4/14, will receive the education prior to starting their next shift. Although the immediacy of the citation is removed through facility corrective actions taken on 9/3 & 9/4/14, the deficient practice continues at a scope/severity level of potential for harm/isolated related to concerns identified during reviews of the 2 residents with pressure ulcers, who currently reside in the facility. 2.) Surveyor # reviewed Resident #5's record from 8/28 - 9/4/14. Resident #5 was admitted to the facility with pressure ulcers in January 2014. Resident #5 has lower extremity contractures. The most recent Quarterly Minimum Data Set ((MDS) dated [DATE], indicates Resident #5 remains at risk for developing pressure ulcers and has 2 - Stage 3 pressure ulcers. A BRADEN Risk Assessment scale completed 6/2/14 indicates Resident #5 is at moderate risk for skin breakdown. Resident #5's most recent Wound Clinic visit was on 8/26/14, with the following wound treatment orders: Left lateral foot wound: Wash wound with NS (normal saline), pat dry, apply [MEDICATION NAME] AG and Allevyn gentle dressing 3x weekly and PRN (as necessary). Left ischial tuberosity: Wash wound with NS, pat dry, apply [MEDICATION NAME] AG and Allevyn gentle dressing 3x weekly and PRN. Right lateral foot: Wash wound with NS, pat dry, apply Allevyn gentle dressing. Resident #5 had a previous treatment ordered on [DATE], to apply no sting barrier spray to the right 5th metatarsal and left lateral heel after a NS wash, followed by an Allevyn dressing every 3 days. On 8/19/14, Resident #5 received a physician's orders [REDACTED]. On 9/2/14 from 1:30pm until 2:30pm, Surveyor # observed LPN-M complete treatments and measure Resident #5's pressure ulcers. LPN-M removed the Allevyn dressing from the left lateral foot wound. After cleansing with NS, the left lateral foot pressure ulcer was measured at 1.3cm x 1.4cm. The left metatarsal was measured at .5cm x .7cm. Skin prep was applied to the left metatarsal and left heel, then the left lateral foot pressure ulcer was redressed with [MEDICATION NAME] AG and an Allevyn dressing. An Allevyn dressing was not applied to the left heel. LPN-M removed the left ischial dressing. Surveyor # noted there was no [MEDICATION NAME] AG removed with the Allevyn dressing. This wound should have had [MEDICATION NAME] AG in place according to the physician's orders [REDACTED]. After cleansing the the ischial pressure ulcer, LPN-M measured the area as 3.4cm x 3.8cm x 0.7cm. Surveyor # observed the ischial pressure ulcer with two unconnected open areas. One full thickness wound located centrally, and a partial thickness wound located at 10 - 11 'clock. LPN-M applied [MEDICATION NAME] AG and an Allevyn dressing. LPN-M then repositioned Resident #5 to complete treatments on the right foot. Resident #5 had a thick foam dressing taped over the lateral right foot pressure ulcer and the right metatarsal pressure ulcer. LPN-M removed the foam dressing and the [MEDICATION NAME] AG. The right lateral foot pressure ulcer was cleansed with normal saline and measured (1.3cm x 2.5cm). LPN-M applied skin prep to the peri wound area, then applied [MEDICATION NAME] Ag and a small Allevyn dressing. LPN-M cleansed the right metatarsal pressure ulcer, then measured the area (0.8cm x 1.2cm). LPN-M applied skin prep, [MEDICATION NAME] AG and a small Allevyn dressing. There is no current physician's orders [REDACTED]. On 9/3/14 at 8:30am, Surveyor # received a copy of the Skin Grid sheets for Resident #5. There were no Skin Grid Sheets for the pressure ulcers on the right and left 5th metatarsals, even though the areas had been measured on 9/2/14. The left lateral foot pressure ulcer had been present on admission. According to weekly assessments the left lateral foot pressure ulcer, in the past month, has been slowly improving. The right lateral foot pressure ulcer was first noted on 8/19/14. The area had been measured on 8/19/14 at 1.6cm x 1.7cm. The right lateral foot pressure ulcer had been measured in Wound Clinic on 8/26/14 at 2.9cm x 1.8cm x 0.2cm. The measurement documented on the Skin Grid form for the right lateral foot pressure ulcer on 9/2/14, was 0.7cm x 0.5cm. This was a discrepancy when compared to the 1.3cm x 2.5cm measurement told to Surveyor # while the measurements for the right lateral foot pressure ulcer were being taken on 9/2/14. After noting the questionable documentation of Resident #5's left ischial and right lateral foot pressure ulcers, Surveyor # asked if Resident #5's left ischial wound and right lateral foot wound could be reassessed by facility nursing staff with Surveyor # present. On 9/3/14 at 1:30pm, Surveyor # accompanied Assistant Director of Nursing (ADON)-N and LPN-E to reassess Resident #5's left ischial and right lateral foot pressure ulcers. LPN-E removed the Allevyn dressing from the left ischium. There was a small amount of drainage on the dressing. LPN-E removed her gloves, then applied new gloves without washing her hands. The center area of the left ischial pressure ulcer measured 0.6cm x 0.4cm x 0.4cm. The second area located at 10 - 11 o'clock was measured as 1.3cm x 0.8cm. ADON-N measured the areas, removed her gloves, washed her hands and re-gloved. LPN-E washed the left ischial pressure ulcer with NS, removed her gloves and re-gloved without washing her hands. LPN-E applied [MEDICATION NAME] AG and the Allevyn dressing, and removed her gloves. Accurate wound measurements are essential to monitor wound healing or deterioration. The discrepancy between measurements of the left ischial pressure ulcer on 9/2 to 9/3/14, make it impossible to determine how the wound is progressing. LPN-E re-gloved without washing her hands, and removed the [MEDICATION NAME] AG and Allevyn from the right 5 metatarsal pressure ulcer. The area was cleansed with NS, and measured at 0.8cm x 1.6cm. LPN-E applied an Allevyn dressing. LPN-E removed the right lateral foot pressure ulcer dressing, removed her gloves and re-gloved without washing her hands. LPN-E cleansed the right lateral foot pressure ulcer with NS, removed the gloves, then re-gloved without washing her hands. The area was measured as 0.9cm x 2.0cm. (Measurements on 9/2/14 were documented as 0.7cm x 0.5cm) LPN-E applied [MEDICATION NAME] AG to the right lateral foot pressure ulcer then covered it with an Allevyn dressing. There is no order for the use of [REDACTED]. 