Every finding on record at Mercy Health Services

Based on observation and interviews, the facility did not store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect 40 of 43 residents residing in the facility that receive meals served from the kitchen.Multiple food items stored in the kitchen cooler and freezer were open, not covered, not dated and/or were expired and fruit and vegetables were moldy.Findings include:The facility policy titled Food Storage: Cold Foods revised 2/2023 documents (in part) . All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food Drug Administration) food code.5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.On 8/11/26 at 8:20 AM, Surveyor observed the kitchen cooler and freezer. Inside the cooler, Surveyor observed the following: On the right-side middle shelf was an open box containing 8 cucumbers and an open box containing 7 oranges, all of which had mold on them, a box containing 1 bag of shredded cheese that was open, not covered and not dated when opened and 2 meatballs wrapped in aluminum foil that was not dated. On the right-side top shelf was a gallon of mayonnaise 3/4 full with a best by date of 7/17/26 (expired), a gallon of honey mustard 1/4 full with a use by date of 7/25 (expired), and a gallon of barbeque sauce 1/2 full that was not dated when opened.On the left-side top shelf were two white 5-pound plastic containers labeled chicken salad, dated opened 7/30 and a use by date of 8/6 (both expired). The tops of both containers were wet and slimy. On the middle shelf was a metal tub of sliced turkey only half covered with saran wrap, a box of hot dogs in an open bag/not covered dated open 7/29. Surveyor noted the shelves were wet and dirty.Inside the freezer, Surveyor observed 2 small birthday cakes in aluminum tins with a plastic cover that were not dated, an open bag of peas not covered or dated when opened and a box containing an open bag of [NAME] fish fillets that were not covered or dated when opened. On 8/11/26 11:39 AM, Surveyor asked Kitchen Manager-T to accompany Surveyor to the cooler and freezer. Surveyor told Kitchen Manager-T of the above observations and noted the following items had been removed: Moldy cucumbers and oranges, open shredded cheese, meatballs in foil, two 5-pound plastic containers of expired chicken salad, open peas and fish filets. Surveyor showed Kitchen Manager-T the expired honey mustard and mayonnaise and barbeque sauce that was not dated, the hot dogs not covered or dated, and the birthday cakes not dated. Kitchen Manager-T told Surveyor she did not know who removed the other previously observed items. Surveyor asked who is responsible for dating items and knowing how long they are good for once opened. Surveyor was told the cooks, or kitchen aides should be covering and dating everything when it's opened. Surveyor showed Kitchen Manager-T the shelving in the cooler that was wet and dirty and asked who is responsible for cleaning. Surveyor was told the cook or kitchen aide, or whoever notices it's dirty can wipe it down.On 8/13/26 at 9:10 AM, Surveyor told Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, [NAME] President of Success (VPS)-C and Registered Nurse Consultant (RN)-D of each above observation in the cooler and freezer and concern regarding food storage. No additional information was provided.

Based on observation and interview, the facility did not maintain an effective pest control program to address flies and fruit flies in the facility. This has the potential to affect all 43 of 43 residents residing in the facility at the time of the survey.*Surveyors observed fruit flies and flies in the resident unit hallways, the common dining room for residents, the kitchen, and the conference room.*Resident counsel residents shared concerns regarding flies and fruit flies in the facility.Findings include:During the Survey from 8/11/2026 - 8/17/2026, Surveyors noted flies and fruit flies flying in the hallways throughout the facility. On 8/11/2026, at 10:30 AM, Surveyor observed a Certified Nursing Assistant (CNA) assisting a resident in the hallway. The CNA waved a hand in front of their face and stated, These darn flies the resident then responded, Tell me about it.On 8/11/2026, at 12:01 PM, A Surveyor noted a fly flying around the dining room.On 8/11/2026, at 12:10 PM, Surveyor noted two flies flying around the entrance way of the dining room. On 08/11/2026, 1:49 PM, A Surveyor noted a large garbage can next to dishwashing station with food scraps from meals, Surveyor noted many fruit flies in the area of garbage can/dishwashing area.On 8/12/2026, at 3:08PM, Surveyors noted fruit flies flying around the conference room.On 8/13/2026, at 8:42 AM, Surveyor noted two moths flying around the nurse's station.On 8/13/2026, at 9:42 AM, Surveyors noted fruit flies flying around the conference room.On 8/13/2026, at 9:46 AM, Surveyor interviewed Maintenance-DD who stated they are the Maintenance Director at a sister facility and is only in the building today to help out because Maintenance Director-G is on vacation. Surveyor asked what Maintenance-DD assists with while covering the facility for Maintenance Director-G. Maintenance-DD stated they are only doing the things that need to get done/ fixed. Surveyor asked if anything being completed is routine. Maintenance-DD stated no, they are only doing what needs to be fixed. Surveyor asked if there have been concerns brought to their attention regarding flies in the facility. Maintenance-DD stated no, but they did note some flying around and was not sure if this was a common occurrence for the facility or not. Maintenance-DD stated the pest control company was at the facility last week but was not sure what all was completed.On 8/17/2026, at 11:24 AM, Surveyor interviewed Maintenance Director-G who stated they have been on vacation the last two weeks. Surveyor asked if there has been concerns brought up regarding flies in the facility. Maintenance Director-G stated not to their knowledge, has had some concerns in the past regarding flies in the facility. Maintenance Director-G stated they pour a biofilm liquid in the sinks and drains in the facility once a week to help prevent the flies and fruit flies from getting in the facility and it has helped. Maintenance Director-G stated the biofilm liquid pouring down sinks and drains were not completed while they were gone on vacation for the last two weeks, so it is possible flies and fruit flies increased during that time. Surveyor asked when pest control comes out and what is completed. Maintenance Director-G stated the pest control company is the one that gave them the biofilm liquid to use and they have not had any concerns since. On 8/17/2026, Surveyor received and reviewed the last service report from the facility pest control company that was dated 6/8/2026. Maintenance Director-G could not locate the service report for July. Surveyor shared concerns regarding flies and fruit flies in the facility and resident counsel concerns. RESIDENT COUNSEL CONCERNS:On 8/12/2026, at 11:08 AM, Surveyor conducted the Resident Council group interview. R3, R5, R15, R16, and R27 were in attendance and R3, R5, R15, R16, and R27 all actively participated. Surveyor asked R3, R5, R15, R16, and R27 about the facility environment. All Residents (R3, R5, R15, R16, and R27) agreed that there were flies, gnats, and fruit flies everywhere. R3 stated there are horse flies in the facility and they bite. R3 stated, the flies bug the hell out of you. All Residents (R3, R5, R15, R16, and R27) agreed the flies were in the dining room, and individual rooms and were very annoying.R3's Quarterly Minimum Data Set (MDS) assessment, dated 7/16/26, indicated that R3's Brief Interview for Mental Status (BIMS) score was 14, which indicated R3 did not have cognitive concerns. R5's Quarterly Minimum Data Set (MDS) assessment, dated 7/6/26, indicated that R5's Brief Interview for Mental Status (BIMS) score was 13, which indicated R5 did not have cognitive concerns.R15's admission Minimum Data Set (MDS) assessment, dated 6/18/26, indicated that R15's Brief Interview for Mental Status (BIMS) score was 15, which indicated R15 did not have cognitive concerns.R16's Quarterly Minimum Data Set (MDS) assessment, dated 5/26/26, indicated that R16's Brief Interview for Mental Status (BIMS) score was 14, which indicated R16 did not have cognitive concerns.R27's Quarterly Minimum Data Set (MDS) assessment, dated 5/29/26, indicated that R27's Brief Interview for Mental Status (BIMS) score was 9, which indicated R27 demonstrated moderately impaired skills for decision making.On 8/17/2026, Surveyor shared concerns with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, [NAME] President of Success (VPS)-C, and Registered Nurse Consultant (RNC)-D of Surveyors observations and resident counsel concerns of flies and fruit flies throughout the facility. Surveyor shared concern there was not a replacement put in place to continue pouring the biofilm down the sinks and drains to prevent flies and fruit flies during the time Maintenance Director-G was on vacation the last two weeks. VPS-C stated they did note some flies around the facility. NHA-A understood the concerns and was not aware the biofilm drain liquid was not being completed.

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 2 (R13 and R42) of 6 residents reviewed and 2 of 3 medication carts observed. *R13 had falls on 2/23/2026, 3/29/2026, 4/28/2026, and 7/23/2026. R13's fall investigations did not include staff statements for thorough investigations for R13's falls. *R42 did not have smoking or elopement assessments completed on admission. R42 started to have exit seeking behaviors and got a wander guard applied. R42 did not have a smoking or wandering care plan or interventions initiated for supervised smoking or to check wander guard. *Observations were made of medication carts being unlocked while unattended and medications left on top of the medication cart while unattended. This had the potential to affect all residents passing by those medication carts. Findings include: The facility policy titled NSG (Nursing) Accidents and Supervision last reviewed/revised on 7/14/2022 documents: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes:1. Identifying hazards and risks.2. Evaluating and analyzing hazards and risks.3. Implementing interventions to reduce hazards and risks.4. Monitoring for effectiveness and modifying interventions when necessary.Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents.1. Identification of Hazards and Risks- The process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident.a. All staff . are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident.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.a. Analysis may include . considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc.b. Both the facility0centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk,c. Evaluations also look at trends such as time of day, location, etc 3. Implementation of Interventions- Using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: .d. Documenting interventions .e. Ensuring the interventions are put into action.f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practices.g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully.i. Resident-directed approaches may include:i. Implementing specific interventions as part of the plan of care.4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks.5. Supervision- . interventions and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. 1.) R13 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia with behavioral disturbance, metabolic encephalopathy, history of repeated falls, muscle wasting and atrophy, type 2 diabetes mellitus, insomnia, anxiety, . and depressive disorder. R13's quarterly Minimum Data Set (MDS) dated [DATE] indicated R13 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4 and the facility assessed R13 needing maximal assistance with 1 staff member for toileting/ personal hygiene, and repositioning. R13 is frequently incontinent of bowel and bladder and wears a protective brief and transfer with assist of 1 staff member using a gait belt and pivoting. R13 was assessed on 7/13/2025 to be a low risk for falls with a fall risk score of 7.0. R13's care plan for at risk for falls due to history of falls, pain, confusion, incontinence, use of psychotropic medications, weakness, vascular dementia with behavioral disturbances, and anemia care plan was initiated on 7/13/2023 with the following interventions and revisions:- Fall Risk.- Have commonly used articles within easy reach.- Reinforce wheelchair safety as needed such as locking brakes.- Anti rollbacks on wheelchair (11/28/2023)- Transfer status changed to assist of 1 staff member (10/22/2024)- Reinforce need to call for assistance (1/11/2024)- Keep (R13) in a room close to the nurse's station (1/12/2024)- Therapy to screen for benefits related to fall and weakness (7/14/2024)- Therapy evaluation and treatment as ordered- Offer and assist (R13) to bathroom during shift and prior to retiring for the evening (7/15/2024)- Anti rollbacks fixed (7/15/2025)- Reinforce wheelchair safety education, ensure brakes are engaged prior to attempting to stand (2/25/2026)- Provide assist to transfer and ambulate as needed (3/13/2026)- Reorient to surroundings, provide verbal reminders to ask for assistance as needed (3/29/2026)- Assist (R13) with calling family member when increased anxiety is observed to help calm resident and provide reassurance (4/11/2026)- Pharmacy to complete medication review (4/28/2026)- Report development of pain, bruises, change in mental status, activities of daily living (ADLs) function, appetite, or neurological status post fall (7/23/2026) On 2/23/2026, at 6:58 PM, in the progress notes, nursing documented R13 was observed sitting on the ground. (R13) stated they were grabbing a bag, went to sit, and missed the chair. Surveyor reviewed R13's fall investigation and interdisciplinary team (IDT) review for R13's 2/23/2026 fall and noted there were no staff statements indicating when R13 was last observed, last toileted, if R13 was incontinent at time of fall, or if R13 had commonly used items close by. On 3/29/2026, at 14:12 (2:12 PM), in the progress notes, nursing documented (R13) was observed lying on the floor next to the nurse's station. (R13) stated was trying to reach down and pick up a book from the floor. Surveyor reviewed R13's fall investigation and IDT review for R13's fall on 3/29/2026 and noted there were no staff statements indicating when R13 was last observed, toileted, if R13 was incontinent at time of fall, if R13 required any assistance at the time of the fall, and if R13's items were close by. On 4/28/2026, at 3:10 AM, in the progress notes, nursing documented a sound was heard coming from R13's room, went to check it out and observed R13 sitting on the floor next to R13's bed. R13 stated they were trying to get up to sit in the wheelchair and it slid back and fell onto buttocks. Surveyor reviewed R13's fall investigation and IDT review for R13's fall on 4/28/2026 and noted there were no staff statements indicating when R13 was last observed and what they were doing prior to fall, when R13 was last toileted or if they were incontinent, or why R13 could have been awake at that time of night. On 7/23/2026, at 4:20 AM, in the progress notes, nursing documented R13 observed R13 on the floor next to R13's bed. Surveyor reviewed R13's fall investigation and IDT review for R13's fall on 7/23/2026 and noted there were no staff statements indicating when R13 was last observed and what they were doing, when R13 was last toileted or if they were incontinent at the time of fall, or why R13 could have been awake at that time. Surveyor noted the fall investigation does not specify how R13 was found on the floor, if they were lying down or in sitting position. On 8/17/2026, at 10:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-FF who stated if a resident falls, after all the assessments are completed, then the nurse is to start a fall investigation packet which includes what happened, vital signs, neurological checks if indicated, interventions implemented if indicated, and gathering staff statements regarding what was going on prior to, during, and after the resident fell. LPN-FF stated the information gathered goes to management to review and determine if the interventions implemented were appropriate or not and revise accordingly. On 8/17/2026, at 10:28 AM, Surveyor interviewed Certified Nursing Assistant (CNA)/ Unit Clerk-W who stated if a resident falls the CNA is to make sure the resident is safe and then get help by either calling or getting someone. CNA/Unit Clerk-W stated nursing is responsible for filling out any assessment or fall investigation and sometimes CNA/Unit Clerk-W is given a paper to write a statement down documenting what happened at time of fall, and if saw the resident before the fall, and sometimes nursing just asks them and the nurse fills it out. CNA/Unit Clerk-W stated sometimes they are not even asked, it all depends on the nurse filling out the fall information. On 8/17/2026, at 10:33 AM, Surveyor interviewed Registered Nurse (RN) Consultant-D who stated all falls should have staff interviews from everyone that worked that shift and documentation on when they last saw the resident, what they were doing at time of residents fall and what was observed at the time of the fall or after the fall. Surveyor shared concern that no staff statements were included with the fall investigations for R13 on 2/23/2026, 3/29/2026, 4/28/2026, and 7/23/2026, and there was no documentation when R13 was last observed and what they were doing, last toileted or if incontinent at time of fall. RN consultant-D stated they understood the concerns and would look to see if staff statements could be located for R13's falls on 2/23/2026, 3/29/2026, 4/28/2026, and 7/23/2026. On 8/17/2026, at 12:15 PM, RN consultant-D informed Surveyor staff statements could not be located for R13's falls in 2/23/2026, 3/29/2026, 4/28/2026, and 7/23/2026 and understood the concerns with not having the staff statements regarding R13's falls. On 8/17/2026, at 12:57 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B R13's falls were not thoroughly investigated, and no staff statements could be located for R13's fall investigations on 2/23/2026, 3/29/2026, 4/28/2026, and 7/23/2026. DON-B stated they were made aware and could not locate staff statements in the medical records or paper statements and understands the concerns with not having those staff statements for R13's falls regarding what R13 was doing at the time of the fall, or when R13 was last checked on/ toileted. 2.) Smoking: The facility policy, entitled Smoking, implemented 5/19 and reviewed/revised 7/14/22, stated: Purpose To identify factors that may put residents at risk for smoking or nicotine use independently and to provide appropriate supervision/approaches for safety. Smoking Policy This center shall establish and maintain a safe resident environment, while maintaining resident rights, smoking or nicotine use will be limited to designated areas, supervision and safety plans. Policy Explanation and Compliance Guidelines 1. Residents who smoke or use smokeless tobacco products shall have a Nicotine Assessment completed upon admission, quarterly, annual and as needed (PRN). Resident or responsible party must be in agreement to nicotine use. 2. Risk factors identified through the assessment process shall be used in the development of the plan of care. 3. Physician (MD) will be notified, and order will be obtained for nicotine use. R42 was admitted to the facility on [DATE] and had diagnoses that included anoxic brain damage, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, epilepsy, anxiety disorder, and schizophrenia. R42's Significant Change Minimum Data Set (MDS) assessment, dated 5/30/26, indicated a Brief Interview for Mental Status (BIMS) score of 2 which indicated R42 demonstrated severely impaired skills for daily decision making. Section J does not indicate R42 uses tobacco. Nicotine assessments dated 5/5/26 and 5/14/26 indicated R42 did not smoke. On 7/9/26, Psychiatric PhD (Psych PhD)-N documented: His (R42) favorite activity appears to be smoking cigarettes. An updated Nicotine Assessment was not initiated to document that R42 wished to smoke or was currently smoking. A smoking care plan was not initiated. On 8/6/2026, Licensed Practical Nurse (LPN)-BB documented: Resident's (R42) family came to visit and left resident (R42) 2 boxes of cigarettes, 1 lighter, and a bag of snacks. Writer put resident (R42) name on items and placed them in med (medication) room and lock box. Resident (R42) able to get items whenever asked. Resident (R42) aware of exchange. No concerns at the time. A Nicotine Assessment was not initiated to document R42 was currently smoking. A smoking care plan was not initiated. On 8/11/26, a smoking care plan was initiated for R42. Interventions: -Assist to and from designated smoking area -Assure smoking material is extinguished prior to resident (R42) leaving smoking area -Complete nicotine assessment per facility policy -Observe resident (R42) for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management of concerns -Review smoking policy with resident and/or family -Storage of smoking materials per facility policy On 8/12/2026, at 1:52 PM, Surveyor asked Registered Nurse (RN)-J about R42's smoking. RN-J informed Surveyor that R42's family had stated that R42 was a regular smoker prior to admission to the facility. RN-J informed Surveyor that R42 had been smoking for a while since admission to the facility. On 8/12/2026, at 2:03 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I. CNA-I stated that R42 started asking for cigarettes about 3 weeks after admission to the facility. CNA-I stated: I believe (R42) was exit seeking because (R42) wanted to get outside and smoke. I think the family told us then that (R42) had been a smoker prior to being admitted to the facility. On 8/12/26, the facility completed a Nicotine Assessment which documented R42 currently smoked cigarettes and was at risk. R42 required assistance from staff and smoking materials would be kept under control of facility staff. On 8/13/26, at 10:13 AM, Surveyor interviewed Unit Manager (UM)-K regarding R42. UM-K informed Surveyor that R42 started asking for cigarettes about one month after being admitted to the facility. UM-K confirmed that UM-K was responsible for completing the Nicotine Assessment. Surveyor asked UM-K what the expectation was for completing assessments. UM-K stated assessments are completed on admission, quarterly, and when there was a change. UM-K stated it was everyone's responsibility to complete the assessments. Surveyor asked why a new Nicotine Assessment was completed on 8/12/26. UM-K stated that R42 was due for a quarterly assessment. On 8/13/2026, at 10:26 AM, Surveyor interviewed CNA-H. CNA-H was familiar with R42 and stated that R42 started smoking about 2 months after admission to the facility. R42's electronic medical record (EMR) contained multiple progress notes of R42 exit seeking and required close supervision. 4/16, 4/17, 4/23, 5/8, 5/14, 5/23, 5/24, and 5/27/26. The facility did not complete a root/cause analysis as to why R42 was exit seeking. Based on interviews, R42 was a previous smoker prior to admission to the facility and there was likelihood R42 was attempting to get out and smoke. On 8/17/2026, at 11:19 AM, [NAME] President of Success (VPS)-C informed Surveyor that VPS-C understood the concern of the smoking assessment not being completed when first identified for R42. R42 required supervision from staff to smoke. Elopement/Exit seeking: The facility policy, entitled Elopement/Unsafe Wandering, implemented 7/7/15 and reviewed/revised 8/9/22, stated: Policy: This facility ensures that residents who exhibit wandering behavior and/or are risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 2. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 3. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission, quarterly, and with a significant change in condition. c. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered plan of care. d. The resident and family/authorized representative should be encouraged to participate in the development of the plan of care. e. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's plan of care and communicated to appropriate staff. f. Supervision as per the plan of care is to be provided to help prevent accidents or elopements. g. Licensed nurses will monitor the implementation of interventions, response to interventions, and document accordingly. h. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. The facility 'wander guard' book contained 'code alert instructions' Complete these Steps: -Get consent from responsible party and physician (MD) order -Complete elopement assessment/care plan -Put on treatment administration record (TAR) to check placement every shift and to check function at HS -Place 'code alert' expiration date on TAR A Wandering Risk assessment dated [DATE] documented R42 was low risk for wandering. R42's electronic medical record (EMR) documented multiple exit seeking behaviors. On 4/16/26, R42's day of admission, Licensed Practical Nurse (LPN)-EE documented: Repetitive redirection needed for safety. On 4/17/2026, LPN-L documented: Resident (R42) became very agitated, combative and aggressive while exit seeking. Summary: Resident (R42) is a new admit, he (R42) has exhibited agitated behaviors, increased confusion and resident (R42) crawls out of bed. Resident (R42) sent to hospital for unsafe behaviors. On 4/23/26, LPN-L documented: Safety: Resident (R42) displayed the following: Behaviors wandering, impulsive, combative, agitated, confused, not directable. A Wandering Risk assessment dated [DATE] documented R42 was low risk for wandering. On 5/8/2026, at 2:50 AM, LPN-BB documented: Resident (R42) remained alert and awake throughout the shift. Resident (R42) refuse redirection attempts by writer and continued attempting to exit the building, activating the door alarm multiple times. Resident (R42) stated, I want to go with my brother. Writer notified DON (Director of Nursing) of resident's (R42) behaviors. Per DON (Director of Nursing) instruction, resident (R42) will remain monitored until next shift arrives. Writer continued providing one-to-one supervision and intervention to prevent resident (R42) from exiting through the front door. On 5/8/2026, at 9:31 PM, LPN-L documented: Resident (R42) was in wheelchair sleeping when he (R42) got up and rolled to the back entrance. Resident (R42) was trying to elope, resident (R42) was unresponsive to commands, not responding to any cues and becoming physically aggressive with multiple staff members. Resident (R42) was finally directed back to his (R42) wheelchair after attempting to break down the back door and lead to the nurse's station. Resident (R42) was still agitated but allowed staff to give medications. On 5/10/2026, LPN-GG documented: resident (R42) was rolling towards the front door. I was walking beside him (R42) gently redirecting him (R42) from front door. Resident (R42) looked over at me and started to swear. Stood up trying to walk along the wall swinging his (R42) fists. He (R42) told me I'm going to f**k you up bitch, he (R42) connected, he (R42) hit me on the right arm. The second incident started with the resident (R42) hearing me talk to the 911. He (R42) turned to look at me yelling you f*****g b***h, standing up walking around my med. cart swing trying to hit me, trying to climb over the nurses desk to get to me. The police came and saw the behaviors. Called for an ambulance. A Wandering Risk assessment dated [DATE] documented R42 was moderate risk for wandering. On 5/14/2026, at 5:50 AM, LPN-BB documented: Resident (R42) was noted to be exit-seeking prior to the incident. Per staff report, the resident (R42) became irritated when the aide attempted to redirect resident (R42) from exiting to the street. The resident (R42) began wheeling his (R42) wheelchair at a fast pace in the hallway, lost balance, and had a witnessed fall. On 5/20/26, Psychiatric Nurse Practitioner (Psych NP)-M documented in the initial psychiatry evaluation: Patient (R42) has been redirected multiple times away from the door in an attempt to elope. On 5/21/26, Psychiatric PhD (Psych PhD)-N documented: Patient (R42) would benefit from a wander guard for safety exit seeking behavior. Insight, judgement, attention, and concentration are impaired. Surveyor noted there was no documentation that R42 had a wander guard initiated. On 5/23/2026, at 7:37 AM, LPN-BB documented: The resident (R42) slept for a few hours during the shift. However, at approximately 6:00 AM, the resident (R42) attempted to exit the building. Writer redirected the resident (R42). On 5/23/2026, at 10:17 PM, LPN-GG documented: Resident (R42) was on a 1:1 until 6pm. Then hourly checks were on. Resident (R42) made several attempts to leave facility. On 5/24/2026, at 7:24 AM, LPN-BB documented: Patient (R42) had a quiet night. No hourly checks or one-on-one supervision were provided this shift. The resident (R42) made several attempts to leave the facility; however, staff were able to redirect the resident (R42) successfully. A Wandering Risk assessment dated [DATE] documented R42 was moderate risk for wandering. On 5/26/26 a comprehensive care plan for potential for elopement due to cognitive impairment, mental illness wander guard in place, (R42) still continues with wandering tendencies Interventions: -At high risk for elopement 5/26/26 -Accompany to meals and scheduled activities 6/9/26 -Calmly redirect to an appropriate area 6/9/26 -Check alert bracelet functioning per manufacturer recommendations 6/9/26 -Check alert bracelet placement per facility guidelines 6/9/26 -Educate family/visitors to advise when leaving resident (R42) following visit 6/9/26 On 5/27/2026, at 5:27 AM, LPN-HH documented: Overall, no major difficulty for redirecting, pt (R42) does continue to want to go outside the facility. On 5/29/202, at 7:10 AM, LPN-II documented:Resident (R42) continues to be on the 24-hour board for 1:1 monitoring due to behaviors and exiting the facility. On 5/29/26, Psych PhD-N documented: Goal 3: Implement wander guard for exit -seeking behavior. Recommendation remains in place from previous visit; staff reports patient continues to be exiting seeking. No update on implementation status this session. On 6/4/26, Psych PhD-N documented: Goal 3: Implement wander guard for exit -seeking behavior. Recommendation remains in place from previous visit; staff reports patient continues to be exiting seeking. No update on implementation status this session. On 6/25/26, Psych PhD-N documented: Goal 3: Implement wander guard for exit -seeking behavior. Recommendation remains in place from previous visit; staff reports patient continues to be exiting seeking. No update on implementation status this session. On 7/9/26, Psych PhD-N documented: Goal 3: Implement wander guard for exit -seeking behavior. Recommendation remains in place from previous visit; staff reports patient continues to be exiting seeking. No update on implementation status this session. Surveyor noted R42's physician orders did not document a physician order had been obtained for a wander guard. Surveyor reviewed R42's Medication Administration Record (MARS) and Treatment Administration Record (TARS) from admission to present. R42's wander guard was not being checked for placement or function every shift. R42's progress notes did not document that consent had been obtained by R42's HCPOA. R42's Certified Nursing Assistant (CNA) instruction in the care of R42, as of 8/12/26, documented R42 was high risk for elopement. On 8/11/26, at 1:47 PM, Surveyor observed R42 had a wander guard bracelet on the right ankle. On 8/13/26, at 10:13 AM, Surveyor interviewed Unit Manager(UM)-K. UM-K stated that the expectation is that assessments should be done on admission, quarterly, and as needed when there is a change. UM-K was not able to tell Surveyor when R42's wander guard was initiated and would need to do some digging. On 8/13/26, at 10:26 AM, Certified Nursing Assistant (CNA)- H informed Surveyor that it comes up on our daily charting to check for wander guard placement. On 8/13/26, at 10:26 AM, Surveyor interviewed Registered Nurse (RN)-F. RN-F stated that nursing staff is responsible for checking under the skin of the wander guard, expiration date, and placement. RN-F confirmed that a wander guard would be documented in the physician's orders. RN-F also confirmed that it should be in the MAR for nursing staff to check off on. Surveyor had RN-F check to validate that R42's wander guard was documented in R42's physician orders and located in R42's MARs. RN-F stated R42's wander guard was not documented in R42's physician orders or MARs. On 8/17/26, at 10:43 AM, Surveyor observed R42 had a wander guard bracelet on the right ankle. On 8/17/2026, at 8:57 AM, [NAME] President Success (VPS)-C informed Surveyor that the facility was not able to tell Surveyor when the wander guard was actually placed on R42. VPS-C stated that with R42's exit seeking behavior, R42 would have been high risk for wandering. On 8/17/2026, at 11:19 AM, VPS-C confirmed R42's elopement assessment was not completed when R42 was first identified to be a high risk for wandering and the facility did not obtain a physician order, consent from the representative, and did not initiate a wandering care plan until 5/26/26. R42's wander guard has not been checked for placement and function each shift. 3.) The facility policy titled Medication Administration General Guidelines dated 01/26 documents (in part) . . Medication Administration: 17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked. On 8/11/26 at 10:00 AM, Surveyor observed the middle medication cart to be open/not locked and not within view of a nurse. Surveyor proceeded to open the cart and review the contents for the medication storage task. Surveyor noted that a nurse did not return to the medication cart during the entire time Surveyor had the cart open and was viewing the contents. On 8/13/26 at 8:24 AM, Surveyor observed a medication cart in the corner between rooms [ROOM NUMBERS]. Surveyor observed a plastic cup containing pills on top of the medication cart and there was not a nurse in view of the cart. Approximately 2 minutes later, Surveyor observed a nurse walking down the hallway and returned to the medication cart. On 8/13/26 at 9:10 AM, Surveyor told Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, [NAME] President of Success (VPS)-C and Registered Nurse Consultant (RN)-D of the above observations and concerns regarding the medication cart left unlocked/not within view of the nurse and pills left unattended on top of the cart with no nurse in view of the cart. No additional information was provided.