3.) Surveyor # reviewed Resident #6's record from 8/28 - 9/4/14. Resident #6 is receiving hospice services and has a Stage 3 pressure ulcer on the right ischium. Resident #6 has pressure relief devices and nutritional interventions in place. Resident #6 has a physician's orders [REDACTED]. gauze and apply an Allevyn dressing once daily. On 8/28/14, Surveyor # observed RN-F and RN-O complete the treatment to Resident #6's pressure ulcer. RN-F removed the soiled dressing, removed her gloves, and re-gloved without washing her hands. RN-F cleansed the wound with Dakin's solution, removed her gloves, used hand sanitizer and re-gloved. RN-F then packed the pressure ulcer with a Dakin's solution moistened 2x2 gauze, leaving a tail to facilitate removal with the next dressing change. An Allevyn dressing was applied over the Dakin's packing. RN-E removed her gloves and washed her hands. On 9/3/14, Surveyor # reviewed the pressure ulcer documentation for Resident #6. There were weekly assessments except for the week of 8/26/14. On 8/19/14, the right ischial pressure ulcer measured 1.0cm x 0.8cm x 3.0cm. On 9/2/14, the right ischial pressure ulcer measured 0.9cm x 0.7cm x 2.8cm, showing an improvement since the 8/19/14 measurement. On 9/3/14, RN Consultant-J told Surveyor # that the facility wound nurse was on leave the week of 8/25/14, and Resident #6's hospice nurse who usually measures the area was on vacation the week of 8/25/14; consequently, Resident #6 did not have his right ischial pressure ulcer measured on 8/26/14.

Based on record reviews and interviews, the facility did not ensure that 1 (Resident #4) of 9 sampled residents maintained acceptable parameters of nutritional status, such as body weight, unless the clinical condition demonstrates that this is not possible. Resident #4 experienced a significant weight loss of 14 pounds or 6% in one month. Although Resident #4 was still considered overweight with a Body Mass Index (BMI) of 27.1, Registered Dietician (RD)-G recommended on 7/29/14, to increase Med Pass 120cc from daily to three times daily. This recommendation was not acted upon. Resident #4 was admitted to the hospital on [DATE], where an admission weight revealed he had lost an additional 3 pounds. Findings include: Surveyor # reviewed Resident #4's record on 8/28 - 9/4/14. Resident #4 has resided in the facility since November 2013. His admission weight in November 2013, according to the Nutrition Risk Data Collection and Assessment form, was 266.4 pounds. Resident #4 had experienced non-significant weight losses in the months between November 2013 and July 2014. On 6/24/14, RD-G writes in a nutrition progress note that Resident #4 has developed a pressure ulcer to the right heel and will start ProStat 1 ounce twice daily for extra protein for wound healing. A review of the Medication Administration Records (MAR'S) for June, July and August 2014, reveals Resident #4 received the ProStat 6/25 through 6/30/14, but the ProStat was not transcribed on to the July or August 2014 MAR's, therefore Resident #4 did not receive the ProStat after 6/30/14. Cross reference F314. A Nutrition Progress Note dated 7/15/14, indicates Resident #4's weight had decreased 4.3% in 1 month and 9.3% in 6 months, non-significant. His current weight was 233.3 pounds, and his intake remained good, with 98% of meals/fluids and 100% of snacks consumed. Supplements include ProStat twice daily for 200 calories. RD-G recommends Med Pass 120cc daily for extra calories. There is a physician's orders [REDACTED]. According to the July 2014 MAR, Resident #4 is given Med Pass 120cc daily beginning 7/15/14. On 7/29/14, RD-G documents the following in the Nutrition Progress Notes. Weight down 14 pounds in one months, 6%. Significant weight loss. Current weight is 223 pounds, previous weight was 237.4 pounds. BMI is 27.1 - overweight. Intakes are down to 66% with meals. Resident now assisted with meals. Will increase Med Pass to 120cc three times daily. Also on ProStat twice daily for skin (pressure ulcer) right inner heel, unstageable, increased in size. Continue to encourage intake. Resident accepts ProStat and Med Pass 100% per nursing. A review of the physician's orders [REDACTED]. A review of the July and August MAR's reveals Resident #4 continued to receive Med Pass 120cc daily until discharged to the hospital on [DATE]. According to information contained in Resident #4's hospital record, his admission weight on 8/5/14, was 220 pounds indicating another 3 pound weight loss since the recommendation to increase the Med Pass on 7/29/14. On 9/3/14 at 8:30am, Surveyor # received a written response from the Administrator regarding how dietary recommendations are communicated to nursing. The response indicates: when the dietician has a recommendation she writes a telephone order and flags the chart. Clinical (nursing) then needs to follow up with the recommendation to include obtaining the order and transcribing it. On 9/3/14 at 8:45am, Surveyor # spoke with RD-G regarding her progress note written on 7/29/14, to increase Resident #4's Med Pass from daily to three times daily. RD-G stated she had written the note because she was concerned about Resident #4. RD-G stated she was not sure what happened, that she usually writes the order for the supplement, but could not find evidence in the record that she had written the order to increase the Med Pass to three times daily on 7/29/14.