Based on interview and record review the facility did not ensure residents with non-pressure wounds or unwitnessed falls received treatment and care in accordance with professional standards of practice and/or facility policy for 2 (R13 and R48) of 13 residents reviewed for quality of care. *R13 had an unwitnessed fall on 4/28/2026. Neurological checks were not implemented until 4/29/2026. *R48 had wounds to the scalp discovered at an appointment outside of the facility. The wounds were not assessed by facility staff upon return to the facility, and the treatment ordered was not transcribed or provided. Findings include: The facility policy titled Neurological Checklist UDA Quick Reference Guide with no date documented documents: The neurological checklist UDA is required for all unwitnessed falls. Once the incident report is created in Point Click Care (PCC), the Neurological Checklist UDA will automatically trigger to be completed at the time of the Incident, then hourly X3, then every 4 hours X6, and then every 8 hours X6. The facility policy titled Pressure Injuries and Non-Pressure Injuries last reviewed/revised 7/20/2022 documents: . For those residents admitted with, or who subsequently developed a . or impaired skin integrity will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of . impaired skin integrity. Policy Explanation and Compliance Guidelines: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: .ii. If non-pressure, initiate the non-pressure injury tracker UDA- one per wound.iii. Ensure primary care physician (PCP) is aware of wounds/location of wounds and current treatment orders.iv. Ensure appropriate treatment orders for each wound area as needed.v. Ensure resident/ responsible party is aware of wounds and current treatment plan. 1.) R13 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia with behavioral disturbance, metabolic encephalopathy, repeated falls, muscle wasting and atrophy, type 2 diabetes mellitus, . and long term use of anticoagulants. On 4/28/2026, at 3:10 AM, in the progress notes, nursing documented they heard a noise coming from R13's bedroom, upon entering they observed R13 in sitting position next to R13's bed and wheelchair. R13 stated was trying to get into their wheelchair. Surveyor noted Nursing documented negative neuro checks. Surveyor requested to review the neuro checks for R13's unwitnessed fall on 4/28/2026. Surveyor received R13's neuro checks that started on 4/29/2026 at 04:46 (4:46 AM). According to facility policy R13 should have documented neuro checks for:-4/28/2026 at 3:10 AM, 4:10 AM, 5:10 AM, 9:10 AM, 1:10 PM, 5:10 PM, 9:10 PM and-4/29/2026 at 1:10 AM On 8/17/2026, at 10:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-FF who stated when a resident has an unwitnessed fall neuro check should be implemented right away. LPN-FF stated there is a document in PCC that gets filled out after a neuro assessment is completed. LPN-FF stated the assessments pop up when it is time to complete them, but that only gets triggered when the incident is documented, so if it doesn't get documented right away the assessments will not pop up to be completed or sometimes nursing staff do not realize it has to be completed. Nursing staff should write about the incident in the 24 hour board, so staff is aware neuro checks have to be completed. LPN-FF stated they would have to look to see how often residents are supposed to get neuro checks after an unwitnessed fall. On 8/17/2026, at 12:15 PM Surveyor asked Registered Nurse Consultant (RNC)-D if R12 had neuro checks completed on 4/28/2026. RNC-D stated they could not locate R12's neuro checks for 4/28/2026 when R12 had an unwitnessed fall. RNC-D understood there was a concern related to not being able to have access to the neuro checks or documentation neuro checks were completed after R13's unwitnessed fall on 4/28/2026. On 8/17/2026, at 12:57 PM, Surveyor interviewed Director of Nursing (DON)-B who stated they were made aware of missing neuro checks for R13's unwitnessed fall on 4/28/2026. DON-C stated re-education has begun with nursing staff. Surveyor asked if neuro checks are completed on paper or in PCC. DON-B stated they looked to see if there were paper copies and could not find any, however, all neuro checks are to be completed in PCC. 2.) R48 was admitted to the facility on [DATE] and was hospitalized from [DATE] to 5/26/2026 for diplopia (double vision) and concern for giant cell arteritis which is an inflammation of the large arteries in the head, neck, and arms. On 6/5/2026, R48 went to a neurological eye appointment. The consult form that was returned with R48 to the facility documented R48 had multiple scalp wounds that were small but open, and a treatment was ordered to clean the scalp wounds and apply Neosporin twice daily for one week. R48's medical record did not have any documentation of an assessment of the scalp wounds after the appointment on 6/5/2026 and no treatment orders were transcribed or completed. In an interview on 8/13/2026 at 9:56 AM, Surveyor asked Scheduler-R what the process was for the paperwork that is returned with a resident after an appointment. Scheduler-R stated that the nurse on the unit would enter any orders that were on the consult form and Scheduler-R would make any follow up appointments from that consult, and then have the form scanned into the resident's record. On 8/13/2026 at 1:38 PM, Surveyor shared with Director of Nursing (DON)-B and Licensed Practical Nurse Unit Manager (LPN UM)-Y the concern R48 was seen at the neurology eye clinic on 6/5/2026 with documentation of multiple scalp wounds and a treatment order for the wounds and no documentation was found by facility staff of assessing the wounds or putting the ordered treatment in place. DON-B stated the nurse on the unit may not have seen the consult because Scheduler-R grabs the paperwork to scan them into the health record. DON-B stated Scheduler-R has a timeframe to get the information scanned in. DON-B stated the expectation is to put in the orders right when the resident gets back from an appointment and to do an assessment of any wounds. On 8/13/2026 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R48 had treatment orders for multiple scalp wounds after an appointment and the wounds were not assessed and the treatment orders were not transcribed or initiated.

Based on observation, interview, and record review, the facility did not ensure 1 (R13) of 13 residents who are dependent of staff to carry out their activities of daily living were provided with the necessary services.*On 8/12/2026, R13 was not provided with incontinence care or repositioning for approximately 6 1/2 hours and was observed to have a very wet incontinence pad. R13 was not woken up or offered assistance with setting up for noon meal.Findings include:The facility policy titled NSG (Nursing) Activities of Daily Living (ADLs) last reviewed/ revised on 7/26/2022 documents: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming, oral care.3. Toileting. 4. Eating to include meals and snacks .Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.5. The facility will maintain individual objectives of the care plan and periodic review and evaluation.R13 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia with behavioral disturbance, metabolic encephalopathy, history of repeated falls, muscle wasting and atrophy, type 2 diabetes mellitus, insomnia, anxiety, and depressive disorder.R13's quarterly Minimum Data Set (MDS) dated [DATE] indicated R13 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 5 and the facility assessed R13 dependent on 1 staff member for all ADLs, required assistance with meal set up and ate independently. R13 was frequently incontinent of bowel and bladder and wears a protective brief.R13's care plan for ADL self-care deficit related to headache, left shoulder pain, polyosteoarthritis, bilateral sensorineural hearing loss, morbid obesity, type 2 diabetes mellitus, depression, anxiety, and history of cerebral infarction was initiated on 7/12/2023 with the following interventions and revisions.- Alert and oriented to self with forgetfulness and confusion. Refuses showers and cares.- Vascular dementia, activated power of attorney (POA).- Bed Mobility: Assist of 1 with bed mobility (2/17/2023)- Personal Hygiene: Assist of 1 (7/12/2023)- Wears 3XL brief for incontinence and XL pull up (8/4/2023)- Eating: Independent with eating/ meals (2/17/2025)- Encourage and/or assist to reposition frequently - Encourage intake of water between meals (6/23/2025)- Encourage sleep at night. Avoid waking as able- Lights on during the day. Encourage wakefulness.- Toileting: Assist of 1 with incontinence, peri-hygiene. Assist of 1 with toileting transfers (12/22/2025)-Transfer: Assist with 1 and a gait belt. R13's care plan for urinary incontinence related to impaired mobility; medications was initiated on 7/22/2023 with the following interventions and revisions: .- Apply skin moisturizer/ barrier creams as needed - Provide assistance with toileting- Provide incontinence care as needed- Adjust toileting times to meet (R13's) needs (2/5/2024)- At established toileting times, ask if toileting is needed and remind (R13) that it is time to use the toilet - Toileting Plan: Toilet upon rising, before lunch, before activities and dinner, before bedtime and as needed (6/5/2025)R13's care plan for unintended weight loss related to inadequate oral intake . variable oral intake, and moderate protein calorie malnutrition was initiated on 7/13/2023 with the following interventions and revisions: .-Eating- setup, offer cues/ assistance as needed to help promote intake (5/7/2026)R13's care plan for at risk for skin integrity related to edema, impaired mobility, and incontinence care plan was initiated on 7/12/2023 with the following interventions and revisions: .- Encourage to reposition as needed; use assistive devices as needed.- Barrier cream to peri area/buttocks after each incontinence episode (2/4/2024)- Float heels as able- Provide preventative skin care routinely and as needed (7/22/2025)R13's certified nursing assistant (CNA) Care Kardex has the following interventions: .Bed Mobility:-Elevate bilateral lower extremities as tolerated.Bathing:-Bathing/Showering: Wednesday AM. Extensive assist of 1.Bowel/Bladder:-Provide incontinent care as needed-Toilet upon rising, before/after meals, at bedtime and as needed.Communication:-Provide frequent passive re-orientation to time of day and daily events.Dressings/ Splint Care:-Assist to apply tubi grips to legs, on in AM and off in PMEating/ Nutrition:-Eating: setup, offer cues/assistance as needed to help promote intake-Encourage fluids during med pass and with meals-Encourage intake of water between meals.Safety:-Offer and assist (R13) to bathroom during shift and prior to retiring for the evening.Resident Care:-Assist with incontinent care as needed to maintain dignity and prevent skin breakdown-Barrier cream to peri area/ buttocks after each incontinence episode-Float heels as ableToileting:-Toileting Plan: Toilet upon rising, before lunch, before activities and dinner, before bedtime and as needed.On 8/12/2026, Surveyor had the following observations between 7:37 AM - 1:45 PM:- 7:37 AM, 9:41 AM, 11:26 AM, 12:02 PM, 12:34 PM, and 12:41 PM, R13 was lying in bed on their back, heels were not offloaded, bedroom lights were off.- 12:37 PM, CNA-I put R13's lunch tray on the bedside table and walked out of R13's room. Surveyor noted CNA-I did not attempt to wake R13 up for lunch time or assist setting up R13's meal.- 1:00 PM, maintenance stopped at R13's doorway and knocked on R13's door. R13 did not answer. Maintenance went into R13's room and took off a grab bar from the other bed in R13's room and walked out. R13 was still lying in bed on their back, heels were not offloaded, and the bedroom lights were off.- 1:04 PM, CNA-JJ walked into R13's room, looked at R13 and walked out of R13's room.Surveyor noted CNA-JJ did not attempt to wake up R13 to eat lunch, reposition, or check if R13 had been incontinent.-1:25 PM, R13 continues to lay in bed on back, heels not offloaded and lunch on bedside table with food covers still on.-1:29 AM, Surveyor interviewed CNA-I who stated R13 was not their resident today. CNA-I stated there are days when R13 sleeps all day and then they are up all night. CNA-I was not sure if R13 was repositioned or checked for incontinence cares today. CNA-I stated R13's noon meal tray was just dropped off because R13 was sleeping and was not sure if R13's CNA checked on R13 or offered R13 their noon meal.-1:31 PM, Housekeeping went into R13's room and emptied garbage. R13 did not wake up.-1:34 PM, a visitor came to R13's bedroom and tried to wake R13 up. The visitor went to get R13's nurse, registered nurse (RN)-J.-1:36 PM, CNA-JJ walked past R13's room. Looked in and stated, I wish I could sleep that good and kept walking down the hallway.-1:38 PM, RN-J and visitor walked into R13's room and tried to wake R13 up. RN-J turned on R13's bedroom lights and woke R13 up. R13 was answering questions but would fall back asleep. RN-J told the visitor R13 took morning medication but is not sure if R13 ate breakfast or when R13 was last checked and changed.-1:42 PM, RN-J walked out of room with visitor, and CNA-JJ and CNA-I walked into R13's room to provide cares to R13. Visitor asked CNA-JJ if R13 has eaten at all. CNA-JJ replied that R13 has been sleeping all day and has not eaten yet.-1:45 PM, Surveyor observed CNA-JJ and CNA-I provide incontinence cares for R13. CNA-JJ pulled back R13's sheet and surveyor noted R13 was not wearing bilateral tubi-grips and R13's heels were resting on the mattress and not offloaded. CNA-JJ removed R13's incontinent brief and noted it to be very wet. Surveyor asked when the last time R13 was checked and changed. CNA-JJ stated R13 was last changed at 6:30 AM. Surveyor asked if it was before or after CNA-JJ came onto shift. CNA-JJ stated CNA-JJ comes onto shift at 6:30 AM. Surveyor asked if CNA-JJ was the one to provide incontinence care to R13 at 6:30 AM. CNA-JJ did not answer Surveyor. Surveyor asked if R13 was provided with breakfast or repositioned since 6:30 AM. CNA-JJ stated R13 has been asleep and when R13 is like that, staff let R13 sleep. Surveyor asked when R13 gets into a state of sleep how it was decided incontinence care and repositioning are not provided until R13 becomes more awake or alert. CNA-JJ did not answer Surveyor. Surveyor asked if anything was given in report if R13 was up all night or if R13 was sleeping all night. CNA-JJ was not sure.On 8/12/2026, at 15:04 (3:04 PM), in the progress notes RN-J documented (R13) denied breakfast due to sleeping all morning but was able to take medications. Visitor came to visit (R13) and questioned why (R13) has been asleep . RN-J stated (R13) stays up all night and then will sleep all morning. (R13's) visitor assisted with feeding (R13) lunch .On 8/13/2026, at 11:14 AM, Surveyor shared observations from 8/12/2026 of R13 not being repositioned, woken up, or assisted with meals with Director of Nursing (DON)-B. Surveyor shared R13 was not changed between 6:30 am - 1:45 PM and R13's incontinent brief was very wet when cares were provided at 1:45 PM. Surveyor also shared according to progress notes, R13's visitor assisted R13 with eating lunch. DON-B understood the concern and would look into the situation. DON-B stated R13 should not have gone that long without being changed, repositioned, or even checked on if R13 was in such a deep sleep like that. On 8/13/2026, at 3:00 PM, Surveyor shared observations and concerns from 8/12/2026 with Nursing Home Administrator (NHA)-A, [NAME] President of Success (VPS)-C, and RN consultant-D R13 was not repositioned, given incontinence care, or woken up/ checked on or offered meal assistance from 6:30 AM - 1:45 PM when a visitor for R13 came and started to ask questions. Surveyor shared when R13 was checked and changed at 1:45, R13's incontinent brief was very wet. NHA-A understood the concern of R13 not being checked on while in a deep sleep on 8/12/2026.

Based on record review and interviews, in response to allegations of abuse or mistreatment, the facility did not have evidence that alleged violations of abuse were thoroughly investigated and the further potential abuse or mistreatment was prevented while the investigation is in progress for 2 of 2 (R15 and R42) residents reviewed for abuse. R15's allegation of verbal abuse was not thoroughly investigated. R42 was involved in a resident-to-resident altercation that was not thoroughly investigated. Findings include: The facility policy titled Abuse, Neglect and Exploitation reviewed/revised 7/15/22 documents (in part) . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. IV. Identification of abuse, neglect and exploitation. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. 5. Verbal abuse of a resident overheard or inappropriate verbal conduct overheard. 6. Physical abuse of a resident observed. V. Investigation of alleged abuse, neglect and exploitation A. An immediate investigation is warranted when allegations or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation 3. Investigating different types of alleged violations 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s). 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation 1.) R15 was admitted to the facility on [DATE]. The admission Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. On 8/11/26 at 10:25 AM, R15 told Surveyor that over the weekend she was in her room and asked a nurse or CNA (Certified Nursing Assistant), she wasn't sure which, to move her roommate so she could get through (it was later identified to be CNA-U). R15 told Surveyor I said [NAME], can you move her so I can get by? I call everyone [NAME], I didn't mean anything by it. R15 said CNA-U said in a very aggressive, mean way Don't call me [NAME], call me by my name. R15 told Surveyor she didn't know her name and she calls everyone [NAME]. Surveyor asked R15 if she reported it to anyone and she told Surveyor she reported it to Licensed Practical Nurse (LPN)-O. Surveyor asked if anyone has followed up or talked to her about it, R15 said No, no-one. On 8/11/26 at 10:35 AM, Surveyor asked LPN-O if R15 had reported anything to her recently. LPN-O stated, Yes, it was over the weekend, on Saturday 8/8/26. She told me the aid was verbally aggressive and rude to her. She said she called her [NAME], and the aid told her in a rude aggressive manner not to call her [NAME], to call her by her name. I asked her if she felt safe, and she said no, she was afraid of retaliation. Surveyor asked LPN-O what she did after R15 reported the allegation. LPN-O told Surveyor she immediately called Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, told them what happened and what R15 said. On 8/11/26 at 1:19 PM, Surveyor asked DON-B if he was made aware of the allegation of verbal abuse involving R15 on 8/8/26. DON-B told surveyor he was aware of a verbal interaction that went sideways. DON-B stated, I didn't feel good about it, so I suspended the aide. Surveyor asked when the aid was suspended, DON-B told Surveyor it was the same day. DON-B told Surveyor that someone called to tell him about it, and he said to send the aide home. Surveyor asked why he sent the CNA home. DON-B stated, Based on what I was told, I couldn't make a definitive decision if it was verbal abuse, I just know the care giver needed to be out of the building. DON-B told Surveyor he called NHA-A right away and told him what happened. Surveyor asked if an investigation was initiated. DON-B stated, I planned to talk to her yesterday, I just didn't have the chance. Surveyor found no evidence that the facility completed an investigation regarding R15's reported allegation of verbal abuse involving CNA-U. On 8/11/26 at 3:05 PM, during the daily exit meeting, Surveyor asked NHA-A if he was made aware of the allegation of verbal abuse involving R15. NHA-A stated, Yes, I was called. NHA-A told Surveyor it wasn't told to him that it was a case of verbal abuse, it was more of a customer service issue. Surveyor asked NHA-A if he would normally suspend a CNA for a customer service issue. NHA-A stated, Well, I felt that it was appropriate to send her home to avoid any escalation of the situation. On 8/13/26 at 10:07 AM, Surveyor spoke with Scheduler-R who stated she is not aware of any incident or altercation involving CNA-U that would prevent her from working and has not been told she was suspended. Scheduler-R confirmed that CNA-U has not worked since 8/8/26. On 8/13/26 10:15 AM, Surveyor confirmed via punch record that CNA-U punched in at 5:55 AM and punched out early at 1:00 PM on 8/8/26. On 8/13/26 at 1:14 PM, Surveyor spoke with NHA-A and asked if an investigation was initiated regarding R15's allegation. NHA-A reported he asked to get a statement from R15. Surveyor asked if the statement was obtained, NHA-A stated, No, I don't think an investigation was started yet. NHA-A told Surveyor that on Monday he checked in with R15, and she said everything was fine. Surveyor asked if he questioned R15 about the allegation involving CNA-U, he told Surveyor he did not. Surveyor asked why, if he was called at home by DON-B to report that CNA-U was sent home because of the incident with R15, why wouldn't there be follow up or an investigation? NHA-A stated, When (DON-B) called me to tell me what happened, he didn't say anything about aggression. He told me the aid was rude and that he was sending her home so things wouldn't escalate. If I would have heard the term aggression, I would have come in to find out what happened. On Tuesday (8/11/26) I interviewed (R15) after you told me of the concern. I don't feel it was verbal abuse; it was more of a customer service issue. She said the aid was rude but didn't say anything to me about aggression and said she felt safe. Surveyor told NHA-A of concern that R15 reported to LPN-O that CNA-U was verbally aggressive and rude, that she did not feel safe and was afraid of retaliation, which was reported to DON-B. DON-B told Surveyor he couldn't make a definitive decision if it was verbal abuse and he sent the aid home. Surveyor told NHA-A the allegation should have been investigated if there was a question of verbal abuse. There is no evidence that an investigation was initiated, R15 was not interviewed that day and no other residents that CNA-U was caring for were interviewed. NHA-A told Surveyor he understood but based on his conversation with the R15 on Tuesday (8/11/26) she did not mention aggression. Surveyor told NHA-A of concern the facility did not begin an investigation until after Surveyor brought it to their attention. NHA-A reported he understood and no additional information was provided. On 08/13/26 at 1:48 PM Surveyor spoke with R15 again about incident with CNA-U on 8/8/26. Surveyor asked R15 if she could remind me of what the CNA said to her and how she said it. R15 stated, She was mean, and she said very aggressively don't call me [NAME], call me by my name. Surveyor confirmed that R15 felt CNA-U was aggressive. R15 stated, Oh yes, very aggressive. Surveyor asked R15 how that made her feel. R15 stated, I was afraid when I told the nurse that she (referring to CNA-U) would retaliate. 2.) On 5/6/2026, at 4:57 PM, Licensed Practical Nurse (LPN)-L documented: The current status is Resident was seen physically assaulting his roommate. Resident was not responding to cues or commands, three staff members were able to get resident out of room and into a wheelchair safely. Room change, 1:1. On 5/6/2026, at 9:43 PM, LPN-L documented: Writer (LPN-L) was not present in the room when incident occurred, writer (LPN-L) was told resident (R42) was assaulting other residents at the time, but upon other witness accounts in the room resident (R42) charged other resident and stood over other resident attempting to strike roommate. Resident (R42) did not make contact with other resident and was safely taken out of the room by psychologist and two other staff members. Physician, Director of Nursing (DON-B) and Nursing Home Administrator (NHA)-A aware. On 5/6/2026, at 9:43 PM, LPN-L documented: Resident (R42) was seen becoming aggressive and attempting to physically assaulting another resident. Resident (R42) was pulled away from resident, placed safely into a wheelchair and moved to another room. Physician and DON-B aware. On 5/7/2026, at 6:22 AM, Licensed Practical Nursing (LPN)-BB documented: Resident (R42) was involved in a physical altercation with another resident. Resident (R42) appeared angry, agitated, and confrontational throughout the incident. Resident (R42) stood up and attempted to hit the other resident. Resident (R42) was observed banging on the other resident's door and refused staff redirection. Resident (R42) then sat in front of the other resident's door waiting for him to come out to continue the confrontation. Resident (R42) remained highly upset and reactive, attempting to initiate further conflict whenever seeing the other resident in the hallway. What was the resident (R42) doing prior to or at the time of behavior/mood: Resident (R42) was sitting in his (R42) wheelchair and appeared upset from a previous incident. Another resident came out of his room and told him (R42) not to go into his room. This resident (R42) responded, What? The other resident repeated loudly, Don't go into my room. Resident (R42) then became increasingly upset and stood up from his wheelchair to approach the other resident. Before resident (R42) could reach him, the other resident threw a cup of water at resident (R42) and returned to his room. This resident (R42) then began banging on the other resident's door and yelling curse words. Interventions attempted: Staff immediately intervened and attempted to separate both residents. Staff redirected the other resident away from the situation, provided verbal de-escalation, and encouraged both residents to remain calm and return to their respective areas. Staff continued monitoring both residents after the incident. Effectiveness of the interventions: Staff intervention prevented the altercation from escalating into physical violence. Resident (R42) was temporarily redirected; however, a few minutes later, resident (R42) stood up from his wheelchair and attempted to hit the other resident upon seeing him in the hallway. Continued monitoring, verbal redirection, and staff intervention were required to maintain safety and prevent further escalation. Surveyor reviewed the facility reported incidents (FRIs) provided by the facility during the survey process. Surveyor noted there were no FRIs reported to the state survey agency in regard to R42 and resident-to-resident altercations on 5/6/26 and/or 5/7/26. On 8/13/2026, 3:00 PM, Surveyor requested any investigation documentation from Nursing Home Administrator (NHA)-A in regard to R42's resident-to-resident altercations on 5/6/26 and 5/7/26. On 8/17/2026, at 10:39 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to R42's allegations of resident-to-resident altercations on 5/6/26 and 5/7/26. Surveyor asked NHA-A if NHA-A had conducted an investigation in regard to the resident-to-resident altercations that occurred on 5/6/26 and 5/7/26. NHA-A stated that there was no physical contact so no reason to submit a FRI to the State Survey Agency. NHA-A stated the nurse (LPN)-L documented what LPN-L was told and misunderstood what happened from the staff present in the room. NHA-A stated that statements were obtained from staff and will provide the statements to Surveyor. Surveyor reviewed the only 2 statements provided by NHA-A in regard to R42's resident-to-resident altercation on 5/6/26. -Psychiatric Nurse Practitioner (Psych NP)-M documented R42 attempted confrontation with peer, did not make contact and was redirected from situation. -LPN-L documented LPN-L was not present when incident occurred, LPN-L was told R42 was assaulting other residents at the time, but upon other witness accounts in the room R42 charged other resident and stood over other resident attempting to strike roommate. R42 did not make contact. Surveyor was not provided any statements from the resident-to-resident altercation that was documented on 5/7/26. On 8/17/2026, at 11:49 AM, NHA-A informed Surveyor that NHA-A did not feel NHA-A needed to submit a FRI to the State Survey Agency because R42 did not make physical contact with their roommate. The facility attributed the behavior to R42's anoxic brain damage. I felt it did not warrant a FRI. NHA-A did agree with Surveyor that a root/cause analysis was not established. NHA-A did not believe R42's aggression toward other residents was not willful with intent.

Based on record review and interviews, the facility did not ensure that alleged violations involving abuse were reported to the State Survey Agency in the required timeframe for 2 of 2 (R15 and R42) residents reviewed for abuse. R15's allegation of verbal abuse was not reported to the State Agency. R42 was involved in a resident-to-resident altercation that was not reported to the State Agency. Findings include: The facility policy titled Abuse, Neglect and Exploitation reviewed/revised 7/15/22 documents (in part) . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. IV. Identification of abuse, neglect and exploitation. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. 5. Verbal abuse of a resident overheard or inappropriate verbal conduct overheard. 6. Physical abuse of a resident observed. VII. Reporting/Response 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal. 1.) R15 was admitted to the facility on [DATE]. The admission Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. On 8/11/26 at 10:25 AM, R15 told Surveyor that over the weekend she was in her room and asked a nurse or CNA (Certified Nursing Assistant), she wasn't sure which, to move her roommate so she could get through (it was later identified to be CNA-U). R15 told Surveyor I said [NAME], can you move her so I can get by? I call everyone [NAME], I didn't mean anything by it. R15 said CNA-U said in a very aggressive, mean way Don't call me [NAME], call me by my name. R15 told Surveyor she didn't know her name and she calls everyone [NAME]. Surveyor asked R15 if she reported it to anyone and she told Surveyor she reported it to Licensed Practical Nurse (LPN)-O. Surveyor asked if anyone has followed up or talked to her about it, R15 said No, no-one. On 8/11/26 at 10:35 AM, Surveyor asked LPN-O if R15 had reported anything to her recently. LPN-O stated, Yes, it was over the weekend, on Saturday 8/8/26. She told me the aid was verbally aggressive and rude to her. She said she called her [NAME], and the aid told her in a rude aggressive manner not to call her [NAME], to call her by her name. I asked her if she felt safe, and she said no, she was afraid of retaliation. Surveyor asked LPN-O what she did after R15 reported the allegation. LPN-O told Surveyor she immediately called Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, told them what happened and what R15 said. On 8/11/26 at 1:19 PM, Surveyor asked DON-B if he was made aware of the allegation of verbal abuse involving R15 on 8/8/26. DON-B told surveyor he was aware of a verbal interaction that went sideways. DON-B stated, I didn't feel good about it, so I suspended the aide. Surveyor asked when the aid was suspended, DON-B told Surveyor it was the same day. DON-B told Surveyor that someone called to tell him about it, and he said to send the aide home. Surveyor asked why he sent the CNA home. DON-B stated, Based on what I was told, I couldn't make a definitive decision if it was verbal abuse, I just know the caregiver needed to be out of the building. DON-B told Surveyor he called NHA-A right away and told him what happened. Surveyor asked who is responsible for submitting the report to the State Agency. DON-B told Surveyor he thought NHA-A talks to the [NAME] President and decides about the reporting part. On 8/11/26 at 3:05 PM, during the daily exit meeting, Surveyor asked NHA-A if he was made aware of the allegation of verbal abuse involving R15. NHA-A stated, Yes, I was called. Surveyor asked if it was reported to the state agency. NHA-A told Surveyor it was not reported because it wasn't told to him that it was a case of verbal abuse, it was more of a customer service issue. Surveyor asked NHA-A if he would normally suspend a CNA for a customer service issue. NHA-A stated, Well, I felt that it was appropriate to send her home to avoid any escalation of the situation. On 8/13/26 at 10:07 AM, Surveyor spoke with Scheduler-R who stated she is not aware of any incident or altercation involving CNA-U that would prevent her from working and has not been told she was suspended. Scheduler-R confirmed that CNA-U has not worked since 8/8/26. On 8/13/26 10:15 AM, Surveyor confirmed via punch record that CNA-U punched in at 5:55 AM and punched out early at 1:00 PM on 8/8/26. On 8/13/26 at 1:14 PM, NHA-A told Surveyor that on Monday he checked in with R15, and she said everything was fine. Surveyor asked if he questioned R15 about the allegation involving CNA-U, he told Surveyor he did not. Surveyor told NHA-A of concern that R15 reported to LPN-O that CNA-U was verbally aggressive and rude, that she did not feel safe and was afraid of retaliation, which was reported to DON-B. DON-B told Surveyor he couldn't make a definitive decision if it was verbal abuse and he sent the aid home. Surveyor told NHA-A the allegation should have been reported and an investigation initiated if there was a question of verbal abuse. NHA-A told Surveyor he understood but based on his conversation with R15 on Tuesday (8/11/26) she did not mention aggression. Surveyor told NHA-A that an allegation of abuse should be reported to the state agency within the required timeframe, not after the investigation. NHA-A said he understood and no additional information was provided. 08/13/26 at 1:48 PM Surveyor spoke with R15 again about incident with CNA-U on 8/8/26. Surveyor asked R15 if she could remind me of what the CNA said to her and how she said it. R15 stated, She was mean, and she said very aggressively don't call me [NAME], call me by my name. Surveyor confirmed R15 felt CNA-U was aggressive. R15 stated, Oh yes, very aggressive. Surveyor asked R15 how that made her feel. R15 stated, I was afraid when I told the nurse that she (referring to CNA-U) would retaliate. 2.) On 5/6/2026, at 4:57 PM, Licensed Practical Nurse (LPN)-L documented: The current status is Resident was seen physically assaulting his roommate. Resident was not responding to cues or commands, three staff members were able to get resident out of room and into a wheelchair safely. Room change, 1:1. On 5/6/2026, at 9:43 PM, LPN-L documented: Writer (LPN-L) was not present in the room when incident occurred, writer (LPN-L) was told resident (R42) was assaulting other residents at the time, but upon other witness accounts in the room resident (R42) charged other resident and stood over other resident attempting to strike roommate. Resident (R42) did not make contact with other resident and was safely taken out of the room by psychologist and two other staff members. Physician, Director of Nursing (DON-B) and Nursing Home Administrator (NHA)-A aware. On 5/6/2026, at 9:43 PM, LPN-L documented: Resident (R42) was seen becoming aggressive and attempting to physically assaulting another resident. Resident (R42) was pulled away from resident, placed safely into a wheelchair and moved to another room. Physician and DON-B aware. On 5/7/2026, at 6:22 AM, Licensed Practical Nursing (LPN)-BB documented: Resident (R42) was involved in a physical altercation with another resident. Resident (R42) appeared angry, agitated, and confrontational throughout the incident. Resident (R42) stood up and attempted to hit the other resident. Resident (R42) was observed banging on the other resident's door and refused staff redirection. Resident (R42) then sat in front of the other resident's door waiting for him to come out to continue the confrontation. Resident (R42) remained highly upset and reactive, attempting to initiate further conflict whenever seeing the other resident in the hallway. What was the resident (R42) doing prior to or at the time of behavior/mood: Resident (R42) was sitting in his (R42) wheelchair and appeared upset from a previous incident. Another resident came out of his room and told him (R42) not to go into his room. This resident (R42) responded, What? The other resident repeated loudly, Don't go into my room. Resident (R42) then became increasingly upset and stood up from his wheelchair to approach the other resident. Before resident (R42) could reach him, the other resident threw a cup of water at resident (R42) and returned to his room. This resident (R42) then began banging on the other resident's door and yelling curse words. Interventions attempted: Staff immediately intervened and attempted to separate both residents. Staff redirected the other resident away from the situation, provided verbal de-escalation, and encouraged both residents to remain calm and return to their respective areas. Staff continued monitoring both residents after the incident. Effectiveness of the interventions: Staff intervention prevented the altercation from escalating into physical violence. Resident (R42) was temporarily redirected; however, a few minutes later, resident (R42) stood up from his wheelchair and attempted to hit the other resident upon seeing him in the hallway. Continued monitoring, verbal redirection, and staff intervention were required to maintain safety and prevent further escalation. Surveyor reviewed the facility reported incidents (FRIs) provided by the facility during the survey process. Surveyor noted there were no FRIs reported to the state survey agency in regard to R42 and resident-to-resident altercations on 5/6/26 and/or 5/7/26. On 8/13/2026, 3:00 PM, Surveyor requested any investigation documentation from Nursing Home Administrator (NHA)-A in regard to R42's resident-to-resident altercations on 5/6/26 and 5/7/26. On 8/17/2026, at 10:39 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to R42's allegations of resident-to-resident altercations on 5/6/26 and 5/7/26. Surveyor asked NHA-A if NHA-A had conducted an investigation in regard to the resident-to-resident altercations that occurred on 5/6/26 and 5/7/26. NHA-A stated that there was no physical contact so no reason to submit a FRI to the State Survey Agency. NHA-A stated the nurse (LPN)-L documented what LPN-L was told and misunderstood what happened from the staff present in the room. NHA-A stated that statements were obtained from staff and will provide the statements to Surveyor. Surveyor reviewed the only 2 statements provided by NHA-A in regard to R42's resident-to-resident altercation on 5/6/26. -Psychiatric Nurse Practitioner (Psych NP)-M documented R42 attempted confrontation with peer, did not make contact and was redirected from situation. -LPN-L documented LPN-L was not present when incident occurred, LPN-L was told R42 was assaulting other residents at the time, but upon other witness accounts in the room R42 charged other resident and stood over other resident attempting to strike roommate. R42 did not make contact. Surveyor was not provided any statements from the resident-to-resident altercation that was documented on 5/7/26. On 8/17/2026, at 11:49 AM, NHA-A informed Surveyor that NHA-A did not feel NHA-A needed to submit a FRI to the State Survey Agency because R42 did not make physical contact with their roommate. The facility attributed the behavior to R42's anoxic brain damage. I felt it did not warrant a FRI. NHA-A did agree with Surveyor that a root/cause analysis was not established. NHA-A did not believe R42's aggression toward other residents was not willful with intent.

Based on interview and record review the facility did not ensure 1 (R4) of 4 residents had a complete and accurate medical record. R4 was on hospice and a full code. On [DATE] the nurses note documents (R4) time of death per hospice 1840 (6:40 p.m.). There is no documentation of an assessment or actions that preceded R4's death. Interim Director of Nursing (DON)-B stated he documented the assessment and actions on a facility risk management form and did not transfer this information into R4's medical record. Findings include:R4 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), left ischium fracture and hypertension. The significant Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact and needing maximum assistance for eating and dependent for toileting and hygiene. On [DATE] the nurses notes document R4 having a change in condition with R4's oxygenation. R4 was sent to the hospital for evaluation. On [DATE] the nurses notes document R4 readmit to the facility with hospice services and R4 wishes to remain full code. The nurses notes document R4's slow decline due to R4 not wanting to eat anymore and refusing medications. R4 did not want any further hospitalizations and requested just comfort measures. On [DATE] the nurses note documents (R4's) time of death per hospice 1840 (6:40 p.m.). There is no documentation of an assessment or actions that preceded R4 death.On [DATE] at 10:20 a.m. Surveyor interviewed Assistant Director of Nursing (ADON)-C. Surveyor asked ADON-C, what occurred on [DATE] when R4 died. ADON-C stated she was on a lunch break and was called back to the facility because R4 was found unresponsive. ADON-C stated when she arrived at R4's room, she found Interim DON-B performing CPR (cardiopulmonary resuscitation) on R4. ADON-C stated she proceeded to help Interim DON-B. ADON-C stated paramedics were at the facility to attend to a resident that was not distressed and paramedics assisted Interim DON-B. ADON-C stated she notified the hospice team. ADON-C stated she did not document any assessment or CPR being performed. ADON-C stated she believes Interim DON-B documented the assessment. On [DATE] at 1:30 p.m. Surveyor interviewed Interim DON-B. Surveyor asked Interim DON-B what occurred on [DATE] when R4 died. Interim DON-B provided Surveyor with documented assessment and description of what was completed for R4 on [DATE]. Interim DON-B stated he was made aware by a CNA that R4 was unresponsive. Interim DON-B saw R4 was unresponsive with no pulse and no respirations. Interim DON-B stated she released the air mattress and began compressions while telling staff to get the crash cart and ADON-C arrived and she assisted with getting the Automated External Defibrillator (AED) on R4. In the meantime, paramedics were in the building attending to a resident that was not distressed and came to assist Interim DON-B. Interim DON-B stated the paramedics assisted and pronounced R4 dead. Interim DON-B stated ADON-C notified the hospice team and the hospice nurse arrived and officially pronounced R4 dead. Surveyor asked Interim DON-B why the documentation of this event was documented in a risk form instead of R4 medical record. Interim DON-B stated the documentation did not carry over into R4 medical record. On [DATE] at 2:15 p.m. Surveyor explained to NHA-A that the concern R4 medical record did not contain the documented information regarding the incident on [DATE] with R4. NHA-A understood the concern and had no additional information.

Based on facility policy review, record review, facility document review, and interview, the facility failed to protect the resident's right to be free from verbal and mental abuse by staff, which affected 1 (R1) of 3 residents reviewed for abuse. Specifically, Certified Nursing Assistant (CNA) C yelled at and threatened R1.Findings include:A facility policy titled, Abuse, Neglect and Exploitation, revised 07/15/2022, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed, Definitions included 'Mental Abuse' includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. The policy revealed, 1. The facility will develop and implement that, which included a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.An admission Record revealed the facility admitted R1 on 06/27/2018 and readmitted the resident on 08/04/2025. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance; cognitive communication deficit; and generalized anxiety disorder.A skilled nursing facility (SNF) Part A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/06/2025, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. R1's Care Plan Report included a focus area initiated 12/27/2024, that indicated the resident had verbal/physical agitation/aggression that included throwing items, yelling at staff, cussing, hoarding items, rejection of care at times related to dementia, and social determinants. Interventions directed staff to allow the resident time to respond to directions or requests (initiated 12/27/2024); approach and allow the resident time to make their own decisions, reapproach if necessary, if the resident was noncompliant with cares/treatments (initiated 02/24/2025); and use de-escalation techniques with the resident when the resident expresses verbal and physical aggression (initiated 08/18/2025).An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, submitted to the state survey agency on 09/04/2025 at 10:39 PM, indicated the facility reported an allegation of abuse that occurred on 09/04/2025 at 4:30 PM. The Brief Summary of Incident revealed that at approximately 4:30 PM, R1 arrived at the nurses' station to grab a snack and was grabbing at all the snacks. Per the report, CNA C attempted to explain to R1 that she needed to assist the resident by handing the resident a snack of the resident's choice. The report indicated that CNA C proceeded to offer a snack, then set the snack tray on the other side of nurses' station. The report indicated that R1 abruptly became agitated and began to yell derogatory remarks at CNA C while throwing a sandwich. The report indicated that R1 grabbed at CNA C. The report indicated that CNA C reacted with threatening statements and was observed showing her fist at R1. Per the report, CNA C walked away from nurses' station and was then directed to leave facility, pending investigation. The report indicated that law enforcement and a case manager were notified. The report was completed by the Executive Director.A Misconduct Incident Report, dated 09/11/2025 and completed by the Executive Director, indicated that on 09/04/2025, R1 had a verbal interaction with CNA C. The report indicated that R1 became agitated and verballed aggressive toward CNA C, including threatening the CNA, and threw a sandwich at her. Per the report, CNA C reacted with a closed fist and verbally threatened [R1].During an interview on 10/13/2025 at 12:49 PM, with the assistance of a translator, R1 stated that a staff member appeared to want to hurt them (R1) when the staff member raised her arm to attempt to hit the resident. The resident stated that the staff member said something in English at the time, but they did not understand because that was not the resident's native language.During an interview on 10/13/2025 at 2:11 PM, Licensed Practical Nurse (LPN) D stated that on 09/04/2025, she heard R1 yell at CNA C and witnessed CNA C raise her fist, pointed upward in the air, and stated she was going to [expletive] [the resident] up. She stated CNA C was taken away from the incident by CNA E. She stated that she proceeded to call the Executive Director and then the Director of Nursing (DON) while she walked outside to tell CNA C to write a statement and to tell her that she was suspended, pending investigation. LPN D stated that making threats was considered abuse.During an interview on 10/13/2025 at 2:47 PM, CNA E stated that he walked up on an incident between CNA C and R1. He stated that he heard CNA C cursing at R1. He stated that he grabbed CNA C's arm and told her to go with him, and they walked away from R1. CNA E stated that he considered it abuse and intimidation because of the choice words CNA C used and her yelling at R1.During an interview on 10/14/2025 at 2:45 PM, the DON stated that it was reported to her that CNA C told R1 I'm gonna [expletive] you up with a raised arm. The DON stated that the CNA's actions were a form of abuse and intimidation. The DON stated her expectation for the prevention of abuse included staff education, for staff to treat everyone with dignity and respect, to follow policy and procedure, and report anything suspicious or complicated that they might question.During an interview on 10/14/2025 at 11:21 AM, the Executive Director stated CNA C threatened R1 and by definition, that was abuse. The Executive Director stated his expectation for the prevention of abuse was for staff to understand approach and circumstances of physical aggression from a resident. He stated that he expected staff to pause and understand what was going on with the resident, ultimately a need not being met.

Based on facility policy review, record review, facility document review, and interview, the facility failed to ensure allegations of abuse were reported timely, which affected 1 (R1) of 3 residents reviewed for abuse. Specifically, the facility failed to report an incident of verbal and mental abuse to the state survey agency withing two hours when Certified Nursing Assistant (CNA) C yelled at and threatened R1.Findings included:A facility policy titled, Abuse, Neglect and Exploitation, revised 07/15/2022, indicated, VII. Reporting/Response included, A. The facility will have written procedures that include, which included 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all required agencies (e.g. [exempli gratia; for example], law enforcement when applicable) within specified timeframes, which revealed, a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.An admission Record revealed the facility admitted R1 on 06/27/2018 and readmitted the resident on 08/04/2025. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance; cognitive communication deficit; and generalized anxiety disorder. A skilled nursing facility (SNF) Part A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/06/2025, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. R1's Care Plan Report included a focus area initiated 12/27/2024, that indicated the resident had verbal/physical agitation/aggression that included throwing items, yelling at staff, cussing, hoarding items, rejection of care at times related to dementia, and social determinants. Interventions directed staff to allow the resident time to respond to directions or requests (initiated 12/27/2024); approach and allow the resident time to make their own decisions, reapproach if necessary, if the resident was noncompliant with cares/treatments (initiated 02/24/2025); and use de-escalation techniques with the resident when the resident expresses verbal and physical aggression (initiated 08/18/2025). An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report indicated that the facility reported an allegation of abuse that occurred on 09/04/2025 at 4:30 PM. The Brief Summary of Incident revealed that at approximately 4:30 PM, R1 arrived at the nurses' station to grab a snack and was grabbing at all the snacks. Per the report, CNA C attempted to explain to R1 that she needed to assist the resident by handing the resident a snack of the resident's choice. The report indicated that CNA C proceeded to offer a snack, then set the snack tray on the other side of nurses' station. The report indicated that R1 abruptly became agitated and began to yell derogatory remarks at CNA C while throwing a sandwich. The report indicated that R1 grabbed at CNA C. The report indicated that CNA C reacted with threatening statements and was observed showing her fist at R1. Per the report, CNA C walked away from nurses' station and was then directed to leave facility, pending investigation. The report indicated that law enforcement and a case manager were notified. The report was completed by the Executive Director and indicated that it was submitted to the state survey agency on 09/04/2025 at 10:39 PM.R1's Progress Note dated 09/05/2025 at 12:40 AM, documented by Licensed Practical Nurse (LPN) D, revealed R1 was involved in an incident with a staff member on 09/04/2025 at approximately 4:10 PM. The note indicated that the Executive Director was notified at 4:13 PM, and the Director of Nursing (DON) was notified at 4:16 PM.During an interview on 10/13/2025 at 2:11 PM, LPN D stated that on 09/04/2025, she heard R1 yell at CNA C and witnessed CNA C raise her fist, pointed upward in the air, and stated she was going to [expletive] [the resident] up. She stated CNA C was taken away from the incident by CNA E. She stated that she proceeded to call the Executive Director and then the DON while she walked outside to tell CNA C to write a statement and to tell her that she was suspended, pending investigation. LPN D stated that making threats was considered abuse. During an interview on 10/14/2025 at 2:45 PM, the DON stated that it was reported to her that CNA C told R1 I'm gonna [expletive] you up with a raised arm. The DON stated that the CNA's actions were a form of abuse and intimidation. The DON stated her expectation for the prevention of abuse included reporting anything suspicious or complicated that they might question.During an interview on 10/14/2025 at 11:21 AM, the Executive Director stated that on 09/04/2025, the two-hour time reporting timeframe for abuse to the state survey agency was not followed per the facility policy.During an interview on 10/14/2025 at 3:59 PM, the Executive Director stated that he expected reporting abuse allegations to the state survey agency to meet regulatory guidelines. He stated that anything that was abuse, or serious bodily injury was to be reported within two hours of the incident being reported to staff.

3) Surveyor reviewed R2's medical record. On 12/16/24 the nurses note indicate R2 had a change of condition and experiencing chest pain and shortness of breath. R2 was sent to the hospital with an admitting diagnoses of exacerbation CHF (congestive heart failure) and UTI (urinary tract infection). On 5/19/25 during the daily exit meeting with DON (director or nursing)-B and NHA (nursing home administrator)-A, Surveyor asked for the transfer and bed hold notice for R2's hospitalization on 12/16/24. On 5/20/25, at 12:00 p.m., VP (Vice President) of Success D explain to Surveyor they have no bed hold and transfer notice for any resident. 4) Surveyor reviewed R10's medical record. On 2/24/25 R10's medical record documents: was experiencing seizures and was sent to the hospital. R10 was admitted for seizures. On 5/19/25 during the daily exit meeting with DON-B and NHA-A, Surveyor asked for the transfer and bed hold notice for R10 hospitalization on 2/24/25. On 5/20/25, at 12:00 p.m., VP of Success D explain to Surveyor they have no bed hold and transfer notice for any resident. 5) Surveyor reviewed R15's medical record. On 2/19/25 R15 was experiencing a change in altered mental status and was sent to the hospital. R15 was admitted for altered mental status. On 5/19/25 during the daily exit meeting with DON-B and NHA-A, Surveyor asked for the transfer and bed hold notice for R15 hospitalization on 2/19/25. On 5/20/25, at 12:00 p.m., VP of Success D explain to Surveyor they have no bed hold and transfer notice for any resident. 6) Surveyor reviewed R22's medical record. On 4/10/25 R22 was vomiting coffee brown emesis and was sent to the hospital. R22 was admitted due to vomiting coffee brown emesis. On 5/5/25 R22 was experiencing a change in altered mental status. R22 was admitted to the hospital. On 5/19/25 during the daily exit meeting with DON-B and NHA-A, Surveyor asked for the transfer and bed hold notice for R22 hospitalization on 4/10/25 and 5/5/25. On 5/20/25, at 12:00 p.m., VP of Success D explain to Surveyor they have no bed hold and transfer notice for any resident Based on staff and resident interview and record review, the facility did not ensure 9 resident's (R4, R5, R2, R10, R15, R22, R26, R31 and R233) of 9 resident's reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R4, R5, R2, R10, R15, R22, R26, R31, R233 and/or their representative received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. *R2 was transferred to the hospital on [DATE] and a transfer and bed hold notice were not given to R2 and/or R2's representative. *R4 was transferred tot he hospital on 1/26/25 and a transfer and bed hold notice were not given to R4 and/or R4's representative. *R5 was transferred to the hospital on 2/1/25 and a transfer and bed hold notice were not given to R5 and/or R5's representative. *R10 was transferred to the hospital on 2/24/25 and a transfer and bed hold notice were not given to R10 and/or R10's representative. *R15 was transferred to the hospital on 2/19/25 and a transfer and bed hold notice were not given to R15 and/or R15's representative. *R22 was transferred to the hospital on 4/10/25 and 5/5/25 and a transfer and bed hold notice were not given to R22 and/or R22's representative. *R26 was transferred to the hospital on 3/20/25 and a transfer and bed hold notice were not given to R26 and/or R26's representative. *R31 was transferred to the hospital on 4/23/25 and a transfer and bed hold notice were not given to R31 and/or R31's representative. *R233 was transferred to the hospital on 2/17/25 and a transfer and bed hold notice were not given to R233 and/or R233's representative. Findings include: On 5/20/25 at 12:11 PM, [NAME] President of Success-D was interviewed and indicated the business manager was doing the bed hold and transfer notices and went on leave and it fell by the wayside and wasn't being done. [NAME] President of Success-D indicated R2, R4, R5, R10, R15, R22, R26, R31, R233 and/or their representative did not receive transfer/bed hold notices for the above hospitalizations. On 5/20/25, the facilities policy titled Bed Hold Notice dated 4/23/25 was reviewed and documented: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices at the time of a transfer of hospitalization. The facility will keep a signed and dated copy of the bed hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. On 5/20/25, the facilities policy titled Transfer and Discharge dated 7/15/22 was reviewed and documented: Provide transfer notice as soon as practicable to resident and representative. 1.) On 5/20/25, the Surveyor reviewed R4's medical record and it indicated R4 was transferred to the hospital on 1/26/25. R4's medical record did not include documentation that a transfer notice had been given to the resident and/or their representative for the hospitalization. On 5/20/25 at 3:00 PM, the above findings were shared with Nursig Home Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided as to why a transfer and bed hold notice were not given to R4 and/or their representative for their hospitalization on 1/26/25. 2.) On 5/20/25, the Surveyor reviewed R5's medical record and it indicated R5 was transferred to the hospital on 2/1/25. R4's medical record did not include documentation that a transfer notice had been given to the resident and/or their representative for the hospitalization. On 5/20/25 at 3:00 PM, the above findings were shared with Nursing Home Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided as to why a transfer and bed hold notice were not given to R4 and/or their representative for their hospitalization on 2/1/25. 9) R233 was admitted to the facility on [DATE]. Surveyor reviewed R233's Electronic Medical Record (EMR) and noted R233 was hospitalized on [DATE]. R233 has not returned to the facility. On 5/20/25, at 3:35 PM, during the daily exit meeting with the facility, Surveyor requested the bed hold and transfer notice from R233's discharge to the hospital from [NAME] President (VP) of Success-D. On 05/21/2025, at 10:35 AM, VP of Success-D informed Surveyor there is no bed hold or transfer notice regarding R233's hospitalization on 2/17/25. No additional information was provided by the facility at this time. 7) R26 was admitted to the facility on [DATE]. Surveyor reviewed R26's Electronic Health Record and noted R26 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Surveyor requested the bed hold and transfer notice from R26's transfer to the hospital. On 05/20/2025, at 09:07 AM, [NAME] President (VP) of Success-D informed Surveyor there is no bed hold notice for R26 in March and the transfer notice is part of bed hold. 8) R31 was admitted to the facility on [DATE]. Surveyor reviewed R31's Electronic Health Record and noted R26 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. On 05/19/2025, at 03:12 PM, VP of Clinical-K could not find bed hold/transfer notice for R31 for the 4/23/2025 transfer to the hospital. On 05/20/2025, at 12:00 PM, VP of Success-D informed Surveyor the Business Office Manager was responsible for the bed hold/transfer notifications, but the Facility will now go back to nurses doing them, to ensure they are to be done in real time. On 05/21/2025, at 01:24 PM, Surveyor informed the Facility of the above concerns. No further information was provided at time of write up.