Based on record review and staff interviews, the facility had not provided or obtained laboratory services to meet the need of 1 (resident #1) of 10 sampled residents. The facility is responsible for the quality and timeliness of the services. Resident #1 had presented with increased confusion, decreased appetite, cloudy urine and [MEDICAL CONDITION] on 1/17/13. An on-call physician ordered a CBC (complete blood count) and a UA (urinalysis) on 1/17/13. The CBC results indicated an increased white blood cell count, indicative of an infectious process. The facility had not obtained and processed a UA as ordered for resident #1. Ultimately, resident #1 required an emergency room evaluation on 1/19/13 and transfer to a hospital ICU (Intensive Care Unit) on 1/20/13 with a primary [DIAGNOSES REDACTED]. Findings include: Resident #1's readmission face sheet dated 1/7/13 indicated the resident had a recent left [MEDICAL CONDITION] due to a previous amputation of the right great toe which was not progressing toward healing. Resident #1 had [DIAGNOSES REDACTED]. Resident #1's readmission MDS (minimum data set) indicated the resident had an indwelling Foley catheter in place and scored a 3 of 15 (the higher the score, the more cognizant) on the cognitive assessment screen. A physician communication form, dated 1/17/13 and located in the resident's medical record indicated that at 5:00 a.m., the facility had contacted resident #1's physician with assessment that the resident had a recorded blood pressure reading of 82/48 and a temperature of 95.7 degrees F (Fahrenheit). The correspondence indicated the resident was "asymptomatic." Resident #1's physician ordered changes in the resident's antihypertensive medications to include discontinuation of [MEDICATION NAME], and hold the [MEDICATION NAME] if systolic blood pressure was less than 110. An additional physician communication form, dated 1/17/13 and located in the resident's medical record indicated that at 4:00 p.m., the facility again contacted an on-call physician indicating,"The resident's family and friends concerned with increased confusion over the past few days, also state saw blood in Foley bag. Currently no blood in urine, however sediment present. Therapy also noted change in behavior noting increased confusion and decreased appetite. Writer noted increased confusion". At 5:40 p.m. on 1/17/13, the physician ordered a CBC and UA to be completed for resident #1. A corresponding nursing entry into the resident's medical record dated 1/17/13 on the p.m. shift (no exact time noted), indicated, "nursing attempted urine collection from change in Foley catheter. Patient did not have enough urine at time. Passed along to night shift. Will attempt." Review of the facility's 24 hour report dated 1/17/13 indicated that resident #1 had presented with increased confusion and decreased appetite. The report indicated "call out to MD to update change of mental status. Requesting UA, CBC". Resident #1's blood pressure reading documented in the medical record on 1/17/13 "a.m." indicated 128/68 and this "a.m." nursing entry indicated that the resident's Foley catheter was patent and draining concentrated urine. Resident #1's medical record did not have documentation that the facility had successfully obtained and sent a UA specimen it to the laboratory for analysis. Resident #1's medical record included a physician communication form, dated 1/18/13 at 3:00 a.m., that indicated the facility had contacted an on- call physician with concerns of resident #1's low blood pressure readings. The resident's documented temperature was 96 degrees F. The on-call physician ordered to monitor resident #1 through the night. Resident #1's medical record did not have documentation informing the on-call physician that a UA had not been obtained. Review of the facility's 24 hour report dated 1/18/13 indicated that resident #1's blood pressure readings obtained were recorded as "60/48 and 62/46. Hold blood pressure meds. Blood pressure still very low and hard to hear." There was no correspondence to indicate a UA had not been obtained from the resident. A CBC results collected from resident #1 and received by the laboratory at 5:57 a.m. on 1/18/13 was faxed to the facility on [DATE] at 12:01 p.m. which indicated a white blood cell count of 17.6. Normal white blood cell count was listed as 4.2 to 11.0. The laboratory form had no indication that the resident's physician had been alerted to the abnormal findings. A previous white blood count which had been processed on 12/29/12 indicated the resident's white blood count was 12.6. There were no nursing entries in the resident's medical record for 1/18/13. A nursing entry in resident #1's medical record dated 1/19/13 "AM" indicated that resident #1's "Foley patent. Urine concentrated." Resident #1's medical record did not include documentation that a UA had been obtained and sent to the lab as ordered by the physician. A nursing entry in resident #1's medical record dated 1/19/13 at 7:00 p.m. indicated, "resident very lethargic. Awakens only to tactile and verbal stimuli. New order received to send to the emergency room for eval." A corresponding physician communication note dated 1/19/13 at 7:00 p.m. indicated the above information in addition