2.) R5 was admitted to the facility on [DATE] with diagnosis that included Dementia with Behavioral Disturbance, Schizophrenia and Anxiety. On 5/19/25, R5's physician orders were reviewed and documented R5 was on the medication olanzaphine (antipsychotic) for Schizophrenia since 6/21/23 and Seroquel (antipsychotic) since 5/19/23 for Schizophrenia. On 5/19/24, R5's Abnormal Involuntary Movement Assessment (AIMS) dated 1/2/25 was reviewed and indicated a score of 3 due to irregular movements in her upper extremities. The scoring section documented a score of 3 in only one body area requires a referral for a complete neurological exam. On 5/19/24, R5's medical record was reviewed and no neurological exam was found from 1/2/25 to present. On 5/20/25, at 12:03 PM, [NAME] President of Success-D was interviewed and indicated R5 should have had a referral for neurological exam after her score of 3 on the AIMS on 1/2/25 and this was not completed. On 5/20/25, at 3:00 PM, the above findings were shared with Nursing Home Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided as to why R5 was not referred for a complete neurological exam after her AIMS score of 3 on 1/2/25. Based on interview and record review the facility did not ensure adequate monitoring for unnecessary medications for 2 (R26 and R5) of 2 residents requiring neurological testing related to Abnormal Involuntary Movement Scale (AIMS). * R26 had an AIMS assessment score requiring a referral for a complete neurological exam, was not followed through. * R5 had an AIMS assessment score requiring a referral for a complete neurological exam, was not followed through. Findings: R26 was admitted to the facility on [DATE] with diagnoses which include, dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life), Schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves), Anxiety (an emotional state characterized by feelings of unease, worry, or fear, often related to anticipated danger or misfortune) and Bipolar Disorder (a mental health condition characterized by extreme mood swings between periods of high energy and productivity (mania or hypomania) and periods of low energy and depression). R26's most recent, Quarterly Minimum Data Set (MDS), dated [DATE], documents R26 is able to understand and be understood, with a Brief Interview for Mental Status (BIMS) score of 13 indicating R26 is cognitively intact, R26 does not exhibit any behavior concerns or rejection of care, has impairment in upper extremities (Shoulder, elbow, wrist, hand) range of motion on both sides, dependent on staff for upper and lower body dressing. Surveyor reviewed R26's Electronic Health Record and noted R19 had an AIMS assessment completed on 03/24/2025, documenting a score of 5. Surveyor reviewed the Facility provided document, titled AIMS- Abnormal Involuntary Movement NSHC (National Health Service Corps) for R19. Surveyor noted, G. SCORING .1. No single score exceeding 1 (in items 1 to 10), LOW RISK OF MOVEMENT DISORDER. 2. A score of 2 in only one of the 7 body areas (items 1 to 7), BOARDERLINE, OBSERVE CLOSELY. 3. A score of 2 in 2 or more of the 7 body areas (items 1 to 7), REFERRAL FOR NEUROLOGICAL EXAM. 4. A score of 3 or 4 in only one of the 7 body areas (items 1 to 7), REFERRAL FOR COMPLETE NEUROLOGICAL EXAM. On 05/20/2025, at 08:55 AM, Surveyor interviewed [NAME] President (VP) of Success- D regarding R26's AIMS. VP of Success-D indicated that VP of Success-D will do more digging, and the only neurological exam that was preformed for R26 was during full head to toe at the hospital. VP of Success-D indicated R26 was readmitted to the facility on [DATE] and that is when the AIMS assessment was conducted. On 05/20/2025, at 09:30 AM, Surveyor interviewed Registered Nurse (RN)-J. RN-J indicated nurses do the AIMS assessments for residents receiving psychotropic medications. Surveyor asked RN-J by looking at R26's AIMS dated 03/24/2025, what would the nurse do. RN-J indicated with a score of 5- refer for complete assessment, need to be evaluated more closely and notify the physician. On 05/20/2025, at 11:22 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R26's AIMS conducted on 03/24/2025. DON-B indicated that triggers every quarter and the nurse on days or PM is supposed to complete them but sometimes DON-B will complete the AIMS. For the AIMS dated 03/24/2025, DON-B indicated she would expect nurses to put in a note, notify the provider and management. DON-B informed Surveyor DON-B started re-education beginning today. On 05/21/2025, at 01:24 PM, Surveyor informed the Facility of the above concerns. No further information was provided at time of write up.

Based on observation, record review and staff interviews, the facility did not ensure food was mechanically altered per provided recipe for 3 (R1, R11 & R19) of 3 sampled residents with puree textured diet orders. On 5/19/25, Surveyor observed Dietary Aide-M not preparing pureed breakfast sausage links according to a recipe to provide the highest level of nutrition to residents receiving a puree diet. Findings include: On 5/19/25 at 7:22 AM, Surveyor began a continuous observation of kitchen breakfast food preparation and service. Surveyor observed Dietary Aide-M preparing breakfast sausage link puree. Surveyor noted the kitchen's robot coupe (a blending device for preparing pureed foods) contained approximately 25 breakfast sausage links. Surveyor asked Dietary Aide-M how many portions of puree breakfast sausage they would be preparing. Dietary Aide-M responded There should be six. Dietary Manager-N who was observing Dietary Aide-M then told Surveyor they actually believe there are 3 or 4 residents who are receiving a puree diet at this time. Surveyor observed preparation of the breakfast sausage link puree. Surveyor observed Dietary Aide-M pouring 3 unmeasured spoonfuls of thickening powder to the robot coupe and an unmeasured amount of boiling water to the breakfast sausage mixture which they pureed at this time. On 5/19/25 at 8:35 AM, Surveyor completed observations of dining room breakfast service and requested facility menus and puree recipe for breakfast sausage links from Dietary Manager-N. Dietary Manager-N told Surveyor they would print out the menus and recipes for Surveyor to review. On 5/19/25 at 9:12 AM, Surveyor returned to the facility's kitchen to observe dishwashing service. At 5/19/25 at 9:28 AM, Surveyor followed up with Dietary Manager-N to request the puree recipe for breakfast sausage links for a second time. On 5/19/25 at 9:35 AM, Dietary Aide-M approached Surveyor. Dietary Aide-M told Surveyor they had meant to add gravy to the breakfast sausage puree this morning and had forgotten to add the gravy to the recipe instead of boiling water to make the breakfast sausage puree more nutritious. On 5/19/25 at 10:05 AM, Dietary Manager-N provided Surveyor with a recipe for pureed breakfast sausage patties. On 5/19/25 at 10:35 AM, Surveyor spoke to [NAME] President (VP) of Success-D to request the proper puree recipe for breakfast sausage links in lieu of puree breakfast sausage patties. On 5/19/2025 3:55 PM at the daily exit meeting, Surveyor was told by VP of Success-D that there was no current recipe in place for puree breakfast sausage links. On 5/21/2025 at 12:35 PM, Surveyor conducted interview with Director of Nursing (DON)-B, VP of Success-D and VP of Clinical-K. Surveyor shared concerns regarding the observations of Dietary Aide-M not following a recipe during preparation of the puree breakfast sausage links and adding unmeasured amounts of thickener and water that could impact the nutritive value of the puree food. Surveyor also voiced concerns related to dietary staff not having awareness of how many portions of puree to prepare for residents who are in need of a puree diet. VP of Success-D confirmed with Surveyor that as of the start of the recertification and complaint survey on 5/18/25 that there were 3 residents at the facility that required a puree diet. No additional information was shared by the facility at this time.

Based on interview, record review, and policy review, the facility failed to investigate a potential misappropriation of medication for one of one resident (Resident (R) 3) reviewed for misappropriation of medication out of total sample of 11. Specifically, the failure to ensure misappropriation had not occurred, had the potential to allow one nurse to continue to pass medications to residents for an indefinite period. Findings include: Review of the facility provided policy titled, Medication Administration General Guidelines, dated 01/2024, revealed . Medications are to be administered at the time they are prepared . The individual who administered the medication dose records the administration on the resident's MAR (Medication Administration Record) immediately following the medication being given. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications . Review of the facility provided policy titled, Abuse, Neglect and Exploitation, dated 07/15/22, revealed an immediate investigation is warranted when allegations or suspicion of abuse . occur . Providing complete and thorough documentation of the investigation . Review of R3's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R3 was admitted to the facility on [DATE] for a five-day respite stay. R3 had a diagnosis of Alzheimer's disease. Review of R3's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/24 and located in the EMR under the MDS tab, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 2/15, which indicated the resident was severely cognitively impaired. Per the MDS, the resident exhibited delusions during the assessment period. Review of R3's Medication Administration Record (MAR), located in the EMR under the Orders tab, revealed R3 had an order for Lorazepam (also known as Ativan, an anti-anxiety medication) oral tablet 0.5mg (milligrams), one tablet by mouth every four hours as needed for anxiety or restlessness with a start date of 08/15/24. R3 received one tablet of the medication on 08/15/24 at 10:42 PM, 08/16/24 at 12:29 AM, 3:45 AM and 12:22 PM, and 08/17/24 at 8:14 PM. Review of R3's Medication Administration Record (MAR), located in the EMR under the Orders tab, revealed R3 also had an order for Lorazepam oral tablet 0.5mg (milligrams), two tablets by mouth every four hours as needed for anxiety or restlessness If 1 (one) tab is ineffective second tab can be administered two hours before next dose. R3 received two tablets on 08/16/24 at 8:19 AM, 08/17/24 at 8:12 PM, 08/18/24 at 9:06 PM, 08/19/24 at 7:48 AM and 8:28 PM, and 08/20/24 at 8:31 AM. Review of the Resident Controlled Substance Record, revealed on 08/18/24 seven Lorazepam were signed out, however, according to the MAR and the Progress Notes, only four tablets were given. Review of the Progress Notes under the Progress Notes tab revealed R3 received four 0.5mg tablet of Lorazepam on 08/18/24. The Resident Controlled Substance Record, the Progress Notes and the MAR revealed seven Lorazepam were signed out on 08/18/24, but only four were documented on the MAR as being administered to R3. During an interview on 09/18/24 at 5:22 PM, the Director of Nursing (DON) said they had begun their investigation 09/06/24 when R3's family member contacted the facility concerned about how much medication R3 received during his five-day respite stay. The DON confirmed Registered Nurse (RN) 1, who administered the medication on 08/17/24, 08/18/24 and 08/19/24 did not document in the MAR on 08/18/24 that the Lorazepam had been administered to the resident. She said the nurse had documented on the Resident Controlled Substance Record that she had removed three 0.5mg Ativan on 08/18/24 and two 0.5mg Ativan on 08/19/24. The DON said when they completed the investigation, they were investigating whether the resident had received too much Ativan. The DON stated they did not investigate whether the medication had been misappropriated. The DON said RN1 received education to ensure administered medication was documented on the MAR. She said RN1 did not receive education until 09/16/24, 10 days after the investigation started, because that was the first day they had worked together. RN1 worked four shifts prior to education. During an interview on 09/19/24 at 9:18 AM, the Regional Nurse Consultant (RNC) confirmed Registered Nurse (RN) 1, who administered the medication on 08/17/24, 08/18/24 and 08/19/24 did not document in the MAR on 08/18/24 that the Lorazepam had been administered to R3. The RNC said it had never occurred to her that the medication had been misappropriated, just that RN1 had not documented. During an interview on 09/19/24 at 5:51 PM, the Assistant Director of Nursing (ADON) said when a narcotic was administered, it was important to sign the medication out in the Resident Controlled Substance Record and the MAR at the same time. He said that if it was only documented in the Resident Controlled Substance Record and not in the MAR, he would contact the nurse for the previous shift to verify whether the medication had been administered to avoid a double dose, which could increase sedation and risk of falls for the resident.

Based on interview, record review, and facility policy review, the facility failed to exercise reasonable care for the protection of personal items for one of one sampled resident (Resident (R) 3) reviewed for protection of personal property out of a total sample of 11 residents. Specifically, when R3 was discharged from his five-day respite stay, the facility was unable to provide him with all of the personal items he had admitted to the facility with. This failure has the potential to cause undue stress and expense to the family and/or resident. Findings include: Review of the Resident Rights policy, revised 07/2022, revealed, . The resident has the right to retain and use personal possessions, including furnishings and clothing, as space permits . Review of R3's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R3 was admitted to the facility on [DATE] for a five-day respite state. R3 had a diagnosis of Alzheimer's disease. Review of R3's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/24, located in the EMR under the MDS tab, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 2/15, which indicated the resident was severely cognitively impaired. Review of the Grievance/Complaint Report. provided by the facility and dated 09/06/24, revealed R3's family member had contacted the Administrator regarding R3's personal belongings of clothing and a back scratchier. During an interview on 09/18/24 at 12:45 PM, R3's family member said when she brought R3 home, the facility did not give her all of his clothes that he had admitted with. She said after she brought him home, she called the Administrator to report her concerns. She said she did receive a few of his items in the mail but received clothing that belonged to another resident because their name was written on the collar. During an interview on 09/19/24 at 7:30 PM, Certified Nurse Aide (CNA) 1, CNA2 and CNA3 said whenever they assist a resident with their discharge, they use the inventory sheet to compare what personal items the resident had when they admitted and what personal items the resident leaves with to ensure they have all of their personal items. All agreed this was very important because residents' items are important to the residents. During an interview on 09/19/24 at 8:15 PM, the Administrator said that when R3 discharged on [DATE], facility staff were unable to give him all clothes he had admitted with. She said after hearing from R3's family regarding the missing clothes, she sent the family some of his additional clothing via certified mail. The Administrator said they had not been able to provide everything to R3 at that time. During the survey, the Administrator said she had found more of R3's additional items and would contact the family to determine what else was missing and what the facility could purchase to ensure R3 had everything he had admitted with.

Based on interview, record review, and policy review, the facility failed to clarify a physician's order for as needed (PRN) lorazepam (Ativan, a controlled anti-anxiety medication) for one of 11 sampled resident (Resident (R) 3) reviewed for medication administration out of a total sample of 11. Specifically, the failure to clarify the order caused confusion in medication administration for R3. Findings include: Review of the facility provided policy titled, Medication Orders Controlled Substance Medication Orders, dated 01/2023, revealed . Dosage form . Time and frequency of administration . Elements of a valid controlled substance prescription PRN (as needed) orders clearly delineate the condition for which they are being administered . Review of R3's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R3 was admitted to the facility on [DATE] for a five-day respite stay. R3 had a diagnosis of Alzheimer's disease. Review of R3's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/24 and located in the EMR under the MDS tab, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 2/15, which indicated the resident was severely cognitively impaired. Per the MDS, the resident exhibited delusions during the assessment period. Review of R3's Medication Administration Record (MAR), located in the EMR under the Orders tab, revealed R3 had an order for lorazepam oral tablet 0.5mg (milligrams), one tablet by mouth every four hours as needed for anxiety or restlessness with a start date of 08/15/24. Review of R3's Medication Administration Record (MAR), located in the EMR under the Orders tab, revealed R3 also had an order for lorazepam oral tablet 0.5mg (milligrams), two tablets by mouth every four hours as needed for anxiety or restlessness. It was recorded, If 1 (one) tab is ineffective second tab can be administered two hours before next dose. During an interview on 09/18/24 at 5:22 PM, the Director of Nursing (DON) stated R3's family member had contacted the facility regarding the amount of lorazepam R3 had received during his stay, and when the facility began an investigation into the concern, they had identified the orders for the lorazepam were confusing. The DON stated the order should have been clarified upon R3's admission. She said she and the Assistant Director of Nursing (ADON) had received education, and she had sent a text to all nurses with the guidance. During an interview on 09/19/24 at 9:18 AM, the Regional Nurse Consultant (RNC) confirmed the order should have been clarified upon R3's admission. The RNC said she had provided the DON and the ADON with education on 09/06/24, when they started their investigation, regarding the importance of clarifying Range Orders and a Standard Dose Order should be obtained.

Based on record review and staff interview, the facility did not ensure that 1 allegation of a Resident to Resident altercation involving 2 Residents (R2 and R9) was reported immediately to the State Survey Agency. * On 7/14/24, R2 received a closed fist hit to the left forearm resulting in a bruise which was not reported to the State Survey Agency. Findings Include: The facility's policy Abuse, Neglect, and Exploitation policy and procedure implemented 3/2018 and last reviewed/revised on 7/15/2022 documents: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures investigations include: 1. Identifying staff responsible for the investigation 3. Investigating different types of alleged violations 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause 6. Providing complete and thorough documentation of the investigation VII. Reporting Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury 4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes may be needed to prevent further occurrences b. Defining whether care provision should be changed and/or improved to protect Residents receiving services c. Training of staff on changes made and demonstration of staff competency after training is implemented d. Identification of staff responsible for implementation of corrective actions e. The expected date for implementation f. Identification of staff responsible for monitoring the implementation of the plan B. The Administrator will follow up with government agencies to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1) R2 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Generalized Idiopathic Epilepsy, Hypothyroidism, Anxiety, Major Depressive Disorder, Schizophrenia, and Pervasive Developmental Disorder. R2's Quarterly Minimum Data Set (MDS) completed on 5/4/24 documents that R2 has both short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R2 has a Patient Health Questionnaire(PHQ-9) score of 0 and no behaviors are documented. R2 is dependent on staff for mobility, transfers, dressing, and toileting needs. R2's comprehensive care plan documents the following applicable focused problems with interventions: 1. Behavior monitoring due to anxiety, cognitive impairment, schizophrenia, history of verbal/physical agitation/aggression, yelling out, calling out, grabbing at others, hitting self and other Residents, lack of response to interventions/becomes combative/agitation, history of picking at skin and putting objects in mouth, history of taking food from other Resident, history of wandering and pacing. Initiated 10/3/19, Revised 7/9/24 -May be physically abusive-11/4/20 -May be verbally abusive-11/4/20 -Verbal/Physical Aggression-11/5/20 1. Provide consistent staff 2. Anticipate and meet needs in a timely manner 3. Provide music for R2 -Encourage R2 to propel wheelchair in areas where there is more personal space-7/9/24 2. Episodes of anxiety as evidenced by (yelling out, calling out, hitting at self) due to cognitive impairment, impaired communication, loss of control-11/4/20 -Target Behavior-calling out/yelling out, hitting at self-11/5/20 1. Provide reassurance 2. Provide comfort items 3. Provide music 4. Anticipate and meet needs in a timely manner -Target Behavior-throwing self on floor-11/5/20 1. Allow for R2 to sit in common areas with other Residents 2. Give positive praise 3. Provide R2 comfort with stuffed animals/music -Target Behavior-yelling out/calling out, grabbing at others-11/5/20 1. Family visits/calls 2. Address pain, toileting needs, and other caregiver needs in a timely manner 3. Keep hands occupied with stuffed animals 3. Vulnerability: R2 is a vulnerable adult and is at risk for potential abuse due to cognitive deficit, ability to communicate, inappropriate behavior, wandering-2/10/24 -Facility staff educated on reporting abuse-2/10/24 -Facility staff will follow facility policy and procedure-2/10/24 -Facility staff will observe for changes in mood, behavior, psychological needs and cognition-2/10/24 -Redirect from potentially dangerous situations-2/10/24 -Redirect when around others that disturb me or that I disturb-2/10/24 -R2 will be free of retaliation if alleged abuse is reported-2/10/24 2) R9 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left On-Dominant Side, Dyspagia, Chronic Obstructive Pulmonary Disease, Adult Failure to Thrive, Chronic Systolic Heart Failure, and Dementia. Surveyor noted that that R9's comprehensive care plan was not updated with interventions after the Resident to Resident altercation on 7/14/24. On 7/14/24 at 10:48 AM, Licensed Practical Nurse (LPN)-C documented: R2 received aggression(closed fist hit) to the right forearm by another Resident. No apparent injury noted at this time. Residents immediately separated. Notifications to Director of Nursing (DON)-B, physician, HCPOA, and caseworker. On 7/14/24 at 10:51 AM, LPN-C documented: The current status is Resident to Resident altercation. Monitor right forearm for bruising entered. On 7/15/24 at 2:43 AM, Registered Nurse (RN)-D documented: Current status is R2 remains on 24 hour board for peer-to-peer incident that leg to a bruise right forearm. R2 is resting in bed with eyes closed and doesn't appear to be in any pain or discomfort. Right forearm bruise is more in AC area which is pinkish in color. R2 can move right forearm without any limitations. On 7/15/24 at 2:52 AM, RN-D documented: Current status is R9 remains on 24 hour board for peer to peer behavioral incident. On 7/15/24 at 6:49 AM, LPN-E documented: Current status is peer to peer altercation. Bruise to left forearm continue to resolve. On 7/15/24 at 10:50 AM, LPN-C documented: Correction: Bruise is to the left forearm. On 7/16/24 at 10:55 AM, LPN-C documented: The current status is Post Resident to Resident: R2 sustained a left forearm bruise. Bruise remains no signs/symptoms of bleeding/infection. No signs/symptoms of pain/discomfort. On 7/16/24 at 12:47 AM, DON-B documented: Bruise/redness to the left forearm is resolved. All parties of the care team and HCPOA notified. On 7/18/24 at 11:25 AM, LPN-C documented: Current status is post new left forearm bruise. Bruise has no signs/symptoms of bleeding/infection. Nursing staff continue to monitor behaviors. Surveyor noted R9's nursing progress notes located in R9's medical record document that R9 is being monitored for aggressive behavior due to Resident to Resident altercation. On 8/1/24 at 3:01 PM, DON-B informed Surveyor that the team did not feel R9 hitting R2 with a closed fist was an intent to harm R2. DON-B explained that R2 can get very loud, vocal, and gets too close to other Residents. Surveyor shared the concern that this altercation was not submitted to the State Survey Agency within the required reporting time frame. No further information was provided by the facility at this time. On 8/5/24 at 11:37 AM, Surveyor again shared the concern that R2's progress notes contain documentation that R2 was hit with a closed fist by R9 resulting in a bruise to the left forearm. DON-B stated, the team did not feel there was intent and there actually was no bruise on R2. Surveyor informed DON-B that R2's progress notes document R2 had a bruise and was being monitored for the bruise. Surveyor shared that R9 was being monitored for aggressive behaviors. Surveyor asked to the facility if there is any additional information to provide that explained why the facility did not report this incident to the State Survey Agency within the required timeframes. No additional information was provided as to why the Resident to Resident altercation involving R2 and R9 was not reported immediately to the State Survey Agency.

Based on record review and staff interview, the facility did not ensure that 2 allegations of Resident to Resident altercations involving 4 Residents(R2 and R3 and R2 and R9) were thoroughly investigated. *On 7/12/24 the facility submitted a Misconduct Incident Report describing an altercation of R2 scratching R3 on 7/5/24. The facility did not complete a thorough investigation including staff statements, other resident statements, and a root/cause analysis of the altercation. *On 7/14/24 the facility did not complete a thorough investigation of the altercation between R9 and R2. R9 hit R2 with a closed fist on the left forearm resulting in a bruise. The facility did not obtain staff statements, other resident statements, and a root/cause analysis of the altercation. Findings Include: The facility's policy Abuse, Neglect, and Exploitation policy and procedure dated as last reviewed/revised on 7/15/2022 documented: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures investigations include: 1. Identifying staff responsible for the investigation 3. Investigating different types of alleged violations 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause 6. Providing complete and thorough documentation of the investigation VII. Reporting Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury 4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes may be needed to prevent further occurrences b. Defining whether care provision should be changed and/or improved to protect Residents receiving services c. Training of staff on changes made and demonstration of staff competency after training is implemented d. Identification of staff responsible for implementation of corrective actions e. The expected date for implementation f. Identification of staff responsible for monitoring the implementation of the plan B. The Administrator will follow up with government agencies to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1) R2 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Generalized Idiopathic Epilepsy, Hypothyroidism, Anxiety, Major Depressive Disorder, Schizophrenia, and Pervasive Developmental Disorder. R2's Quarterly Minimum Data Set (MDS) completed on 5/4/24 documented R2 has both short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R2 has a Patient Health Questionnaire(PHQ-9) score of 0 and no behaviors are documented. R2 is dependent on staff for mobility, transfers, dressing, and toileting needs. R2's comprehensive care plan documented the following applicable focused problems with interventions: 1. Behavior monitoring due to anxiety, cognitive impairment, schizophrenia, history of verbal/physical agitation/aggression, yelling out, calling out, grabbing at others, hitting self and other Residents, lack of response to interventions/becomes combative/agitation, history of picking at skin and putting objects in mouth, history of taking food from other Resident, history of wandering and pacing. Initiated 10/3/19, Revised 7/9/24 -May be physically abusive-11/4/20 -May be verbally abusive-11/4/20 -Verbal/Physical Aggression-11/5/20 1. Provide consistent staff 2. Anticipate and meet needs in a timely manner 3. Provide music for R2 -Encourage R2 to propel wheelchair in areas where there is more personal space-7/9/24 2. Episodes of anxiety as evidenced by (yelling out, calling out, hitting at self) due to cognitive impairment, impaired communication, loss of control-11/4/20 -Target Behavior-calling out/yelling out, hitting at self-11/5/20 1. Provide reassurance 2. Provide comfort items 3. Provide music 4. Anticipate and meet needs in a timely manner -Target Behavior-throwing self on floor-11/5/20 1. Allow for R2 to sit in common areas with other Residents 2. Give positive praise 3. Provide R2 comfort with stuffed animals/music -Target Behavior-yelling out/calling out, grabbing at others-11/5/20 1. Family visits/calls 2. Address pain, toileting needs, and other caregiver needs in a timely manner 3. Keep hands occupied with stuffed animals 3. Vulnerability: R2 is a vulnerable adult and is at risk for potential abuse due to cognitive deficit, ability to communicate, inappropriate behavior, wandering-2/10/24 -Facility staff educated on reporting abuse-2/10/24 -Facility staff will follow facility policy and procedure-2/10/24 -Facility staff will observe for changes in mood, behavior, psychological needs and cognition-2/10/24 -Redirect from potentially dangerous situations-2/10/24 -Redirect when around others that disturb me or that I disturb-2/10/24 -R2 will be free of retaliation if alleged abuse is reported-2/10/24 2) R3 was admitted to the facility on [DATE] with diagnoses of Parkinsons Disease, Chronic Kidney Disease, Stage 3, Cardiomyopathy, Malignant Neoplasm of Liver, Dementia, and Bipolar. R3's Quarterly Minimum Data Set (MDS) completed on 7/15/24 documented R3 has a Brief Interview for Mental Status(BIMS) score of 9, which means R3 demonstrates moderately impaired skills for daily decision making. R3's MDS does not document any mood or behavior issues. R3 is dependent for mobility. transfers, and dressing. R3's comprehensive care plan documented: -R3 is at risk for changes in mood due to anxiety, depression, psychiatric illness, history of peer-to-peer altercation Initiated 11/8/23 Revised 7/17/24 -Vulnerability: R3 is a vulnerable adult and is at risk for potential abuse due to cognitive deficit-3/4/24 3) R9 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left On-Dominant Side, Dyspagia, Chronic Obstructive Pulmonary Disease, Adult Failure to Thrive, Chronic Systolic Heart Failure, and Dementia. R9's Quarterly Minimum Data Set (MDS) completed on 5/3/24 documented R9 has a Brief Interview for Mental Status(BIMS) score of 9, which means R9 demonstrates moderately impaired skills for daily decision making. R9 has no mood issues and delusions is documented for R9. R9 is dependent for mobility, transfers, and dressing. Surveyor notes that R9's comprehensive care plan was not updated with interventions after the Resident to Resident altercation on 7/14/24. On 7/14/24 at 10:48 AM, Licensed Practical Nurse (LPN)-C documented R2 received aggression(closed fist hit) to the right forearm by another Resident. No apparent injury noted at this time. Residents immediately separated. Notifications to Director of Nursing (DON)-B, physician, HCPOA, and caseworker. On 7/14/24 at 10:51 AM, LPN-C documented the current status is Resident to Resident altercation. Monitor right forearm for bruising entered. On 7/15/24 at 2:43 AM, Registered Nurse (RN)-D documented current status is R2 remains on 24 hour board for peer-to-peer incident that leg to a bruise right forearm. R2 is resting in bed with eyes closed and doesn't appear to be in any pain or discomfort. Right forearm bruise is more in AC area which is pinkish in color. R2 can move right forearm without any limitations. On 7/15/24 at 2:52 AM, RN-D documented: Current status is R9 remains on 24 hour board for peer to peer behavioral incident. On 7/15/24 at 6:49 AM, LPN-E documented: Current status is peer to peer altercation. Bruise to left forearm continue to resolve. On 7/15/24 at 10:50 AM, LPN-C documented: Correction:bruise is to the left forearm. On 7/16/24 at 10:55 AM, LPN-C documented The current status is Post Resident to Resident: R2 sustained a left forearm bruise. Bruise remains no signs/symptoms of bleeding/infection. No signs/symptoms of pain/discomfort. On 7/16/24 at 12:47 AM, DON-B documented: Bruise/redness to the left forearm is resolved. All parties of the care team and HCPOA notified. On 7/18/24 at 11:25 AM, LPN-C documented: Current status is post new left forearm bruise. Bruise has no signs/symptoms of bleeding/infection. Nursing staff continue to monitor behaviors. Surveyor noted that R9's nursing progress notes located in R9's medical record document that R9 is being monitored for aggressive behavior due to Resident to Resident altercation. On 7/5/24 the facility submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the State Survey Agency documenting R2 was observed reaching out and scratching R3 on the right forearm measuring 11x0.5x0.1. The facility submitted the Misconduct Incident Report on 7/12/24. The report was submitted along with 1 staff statement from the Social Worker (SW)-F who witnessed it. Education on how to recognize behaviors to help prevent incident from recurring was given to the staff. Surveyor noted the Misconduct Incident Report was missing a page. On 8/1/24 at 3:01 PM, DON-B informed Surveyor that the team did not feel R9 hitting R2 with a closed fist was an intent to harm. DON-B explained that R2 can get very loud, vocal, and gets too close to other Residents. Surveyor shared the concern that this altercation was not submitted to the State Survey Agency with-in the required reporting time-frame. No further information was provided by the facility at this time. Surveyor shared the concern that a thorough investigation was not completed with staff statements, Resident interviews, and a root/cause analysis completed for each of R2 peer to peer altercation with R3 and R9 peer to peer altercation with R2. No further information was provided at this time by the facility. On 8/5/24 at 11:37 AM, Surveyor again shared the concern that R2's progress notes contain documentation that R2 was hit with a closed fist by R9 resulting in a bruise to the left forearm. DON-B stated, the team did not feel there was intent and there actually was no bruise on R2. Surveyor shared R2's progress notes document R2 had a bruise and was being monitored for the bruise. Surveyor shared that R9 was being monitored for aggressive behaviors. Surveyor shared again the concern that R2 and R3's altercation investigation did not contain staff statements, Resident interviews, and a root/cause analysis was identified. Surveyor expressed to the facility if there is any additional information to provide it for Surveyor to review. No additional information was provided as to why the facility did not ensure that the two allegations of Resident to Resident altercations involving R2 and R3 and R2 and R9 were thoroughly investigated.