to, "no real verbalization. Decreased appetite. Blood pressure 87/67. Temperature 95 degrees F. Lung sounds decreased" was corresponded to an on call physician. Review of the emergency room note for resident #1 dated 1/19/13 indicated, "the resident was a little bit lethargic and slightly hypotensive earlier today and then staff noted low blood pressure as well as low temperature. The patient denies shortness of breath, chest pain, abdominal pain, cough or headache. Feels very weak and feels very thirsty, very dry, just really has not been eating or drinking anything for the last several days. The patient has very dry lips and dry mucous membranes. Elevated white blood count at 24.5. Cardiac monitor did show [MEDICAL CONDITION] with a slow ventricular response. BUN (blood urea nitrogen) 91 (normal 10-20) and creatinine 1.21 up from .9 about 2 weeks ago". Elevated BUN and Creatinine are indicators of kidney injury. "Cardiac enzymes elevated. Urinalysis did show a large amount of leukocyte esterase and a large amount of blood with 20 to 30 white blood cells and 1+ bacteria consistent with urinary infection. Chest X-Ray showed atelectasis and infiltrate. Given that, it appears as though patient has a urinary tract infection and maybe a concurrent pneumonia. He will be treated with [MEDICATION NAME] and [MEDICATION NAME] (all antibiotics). The patient was then started on some [MEDICATION NAME] to help support blood pressure. Likely the patient has a disseminated infection, appears to may have some early forms of SIRS (Systemic [MEDICAL CONDITION] response syndrome) and [MEDICAL CONDITION]. Given these findings, the patient actually will be transferred to Froedtert Hospital for intensive care setting as there are no intensive care beds here. Admitting Diagnoses: [REDACTED]. 2 Urosepsis. 3. Pneumonia. 4. Elevated cardiac enzymes. 5. Leukocytes. 6. [MEDICAL CONDITION]. 7. Hypothermia. The resident was transferred to the alternative hospital's intensive care unit on 1/20/13. SIRS is an [MEDICAL CONDITION] state affecting the whole body, frequently a response of the immune system to infection. It is related [MEDICAL CONDITION], a condition in which individuals both meet criteria for SIRS and have a known or highly suspected infection. Criteria for SIRS were established in 1992 as part of the American College of Chest Physicians/Society Critical Care Medicine Consensus Conference. The conference concluded that the manifestations of SIRS include, but are not limited to: * Body temperature of less than 96.8 degrees F or greater than 100.4 degrees F. *Heart rate greater than 90 beats/minute. *High respiratory rate, with greater than 20 breaths per minute; or, an arterial partial pressure of carbon [MEDICATION NAME] less than 32 mm/Hg ( millimeters/hemoglobin). *White blood cell count less than 4.0 or greater than 12.0; or the presence of greater than 10% immature [DIAGNOSES REDACTED]s. Sepsis induced [MEDICAL CONDITION] is defined as the presence of a systolic blood pressure of less than 90 mm/Hg or a reduction of more than 40 mm/Hg from the baseline in the absence of other causes of [MEDICAL CONDITION]. SIRS can be diagnosed when two or more of these criteria are met. The clinical condition may lead to [MEDICAL CONDITION], electrolyte abnormalities, nosocomial pneumonia, deep vein [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], central nervous system dysfunction, and possible [MEDICAL CONDITION]. The resident's hospital intensive care admission note dated 1/20/13 indicated the resident presented for, "[MEDICAL CONDITION] and hypothermia. Concerning [MEDICAL CONDITION] secondary to urinary tract infection versus wound infection (resident had a sacral ulcer). Resident lethargic but arousable; answering some questions; most likely due to dehydration and hypothermia in setting [MEDICAL CONDITION]. Patient with urinary tract infection and pneumonia. Also worsening sacral ulcer". Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additionally, documentation indicated that resident #1's antihypertensive's were held during hospital stay due [MEDICAL CONDITION]. On 2/20/13 at 9:00 a.m., surveyor # reviewed resident #1's medical record and was unable to locate UA results which had been ordered by a physician on 1/17/13, when the resident had presented with indwelling Foley catheter clinical criteria for UTI On 2/20/13 at 10:40 a.m., LPN (Licensed Practical Nurse)-A verified to surveyor # that resident #1's medical record did not include UA results that had been ordered on [DATE]. LPN-A called the facility's contracted laboratory and they indicated that a UA for resident #1 had not been processed through their facility at any time from 1/17/13 thorough 1/19/13. On 2/20/13 at 3:10 p.m., surveyor # interviewed RN (Registered Nurse)-C. RN-C verified to the surveyor that a UA had not been processed for resident #1 after it had been ordered by the physician on 1/17/13. RN-C stated, "There is no notation in his (#1) record why the UA wasn't done. The 24 hour report that is utilized to communicate issues from shift to shift nurses doesn't say that the staff were unable to obtain the urine sample after 1/17/13 when the catheter was changed on the p.m. shift when there wasn't enough urine at that time to process a specimen."

Based on observation, staff interview and record review, the facility did not ensure 3 (resident #4, resident #2 and resident #3) of 6 residents reviewed for pressure ulcer risk in a total sample of 15 residents received the necessary treatment and services to prevent pressure ulcers from developing. Resident #4 had a history of [REDACTED]. Resident #4's plan of care directed staff to use extreme caution with cares to protect the skin. Although staff used a draw sheet to reposition resident #4 in bed, they allowed her heels to be dragged across the pillow that was used to free float her heels, resulting in friction and shearing to the heels. Resident #2 had history of skin breakdown to the buttock and groin areas. The plan of care for resident #2 included repositioning every two hours, elevate heels off bed and xenadern to the buttocks and groin, twice daily. The plan of care was not consistently implemented. Resident #3 was a very high risk for pressure ulcer development and currently had a stage IV pressure ulcer. The plan of care for resident #3 included repositioning every two hours. The plan of care was not consistently implemented. Findings include: Resources: 1. The Quick Reference Guide entitled, "Pressure Ulcer Prevention" published by the National Pressure Ulcer Advisory Panel in 2009 indicated to ensure that the heels are free of the surface of the bed. Heel protection devices should elevate the heel completely (offload them). 2. The article 11/6/00 "Preventing Heel Breakdown" by Marilyn K. Graff, MSN, RN; Janet Bryant, MSN, RN, CNS, CWOCN; and Nancy Beinlich, RN, BSN, CWOCN indicates "the prevalence of heel pressure ulcers is a major health care problem. Heel ulcers develop as a result of pressure, shear, or friction concentrated on a small area over a bony prominence that lacks subcutaneous tissue. Significant risk factors for development of heel breakdown include immobility, age, mental status, nutrition and chronic illness... It is important for nurses to identify patients at risk for heel pressure ulcers and to initiate appropriate preventative interventions". "Shear, while pressure is the main cause in the formation of pressure ulcers, shear is a major factor in tissue necrosis. Shearing forces occur when the epidermis is pulled in one direction and underlying tissues remain in place. The main consequences of shearing are found in deep tissues attached to the bone, which move with the patient's body while surface tissues stick to the sheets, pausing parallel movement of adjacent tissues (Maklesbust & Sieggreen, 1996). A separation of the dermis and epidermis occurs as evidenced by the development of a large bulla (blister)." "The amount of pressure needed to produce occlusion with resultant ischemia is cut in half when sufficient shearing occurs (Bennett et al., 1979). Shearing cuts off a larger vascular supply than does pressure, making the combination of shear and pressure sufficient to cause the occlusion of blood supply to tissues (Bennett et a1., 1979)." "Friction is a factor in the formation of pressure ulcers as it increases the effects of mechanical forces on the epidermis by removing the outer, protective layer called the stratum corneum (Yarkony, 1994). This mechanical wearing away of surface tissue increases the potential for deeper tissue damage (Makleburst & Sieggreen, 1996) and decreases the amount of pressure needed to develop [MEDICAL CONDITION]". "Heels are exposed to friction when dragged across bed linen during transfers from cart to bed or when being moved up in bed. Friction occurs during frequent movements of an agitated patient or by muscle [DIAGNOSES REDACTED] resulting from recurrent contact between the heels and sheets." 3. Facility procedure for pressure ulcer prevention/treatment indicated: * All residents will be assess on admission and weekly for four weeks, quarterly, and with a significant change of condition using the Braden Risk Assessment... * The following interventions are efforts to stabilize, reduce or remove underlying risk factors: At Risk (15-18) ? frequent turning ? reduce pressure to heel ? manage moisture, nutrition and friction and shear On 8/15/12 at 9:00 a.m. DON-A provided the facility "yellow dot" procedure, revised April 2009. The procedure indicated: *turn and reposition residents every 1-2 hours when in bed/in wheelchair/gerichair. *offer turn and reposition reminders to residents able to do so themselves 1. According to the 8/7/12 face sheet contained within resident #4's medical record, resident #4 was admitted to the facility on [DATE], and readmitted [DATE] following a left [MEDICAL CONDITION] with gangrene to her first toe, status [REDACTED]. According to the resident's [DIAGNOSES REDACTED]. A Braden assessment dated [DATE] indicated resident #4 had a score of 13 which placed her at moderate risk for the development of pressure ulcers. Resident #4's significant change of condition MDS (Minimum Data Set) completed on 5/15/12 indicated resident #4 had moderate cognitive deficits, required extensive assistance from staff for bed mobility, transfers, personal hygiene, toileting, and was always incontinent of bowel and bladder. Resident #4 was identified at risk for the development of pressure ulcers and currently had two stage II pressure ulcers. The 5/15/12 CAA's (Care Area Assessment) indicated resident #4 required extensive assistance with ADL's (activities of daily living), was alert and able to make needs known, and had pressure ulcers to bilateral heels. A Podiatry consult dated 6/19/12 indicated resident #4 had a weak right and left dorsal pedis pulse of 1 out of a scale of 1 to 4, with 4 being the best. Resident #4's right and left posterior tibial pulse was absent. In addition, resident #4 had non[MEDICAL CONDITION] bilaterally, absence of hair growth bilaterally, and increased distal cooling bilaterally. Resident #4's skin color was cyanotic, the temperature was cool and her