Based on observation, interview, and record review the Facility did not ensure each Resident received adequate supervision and assistance devices to prevent accidents for 2 (R1 & R2) of 3 Residents reviewed for accidents. *R1 was assessed to require one-to-one staff supervision. R1 was left unattended and sustained a fall on 04/16/2024 that resulted in multiple fractures. Surveyor had observations of R1 not having fall prevention interventions in place of antiroll back equipment or a fall mat in place as documented in the care plan. *R2 was observed to not have current fall prevention interventions of auto lock brakes and Dycem in place. Findings include: The facility's policy titled:NSG (nursing) Accidents and Supervision with a last revision date of 07/04/2022, documents, . 3. Implementation of Interventions-Using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: e. Ensuring that the interventions are put into action. 5. Supervision-supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency b. Based on the individual resident's assessed needs and identified hazards in the resident environment. Surveyor reviewed the one-to-one training provided to staff for R1, titled 1:1 (one-to-one) Caregiver Basics which documents . Under no circumstance is the resident to be left unattended (unless otherwise specified in the care plan). Even if the resident is sleeping the assigned one-to-one staff must be present. -If providing one-to-one supervision and the assigned staff needs to be relieved for any reason, the assigned staff must utilize the call light and wait for another staff member to respond and provide supervision of the resident. - If the resident has a need (food, water, etc.) the assigned one-to-one staff should utilize the call light so that another staff member can respond and retrieve the needed items. R1 was initially admitted to the facility on [DATE] with diagnoses of Parkinson's disease, Alzheimer's disease, weakness, and moderate dementia. R1's annual Minimum Data Set (MDS), dated [DATE], indicates R1 is severely impaired cognitively with no BIMS (Brief Interview of Mental Status) score. Per R1's MDS, R1 experiences hallucination, delusions, and behavioral symptoms. Section GG0170 (Mobility) of R1's MDS indicates R1 requires partial/moderate assistance with roll left to right, sit to lying, lying to sitting, and sit to stand. Section E0200 (Behavior Symptoms) indicates behavior occurred daily for physical behavioral symptoms directed toward others, verbal behavior symptoms directed toward others, and other behavioral symptoms not directed toward others. Section E0500 (Impact on Resident) indicated Yes for, put the resident at significant risk for physical illness or injury, significantly interfere with the resident's care, and significantly interferes with the resident's participation in activities or social interactions. R1's Risks For Falls care plan, with an initiation date of 01/31/2024, documents in part interventions of, [R1] is to have anti roll back on wheelchair. R1's Risk For Fall Care Plan revised on 02/07/2024, documents an intervention of a fall mat for comfort and as fall intervention. The interventions were revised on 04/22/2024, to include bed to be in low position. R1's Behavior Care Plan, with an initiation date of 02/15/2024, documents in part the intervention of, one-to-one will be provided by staff unless family is present and provide mat or covering on floor for resident to sit on. On 4/16/2024, the Facility submitted a Facility Reported Incident (FRI), Misconduct Incident Report, to the State Agency regarding R1 being found lying on the floor next to the bed. R1 was sent to the hospital for further evaluation and found to have a right hip fracture. Surveyor reviewed R1's hospital discharge summary dated 04/22/2024. R1 was discharged from the hospital with a right hip fracture, right femur fracture and multiple right rib fractures. R1 required surgical intervention and had a right intramedullary nailing by orthopedics on 04/17/2024. The Facility investigated R1's fall and found on 04/16/2024, Certified Medication Aide (CMA)-F was assigned to provide one-to-one care to R1. Per the FRI, CMA-F stated R1 was sleeping, and CMA-F left R1's room to use the restroom. The Facility's Investigation Summary documents Staff educations [sic] was initiated immediately following the incident to ensure all care plan interventions are in place. Audit completed on all residents to ensure that care plan information was accurate and reflective interventions listed on the kardex. On 05/13/2024, at 09:37 AM, Surveyor observed R1 in R1's room. Certified Nursing Assistant (CNA)-C was providing one-to-one supervision. R1 was sitting in the wheelchair eating chips from the bedside table. Surveyor noted R1 did not have anti rollback device on the wheelchair as indicated in R1's care plan. On 05/13/2024, at 09:59 AM, CNA-C left the room with R1 and returned to the room at 10:26 AM. Surveyor noted R1 to now have anti tip back device on the wheelchair. Surveyor noted R1's At Risk for Falls Care Plan did not have anti tip back devices listed as an intervention, rather anti roll back devices were to be on the wheelchair. CNA-C informed Surveyor R1 is on one-to-one supervision due to falls and behaviors. On 05/13/2024, at 10:30 AM, Surveyor interviewed Registered Nurse (RN)-D. RN-D informed Surveyor RN-D works as needed and started working at the facility in February of 2024. RN-D informed Surveyor R1 has been on one-to-one supervision since RN-D started working at the Facility. RN-D states RN-D was working the day of R1's fall. RN-D states she was in a treatment room at the time when she was informed of the fall. RN-D states she went to R1's room, assessed R1, and ultimately sent R1 to the hospital for hip pain. RN-D indicated R1 had not been moved prior to transport arriving. RN-D informed Surveyor if a resident requires one-to-one supervision it is relayed in the daily report between shifts and a CNA is assigned to the one-to-one on the schedule. RN-D states if the assigned one-to-one CNA needs a break, the CNA's will work that out between the CNA's to relieve each other. On 05/13/2024, at 10:35 AM, Surveyor interviewed Social Services Director (SSD)-E. SSD-E states she was working the day R1 was found on the floor and was in the conference room across the hall from R1's room. SSD-E states she heard something across the hall and went to see what happened. SSD-E states she saw R1 on the floor. SSD-E verified CMA-F was to be a one-to-one with R1 and was not present in the room with R1 at that time. On 05/13/2024, at 11:10 AM, Surveyor interviewed the Maintenance Director (MD)-G. MD-G states Nursing staff will put in a request for wheelchair equipment for residents through a computer maintenance request system. MD-G informed Surveyor anti tip back equipment prevents resident's wheelchair from tipping backwards and anti-roll back equipment prevents residents' wheelchairs from rolling backwards. MD-G states he will print out a report once a month to check equipment. Surveyor asked MD-G if there is antiroll back equipment on R1's wheelchair. MD-G states no, there is not antiroll back equipment on R1's wheelchair. MD-G informed Surveyor he had just installed anti tip back equipment to R1's wheelchair today. Surveyor asked MD-G if there was an order put into a computer maintenance request system for R1's wheelchair equipment, MD-G states no, he received a verbal order to equip R1's wheelchair with anti-tip back equipment today. On 05/13/2024, at 12:20 PM, Surveyor called CMA-F confirmed being the one-to-one staff assigned to R1 on 04/16/2024 when R1 was found on the floor. CMA-F states while supervising R1, CMA-F needed to use the restroom. CMA-F indicated R1 was sleeping in bed and CMA-F looked into the hall but did not see anyone to ask for assistance. CMA-F states she went to the bathroom and when she came out, she saw staff members by R1's room. CMA-F states once she got to R1's room, R1 was on the floor. CMA-F informed Surveyor she received training on the Facility one-to-one policy immediately during the investigation and after the investigation. CMA-F states during a one-to-one supervision, the resident is not to be left alone and to ensure staff is always with one-to-one resident. On 05/13/2024, at 12:28 PM Surveyor observed R1 in bed, with a family member in the room. Surveyor noted R1's bed was not in the low position and a fall mat was not on the floor as per R1's care plan. On 05/13/2024, at 12:58 PM, Surveyor interview MDS Coordinator, Licensed Practical Nurse (LPN)-I. LPN-I states on 04/16/2024, LPN-I was coming from the front office when she heard a staff member say, Call 911. LPN-I states R1 was found on the floor in R1's room. LPN-I informed Surveyor R1 was to have a mat on the floor but did not at the time she was found on the floor. LPN-I also states, R1's bed was at the height of LPN-I's hip, about 30 inches from the ground at that time. LPN-I states reeducation on one-to-one supervision was provided to all CNA's after the incident. On 05/13/2024, at 01:15 PM, Surveyor interviewed [NAME] President of Success (VP)-J. VP-J states there is no Facility policy for one-to-one supervision and states the training provided for one-to-one supervision is specific for R1 only. On 05/13/2024, at 01:39 PM, Surveyor shared with the Nursing Home Administrator (NHA)-A and VP-J the concern R1 was assessed to require one-to-one supervision, was left unattended and sustained a fall on 04/16/2024 which resulted in multiple fractures. Surveyor shared the concern R1 was observed to not have antiroll back equipment or a fall mat in place as care planned. No further information was provided at that time. 38253 2) R2 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis of the right side due to a cerebral infarction, dysphagia, pervasive developmental disorder, congestive heart failure, epilepsy, anxiety, depression, and schizophrenia. R2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R2 had severe cognitive impairment per staff assessment. R2 had a Legal Guardian. R2's Activities of Daily Living Care Plan interventions stated R2 needed assistance of one for bed mobility, dressing, personal hygiene, toileting, and transfers. R2 had an At Risk for Falls Care Plan initiated 9/19/2019 and had been last revised on 6/5/2023. The interventions in place on 5/13/2024 during the survey included: -Anticipate and meet R2's needs; encourage R2 to always call for assistance; keep frequently used items within reach. -Auto lock brakes to wheelchair. -Dycem for wheelchair cushion. -Follow therapy recommendations for transfers, mobility and ambulation. -Frequent rounds on [R2]. -Nurse Practitioner to follow for anxiety diagnosis. -Once [R2] is awake, after morning ADL (Activities of Daily Living) cares, offer to assist into wheelchair. -Reclining back wheelchair. -Saddle gel cushion in wheelchair. On 5/13/2024, at 9:59 AM, Surveyor observed R2 lying awake in bed. The bed was in a low position. R2's reclining back wheelchair was on R2's side of the room across from the bed. The wheelchair had a gel saddle cushion in place. Auto lock brakes were not observed to be on the wheelchair and Dycem was not under the wheelchair cushion as per care plan. In an interview on 5/13/2024, at 11:11 AM, Surveyor asked Maintenance Director-G what the facility process was for a resident to have a device put on a resident wheelchair. Maintenance Director-G stated a request is entered by the nurse into a computer maintenance request system and Maintenance Director-G then completes the request and signs out the work order is completed in the system. Surveyor asked Maintenance Director-G what the difference was between anti-tippers and anti-rollbacks for a wheelchair. Maintenance Director-G stated the anti-tippers keep the chair from tipping over backwards and the anti-rollbacks keep the chair from going backwards. Surveyor asked Maintenance Director-G if R2 had any devices on the wheelchair. Maintenance Director-G was not able to recall R2 having any devices. Surveyor asked Maintenance Director-G if Maintenance Director-G had a list of all the resident wheelchairs that had devises on them. Maintenance Director-G stated once a month a list is printed to check the equipment on the wheelchairs. Surveyor requested that list from Maintenance Director-G. Review of the list did not show R2 had any device on the wheelchair. R2's CNA (Certified Nursing Assistant) Kardex, which provides interventions that should be in place per the care plan, listed the following interventions: -Auto lock brakes to wheelchair. -Saddle gel cushion in wheelchair. -Once R2 is awake, after morning ADL cares, offer to assist into wheelchair. -Reclining back wheelchair. In an interview on 5/13/2024, at 12:24 PM, Surveyor asked Certified Nursing Assistant (CNA)-H if CNA-H was familiar with R2. CNA-H stated CNA-H was caring for R2 that day. Surveyor asked CNA-H if R2 had any interventions to keep R2 safe or to keep from falling. CNA-H stated R2 did not have any specific interventions. Surveyor asked CNA-H if R2 had a special cushion in the wheelchair or Dycem that needed to be placed under the wheelchair cushion. CNA-H stated no. On 5/13/2024, at 1:15 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the observation of R2's wheelchair that did not have auto lock brakes in place and no Dycem was under the wheelchair cushion. Surveyor shared with NHA-A the interview Surveyor had with CNA-H and CNA-H not being aware of any interventions for R2's safety. NHA-A did not have any further information at that time.

Based on observations, interviews, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and to ensure residents do not develop new pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. This affected 2 of 4 residents (R23 and R12) reviewed for pressure injuries. *R23 was admitted to the facility with hospital discharge documents indicating R23 was being discharged with three stage 3 pressure injuries: one to the left and right buttock and one to the coccyx. The facility did not comprehensively assess these areas upon admission. The facility did not take note of the pressure injuries on R23's buttocks upon admission. The admission evaluation identifies R23 as having a pressure injury on the sacrum - stage 2 - with no comprehensive details of the wound bed or characteristics of the wounds. The sacral wound deteriorated to a facility acquired unstageable pressure injury that became a stage 4 pressure injury due to the continual need for debridement. The facility did not comprehensively assess R23's wounds to show the characteristics of the wound beds or details of the wound(s). The facility did not make timely revisions to R23's care plans to address the ongoing deterioration of R23's sacral pressure injury and to assist in healing. *R12 developed two facility acquired pressure injuries that were not comprehensively assessed. The facility assessed one area to be a stage two pressure injury with the presence of granulation, which would be an incorrect stage. During observations of R12's pressure injury, it was noted R12 had two open areas on the buttocks that were not comprehensively assessed or properly treated. The areas were observed with one large piece of gauze covering both areas, which is not what the physician ordered. Surveyor shared her observation and concerns with facility administration and noted the areas still were not comprehensively assessed or had clarified treatment orders for each of the areas of pressure injury on R12's buttocks. 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. Policy Explanation and Compliance Guidelines: 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. ii. If non pressure: Initiate the Non-Pressure Injury tracker UDA - one per wound. iii. Ensure primary care physician (PCP) is aware of wounds/location of wounds and current treatment orders. iv. Ensure appropriate treatment orders for each wound area, as needed. 1. R23 admitted to the facility on [DATE] and has diagnoses that include Chronic Kidney Disease stage 3, dependence on renal dialysis, Type 2 Diabetes Mellitus, Thrombocytopenia, and Lymphedema. R23 receives dialysis three times a week. On 2/27/24 at 9:38 AM, Surveyor spoke with R23. He reported he was down at home for 3 days before his neighbor alerted his family and police. He reported he does not remember anything, was in the hospital for weeks, and only remembers waking up in the facility. R23 reported he developed a pressure injury on his butt. R23 stated, It was pretty bad, but they're taking good care of it now. R23 reported he still goes to the wound clinic. When asked how he thought the wound developed, he stated probably from lying in bed. R23 reported he was not sure if the wound developed in the hospital or after admission to the facility. R23's Annual Brief Interview for Mental Status (BIMS) dated 2/10/24 documents a score of 15 indicating no cognitive impairment. R23's Hospital Discharge Summary included documentation dated 1/30/23 of: Stage 3 left buttock, right buttock, coccyx. Facility progress note on 2/3/23 at 22:17 (10:17 pm) documents: Admission Summary Note Text: Resident is alert and orientated, able to make all needs known. Resident is aware of situation and is responsible for self. Resident complains of chronic pain to knees from arthritis. Denies needing pain medication at this time. Resident has pressure sore to coccyx area which the hospital was packing with Dakin's and covered with gauze. Surveyor noted there is no reference to the possible stage 3 areas on R23's left and right buttocks. R23's Admission evaluation dated 2/3/23 documents: - Sacrum. Pressure stage II. There were no measurements or description of the wound and no documentation about the right and left buttock pressure injuries. Surveyor noted the admission evaluation references a sacrum wound vs. the coccyx as noted by facility staff in progress notes. Surveyor also noted the change in staging of the wounds from the hospital discharge summary without a full assessment to show how the wounds were downstaged. R23's ADL (Activities for Daily Living) care plan initiated 2/4/23 indicates R23 requires assist of 2 staff for bed mobility. R23's Admission Minimum Data Set (MDS) dated [DATE] documents: R23 requires substantial/maximal assistance for rolling left and right, sitting to lying requires substantial/maximal assist with helper doing more than half of the effort. The MDS also indicates R23 has a stage 1 or greater pressure injury and is at risk for pressure injuries. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Number of Stage 3 pressure ulcers (2). Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry (2). Unstageable - Slough and/or eschar - Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar (1). Number of these unstageable pressure ulcers that were present upon admission/entry or reentry (1). Surveyor noted the reference to 2 stage three areas is possibly consistent with the hospital discharge summary, however the facility had not assessed the pressure areas on R23's right and left buttocks upon admission to include staging or characteristics of the wounds. Surveyor noted the facility staged R23's sacrum to be a stage 2 on 2/3/23 without measurements or description of the wound bed. The MDS assessment of R23 having an unstageable pressure injury would be considered a decline in a pressure injury possibly since admission and would no longer be a wound present upon admission. This would now be a facility acquired unstageable pressure injury. The facility's Pressure Injury Weekly Tracker dated 2/10/23 is the first documentation of an assessment and measurements of R23's wounds which documented: Sacrum unstageable 4.5 x 2.6 x 0.1 cm (centimeters) 20% gran, 30% slough, 50% necrotic. Right buttock stage 3 - 1.9 x 4 x 0.1 cm. Left buttock stage 3 - 4 x 1.9 x 0.1 cm. Specialty mattress. Surveyor noted there were no details of the tissue type for the right and left buttock pressure injuries despite being stage 3 areas. R23's wounds were followed by the (name of contracted wound group) wound Physician. The (name of contracted wound group) Wound evaluation & management summary dated 2/10/23 documents: Sacrum: Unstageable (due to necrosis) sacrum full thickness 4.5 x 2.6 x 0.1 cm Right buttock: Stage 3 pressure wound of the right buttock full thickness 1.9 x 4 x 0.1 cm. Left buttock: Stage 3 pressure wound of the left upper buttock full thickness 4 x 1.9 x 0.1 cm. Surgical excisional debridement procedure. Remove Necrotic Tissue and Establish the Margins of Viable Tissue. On 3/30/23, the facility revised R23's ADL care plan to indicate R23 needs the assistance of 1 staff for bed mobility. R23's nutrition care plan dated 3/30/23 included intervention to provide supplements QD (each day) as ordered to aid in wound healing. Surveyor noted R23's nutritional care plan focus area to increase nutritional needs related to wound healing occurred after R23's sacral/coccyx wound had already declined. R23's at risk for skin integrity care plan initiated 3/30/23 indicates R23 is at risk for alteration in skin integrity related to impaired mobility. Goals initiated 3/30/23 include decrease/minimize skin breakdown risks. Interventions initiated 3/30/23 include barrier cream to peri area/buttocks as needed, diet and supplements per MD orders, Encourage fluids, Observe skin condition with ADL care daily, report abnormalities, Pressure redistributing device on bed/chair, Provide preventative skin care routinely and PRN (as needed), Use pillows/positioning devices as needed. On 4/7/23, the (name of contracted wound group) wound Physician evaluation documents: Sacrum: Stage 3 pressure wound 4.3 X 2.5 X 0.2 cm Right buttock: Stage 3 pressure wound 0.5 X 0.5 X 0.1 cm Left buttock: resolved. Surveyor noted there are no details identifying tissue type within the wound or other characteristics of the remaining wounds. Surveyor noted the sacral pressure injury was previously an unstageable area. On 4/20/23, the (name of contracted wound group) wound Physician evaluation documents: Sacrum: Stage 4 pressure wound sacrum full thickness 4 x 1.9 x 0.6 cm. Remove Necrotic Tissue and Establish the Margins of Viable Tissue. Post debridement - stage: 4. Right buttock: Stage 3 pressure wound of right buttock 1.5 x 1 x 0.1 cm. Surveyor noted there are no details describing the wound bed or other characteristics of the wound that would constitute a full assessment of the wound. There are no details identifying the characteristics of the sacral pressure injury prior to debridement. Surveyor noted there were no changes to R23's care plan to address R23 having a stage 4 facility acquired pressure injury. R23's care plan was not updated to reflect R23 having a stage 4 pressure injury until 10/25/23 when the facility initiated a care plan with a focus of: Actual stage IV (4) pressure wound injury to sacrum. Goals initiated 10/25/23 include: will show continual signs of healing, will develop no new areas of skin breakdown, will heal within limits of the disease process, will heal without complication, and resident/representative will perform wound care procedure correctly by discharge date . Interventions initiated 10/25/23 include: Administer treatment per MD orders, Diet and supplements per MD orders, Follow up care with MD as ordered, Obtain labs as ordered and notify MD of results, Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain etc. Notify MD PRN. Surveyor noted there was no review of R23's support surfaces or assessment of need for repositioning leading to a care plan intervention. The care plan for actual stage 4 pressure wound injury to sacrum care plan was revised on 11/1/23 to include an intervention to add an air mattress to R23's bed and check for proper function/inflation every shift. On 11/22/23, R23's at risk for alteration in skin integrity related to impaired mobility care plan had a revised intervention dated 11/22/23 stating to reposition every 2 hours. Surveyor noted these added interventions to R23's plan of care are months after R23 developed a facility acquired stage 4 pressure injury. Surveyor noted through review of R23's plan of care there is no intervention to address R23 attending dialysis three times a week and the increased risk this may pose to R23's skin integrity. At some point, which the facility was unable to definitively provide, R23 began to be followed by the hospital wound clinic versus the (name of contracted wound group) wound Physician. R23's stage 3 pressure injuries to the right and left buttock healed and only the sacrum pressure injury remains. R23's Outpatient wound care progress note dated 12/28/23 states - Pressure ulcer stage (4) sacrum. Coccyx wound base with moist viable granulation tissue to base today. Some slough visible in wound bed at 12 o'clock debrided today. Still some gray necrosis on underside of undermining at 12 o'clock - this is not visible on examination but through exploratory curetting of the tissue here. Debrided today. Palpates near bone but covered by soft tissue at 12 o'clock. Periwound with dull erythema without warmth. Previous posterior thigh wounds bilateral ischial healed. See back in wound clinic 2 weeks. Outpatient wound care note dated 1/18/24 documents: Sacrum with small opening with undermining circumferentially. 2 x 0.5 x 2.7 cm. Not conducive to bedside debridement. Patient does not appear septic or ill today. Review of R23's plan of care for actual stage 4 pressure wound injury to sacrum initiated 10/25/23 included a revised intervention dated 1/8/24 stating: encourage resident to offload area of pressure injury every 2-3 hours. Roho cushion to wheelchair. R23's 2/10/24 annual MDS indicates R23 is independent at rolling left to right however needs supervision or touching assistance as R23 completes other mobility actions such as sit to lying, lying to sitting on edge of bed etc. Actions that can be related to repositioning. R23's MDS indicates R23 does not demonstrate behaviors including the rejection of care. The MDS indicates R23 does not have a stage 1 or greater pressure injury but is at risk for pressure injuries. The MDS indicates R23 has no unhealed pressure injuries. Review of R23's care plan for at risk for alteration in skin integrity related to: impaired mobility initiated 3/30/23 included an intervention dated 2/12/24 stating: risk vs benefit in place d/t (due to) resident not wanting to reposition self, continue to encourage resident to reposition. Review of R23's plan of care for actual stage 4 pressure wound injury to sacrum initiated 10/25/23 included a revised intervention dated 2/12/24 stating: risk vs benefit in place d/t (due to) resident not wanting to reposition self, continue to encourage resident to reposition. On 2/27/24 at 2:02 PM, Surveyor spoke with Director of Nursing (DON)-B who reported RN-G does wound rounds with the wound doctor every week. Surveyor asked who is responsible for completing an assessment and measurements of new wounds. DON-B reported all nurses are responsible to assess, measure, and document any new wounds. Surveyor asked what happens if the wound physician is unable to come to the facility for scheduled wound rounds. DON-B reported he sends a replacement. Surveyor was advised R23 currently has only 1 wound, on the coccyx. Surveyor advised unable to locate a comprehensive assessment and measurement of R23's coccyx wound upon admission to the facility on [DATE] and the first documentation was completed on 2/10/23 by the wound physician. DON-B reported she would get the information for Surveyor. DON-B informed Surveyor R23 began going out to the wound clinic a few months ago and is no longer seen by the facility wound Physician. On 2/28/24 at 10:02 AM, Surveyor spoke with DON-B and RN-G. Surveyor asked who is responsible to complete an assessment and measurements on residents that admit with wounds or when wounds are found. DON-B reported the nurse doing the admission is supposed to measure the wound and describe what it looks like. RN-G added: Then we rely on the doctor to stage it. I am not wound certified, and we don't have anyone here that is wound certified, so we have the doctor look at it and go by what he says. Surveyor asked what happens if the doctor doesn't come until the following week. RN-G stated: Well, we have the documentation of the measurements and what it looked like when first seen, so he can see that. I know he (R23) came in with wounds, so he was put on the list to be seen by the wound doctor. Surveyor advised DON-B and RN-G that R23's admission assessment on 2/3/23 documents only the sacral pressure injury as a stage 2 and there was no comprehensive assessment, description of the wound, or measurements. One week later on 2/10/23 the wound Physician documented the unstageable sacral pressure injury and stage 3 pressure injuries to right and left buttock. DON-B reported the assessment and measurements should be on the admission assessment, adding: We'll have to do education with the nurse responsible for doing the admission. I think the admission skin assessment was not accurately completed. DON-B reported it is the expectation the nurses are supposed to measure and describe what the wound looks like, and the doctor will stage it. Surveyor asked when R23's stage 3 buttocks pressure injuries healed. RN-G reported she did not remember, I know his sacral wound got worse and deteriorated really quick, that's when he started to go to the wound clinic. On 2/28/24 at 3:15 PM, Nursing Home Administrator (NHA)-A and DON-B were advised of the concerns related to R23's pressure injury care. No additional information was provided. 2. R12 admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following Cerebral Infarction affecting right dominant side, Gastrostomy, Epilepsy, and Dementia. R12's Brief Interview for Mental Status (BIMS), dated 1/13/24, documented a score of 0 indicating severe cognitive impairment. R12's Care plan focus area revised 3/7/23 documents: Resident is at risk for skin integrity condition, or pressure sores r/t (related to): Impaired mobility, incontinence, thin/fragile skin, dementia, rt (right) side cva (Cerebral Vascular Accident), epilepsy - revised 3/7/23. The resident has potential for pressure ulcer development r/t Imp (impaired) mobility; incontinence; dementia - revised 8/22/19. The resident has pressure ulcer right buttock r/t Immobility initiated 1/15/24, revised 1/18/24. Interventions include Administer treatments as ordered and monitor for effectiveness. On 2/27/24 at 9:56 AM, Surveyor observed R12 lying in bed on her back with a pillow under her head. R12's legs were turned toward the left side, she was wearing fuzzy socks on her feet, which were not offloaded. Surveyor observed an air mattress on the bed and the head of her bed was elevated 30 degrees. Facility progress notes dated 1/15/24 at 2:05 AM document: Clinical Follow Up Note Text: Resident is on follow up for 1/14 nights superficial O/A (open area). The current status is Writer received report from pm (evening) nurse that pm CNA (Certified Nursing Assistant) reported the O/A right buttock, but pm nurse didn't proceed with tx (treatment). 1 cm (centimeter) x 1 cm superficial pink wound distal end of Right buttock as well as 2 superficial scratches 1 cm and 2 cm long that are scabbed from self-infliction. Writer left scratches OTA (open to air), cleansed wound with NS (normal saline) applied medihoney on wound, applied skin prep around wound and apply borderline drsg (dressing) over wound. R12's current February 2024 Treatment Administration Record (TAR) documents: Cleanse O/A with NS apply skin prep surrounding skin and apply medi honey to wound, apply borderline drsg (dressing) every 3 days and prn (as needed) one time a day every 3 day(s) for wound Right buttock - start Date 1/15/24, discontinue date 2/7/24. Surveyor noted the (name of contracted wound group) Physician notes dated 1/19/24 documents: Signing off on patient who remains in the facility - no open wound. Surveyor noted although the wound physician documented no open wounds on 1/19/24, the ordered treatment for R12's right buttock pressure injury had been signed out as completed in the TAR through 1/30/24. Surveyor noted R12's current February 2024 TAR documents 9 for 2/2/24 and 2/5/24 which indicates other/see progress notes. There was no documentation in R12's progress notes on these dates related to the right buttock wound or treatment. Facility progress note dated 2/5/24 at 10:28 AM documents: Skin/Wound Note Text: Patient received a bed bath this am shift. Wound to right buttock and gastric tube site remains. There were no new skin issues noted or reported at this time. Will continue to monitor. The Facility Pressure Injury Weekly Tracker dated 2/13/24 documents: Right buttock stage II. 1.5 x 0.5 cm (centimeters) 100% granulation. Surveyor noted this is not correctly staged as a stage 2 pressure injury would not include a wound with granulation. According to the National Pressure Injury Advisory Panel (NPIAP) the definition of a Stage 2 Pressure Injury is: Partial-thickness skin loss with exposed dermis 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). R12's February 2024 TAR included an order: Provide wound care to right buttock as follows: Cleanse wound with soap and water, rinse with water and pat dry. Skin prep peri-wound followed by Medihoney and bordered gauze dressing until healed. Wound care daily and as needed. one time a day for wound care to right buttock. Wound Doctor to assess - start date 2/14/2024 - signed out as completed through 2/28/24. The (name of contracted wound group) Physician note dated 2/23/24 documents: Non-pressure wound of the right buttock etiology (quality) trauma/injury 1 x 4.1 x 0.1 cm. The Facility Skin Review Weekly dated 2/26/24 documents: Pressure injury right and left buttock treatment noted. Surveyor noted there was no comprehensive assessment or measurements of the left buttock pressure injury, and no treatment was ordered or implemented on the TAR. On 2/28/24 at 9:15 AM, Surveyor observed R12's pressure injuries with assistance of Certified Nursing Assistant (CNA)-H. Surveyor observed both of R12's buttock cheeks covered together with the same large white gauze dressing and tape. Surveyor observed an opening at the inferior aspect of the dressing. CNA-H pulled back the dressing revealing 2 separate pressure injuries, 1 on her left buttock and 1 on her right buttock. Surveyor noted there was not a separate dressing on each pressure injury. Both pressure injury wound beds were shallow and pink with no active drainage or signs of infection noted. On 2/28/24 at 10:02 AM, Surveyor spoke with Director of Nursing (DON)-B and Registered Nurse (RN)-G about R12's pressure injuries. RN-G reported she has been doing wound rounds with the wound doctor as of Friday, which was the last time. Surveyor advised of facility progress notes which documented a pressure injury on R12's right buttock was noted 1/15/24. Treatment was implemented for medihoney and border dressing which was signed out as completed through 1/30/24, however wound Physician note on 1/19/24 documented no wounds. RN-G stated: That treatment should have been discontinued. Surveyor advised the treatment was being signed out in the TAR as having been completed. RN-G stated: They're probably just signing it out without reading it, that happens sometimes. Surveyor looked at DON-B and clarified: So you are saying the nurses are signing out treatments in the TAR without having completed them? DON-B stated: Probably. We'll have to do education. Surveyor asked RN-G why the (name of contracted wound group) Physician note on 2/23/24 note documents non-pressure wound of the right buttock etiology (quality) trauma/Injury 1 x 4.1 x 0.1 cm. RN-G stated: I don't know, maybe he was referring to the scratches. Surveyor advised R12's weekly skin review dated 2/26/24 documents pressure injury to right and left buttock with no documentation of an assessment or measurements of the left buttock pressure injury, and no treatment for the left buttock pressure injury implemented on the TAR. RN-G reported she was only aware of the right buttock pressure injury. Surveyor asked what a border dressing is. RN-G reported it is a 1-piece dressing with gauze in the center and an adhesive border surrounding it. Surveyor advised of observations of R12's pressure injuries, 1 on each buttock covered with 1 large piece of gauze dressing secured with several pieces of tape covering both buttocks with opening at inferior dressing/buttocks cheeks. RN-G stated: So there wasn't a border dressing on each wound? Surveyor replied no. RN-G stated: OK, well that's not right, there should be a border dressing on each one if there is (sic) 2 separate wounds. On 2/28/24 at 3:14 PM, Surveyor advised Nursing Home Administrator (NHA)-A and DON-B of concerns: Nurses signed out treatment for R12's right buttock pressure injury on the TAR as completed after the wound allegedly was healed per Physician, and statement that facility aware nurses sign out treatments without completing them. R12's weekly wound tracker dated 2/26/23 documents pressure injuries right and left buttock. The left buttock pressure injury has no treatment ordered or implemented and there are no comprehensive assessments or measurements of the pressure injury. In addition, Surveyor observed the ordered treatment for R12's right buttock pressure injury was not in place. No additional information was provided. On 2/29/24 at 11:52 AM, Surveyor review of R12's TAR revealed there was still no treatment implemented for her left buttock pressure injury. In addition, there was no documentation of a comprehensive assessment or measurements of the left buttock pressure injury. Surveyor advised the facility. No additional information was provided.

Based on observations, interviews and record review, the facility did not implement an effective infection control and prevention program before, and during a COVID outbreak in the facility. This deficient practice has the potential to affect all 49 residents who reside in the facility. As of 2/22/23 the facility was having a COVID-19 outbreak with 10 staff and 24 of their 49 residents positive for COVID-19. The outbreak began on 2/9/23 with 2 residents (R2 and R3) testing positive. R2 and R3 ate in the communal dining room until they tested positive for COVID-19. On 2/9/23, the facility did not implement infection control measures to stop the transmission of COVID-19. The facility did not conduct contract tracing of those residents who were in the dining room seated near R2 and R3 to determine their risk of getting COVID-19. The facility did not implement measures to reduce the spread of COVID-19 in the communal dining and activities such as identifying which residents were vaccinated against COVID-19, residents wearing face masks, 6-foot distancing, ensuring hand hygiene. The facility did not limit other residents who had been in close contact with R2 and R3 from attending group dining or any other group activities until 2/12/23, potentially spreading the virus. During the survey, staff were observed entering and exiting resident rooms who had COVID-19 and going into resident rooms with no COVID-19 without wearing appropriate personal protective equipment (PPE), wearing the PPE incorrectly, and without disinfecting their eye protection. The facility did not implement policy and procedures related to staff fit testing for N95 masks, staff wearing appropriate personal protective equipment (PPE), surveillance of staff wearing appropriate PPE and following infection control policy and procedures. There was no staff education with the onset of the COVID-19 outbreak to discuss interventions to control the spread of COVID-19. The facility's failure to implement an effective infection control and prevention program to prevent the transmission of COVID-19 resulted in an immediate jeopardy which began on 2/9/23 with a COVID outbreak. Surveyor notified Administrator-A and DON-B of the immediate jeopardy on 2/22/23 at 4:35 PM. The immediate jeopardy was not removed at the time of the facility exit on 2/22/23. Findings include: Surveyor reviewed the facility's policy and procedure for Coronavirus Prevention and Response dated 10/11/22. The policy indicates the facility will respond promptly upon suspicion of illness associated with COVID infection in efforts to identify, treat and prevent the spread of the virus. The procedures include: -Residents are placed in empiric transmission-based precautions based on close contact with someone with COVID infection should be maintained in transmission-based precautions for the following time periods: - Residents can be removed from transmission-based precautions after day 7 following the exposure if they do not develop symptoms and all viral testing as per CDC (Centers for Disease Control) guidance is negative. - The facility may consider designated units with dedicated HCP (Health Care Personnel) to care for residents with COVID infections. - HCP who enter the room of a resident with suspected or confirmed COVID infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. - Respirators should be used in the context of a comprehensive respiratory protection program in accordance with OSHA Respiratory Protection Standard. Surveyor reviewed the facility's policy and procedure for COVID-19 Visitation and Communal Activities/ Dining dated 10/4/22. The procedures for Communal activities (including activity and dining groups) indicate: Communal activities and dining do not have to be paused during an outbreak, unless directed by the state or local health department. Residents who are on transmission-based precautions should not participate in communal activities and dining until the criteria to discontinue transmission-based precautions are met. On 2/22/23 at 8:40 AM Surveyor met with Administrator-A and DON-B. DON-B is also the Infection Preventionist for the facility and has been the Infection Preventionist since August 2022. DON-B has a certificate of completion of an Infection Control program. On 2/22/23, Surveyor noted the facility currently has a COVID-19 outbreak which began on 2/9/23. Surveyor was informed the facility does not have a designated COVID unit, and the units are mixed with residents who are positive for COVID-19 and residents who are not positive for COVID-19. The facility does not have designated staff specifically for Residents who have COVID. In an interview on 2/22/2023 at 9:15 AM, Nursing Home Administrator (NHA)-A stated the COVID-19 outbreak started with two residents (R2 and R3) on 2/9/2023 when both residents tested positive for COVID 19. NHA-A stated a nurse came in for work on 2/9/2023 and was told everyone was being tested for COVID-19. NHA-A stated the intent was for all the employees to be tested , but not the residents. NHA-A stated the nurse misunderstood and tested all the residents on the unit. NHA-A stated it was a good mistake because that was how they discovered COVID-19 was in the building. NHA-A stated once they had the two positive residents on the one unit, all residents were tested , and no other residents were positive for COVID-19. NHA-A stated one of the residents (R2) was a dialysis resident so went out into the community on a regular basis and the other resident (R3) had recently had out-of-state visitors, so they determined that was where the COVID-19 came from. NHA-A stated R3 kept close company with another resident so they monitored that resident closely, along with their roommate, and on 2/12/2023, both of those residents (R8 and R11) tested positive for COVID-19. R8 was unvaccinated for COVID-19. R8 had symptoms of a sore throat. No antiviral was given due to hospice status per the line list. R11 was unvaccinated for COVID-19. R11 had symptoms of a cough. An antiviral was given per the line list. Surveyor reviewed a facility summary of events which indicated: On 2/9/23 after R2 and R3 tested positive for COVID-19, the facility did not limit other residents who had been in close contact with R2 and R3 from attending group dining or any other group activities until 2/12/23, potentially spreading the virus. Surveyor noted on 2/9/23, the facility did not implement infection control measures to stop the transmission of COVID-19 in regard to the other residents who ate in the communal dining room and participated in group activities. The facility did not conduct contract tracing of those residents who were in the dining room seated near R2 and R3 to determine their risk of getting COVID-19. The facility did not implement measures to reduce the spread of COVID-19 in the communal dining and activities such as identifying which residents were vaccinated against COVID-19, residents wearing face masks, 6-foot distancing, ensuring hand hygiene The facility did not limit other residents who had been in close contact with R2 and R3 from attending group dining or any other group activities until 2/12/23, potentially spreading the virus. On 2/12/23 there was 2 additional residents who tested positive for COVID who had contact with the 2 residents on 2/9/23. On 2/13/23 an additional 5 residents were positive for COVID with 1 resident going to the hospital. On 2/14/23 1 additional resident tested positive. On 2/15/23 there was an additional 7 residents who tested positive for COVID. There was 3 symptomatic staff who tested positive for COVID. The COVID Line List indicates 1 resident was sent to the hospital. On 2/16/23 there was an additional 7 residents who tested positive for COVID. The COVID Line List indicates 5 residents. There was 2 symptomatic staff tested positive for COVID. On 2/17/23 there was 2 residents (R11) who tested positive for COVID and 1 staff. The Covid Line List indicates 3 residents with COVID. On 2/18/23 3 staff tested positive for COVID. The COVID Line List indicates 1 resident went out to the hospital. On 2/21/23 2 residents tested positive for COVID and 1 staff. This COVID-19 summary was not consistent with the facilities COVID-19- out break line list provided to Surveyors. On 2/9/2023 at 11:00 AM in the progress notes, nursing charted R2 tested positive for COVID-19 using a rapid test. A viral respiratory panel was ordered to confirm the result. At 1:39 PM nursing charted an SBAR (Situation, Background, Assessment, Recommendation) was completed with the onset of a respiratory infection and respiratory isolation was implemented. R2 was vaccinated for COVID-19 with two initial doses and one booster dose. On 2/10/2023 at 11:32 AM in the progress notes, nursing charted R2 remained asymptomatic for COVID-19 and would be starting a medication for COVID-19 in the morning. On 2/22/2023 at 12:44 PM, Surveyor observed R2's door closed. Signs were posted on the door for contact and droplet isolation as well as a sign that stated to keep door closed. An isolation bin was outside of the room with personal protective equipment (PPE) in the drawers. Surveyor noted R2's roommate, R11, was being monitored for COVID-19 as of 2/14/2023 per the surveillance line list provided of the COVID-19 outbreak. R11 tested positive for COVID-19 on 2/17/2023. R11 was unvaccinated for COVID-19. On 2/9/2023 at 10:59 AM in the progress notes, nursing charted R3 tested positive for COVID-19 using a rapid test. A viral respiratory panel was ordered to confirm the result. At 1:04 PM nursing charted R3 was in respiratory isolation pending final results for COVID-19 test. R3 was short of breath at times but takes oxygen off frequently. The head of the bed was elevated, vital signs were stable, and no cough was present. R3 was vaccinated for COVID-19 with two initial doses and one booster dose. On 2/10/2023 at 11:25 AM in the progress notes, nursing charted R3 had oxygen on at 2 liters per nasal cannula with an oxygen saturation of 95%. R3 was asymptomatic but positive for COVID-19. R3 would be starting a medication for COVID-19 in the morning. On 2/22/2023 at 12:45 PM, Surveyor observed R3 sitting in their room in a wheelchair with oxygen on. R3 was no longer in isolation for COVID-19. The facility line list for the COVID-19 outbreak indicated R3 was symptomatic with shortness of breath yet nursing charted R3 was asymptomatic. In an interview on 2/22/2023 at 1:45 PM, DON-B stated on 2/9/2023, all communal activities were still going on including communal dining. Surveyor noted R8 and R11 were not restricted after 2/9/2023 after having close contact with R2 and R3. DON-B stated residents and staff were tested , but visitors were not tested so they must have brought COVID-19 into the building. DON-B stated on 2/12/2023, when two more residents tested positive, was when they shut down, stopping communal dining and activities. Surveyor asked DON-B if education was done with staff when the outbreak started on how to stop or contain the spread of COVID-19. DON-B stated no formal education was given to staff. NHA-A stated general conversations were had, but nothing was formally documented regarding specific education. Surveyor reviewed the resident COVID-19 outbreak line list. The line list did not include date isolation started or ended. Surveyor noted discrepancies between what was entered onto the line list and what was documented in resident records. *R3 had shortness of breath per the line list. Progress notes stated R3 was asymptomatic. *R4, unvaccinated for COVID-19, had a positive rapid test on 2/16/2023 per the line list. Progress notes stated R4 tested positive on 2/18/2023. *R7, unvaccinated for COVID-19, tested negative on 2/16/2023 and tested positive on 2/21/2023 per the line list. Progress notes stated R7 tested positive on 2/16/2023. In an interview on 2/22/2023 at 10:58 AM, Surveyor asked NHA-A about the line list and progress notes for R7 on 2/16/2023 because they did not match. NHA-A stated DON-B was not in the facility at that time and NHA-A and DON-B went through the line list when DON/IP-B returned and separated the residents from the staff, so they created two-line lists. NHA-A stated DON-B would be able to answer Surveyor's question about R7 better than NHA-A. On 2/22/2023 at 11:05 AM, Surveyor asked DON-B for clarification of the discrepancy with the line list and the progress notes for R7 on 2/16/2023. DON-B stated the line list was correct and the documentation in the progress notes was inaccurate. DON-B stated R7 tested negative on 2/16/2023 and then when retested on [DATE], R7 was positive. R1, vaccinated for COVID-19 with the first two initial doses and no boosters, tested positive on 2/13/2023 and was hospitalized on [DATE] per the line list. Progress notes are as follows: On 2/13/2023 at 6:46 PM in the progress notes, a physician telehealth visit was documented by the physician. The physician charted R1 presented with a one-day history of respiratory concerns including: loose cough, white sputum, and the need for supplemental oxygen. The physician charted per the nurse, R1 had worsening of symptoms. The physician charted R1 stated they were short of breath and nursing reported R1 was requiring more supplemental oxygen. The physician charted R1 was receiving oxygen at 2 liters per nasal cannula with an oxygen saturation of 92-93% with a baseline of less than 95%. The physician charted the nurse informed the physician the facility was in an outbreak of COVID-19, however R1 had tested negative twice that day. The physician charted a conversation was had with the nurse that despite a negative COVID-19 test, R1 could still have a positive COVID-19 PCR and ordered R1 to be sent to the hospital. On 2/13/2023 at 7:15 PM in the progress notes, nursing charted R1 tested negative for COVID-19 but spoke to physician via telehealth to update on R1's change in condition of lethargy, complaints of not being able to breathe, and sore throat. R1 was sent to the emergency room . On 2/14/2023 at 4:07 AM in the progress notes, nursing charted R1 had been admitted to the hospital with COVID-19. Surveyor noted the physician documented on 2/13/2023 that R1 had a one-day history of symptoms. No documentation was found of symptoms on 2/12/2023 and the line list indicated symptoms started on 2/13/2023. If symptoms were present on 2/12/2023, Surveyor could not determine what interventions were put in place to contain COVID-19 or any other respiratory virus. R1 was sent and admitted to the hospital on 2/13/2022; the line list indicated R1 was sent to the hospital on 2/14/2023. In an interview on 2/22/2023 at 1:44 PM, Surveyor shared with NHA-A and DON-B the concern R1's physician progress note on 2/13/2023 indicated R1 had a history of respiratory symptoms for one day and Surveyor did not see anything was done for R1 on 2/12/2023. NHA-A stated the physician writes their note at the end of the day so R1's symptoms were only there for the day the physician saw R1, which was 2/13/2023. DON-B stated DON-B was not aware of R1 having any symptoms prior to 2/13/2023. Surveyor shared the line list stated R1 went to the hospital on 2/14/2023 when in fact R1 went to the hospital on 2/13/2023. DON-B stated that was just a data entry error. Surveyor shared the concern with NHA-A and DON-B that the line list was inaccurate with the data that was entered for some residents and did not show the complete picture to help with the tracking and trending of the outbreak. On 2/22/2023 at 8:59 AM, Surveyor observed Housekeeper-L cleaning a room with a contact and droplet precaution sign posted on the door. The door to the room was wide open while Housekeeper-L was cleaning the room. Housekeeper-L removed her gown when leaving the room but did not clean the eye protection Housekeeper-L was wearing before entering another non-COVID room. On 2/22/23 at 11:25 AM, Surveyor observed and spoke with HK-K (Housekeeper). HK-K has cleaning responsibility for both the COVID rooms and non-COVID rooms. HK-K indicated she has filled out the medical form however has not been fit tested for an N95. HK-K uses a cleaner for the rooms and has not received any different information related to the outbreak. HK-K indicated she uses the N95 mask that is in the isolation cart outside the room. HK-K was wearing eye protection glasses. On 2/22/23 at 11:35 AM Surveyor observed HK-K in room [ROOM NUMBER] with the door open and a N95 mask over her surgical mask. room [ROOM NUMBER] is a COVID positive room. HK-K did not sanitize her eye wear after leaving the room. HK-K removed her N95 mask however she left her surgical mask on. On 2/22/23 at 12:00 PM, Surveyor observed and spoke with LPN-C (Licensed Practical Nurse). LPN-C has not been fit tested at the facility and brings her own N95 mask to the facility. LPN-C is a contracted Agency staff who was administering medications to residents that were COVID positive. The isolation carts have general N95 masks that do not fit. LPN-C wears a surgical mask over her own N95 mask when she goes into COVID positive rooms. Surveyor noted the isolation carts outside the COVID positive rooms to do not contain extra eye protection or disinfectant products for eye protection. In an interview on 2/22/2023 at 12:34 PM, Licensed Practical Nurse (LPN)-D stated LPN-D was fit-tested for an N95 mask about two years ago at another facility, but had never been fit-tested at this facility. LPN-D stated staff use the N95 masks provided by the facility and are in each bin outside of a room that is COVID-19 positive. Surveyor asked LPN-D if the facility N95 masks were the same brand and model that LPN-D had been fit-tested for. LPN-D did not know. LPN-D was wearing a surgical mask and eye protection. LPN-D prepared to go into a COVID-19 positive room. LPN-D removed the surgical mask and applied the N95 mask from the bin outside of the room. LPN-D did not put both straps of the N95 around her head; the bottom strap was hanging down in front of LPN-D. LPN-D put on a gown and gloves and then entered the room. LPN-D removed the gown, gloves, and N95 mask when exiting the room, performed hand hygiene, and put on a surgical mask. LPN-D did not clean the eye protection after leaving the room. On 2/22/23 at 12:35 PM Surveyor observed CNA-G (Certified Nursing Assistant) in the hallway. CNA-G has a surgical mask on and regular eye wear. CNA-G indicates they use the N95 mask when they go into the COVID rooms. CNA-G assignment includes COVID and non-COVID rooms. In an interview on 2/22/2023 at 12:40 PM, Certified Nursing Assistant (CNA)-F stated CNA-F had been fit-tested for an N95 mask at the beginning of COVID-19 pandemic, over two years ago. CNA-F was wearing a surgical mask with an N95 mask over the top of the surgical mask. Surveyor asked CNA-F what kind of N95 masks were used in the facility. CNA-F went over to a bin outside of COVID-19 positive room and showed Surveyor the mask. The N95 mask was Honeywell DC300. The mask did not have a metal nose piece for ensuring proper fit. Surveyor noted a blue cupped mask in the bin as well as the Honeywell DC300 masks. The blue mask did not have any markings on it to say what brand, model, or type of mask it was. In an interview on 2/22/2023 at 2:52 PM, Nursing Home Administrator (NHA)-A did not know where the blue unmarked masks that was in a bin outside of a COVID-19 positive room came from because they did not have any blue masks in the building. NHA-A stated NHA-A removed them from the isolation bin. NHA-A stated they checked their stock of masks, and they did not have any blue masks like that. NHA-A stated the resident that had the blue masks in their bin was on hospice so thought maybe the hospice agency put them in the bin but did not have confirmation of that. On 2/22/23 at 12:41 PM Surveyor observed and spoke with CNA-E. CNA-E was wearing eye protection and a surgical mask. CNA-E does not recall when they were last fit tested for an N95 or what type of mask she was fit tested for. CNA-E indicated they have COVID and non-COVID residents on their assignment. On 2/22/23 at 12:45 PM Surveyor observed CNA-H with a N95 mask on with the lower strap under the chin in the hallway and no eye protection. CNA-H then donned an isolation gown and gloves and entered a COVID positive room (21). At 1:05 PM, CNA-H removed their gown at the threshold and asked LPN-C for a blanket and a linen sheet. CNA-H came further into the hallway with their gloves still on, no gown and no eye protection, CNA-H obtained the bed linens and returned into the COVID positive room without a gown or eye wear and the N95 mask not utilized correctly. CNA-H then exited the room with a meal tray and placed in a cart down the hallway. CNA-H in the hallway removed their gloves and placed in the medication cart waste bag. CNA-H then used hand sanitizer in the hallway. CNA-H did not have any eye protection and went into the Staff Lounge off the hallway. On 2/22/2023 at 12:50 PM, Surveyor noted R9 sitting in the hallway in a chair with a mask down below the chin. R9 was singing and talking to no one in particular. LPN-D stated R9 sits there every day all day and sings. On 2/22/2023 at 12:52 PM, Surveyor observed CNA-I wearing an N95 mask with a surgical mask over the top. Surveyor observed CNA-I going into a COVID-19 positive room. When CNA-I came out of the room, CNA-I pulled the surgical mask down below the chin, removed the N95 mask, put a new N95 mask on, and pulled the surgical mask back over the N95 mask. CNA-I was observed going into multiple rooms, COVID-19 positive and non-COVID rooms using the same technique with the masks. CNA-I did not clean the eye protection between rooms. On 2/22/23 at 1:08 PM Surveyor observed CNA-G don an isolation gown, a N95 mask upside down and had eyeglasses on, and donned gloves. CNA-G entered room [ROOM NUMBER] non-COVID room. CNA-G exited the room with a meal tray and removed her gown and mask outside the room with glasses. CNA-G utilized hand sanitizer. CNA-G then donned an isolation gown, N95 mask upside down and utilize the same eyeglasses and enter a different resident's room (room [ROOM NUMBER]) to obtain meal tray. CNA-H then placed the meal tray on cart outside the room. CNA-H then removed their gown, gloves, glasses, and mask. CNA-H then used hand sanitizer from the hallway. CNA-H then had no PPE on in the hallway of a mask or eye protection. In an interview on 2/22/2023 at 1:02 PM, Surveyor asked Occupational Therapist (OT)-M if OT-M had ever been fit-tested for an N95 mask. OT-M stated OT-M used to be the one that did the fit-testing for staff but that had been a while ago now. Surveyor asked OT-M when the last time OT-M was fit-tested . OT-M could not recall when OT-M had been last fit-tested but it had been a while. Surveyor observed OT-M changing from a surgical mask to an N95 mask from the bin outside of R1's room. R1 was COVID-19 positive. Surveyor noted OT-M had facial hair making the N95 mask not tight-fitting. Surveyor asked OT-M if OT-M had been fit-tested for the N95 mask OT-M was currently wearing. OT-M did not know. OT-M put on a gown and gloves and went into R1's room. On 2/22/23 at 12:05 PM Surveyor met with Administrator-A, DON-B and HS (housekeeping Supervisor)-J. The facility Housekeeping is a contracted company. HS-J had completed medical forms for N95 mask fit testing for HK (housekeeping)-K and HK-L. These medical forms were completed on 4/5/22. HK-K and HK-L were observed not wearing PPE correctly and going into COVID positive and non-COVID resident rooms to clean. Administrator-A indicated the DON-B and themselves were trained to perform fit testing on 12/14/22. Administrator-A indicated they have not started any employee fit testing yet. The employees should be fit tested every 2 years. Administrator-A indicated there was no fit testing conducted in 2022 and have not started employee fit testing yet. Surveyor noted staff fit testing every 2 years is not consistent with current standards of practice in which N95 fit testing is to be done yearly. The facility provided a list of employees currently working with residents today with their N95 fit test status: -LPN-C and CNA-H are Agency staff with no documentation of being fit tested . -LPN-D and CNA-I are staff that have no record of being fit tested . - CNA-E was fit tested on [DATE], however type of N95 was not provided. -CNA-F and CNA-G was fit tested on [DATE], however type of N95 was not provided. Administrator-A indicated they had a CMS (Centers for Medicare and Medicaid) survey in December 2022. (Surveyor later clarified the survey in December was a Infection Control Assessment & Response (ICAR) resource visit involving public health.) This ICAR survey suggested they receive training to be fit testers for N95 masks. Administrator-A indicated the facility was not in an outbreak during that time. There was no suggestions for PPE or outbreak measures. Administrator-A and DON-B did not have definitive responses to not implementing fit testing for N95 masks promptly, educating and surveillance of staff PPE use and outbreak preventive measures to prevent spread of infection. DON-B indicated they did not do any staff surveillance regarding PPE use during the COVID outbreak, nor infection prevention education. DON-B indicated they did not do any staff surveillance regarding PPE use during the COVID outbreak, nor infection prevention education On 2/22/23 at 9:08 AM Surveyor spoke with MD-N (Medical Director) who was visiting residents. MD-N indicated the facility has been keeping them updated. MD-N indicated they review policies to keep up with CDC (Centers for Disease Control) guidelines. MD-N indicated there has been no shortage of PPE (personal protective equipment) supplies. The COVID outbreak was a lot worse and feels it's going down now. MD-N indicated there was a QAPI (Quality Assurance Performance Improvement) meeting scheduled today to discuss the outbreak. MD-N was not sure if the meeting was still going to take place since there is a survey. Surveyor reviewed the Facility Assessment Tool, dated 1/18/23 (revised) which does not include the role of an Infection Preventionist and does not address the responsibilities or allocated hours for an Infection Preventionist. Surveyor met with Administrator-A and DON-B on 2/23/23 at 4:35 PM. Administrator-A did not have definitive responses regarding the role of the Infection Preventionist in the facility. On 2/22/23 at 4:35 PM Surveyor met with Administrator-A and DON-B. There was no additional information provided related to the staff PPE observations and interviews. There was no additional information related to the outbreak outline. The immediate jeopardy was not removed upon facility exit on 2/22/23.