skin texture was atrophic and thin. According to the 7/17/12 Hyperbaric Oxygen Consultation while at the Select Specialty Hospital, resident #4's left foot was inspected which showed at the medial aspect she had evidence of a healing incision which was dry, however, at the most distal aspect, there was a triangle of black eschar which was also dry and had very minimal bloody drainage on the gauze. There was no active bleeding or drainage seen. The dorsalis pedis and posterior tibial pulse was very faint. Resident #4 had left lower extremity angioplasty with superficial femoral artery stent placement done on 7/3/12. The 8/3/12 admission skin assessment indicated that resident #4 was readmitted s/p (status [REDACTED]. This assessment also indicated resident #4 had a stage 2 pressure ulcer measuring 0.3 cm (centimeters) X 0.4 cm to her left heel, and her right heel was discolored. Although the Hyperbaric Oxygen Consultation on 7/17/12 indicated resident #4 had a triangle of eschar at the most distal aspect of her left heel, the documented 8/3/12 measurements and description of resident #4's pressure ulcer to her left heel were the most current and only documentation until 8/14/12. Resident #4's 8/3/12 Braden score was 14, indicating she was at moderate risk for the development of pressure ulcers. An additional Braden assessment was not completed on 8/9/12 per the Facility's procedure for pressure ulcer prevention/treatment. Nursing notes were reviewed by surveyor # from 8/3/12 to 8/10/12 and they did not include documentation of resident #4's stage 2 pressure ulcer to her left heel. Resident #4's Skin Integrity Assessment: Prevention and Treatment Plan of Care dated 8/6/12 indicated resident #4 was at risk related to generalized weakness, end stage/chronic [MEDICAL CONDITIONS], diabetes mellitus, [MEDICAL CONDITION], bowel and bladder incontinence, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Resident #4's plan of care interventions included the following: ~ complete a Braden Scale on admission and every week for the first four weeks, quarterly, and with change of condition ~ use a lift sheet to move resident #4, lift - do not slide the resident, protect elbows and heels if being exposed to friction ~ inspect skin for s/s (signs and symptoms) of breakdown ~ position calves on pillows to elevate heels off of the bed. A skin grid-pressure/[MEDICAL CONDITION] ulcer/other form was initiated on 8/14/12, which indicated resident #4's pressure ulcer to her left heel on admission measurements were 0.3 cm X 0.4 cm X (less than) 0.2 cm. Resident #4's Braden assessment indicated a score of 14 - moderate risk for the development of pressure ulcers. On 8/14/12, resident #4's pressure ulcer to her left heel measurements were 4.5 cm X 3.5 cm, without depth or drainage. Resident #4's pressure ulcer to her left heel was assessed as unstagable and was described as black eschar, red, and pink. The nurse's note dated 8/14/12 at 11:30 a.m. indicated resident #4's wounds were assessed by a certified wound nurse and an unstagable pressure ulcer to the resident's left heel was documented. On 8/3/12 the facility completed a PUSH (Pressure Ulcer Scale for Healing, created by the National Pressure Ulcer Advisory Panel) Score of resident #4's left heel pressure ulcer. This initial PUSH score which was 3. On 8/14/12 the facility completed a second PUSH score of resident #4's left heel pressure ulcer, which score was 11, indicating that the pressure ulcer had worsened. The PUSH score of 11 was related to the large increase in length and width of resident #4's pressure ulcer on her left heel. The PUSH scores are used to graph the healing progress of a pressure ulcer. On 8/14/12 at 7:50 a.m. surveyor # interviewed LPN (Licensed Practical Nurse)-H regarding resident #4 and LPN-H indicated that the resident was on bedrest and didn't usually get up until lunch time. On 8/14/12 at 8:26 a.m. surveyor # observed resident #4 lying in bed with a pillow under her calves and her heels were directly in contact with the end of the pillow, not free floating as per her plan of care. Surveyor # interviewed resident #4 regarding if she could move her legs. Resident #4 told surveyor # that she could wiggle her feet a little bit. At 9:36 a.m. resident #4's heels remained directly in contact with the end of her pillow. On 8/14/12 at 9:39 a.m. surveyor # interviewed LPN-H and asked LPN-H to observe resident #4's heels. LPN-H and surveyor # observed resident #4's right heel to be in full contact with the end of the pillow, which was verified by LPN-H. Resident #4 had moved her left heel approximately 1 to 1 1/2 inches so that her left heel was at the edge of the pillow, and with the downward slope of the mattress, her left heel was free floating at that time. Surveyor # reviewed the observations of resident #4 from 8:26 a.m. to 9:36 a.m. with LPN-H. LPN-H verified that when resident #4 is in bed, her heels should be free floating at all times. At 9:47 a.m. LPN-H and surveyor # observed resident #4's right heel which was intact and blanchable. Surveyor # was unable to observe resident #4's left heel at that time as her left heel was wrapped. At 9:48 a.m. surveyor # observed LPN-H and CNA (Certified Nursing Assistant)-W boosted resident #4 up in bed using a lift sheet. During this observation, both of resident #4's heels were dragged along the width of the pillow, approximately 1 1/2 feet. At 9:52 a.m., LPN-H explained to surveyor # that the skin on resident #4's left heel was much thinner than the skin on her right heel and stated that resident #4's heels have to be free floating or they're going to open. On 8/15/12 at 10:50 a.m. surveyor # observed LPN-Y complete resident #4's treatment to her great left toe and left heel with [MEDICATION NAME]. Before completing resident #4's treatment, LPN-Y verified that resident #4's right heel was not free floating and in full contact with the mattress. LPN-Y showed surveyor # resident #4's left heel and it was noted that there was a large area of eschar with a surrounding area approximately the size of a dime of pink skin. When LPN-Y applied the [MEDICATION NAME] this area, resident #4 told the nurse it was painful, "felt like it is being mashed." At 11:05 a.m. RN (Registered Nurse)-X entered the room and at 11:08 a.m. assisted LPN-Y to boost resident #4 up in bed using a lift sheet, dragging her heels approximately 1 1/2 to 2 feet along the width of the pillow that was used to free float her heels. At 11:12 a.m. RN-X verified to surveyor # that resident #4's heels should not have been dragged across the pillow while boosting her up in bed. RN-X stated that three staff should have assisted resident #4 to ensure that her heels were not dragged. On 8/16/12 at 8:02 a.m. surveyor # interviewed CNA-V regarding resident #4 and CNA-V verified that she consistently took care of resident #4 and was very familiar with her. When asked by surveyor # if resident #4 could move her legs in bed, CNA-V indicated resident #4 was not able to move her legs as much as before, and that she complained of pain when moving her feet. CNA-V stated that resident #4 never refused free floating her heels and that resident #4 probably would have a very hard time moving her feet off of the pillow. On 8/16/12 at 8:07 a.m. surveyor # interviewed RN-X regarding resident #4. RN-X stated that resident #4's plan of care was updated to include resident #4 wearing blue boots that would provide complete pressure relief to both heels at all times. On 8/16/12 at 11:27 a.m. surveyor # interviewed DON (Director of Nursing)-A regarding resident #4. DON-A indicated that resident #4 was admitted with the blue boots from the hospital and probably should have been wearing them at all times since day one. DON-A stated she was not sure if resident #4's admission skin assessment was accurate because of the documentation included on the 7/17/12 consult while at the Specialty Hospital that indicated resident #4 had a triangular area of eschar to her left heel. DON-A stated that documentation in resident #4's medical record indicated that the pressure ulcer to resident #4's left heel went from a very small stage 2 to a 4.5 cm X 3.5 cm unstagable pressure ulcer in ten days. DON-A stated that the CNA's should have reported to the nurse's that if they observed resident #4's heels were not free floating when she was in bed so that they could reassess resident #4 and revise her plan of care if needed. 2. On 8/13/12 surveyor # reviewed the medical record for resident #2. The current, undated, face sheet, contained in the medical record, indicated resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 6/10/12 MDS indicated resident #2 was alert and oriented, understands and is understood, required total staff assistance for all ADL's, was incontinent of bowel, had a suprapubic catheter, [MEDICAL CONDITION] and [MEDICAL CONDITION] tube. Surveyor # observed that resident #2 communicated by nodding "yes or no" but could speak when the [MEDICAL CONDITION] was capped. The 6/18/12 Braden assessment indicated resident #2 was a high risk for skin breakdown. The 3/6/12 admission skin assessment indicated resident #2 had reddened buttocks. The skin integrity plan of care for resident #2 indicated on 7/11/12 redness to groin and buttock and on 8/10/12 right buttock excoriation. The 7/11/12 physician orders [REDACTED]. The 8/10/12 physician orders [REDACTED]. The skin integrity prevention and treatment plan of care, reviewed 6/12, indicated resident #2 was high risk, increase frequency of turning, supplement with small shifts, protect heels, manage moisture, nutrition, friction and shear. The 8/11/12 CNA care card indicated resident #2 was to be checked, changed and repositioned every two hours, heels off bed and was on the "yellow dot" program. On 8/13/12 surveyor # interviewed FM (family member)-J and FM-K. FM-J and FM-K indicated resident #2 had fragile skin and they were concerned about skin breakdown. FM-J and FM-K indicated resident #2 was not repositioned on a regular basis. On 8/14/12 at 2:30 p.m. LPN-G indicated "I did not get the opportunity to do resident #2 treatment today. They got him up this morning before I had the opportunity to do the treatment. He wasn't laid down after that". The 8/14/12 MAR (medication administration record) indicated the a.m. [MEDICATION NAME] treatment for [REDACTED]. On 8/14/12 3:00 p.m. surveyor # interviewed resident #2. The resident indicated he felt he did not receive enough assistance from staff and that he was concerned about skin breakdown because he remained sitting in the wheel chair all day without repositioning. On that day, resident #2 indicated he had been sitting in the wheel chair since 10:30 that morning. On 8/14/12 at 3:30 p.m. surveyor # interviewed LPN-B. LPN-B indicated resident #2 was reliable and would be accurate if he said he had not been repositioned. On 8/14/12 at 3:45 p.m. surveyor # observed CNA-C and CNA-D provide care for resident #2. After staff transferred resident #2 into bed, surveyor # observed the resident #2's skin and noted the buttocks and groin to be very red with skin indentations from the cushion of the wheel chair. Surveyor # interviewed CNA-C about the observation. CNA-C indicated the condition of resident #2's skin was probably due to sitting too long and that yesterday the redness was worse. CNA-C went on to say if the redness gets too bad, we tell the nurse and she puts cream on it. When care had been completed, CNA-C and CNA-D placed resident #2 in a sitting position. Resident #2's heels were in direct contact with the mattress. Staff did not ask resident #2 about free-floating his heels. On 8/15/12 at 7:30 a.m. surveyor # interviewed LPN-E. LPN-E indicated resident #2 was not able to reposition himself but would allow staff to reposition him by adjusting him in the wheel chair. On 8/15/12 at 10:10 a.m. surveyor # observed resident #2 sitting in the wheel chair. At various times throughout the day on 8/15/12, surveyor # observed resident #2 sitting in the wheel chair, in the same position. At 4:00 p.m. staff placed resident #2 in bed. Resident #2 told surveyor # he had not been repositioned that day and had remained in the same position in the wheel chair for five hours. 