Based on observations, interviews and record review, the facility did not ensure the Infection Preventionist had adequate time to fulfill the responsibilities of the position. DON-B (Director of Nurses) is designated as the facility's Infection Preventionist (IP) in addition to performing full-time DON duties which resulted in the inability to implement an effective Infection Control and Prevention Program. The Infection Preventionist did not implement, monitor, and manage the Infection Control program's policy and procedures related to transmission of COVID-19. On 2/9/23 the facility had an initial onsite of a COVID-19 outbreak. As of 2/22/23, 10 staff and 24 of 49 residents residing in the facility were positive for COVID-19. The Infection Preventionist did not ensure infection control measures were implemented to stop the transmission of COVID on 2/9/23. The Infection Preventionist did not ensure staff were test fitted for N95 masks. The Infection Preventionist did not perform outcome surveillance related to staff adherence to the facility's infection control policy and procedures such as wearing appropriate Personal Protective Equipment (PPE), wearing PPE correctly and to ensure staff were taking infection control measures when exiting a COVID-19 positive room and entering a non-COVID-19 resident room. The Infection Preventionist did not ensure process surveillance such as COVID-19-line listing was accurate. This deficient practice had the potential to affect all 49 residents who reside in the facility. The Director of Nursing's failure to have the time necessary to implement the responsibilities of the Infection Preventionist resulted in an Immediate Jeopardy which began on 2/9/23 with a COVID-19 outbreak. Surveyor notified Administrator-A and DON-B of the immediate jeopardy on 2/22/23 at 4:35 PM. The immediate jeopardy was not removed at the time of the facility exit on 2/22/23. Findings include: Surveyor reviewed the facility policy and procedure dated 9/22/22 titled Infection Preventionist. The policy and procedure indicated: Policy: The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. Definitions: Infection Preventionist is defined as the individual (s) designated by the facility to be responsible for the infection prevention and control program. Policy Explanation and Compliance Guidelines indicate: 1. The facility will designate a qualified individual as Infection Preventionist (IP) whose role is to coordinate and be actively accountable for the facility's infection prevention and control program to include the antibiotic stewardship program. 2. The facility (ED/DON) will ensure the Infection Preventionist is qualified by education, training, experience or certification. 3. The IP must be professionally-trained in nursing, medical technology, microbiology, epidemiology, or other related field . 4. The IP will have the knowledge to perform the role and remain current with infection prevention and control issues and be aware of guidelines from national/state/local public health authorities. 5. The facility will ensure that the individual selected as the IP has the background and ability to carry out the requirements of the IP based on the need of the resident population, such as interpreting clinical and laboratory data. 6. The IP must be employed at least part time. Designated IP hours per week will vary based on the facility and its resident population. 7. The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the IPCP (Infection Prevention and Control Program) for the facility, address training requirements, and participate in required committees such as QAA (Quality Assessment and Assurance). 8. The IP will physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location such as at a corporate office. 9. The IP should be sufficiently trained in infection prevention and control . 10. The IP must have obtained specialized IPC training beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate (s) of completion or equivalent documentation. Specialized training should include the following topics: a. Infection prevention and control overview; b. Infection preventionist role; c. Infection surveillance d. Outbreaks; e. Principles of standard precautions (eg., content on hand hygiene, personal protective equipment, injection safety, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and reprocessing resident care equipment); f. Principles of transmission-based precautions; g. Resident care activities .; h. Water management; i. Linen Management; j. Preventing respiratory infections (eg. Influenza, Pneumonia); k. Tuberculosis prevention; l. Occupational health considerations eg. Employee vaccinations, exposure control plan and work exclusions); m. Quality assurance and performance improvement (QAPI); n. Antibiotic stewardship; and o. Care transitions 11. Responsibilities of the Infection Preventionist include but are not limited to: a. Develop and implement an ongoing infection and control program to prevent , recognize and control the onset and spread of infections in order to provide a safe, sanitary and comfortable environment. b. Establish facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff and visitors. c. Develop and implement written policies and procedures in accordance with current standards of practice and recognized guidelines for infection and control. d. Oversight of and ensuring the requirements are met for the facility's antibiotic stewardship program. e. Oversight of resident care activities . f. Review and/or revise the facility's infection prevention and control program, its standards, policies and procedures annually and as needed for changes to the facility assessment to ensure they are effective and in accordance with current standards of practice for preventing and controlling infections. g. Review/revise and approve infection prevention and control training topics and content, and ensure facility staff are trained on IPCP. The infection preventionist is not necessarily required to perform IPCP training if the facility has designated staff development personnel. 12. The Infection Control Preventionist will participate on and is part of the quality assessment and assurance committee (QAA/QAPI) and will report regularly on the infection prevention and control program activities. Surveyor noted the facility's policy and procedure for the Infection Preventionist defines this role as the individual designated by the facility to be responsible for the infection prevention and control program. The facility procedures includes: The Infection Preventionist must have the time necessary to properly assess, develop, implement, monitor, and manage the Infection Prevention and Control Program for the facility, address training requirements and participate in the Quality Assurance committee. The policy indicates the IP must be employed at least part time. Designated IP hours per week will vary based on the facility and its resident population. Surveyor reviewed the Facility Assessment Tool, dated 1/18/23 (revised) which does not address the Infection Preventionist's role and responsibilities or allocated hours. On 2/22/23 at 4:35 PM Surveyor met with Administrator-A and DON/IP-B. The Administrator-A did not have definitive responses to the role of the IP in the facility. There was no additional information provided related to the shared staff PPE observations and interviews. There was no additional information related to the outbreak outline. On 2/22/23 at 8:40 AM Surveyor met with Administrator-A and DON-B. Surveyor was informed DON-B is also the facility's Infection Preventionist (IP) and has been the IP since August 2022 and has a certificate of completion in an Infection Control program. On 2/22/23, Surveyor noted the facility currently has a COVID-19 outbreak which began on 2/9/23. According to Administrator-A and DON-B, as of 2/22/23, 10 staff and 24 of 49 residents residing in the facility were positive for COVID-19. Surveyor was informed the facility does not have a designated COVID unit, and the units are mixed with residents who are positive for COVID-19 and residents who are not positive for COVID-19. The facility does not have designated staff specifically for Residents who have COVID. In an interview on 2/22/2023 at 9:15 AM, Nursing Home Administrator (NHA)-A stated the COVID-19 outbreak started with two residents (R2 and R3) on 2/9/2023 when both residents tested positive for COVID 19. NHA-A stated a nurse came in for work on 2/9/2023 and was told everyone was being tested for COVID-19. NHA-A stated the intent was for all the employees to be tested , but not the residents. NHA-A stated the nurse misunderstood and tested all the residents on the unit. NHA-A stated it was a good mistake because that was how they discovered COVID-19 was in the building. NHA-A stated once they had the two positive residents on the one unit, all residents were tested , and no other residents were positive for COVID-19. NHA-A stated one of the residents (R2) was a dialysis resident so went out into the community on a regular basis and the other resident (R3) had recently had out-of-state visitors, so they determined that was where the COVID-19 came from. NHA-A stated R3 kept close company with another resident so they monitored that resident closely, along with their roommate, and on 2/12/2023, both of those residents (R8 and R11) tested positive for COVID-19. R8 was unvaccinated for COVID-19. R8 had symptoms of a sore throat. No antiviral was given due to hospice status per the line list. R11 was unvaccinated for COVID-19. R11 had symptoms of a cough. An antiviral was given per the line list. Surveyor reviewed a facility summary of events which indicated: On 2/9/23 after R2 and R3 tested positive for COVID-19, the facility did not limit other residents who had been in close contact with R2 and R3 from attending group dining or any other group activities until 2/12/23, potentially spreading the virus. Surveyor noted on 2/9/23, the facility did not implement infection control measures to stop the transmission of COVID-19 in regard to the other residents who ate in the communal dining room and participated in group activities. The facility did not conduct contract tracing of those residents who were in the dining room seated near R2 and R3 to determine their risk of getting COVID-19. The facility did not implement measures to reduce the spread of COVID-19 in the communal dining and activities such as identifying which residents were vaccinated against COVID-19, residents wearing face masks, 6-foot distancing, ensuring hand hygiene The facility did not limit other residents who had been in close contact with R2 and R3 from attending group dining or any other group activities until 2/12/23, potentially spreading the virus. On 2/12/23 there was 2 additional residents who tested positive for COVID who had contact with the 2 residents on 2/9/23. On 2/13/23 an additional 5 residents were positive for COVID with 1 resident going to the hospital. On 2/14/23 1 additional resident tested positive. On 2/15/23 there was an additional 7 residents who tested positive for COVID. There was 3 symptomatic staff who tested positive for COVID. The COVID Line List indicates 1 resident was sent to the hospital. On 2/16/23 there was an additional 7 residents who tested positive for COVID. The COVID Line List indicates 5 residents. There was 2 symptomatic staff tested positive for COVID. On 2/17/23 there was 2 residents (R11) who tested positive for COVID and 1 staff. The Covid Line List indicates 3 residents with COVID. On 2/18/23 3 staff tested positive for COVID. The COVID Line List indicates 1 resident went out to the hospital. On 2/21/23 2 residents tested positive for COVID and 1 staff. This COVID-19 summary was not consistent with the facilities COVID-19- out break line list provided to Surveyors. On 2/9/2023 at 11:00 AM in the progress notes, nursing charted R2 tested positive for COVID-19 using a rapid test. A viral respiratory panel was ordered to confirm the result. At 1:39 PM nursing charted an SBAR (Situation, Background, Assessment, Recommendation) was completed with the onset of a respiratory infection and respiratory isolation was implemented. R2 was vaccinated for COVID-19 with two initial doses and one booster dose. On 2/10/2023 at 11:32 AM in the progress notes, nursing charted R2 remained asymptomatic for COVID-19 and would be starting a medication for COVID-19 in the morning. On 2/22/2023 at 12:44 PM, Surveyor observed R2's door closed. Signs were posted on the door for contact and droplet isolation as well as a sign that stated to keep door closed. An isolation bin was outside of the room with personal protective equipment (PPE) in the drawers. Surveyor noted R2's roommate, R11, was being monitored for COVID-19 as of 2/14/2023 per the surveillance line list provided of the COVID-19 outbreak. R11 tested positive for COVID-19 on 2/17/2023. R11 was unvaccinated for COVID-19. On 2/9/2023 at 10:59 AM in the progress notes, nursing charted R3 tested positive for COVID-19 using a rapid test. A viral respiratory panel was ordered to confirm the result. At 1:04 PM nursing charted R3 was in respiratory isolation pending final results for COVID-19 test. R3 was short of breath at times but takes oxygen off frequently. The head of the bed was elevated, vital signs were stable, and no cough was present. R3 was vaccinated for COVID-19 with two initial doses and one booster dose. On 2/10/2023 at 11:25 AM in the progress notes, nursing charted R3 had oxygen on at 2 liters per nasal cannula with an oxygen saturation of 95%. R3 was asymptomatic but positive for COVID-19. R3 would be starting a medication for COVID-19 in the morning. On 2/22/2023 at 12:45 PM, Surveyor observed R3 sitting in their room in a wheelchair with oxygen on. R3 was no longer in isolation for COVID-19. The facility line list for the COVID-19 outbreak indicated R3 was symptomatic with shortness of breath yet nursing charted R3 was asymptomatic. In an interview on 2/22/2023 at 1:45 PM, DON-B stated on 2/9/2023, all communal activities were still going on including communal dining. Surveyor noted R8 and R11 were not restricted after 2/9/2023 after having close contact with R2 and R3. DON-B stated residents and staff were tested , but visitors were not tested so they must have brought COVID-19 into the building. DON-B stated on 2/12/2023, when two more residents tested positive, was when they shut down, stopping communal dining and activities. Surveyor asked DON-B if education was done with staff when the outbreak started on how to stop or contain the spread of COVID-19. DON-B stated no formal education was given to staff. NHA-A stated general conversations were had, but nothing was formally documented regarding specific education. Surveyor reviewed the resident COVID-19 outbreak line list. The line list did not include date isolation started or ended. Surveyor noted discrepancies between what was entered onto the line list and what was documented in resident records. *R3 had shortness of breath per the line list. Progress notes stated R3 was asymptomatic. *R4, unvaccinated for COVID-19, had a positive rapid test on 2/16/2023 per the line list. Progress notes stated R4 tested positive on 2/18/2023. *R7, unvaccinated for COVID-19, tested negative on 2/16/2023 and tested positive on 2/21/2023 per the line list. Progress notes stated R7 tested positive on 2/16/2023. In an interview on 2/22/2023 at 10:58 AM, Surveyor asked NHA-A about the line list and progress notes for R7 on 2/16/2023 because they did not match. NHA-A stated DON-B was not in the facility at that time and NHA-A and DON-B went through the line list when DON/IP-B returned and separated the residents from the staff, so they created two-line lists. NHA-A stated DON-B would be able to answer Surveyor's question about R7 better than NHA-A. On 2/22/2023 at 11:05 AM, Surveyor asked DON-B for clarification of the discrepancy with the line list and the progress notes for R7 on 2/16/2023. DON-B stated the line list was correct and the documentation in the progress notes was inaccurate. DON-B stated R7 tested negative on 2/16/2023 and then when retested on [DATE], R7 was positive. R1, vaccinated for COVID-19 with the first two initial doses and no boosters, tested positive on 2/13/2023 and was hospitalized on [DATE] per the line list. Progress notes are as follows: On 2/13/2023 at 6:46 PM in the progress notes, a physician telehealth visit was documented by the physician. The physician charted R1 presented with a one-day history of respiratory concerns including: loose cough, white sputum, and the need for supplemental oxygen. The physician charted per the nurse, R1 had worsening of symptoms. The physician charted R1 stated they were short of breath and nursing reported R1 was requiring more supplemental oxygen. The physician charted R1 was receiving oxygen at 2 liters per nasal cannula with an oxygen saturation of 92-93% with a baseline of less than 95%. The physician charted the nurse informed the physician the facility was in an outbreak of COVID-19, however R1 had tested negative twice that day. The physician charted a conversation was had with the nurse that despite a negative COVID-19 test, R1 could still have a positive COVID-19 PCR and ordered R1 to be sent to the hospital. On 2/13/2023 at 7:15 PM in the progress notes, nursing charted R1 tested negative for COVID-19 but spoke to physician via telehealth to update on R1's change in condition of lethargy, complaints of not being able to breathe, and sore throat. R1 was sent to the emergency room . On 2/14/2023 at 4:07 AM in the progress notes, nursing charted R1 had been admitted to the hospital with COVID-19. Surveyor noted the physician documented on 2/13/2023 that R1 had a one-day history of symptoms. No documentation was found of symptoms on 2/12/2023 and the line list indicated symptoms started on 2/13/2023. If symptoms were present on 2/12/2023, Surveyor could not determine what interventions were put in place to contain COVID-19 or any other respiratory virus. R1 was sent and admitted to the hospital on 2/13/2022; the line list indicated R1 was sent to the hospital on 2/14/2023. In an interview on 2/22/2023 at 1:44 PM, Surveyor shared with NHA-A and DON-B the concern R1's physician progress note on 2/13/2023 indicated R1 had a history of respiratory symptoms for one day and Surveyor did not see anything was done for R1 on 2/12/2023. NHA-A stated the physician writes their note at the end of the day so R1's symptoms were only there for the day the physician saw R1, which was 2/13/2023. DON-B stated DON-B was not aware of R1 having any symptoms prior to 2/13/2023. Surveyor shared the line list stated R1 went to the hospital on 2/14/2023 when in fact R1 went to the hospital on 2/13/2023. DON-B stated that was just a data entry error. Surveyor shared the concern with NHA-A and DON-B that the line list was inaccurate with the data that was entered for some residents and did not show the complete picture to help with the tracking and trending of the outbreak. On 2/22/2023 at 8:59 AM, Surveyor observed Housekeeper-L cleaning a room with a contact and droplet precaution sign posted on the door. The door to the room was wide open while Housekeeper-L was cleaning the room. Housekeeper-L removed her gown when leaving the room but did not clean the eye protection Housekeeper-L was wearing before entering another non-COVID room. On 2/22/23 at 11:25 AM, Surveyor observed and spoke with HK-K (Housekeeper). HK-K has cleaning responsibility for both the COVID rooms and non-COVID rooms. HK-K indicated she has filled out the medical form however has not been fit tested for an N95. HK-K uses a cleaner for the rooms and has not received any different information related to the outbreak. HK-K indicated she uses the N95 mask that is in the isolation cart outside the room. HK-K was wearing eye protection glasses. On 2/22/23 at 11:35 AM Surveyor observed HK-K in room [ROOM NUMBER] with the door open and a N95 mask over her surgical mask. room [ROOM NUMBER] is a COVID positive room. HK-K did not sanitize her eye wear after leaving the room. HK-K removed her N95 mask however she left her surgical mask on. On 2/22/23 at 12:00 PM, Surveyor observed and spoke with LPN-C (Licensed Practical Nurse). LPN-C has not been fit tested at the facility and brings her own N95 mask to the facility. LPN-C is a contracted Agency staff who was administering medications to residents that were COVID positive. The isolation carts have general N95 masks that do not fit. LPN-C wears a surgical mask over her own N95 mask when she goes into COVID positive rooms. Surveyor noted the isolation carts outside the COVID positive rooms to do not contain extra eye protection or disinfectant products for eye protection. In an interview on 2/22/2023 at 12:34 PM, Licensed Practical Nurse (LPN)-D stated LPN-D was fit-tested for an N95 mask about two years ago at another facility, but had never been fit-tested at this facility. LPN-D stated staff use the N95 masks provided by the facility and are in each bin outside of a room that is COVID-19 positive. Surveyor asked LPN-D if the facility N95 masks were the same brand and model that LPN-D had been fit-tested for. LPN-D did not know. LPN-D was wearing a surgical mask and eye protection. LPN-D prepared to go into a COVID-19 positive room. LPN-D removed the surgical mask and applied the N95 mask from the bin outside of the room. LPN-D did not put both straps of the N95 around her head; the bottom strap was hanging down in front of LPN-D. LPN-D put on a gown and gloves and then entered the room. LPN-D removed the gown, gloves, and N95 mask when exiting the room, performed hand hygiene, and put on a surgical mask. LPN-D did not clean the eye protection after leaving the room. On 2/22/23 at 12:35 PM Surveyor observed CNA-G (Certified Nursing Assistant) in the hallway. CNA-G has a surgical mask on and regular eye wear. CNA-G indicates they use the N95 mask when they go into the COVID rooms. CNA-G assignment includes COVID and non-COVID rooms. In an interview on 2/22/2023 at 12:40 PM, Certified Nursing Assistant (CNA)-F stated CNA-F had been fit-tested for an N95 mask at the beginning of COVID-19 pandemic, over two years ago. CNA-F was wearing a surgical mask with an N95 mask over the top of the surgical mask. Surveyor asked CNA-F what kind of N95 masks were used in the facility. CNA-F went over to a bin outside of COVID-19 positive room and showed Surveyor the mask. The N95 mask was Honeywell DC300. The mask did not have a metal nose piece for ensuring proper fit. Surveyor noted a blue cupped mask in the bin as well as the Honeywell DC300 masks. The blue mask did not have any markings on it to say what brand, model, or type of mask it was. In an interview on 2/22/2023 at 2:52 PM, Nursing Home Administrator (NHA)-A did not know where the blue unmarked masks that was in a bin outside of a COVID-19 positive room came from because they did not have any blue masks in the building. NHA-A stated NHA-A removed them from the isolation bin. NHA-A stated they checked their stock of masks, and they did not have any blue masks like that. NHA-A stated the resident that had the blue masks in their bin was on hospice so thought maybe the hospice agency put them in the bin but did not have confirmation of that. On 2/22/23 at 12:41 PM Surveyor observed and spoke with CNA-E. CNA-E was wearing eye protection and a surgical mask. CNA-E does not recall when they were last fit tested for an N95 or what type of mask she was fit tested for. CNA-E indicated they have COVID and non-COVID residents on their assignment. On 2/22/23 at 12:45 PM Surveyor observed CNA-H with a N95 mask on with the lower strap under the chin in the hallway and no eye protection. CNA-H then donned an isolation gown and gloves and entered a COVID positive room (21). At 1:05 PM, CNA-H removed their gown at the threshold and asked LPN-C for a blanket and a linen sheet. CNA-H came further into the hallway with their gloves still on, no gown and no eye protection, CNA-H obtained the bed linens and returned into the COVID positive room without a gown or eye wear and the N95 mask not utilized correctly. CNA-H then exited the room with a meal tray and placed in a cart down the hallway. CNA-H in the hallway removed their gloves and placed in the medication cart waste bag. CNA-H then used hand sanitizer in the hallway. CNA-H did not have any eye protection and went into the Staff Lounge off the hallway. On 2/22/2023 at 12:50 PM, Surveyor noted R9 sitting in the hallway in a chair with a mask down below the chin. R9 was singing and talking to no one in particular. LPN-D stated R9 sits there every day all day and sings. On 2/22/2023 at 12:52 PM, Surveyor observed CNA-I wearing an N95 mask with a surgical mask over the top. Surveyor observed CNA-I going into a COVID-19 positive room. When CNA-I came out of the room, CNA-I pulled the surgical mask down below the chin, removed the N95 mask, put a new N95 mask on, and pulled the surgical mask back over the N95 mask. CNA-I was observed going into multiple rooms, COVID-19 positive and non-COVID rooms using the same technique with the masks. CNA-I did not clean the eye protection between rooms. On 2/22/23 at 1:08 PM Surveyor observed CNA-G don an isolation gown, a N95 mask upside down and had eyeglasses on, and donned gloves. CNA-G entered room [ROOM NUMBER] non-COVID room. CNA-G exited the room with a meal tray and removed her gown and mask outside the room with glasses. CNA-G utilized hand sanitizer. CNA-G then donned an isolation gown, N95 mask upside down and utilize the same eyeglasses and enter a different resident's room (room [ROOM NUMBER]) to obtain meal tray. CNA-H then placed the meal tray on cart outside the room. CNA-H then removed their gown, gloves, glasses, and mask. CNA-H then used hand sanitizer from the hallway. CNA-H then had no PPE on in the hallway of a mask or eye protection. In an interview on 2/22/2023 at 1:02 PM, Surveyor asked Occupational Therapist (OT)-M if OT-M had ever been fit-tested for an N95 mask. OT-M stated OT-M used to be the one that did the fit-testing for staff but that had been a while ago now. Surveyor asked OT-M when the last time OT-M was fit-tested . OT-M could not recall when OT-M had been last fit-tested but it had been a while. Surveyor observed OT-M changing from a surgical mask to an N95 mask from the bin outside of R1's room. R1 was COVID-19 positive. Surveyor noted OT-M had facial hair making the N95 mask not tight-fitting. Surveyor asked OT-M if OT-M had been fit-tested for the N95 mask OT-M was currently wearing. OT-M did not know. OT-M put on a gown and gloves and went into R1's room. On 2/22/23 at 12:05 PM Surveyor met with Administrator-A, DON-B and HS (housekeeping Supervisor)-J. The facility Housekeeping is a contracted company. HS-J had completed medical forms for N95 mask fit testing for HK (housekeeping)-K and HK-L. These medical forms were completed on 4/5/22. HK-K and HK-L were observed not wearing PPE correctly and going into COVID positive and non-COVID resident rooms to clean. Administrator-A indicated the DON-B and themselves were trained to perform fit testing on 12/14/22. Administrator-A indicated they have not started any employee fit testing yet. The employees should be fit tested every 2 years. Administrator-A indicated there was no fit testing conducted in 2022 and have not started employee fit testing yet. Surveyor noted staff fit testing every 2 years is not consistent with current standards of practice in which N95 fit testing is to be done yearly. The facility provided a list of employees currently working with residents today with their N95 fit test status: -LPN-C and CNA-H are Agency staff with no documentation of being fit tested . -LPN-D and CNA-I are staff that have no record of being fit tested . - CNA-E was fit tested on [DATE], however type of N95 was not provided. -CNA-F and CNA-G was fit tested on [DATE], however type of N95 was not provided. Administrator-A indicated they had a CMS (Centers for Medicare and Medicaid) survey in December 2022. (Surveyor later clarified the survey in December was a Infection Control Assessment & Response (ICAR) resource visit involving public health.) This ICAR survey suggested they receive training to be fit testers for N95 masks. Administrator-A indicated the facility was not in an outbreak during that time. There was no suggestions for PPE or outbreak measures. Administrator-A and DON-B did not have definitive responses to not implementing fit testing for N95 masks promptly, educating and surveillance of staff PPE use and outbreak preventive measures to prevent spread of infection. DON-B indicated they did not do any staff surveillance regarding PPE use during the COVID outbreak, nor infection prevention education. DON-B indicated they did not do any staff surveillance regarding PPE use during the COVID outbreak, nor infection prevention education On 2/22/23 at 9:08 AM Surveyor spoke with MD-N (Medical Director) who was visiting residents. MD-N indicated the facility has been keeping them updated. MD-N indicated they review policies to keep up with CDC (Centers for Disease Control) guidelines. MD-N indicated there has been no shortage of PPE (personal protective equipment) supplies. The COVID outbreak was a lot worse and feels it's going down now. MD-N indicated there was a QAPI (Quality Assurance Performance Improvement) meeting scheduled today to discuss the outbreak. MD-N was not sure if the meeting was still going to take place since there is a survey. On 2/22/23 at 1:45 PM, Surveyor spoke with Administrator-A and DON-B. DON-B stated she was not in the building when the COVID-19 outbreak began on 2/9/23. Administrator-A indicated they were going to have the Minimum Data Set nurse cover in DON-B's absence however the MDS nurse was not able to do so. On 2/22/23 at 4:35 PM Surveyor met with Administrator-A and DON-B. There was no additional information provided related to the staff PPE observations and interviews regarding fit testing of N95s. Tere was no additional information related to the outbreak outline. The immediate jeopardy was not removed upon facility exit on 2/22/23.