3. On 8/14/12 surveyor # reviewed the medical record for resident #3. The 5/12/12 face sheet indicated resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/14/11 hospital discharge summary indicated resident #3 had recurrent urinary tract infections. The 4/22/12 MDS indicated resident #3 was alert, oriented and was her own person. The MDS also indicated resident #3 did not ambulate, required extensive staff assistance for all ADL's, had a Foley catheter and a [MEDICAL CONDITION]. The 8/7/12 skin grid indicated resident #3 had a 8.0 cm by 6.7 cm by 2.3 cm pressure ulcer with tunneling. The 8/12/12 plan of care for skin integrity indicated resident #3 was a very high risk for pressure ulcer development. The plan of care indicated resident #3 was on the "yellow dot" program and was to be reminded to repositioned side to side. The plan of care indicated resident #3 would refuse repositioning "from time to time". On 8/15/12 at 11:30 a.m. surveyor # interviewed resident #3. Resident #3 was in bed, lying on the right side in a fetal position and watching television. Resident #3 indicated her preference was to spend the majority of time in bed. Resident #3 indicated her willingness to turn and reposition was dependent on her activity at the time and whether or not her personal items would be within reach. Resident #3 indicated staff rarely offered to reposition her except for meals, then, she is placed back on the right side. On 8/16/12 at 9:15 a.m. surveyor # interviewed CNA-L regarding resident #3's repositioning. CNA-L indicated she was aware that resident #3's plan of care included repositioning, but did not know why resident #3 was not repositioned or reminded to reposition self. CNA-L went on to say "I guess it's because she is contracted".

Based on medical record review, review of the facility's policies and procedures regarding nutritional status and staff interview, the facility did not ensure that 1 of 6 residents reviewed for weight loss maintained acceptable parameters of nutritional status. Resident #6 experienced a significant weight loss of 23.1 pounds between June and August 2010. The facility dietitian did not re-assess Resident #6's weight loss until 08/12/10 at which time, the RD-A recommended Resident #6's tube feeding be changed to [MEDICATION NAME] to 1.2, for extra calories. The physician order [REDACTED]. Findings include: Surveyor # reviewed Resident #6's medical record on 09/13-09/16/10. Resident #6 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Resident #6 receives all nutrition by [DEVICE]. Resident #6 is currently receiving hospice services due to a declining condition and chronic pain. Review of a quarterly Minimum Data Set Assessment (MDS), with a reference date of 06/03/10, indicates that at the time of this assessment Resident #6's body weight was 157 pounds. An annual MDS, with a reference date of 08/28/10, indicates Resident #6's body weight is 142 pounds indicating a 15 pound weight loss from the previous MDS. Review of a Dietary progress note completed by Registered Dietitian-(RD)-A, dated 08/12/10, indicated Resident #6 weighed 156.6 pounds when weighed on 05/10/10, 144 pounds on 07/10/10, 134.6 pounds on 08/03/10 and had increased to 141.1 pounds when weighed on 08/12/10. On 08/12/10, RD-A recommended Resident #6's [DEVICE] feeding be changed to [MEDICATION NAME] 1.2 to provide extra calories to encourage weight gain. On 08/13/10 the physician increased Resident #6's tube feeding to [MEDICATION NAME] per RD-A's recommendation from 8/12/10. Review of the facility's Procedure-Nutritional Status effective April 2010, bullet point #9 indicates, "Report verified weight loss/gain of 3% or greater to the Dietitian." On 09/15/10 at approximately 8:40 a.m., Surveyor # spoke with RD-A. RD-A indicated she reviews residents' weights during the first week of each month. RD-A indicated when she reviewed residents' weights for the month of July 2010, Resident #6's weight was not available as direct care staff weighed Resident #6 after RD-A had completed her monthly weight reviews. RD-A indicated she became aware of Resident #6's 07/10/10 (144 pounds), weight around the middle of July 2010, and requested Resident #6 be reweighed. A routine weight was obtained on 08/3/10 indicating Resident #6's weight was 134.6 pounds. The RD-A was not made aware of the 8/3/10 weight loss until 8/12/10, when RD-A made her monthly weight reviews. On 8/12/10, when RD-A became aware of the 08/3/10 weight loss, RD-A requested a reweigh. The reweigh on 08/12/10 indicated Resident #6's weight on 08/12/10 was 141.1. On 09/16/10 at approximately 10:00 a.m., The Director of Nursing (DON), was asked whether the facility had a policy and procedure for obtaining reweighs of residents after the dietitian recommends it, as there was a delay in reweighing Resident #6. The DON indicated the facility did not have a policy on the timeliness of reweighing residents but that her expectation would be the reweigh would occur the following day. When Resident #6 was weighed on 07/10/10 with a weight loss of 13.7 pounds, RD-A was not made aware of this weight loss until the middle of July 2010. There was no reweigh noted for the middle of July 2010, as requested by RD-A. The RD-A did not reassess Resident #6's 07/10/10 weight loss until 08/12/10. Resident #6 was weighed on 08/3/10 at 134.6 pounds (an additional 9.4 pound weight loss or a total of 23.1 pound weight loss since 06/3/10) and RD-A was not notified of the 08/3/10 weight loss until 08/12/10, at which time the RD-A reassessed Resident #6.