Based on interview, record review and observation, the facility did not consult with the resident's physician regarding an anticoagulant (medication that thins the blood) for 1 of 1 (R23) residents reviewed for anticoagulants not being adequately monitored for therapeutic levels or that an ordered medication was not available. R23 was admitted to the facility on [DATE] with orders for [MEDICATION(S)]/[MEDICATION(S)] (an anticoagulant) medication [MEDICATION(S)] and PT/INR for monitoring for a therapeutic level of INR 2 to 2.5. R23 was receiving [MEDICATION(S)] 3.5 mg, which was on hold from [DATE] to [DATE], and a PT/INR was ordered to be drawn on [DATE]. The facility did not follow up with lab regarding the ordered lab PT/INR and began administering [MEDICATION(S)] 3.5 mg on [DATE]. R23 received [MEDICATION(S)] 3.5 mg each day from [DATE] to [DATE]. The facility did not notify R23's physician that the PT/INR (Prothrombin Time/International Normalized Ratio) blood draw was not done on [DATE] or that staff had begun administering [MEDICATION(S)] 3.5 mg again without knowing the therapeutic level. After R23 fell on [DATE] and hit her head, the physician ordered a PT/INR. This came back abnormally high with INR >10 and PT >90. The physician was notified on [DATE] at 11:45 AM of the abnormally high INR/PT and ordered Vitamin K 5mg x 1 now. The facility did not give the Vitamin K due to a malfunction and inability to access the (E-Kit) emergency pharmacy contingency. The facility did not notify/consult with the physician that Vitamin K was not available in the facility or that R23 did not receive Vitamin K from any of the 3 nurses caring for R23 during the day shift on [DATE], during the PM shift on [DATE], and the night shift on [DATE]. R23 was transferred to the hospital on [DATE] at 2:00 AM due to a change in condition with lethargy, inability to answer questions appropriately, and body leaning sideways. R23 was admitted to the hospital with a high INR of 17.5 and [CONDITION(S)] (Urinary Tract Infection). The Facility's failure to consult with a physician when R23 did not have ordered PT/INR drawn on [DATE], that staff had begun giving [MEDICATION(S)] at the previously ordered level, or that Vitamin K was not available created a finding of immediate jeopardy that began on [DATE]. NHA-A (Nursing Home Administrator), DON-B (Director of Nursing) and CSD-C (Clinical Services Director) were notified of the immediate jeopardy on [DATE] at 12:00 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope and severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor the effectiveness of its removal plan. Findings include: The facility policy, dated [DATE], Change in Condition of the Resident (Observing, Recording & Reporting) indicated the purpose was to observe, record, and report any condition change to the physician so proper treatment can be implemented timely. An acute change in condition refers to a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. It is clinically important in that without intervention, the resident may experience complications. Documentation needs to include: Date, time condition change was identified. Notification of practitioner include date, time, what was conveyed, any orders received (each time notified). Care Plan documentation. The facility policy, dated [DATE], [MEDICATION(S)] Protocol, indicated Residents who are prescribed [MEDICATION(S)] will have appropriate monitoring of PT/INR levels as ordered by the physician. Nurses are required to notify the physician with abnormal PT/INR results by phone. Have the updated [MEDICATION(S)] flow record available when the physician returns the call so that the dosage adjustments can be recorded. R23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to admission, R23 had been hospitalized from [DATE] to [DATE] with a high INR of 6.6 and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R23 was given blood products and monitored for clearing of bruising. The discharge plan indicated the INR be checked regularly including every Monday/Wednesday/Friday with results to the facility physician for [MEDICATION(S)] adjustment with an INR goal level of ,d+[DATE].5. R1 was admitted to the facility on [DATE] with orders for the anticoagulant [MEDICATION(S)] and PT/INR for monitoring of therapeutic level of 2 to 2.5. The facility did not begin an anticoagulant care plan for R23 to monitor for adverse signs and symptoms until [DATE]. R23's Care Plan, dated [DATE], At risk for abnormal bleeding, hemorrhage and/or increased/easy bruising related to anticoagulant usage, ([CONDITION(S)]) included Interventions: If on [MEDICATION(S)], initiate and maintain an anticoagulant flow sheet as indicated. ([DATE]) Schedule lab tests as ordered by the Physician to monitor coagulation factors and report results to Physician promptly. ([DATE]) On [DATE] R23's INR level was 1.8 and PT was 18.2. By [DATE], these levels had increased: INR was 8.4 and PT was 77.1. The physician ordered that [MEDICATION(S)] be held from ,d+[DATE] to [DATE] because of high PT/INR values and that PT/INR levels be drawn on [DATE]. This level would determine the dosage at which [MEDICATION(S)] would be continued. The facility did not ensure the lab work ordered for [DATE]. The facility did not notify the physician that this had not been done. Further, on [DATE], the facility resumed administering [MEDICATION(S)] 3.5 mg. without consulting with the physician to determine if this was what the physician wanted. Beginning with the blood draw that should have occurred on [DATE], there was no subsequent monitoring of R23's PT/INR level. R23 received 3.5 mg [MEDICATION(S)] each day from [DATE] to [DATE] without knowing R23's PT/INR level. On [DATE] at 6:15 AM, R23 fell and hit the back of her head. The physician ordered a PT/INR to be drawn on [DATE] and the stat results of INR >10, PT >90 were relayed to the day nurse RN-D (Registered Nurse) by the lab on [DATE] at 11:45 AM with a subsequent physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-D did not administer the Vitamin K as the contingency medication system was not functioning and the physician was not notified the Vitamin K was unavailable. LPN-E (Licensed Practical Nurse) who was working the PM shift did not administer the Vitamin K as the contingency medication system was not functioning and she called pharmacy to request they send the Vitamin K stat and the physician was not notified the Vitamin K was unavailable. LPN-F who was working the night shift did not administer the Vitamin K as the contingency medication system was not functioning, no Vitamin K was available, and the physician was not notified the Vitamin K was unavailable. On [DATE] at 2:00 AM R23 was sent to the hospital via an ambulance transport company due to lethargy, sitting and leaning to the right, slow mental status, and inability to answer questions appropriately. R23 was admitted to the hospital on [DATE]with an INR of 17.5, [CONDITION(S)], and hematuria (blood in the urine). R23 received Vitamin K in the hospital. R23's INR was 1.8 in the hospital prior to discharge on [DATE]. On [DATE], R23 returned to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] was ordered for 3 mg daily. On [DATE], at 10:40 AM, Surveyor observed R23 lying in bed, bruises noted up and down bilateral arms. R23 stated today is [DATE], and does not know if taking [MEDICATION(S)] or not. On [DATE], at 8:41 AM, Surveyor interviewed LPN-E who worked the PM shift on [DATE] and stated R23 was generally alert and on [MEDICATION(S)]. LPN-E stated the E-Kit System was not working at all, she could not even get it to restart. She unplugged it/tried again and called pharmacy. At 8:00 PM, Pharmacy stated they would stat the Vitamin K out to the facility. LPN-E stated at 10:00 PM, she gave report to LPN-F about the Vitamin K being needed for R23. LPN-E stated she did not call the Physician to say Vitamin K was unavailable because pharmacy was going to stat it out. On [DATE], at 8:24 AM, Surveyor interviewed LPN-F (Licensed Practical Nurse) who works night shift. LPN-F stated she could not give Vitamin K as the E-Kit was down and pharmacy called stating they were not able to find Vitamin K. LPN-F stated she did not call the physician to notify them that the ordered Vitamin K was not given to R23 for the high INR. On [DATE], at 9:23 AM, Surveyor attempted to reach RN-D who worked the day shift on [DATE] for an interview but was unsuccessful. DON-B stated RN-D has not returned to work at the facility since [DATE]. According to the National Institute of Health ([MEDICATION(S)] Plus), [MEDICATION(S)] may cause severe bleeding that can be life-threatening and even cause death. According to the article Bleeding Risks and Response to Therapy in Patients with INR Higher than 9, Close monitoring of INR is necessary to avoid both under and over-anticoagulation. INR higher than 4 has been associated with an increased risk of bleeding, and the risk of intracranial hemorrhage increases approximately 2-fold for every 1 unit rise in INR. INR greater than 9 is associated with a particularly high risk of bleeding, with up to 20% of patients with INR higher than 9 bleeding within the next week, 20-fold higher than patients with INR lower than 9. This source also notes that Among inpatients [with an INR higher than 9] receiving [MEDICATION(S)], 35% had bleeding and 17% died . Factors associated with bleeding were older age, renal failure, and alcohol use. https://academic.oup.com/ajcp/article/[DATE]/ 21 The American Heart Association article Oral Anticoagulants and Intracranial Hemorrhage notes, Anticoagulation . increases the risk of intracranial hemorrhage 7- to 10-fold . Most (70%) anticoagulant-related intracranial hemorrhages are intracerebral hematomas (approximately 60% are fatal); the bulk of the remainder are subdural hematomas. Predictors of anticoagulant-related intracerebral hematoma are advanced patient age, prior ischemic stroke, hypertension, and intensity of anticoagulation. In approximately half of anticoagulated patients with intracerebral hematoma the bleeding evolves slowly over 12 to 24 hours, and emergency reversal of anticoagulation is crucial. http://stroke.ahajournals.org/content/[DATE].full The facility's failure to promptly consult with the physician concerning the fact that the lab draw on [DATE] had not been completed and that staff had resumed giving 3.5 mg. [MEDICATION(S)] and its inability to give Vitamin K as ordered on [DATE] created a finding of immediate jeopardy starting on [DATE]. The facility removed the immediate jeopardy on [DATE] when the facility implemented the following: Education/Training The facility completed a care plan review to ensure R23 had appropriate orders for INR/PT lab value monitoring related to anticoagulant use. The facility completed a review of like residents who require INR/PT monitoring due to anticoagulant use. The facility reviewed the [MEDICATION(S)] event with the Medical Director. The Director of Clinical Services -C completed a review of the event related to the lack of lab monitoring for R23 related to anticoagulant medication use. The Director of Nursing and the Assistant Director of Nursing received re-education on the process of monitoring residents who require INR/PT monitoring related to anticoagulant medication use. The facility initiated re-education and return demonstration training with all licensed nursing staff and medication technicians related to administration of [MEDICATION(S)]. The facility initiated re-education and training with staff related to use of the E-Kit and return demonstration on removing medications from contingency. All staff will be required to complete training before next scheduled date of work. The facility initiated re-education and training with the licensed staff and medication technicians regarding notification to the MD at time of identification when medications ordered STAT are not available. All licensed staff and medication technicians are required to complete return demonstration training prior to next scheduled work day. The facility requested pharmacy completed an assessment of the E-kit system to ensure the system functioning appropriately. The facility consulted with attending MD and Medical Director regarding updated plan and educations. Systems, Policies & Procedures The facility completed a review of the [MEDICATION(S)] Administration Policy. The facility reviewed the E-Kit process on removing medications from contingency and validated the E-Kit was functioning appropriately. Monitoring, Audits, QAPI (Quality Assurance and Performance Improvement), and Facility Assessment The facility will audit lab orders daily during morning meeting to ensure INR/PT lab values are identified and timely follow up notification to the Physician is completed. The facility will audit medications for STAT administration daily during morning meeting. The facility will complete random remedial training with licensed nurses and medication technicians to ensure ongoing competency with the [MEDICATION(S)] administration process. The facility will review the recommended audits at the monthly QAPI committee meeting. Additional follow up will be completed based on the outcome of those findings. Cross reference F757.

Based on interview, record review and observation, the facility failed to ensure that 1 (R23) of 1 residents reviewed for anticoagulants was adequately monitored for therapeutic levels. R23 was admitted to the facility on [DATE] with orders for [MEDICATION(S)]/[MEDICATION(S)] (an anticoagulant) and PT/INR for monitoring for a therapeutic level of INR 2 to 2.5. R23 was receiving [MEDICATION(S)] 3.5 mg, which was on hold from [DATE] to [DATE], and a PT/INR was ordered to be drawn on [DATE]. The facility did not follow up with lab regarding the ordered lab PT/INR and began administering [MEDICATION(S)] 3.5 mg on [DATE] using the physician's previous order prior to the [MEDICATION(S)] being placed on hold. R23 received [MEDICATION(S)] 3.5 mg each day from [DATE] to [DATE]. The facility did not monitor R23's PT/INR levels during this period. On [DATE] the physician ordered a PT/INR after R23 fell and hit her head. This came back abnormally high with INR >10 and PT >90. The physician was notified on [DATE] at 11:45 AM of the abnormally high INR/PT and ordered Vitamin K 5mg x 1. Over the next three shifts the facility did not give the Vitamin K due to a malfunction and inability to access the (E-Kit) emergency pharmacy contingency. R23 was transferred to the hospital on [DATE] at 2:00 AM due to a change in condition with lethargy, inability to answer questions appropriately, and body leaning sideways. R23 was admitted to the hospital with a high INR of 17.5 and [CONDITION(S)] (Urinary Tract Infection). The above created a finding of immediate jeopardy that began on [DATE]. The NHA-A (Nursing Home Administrator), DON-B (Director of Nursing) and CSD-C (Clinical Services Director) were notified of the immediate jeopardy on [DATE] at 12:00 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope and severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor the effectiveness of its removal plan. Findings include: According to the National Center for Biotechnology Information, .[MEDICATION(S)] users require routine coagulation monitoring because of its narrow therapeutic range and interactions between [MEDICATION(S)] and diet or other medications. Bleeding associated with over-anticoagulation can occur in patients taking [MEDICATION(S)], the annual frequency of this complication reportedly being 15%-20%, including 1%-3% of fatal bleeding events. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 45/ The facility policy, dated [DATE], [MEDICATION(S)] Protocol, indicated Residents who are prescribed [MEDICATION(S)] will have appropriate monitoring of PT/INR levels as ordered by the physician. Nurses are required to notify the physician with abnormal PT/INR results by phone. Have the updated [MEDICATION(S)] flow record available when the physician returns the call so that the dosage adjustments can be recorded. R23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to admission, R23 had been hospitalized from [DATE] to [DATE] with a high INR of 6.6 and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R23 was given blood products and monitored for clearing of bruising. The discharge plan recommended the INR be checked regularly including every Monday/Wednesday/Friday with results to the facility physician for [MEDICATION(S)] adjustment with an INR goal level of ,d+[DATE].5. R1 was admitted to the facility on [DATE] with orders for the anticoagulant [MEDICATION(S)] and PT/INR for monitoring of therapeutic level of 2 to 2.5. [MEDICATION(S)] is a blood thinner used to treat residents with Chronic [CONDITION(S)] The facility did not begin an anticoagulant care plan for R23 to monitor for adverse signs and symptoms until [DATE]. R23's Care Plan, dated [DATE], At risk for abnormal bleeding, hemorrhage and/or increased/easy bruising related to anticoagulant usage, ([CONDITION(S)]) included Interventions: If on [MEDICATION(S)], initiate and maintain an anticoagulant flow sheet as indicated. ([DATE]) Schedule lab tests as ordered by the Physician to monitor coagulation factors and report results to Physician promptly. ([DATE]) * The facility did not have a system for ensuring residents who received anticoagulant therapy were monitored and no anticoagulant flow sheet. Surveyor reviewed R23's Pharmacy reviews which had monthly recommendations for routine INR monitoring: [DATE]: INR ([DATE]) (goal ,d+[DATE].5 to prevent hematoma extension). [DATE]: REC (Record) routine INR monitoring. [DATE]: INR (goal ,d+[DATE].5 to prevent hematoma extension) REC routine INR monitoring. [DATE]: REC routine INR monitoring. [DATE]: REC routine INR monitoring. On [DATE] R23's INR level was 1.8 and PT was 18.2. By [DATE], these levels had increased: INR was 8.4 and PT was 77.1. The physician ordered that [MEDICATION(S)] be held from ,d+[DATE] to [DATE] because of high PT/INR values and that PT/INR levels be drawn on [DATE]. This level would determine the dosage at which [MEDICATION(S)] would be continued. The facility did not ensure the lab work ordered for [DATE] was completed and, without notifying the physician, began giving [MEDICATION(S)] at the dosage previously ordered by the physician. Beginning with the blood draw that should have occurred on [DATE], there was no subsequent monitoring of R23's PT/INR level. The physician was not notified that the PT/INR blood draw was never done on [DATE] and R23 received the scheduled 3.5 mg [MEDICATION(S)] each day from [DATE] to [DATE] without the nurses knowing R23's PT/INR level. On [DATE] at 6:15 AM, R23 fell and hit the back of her head. The physician ordered a PT/INR to be drawn on [DATE] and the stat results of INR >10, PT >90 were relayed to the day nurse RN-D (Registered Nurse) by the lab on [DATE] at 11:45 AM with a subsequent physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-D did not administer the Vitamin K as the E-Kit was not functioning. LPN-E (Licensed Practical Nurse) who was working the PM shift did not administer the Vitamin K as the E-Kit was not functioning. She called pharmacy to send the Vitamin K stat, and the physician was not notified the Vitamin K was unavailable. LPN-F who was working the night shift did not administer the Vitamin K as the E-Kit was not functioning. No Vitamin K was available, and the physician was not notified the Vitamin K was unavailable. R23 was sent to the hospital via an ambulance transport company on [DATE] at 2:00 AM due to lethargy, sitting and leaning to the right, slow mental status, and inability to answer questions appropriately. R23 was admitted to the hospital on [DATE] with an INR of 17.5, urinary tract infection, and hematuria (blood in the urine). R23 received Vitamin K in the hospital. R23's INR was 1.8 in the hospital prior to discharge on [DATE]. On [DATE], R23 returned to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] was ordered for 3 mg daily. On [DATE], at 9:21 AM, Surveyor interviewed DON-B (Director of Nursing) and DCS-C who stated the issues with R23's INR, [MEDICATION(S)], and Vitamin K were: *R23's INR was not drawn on [DATE] and we are unable to find an ,d+[DATE] (INR/PT) result. Lab was called and they have no evidence of it being done. *R23's [MEDICATION(S)] should have been discontinued, not held, to eliminate the error of giving from [DATE] to [DATE]. *Nurses should not be giving [MEDICATION(S)] without checking the last INR. *Difficulty opening the E-Kit as Vitamin K is in the contingency but was not given. *The Vitamin K STAT order indicated a need to call Physician back for further steps if Vitamin K not given and the calls were not made. On [DATE], at 10:40 AM, Surveyor observed R23 lying in bed, bruises noted up and down bilateral arms. R23 stated today is [DATE], and does not know if taking [MEDICATION(S)] or not. According to the National Institute of Health ([MEDICATION(S)] Plus), [MEDICATION(S)] may cause severe bleeding that can be life-threatening and even cause death. According to the article Bleeding Risks and Response to Therapy in Patients with INR Higher than 9, Close monitoring of INR is necessary to avoid both under and over-anticoagulation. INR higher than 4 has been associated with an increased risk of bleeding, and the risk of intracranial hemorrhage increases approximately 2-fold for every 1 unit rise in INR. INR greater than 9 is associated with a particularly high risk of bleeding, with up to 20% of patients with INR higher than 9 bleeding within the next week, 20-fold higher than patients with INR lower than 9. This source also notes that Among inpatients [with an INR higher than 9] receiving [MEDICATION(S)], 35% had bleeding and 17% died . Factors associated with bleeding were older age, renal failure, and alcohol use. https://academic.oup.com/ajcp/article/[DATE]/ 21 The American Heart Association article Oral Anticoagulants and Intracranial Hemorrhage notes, Anticoagulation . increases the risk of intracranial hemorrhage 7- to 10-fold . Most (70%) anticoagulant-related intracranial hemorrhages are intracerebral hematomas (approximately 60% are fatal); the bulk of the remainder are subdural hematomas. Predictors of anticoagulant-related intracerebral hematoma are advanced patient age, prior ischemic stroke, hypertension, and intensity of anticoagulation. In approximately half of anticoagulated patients with intracerebral hematoma the bleeding evolves slowly over 12 to 24 hours, and emergency reversal of anticoagulation is crucial. http://stroke.ahajournals.org/content/[DATE].full The facility's failure to ensure the PT/INR level was drawn on [DATE] and its failure to monitor R23's PT/INR from ,d+[DATE] to [DATE] created a finding of immediate jeopardy beginning on [DATE]. The facility removed the immediate jeopardy on [DATE] when the facility implemented the following: Education/Training The facility completed a care plan review to ensure R23 had appropriate orders for INR/PT lab value monitoring related to anticoagulant use. The facility completed a review of like residents who require INR/PT monitoring due to anticoagulant use. The facility reviewed the [MEDICATION(S)] event with the Medical Director. The Director of Clinical Services-C completed a review of the event related to the lack of lab monitoring for R23 related to anticoagulant medication use. The Director of Nursing-B and Assistant Director of Nursing received re-education on the process of monitoring residents who require INR/PT monitoring related to anticoagulant medication use. The facility initiated re-education and return demonstration training with all licensed nursing staff and medication technicians related to administration of [MEDICATION(S)]. The facility initiated re-education and training with staff related to use of the E-Kit and return demonstration on removing medications from contingency. All staff will be required to complete training before next scheduled date of work. The facility initiated re-education and training with the licensed staff and medication technicians regarding notification to the MD at time of identification when medications ordered STAT are not available. All licensed staff and medication technicians will be required to complete return demonstration training prior to next scheduled work day. The facility requested pharmacy completed an assessment of the E-kit system to ensure the system functioning appropriately. The facility consulted with attending MD and Medical Director regarding updated plan and educations. Systems, Policies & Procedures The facility completed a review of the [MEDICATION(S)] Administration Policy. The facility reviewed the E-Kit process on removing medications from contingency and validated the E-Kit was functioning appropriately. Monitoring, Audits, QAPI (Quality Assurance and Performance Improvement), and Facility Assessment The facility will audit lab orders daily during morning meeting to ensure INR/PT lab values are identified and timely follow up notification to the Physician is completed. The facility will audit medications for STAT administration daily during morning meeting. The facility will complete random remedial training with licensed nurses and medication technicians to ensure ongoing competency with the [MEDICATION(S)] administration process. The facility will review the recommended audits at the monthly QAPI committee meeting. Additional follow up will be completed based on the outcome of those findings.

Based on observation, interview, and record review, 2 (R24, R23) of 13 sampled residents were not provided the treatment, care, and services in accordance with professional standards of practice. R24 was not weighed daily as ordered and R24 was not consistently assessed or monitored for signs/symptoms of CHF ([CONDITION(S)]). On 09/01/21 R24's weight was 401 pounds. The next weight obtained on 9/8/21 indicated R24's weight was 416.8 pounds, an increase of 15.8 pounds in 1 week. On 9/10/21 R24 was sent to the hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R23 was readmitted to the facility on [DATE] with the hospital discharge record reflecting multiple wounds, including an open area to the left heel and medial ankle documented as having granulation and slough, which was not assessed or measured for 5 days until 9/13/21, when treatment was initiated and measurements obtained. The measurements obtained on 9/13/21 did not contain a description of the wound beds, did not identify what type of wounds these were and the facility's documentation of the areas did not consistently correlate with hospital identified areas. R23 had a fall on 8/29/21 with a head injury and neurological checks were not completed accurately. Findings include: 1. The Facility Weight Assessment and Intervention policy revised 10/14/20 documented (in part): Policy - The interdisciplinary team will strive to prevent, monitor and intervene for undesirable weight changes for our residents. Procedure. Weight Assessment. 1. The nursing staff will measure resident weights on admission, the next 2 days and weekly for 3 additional weeks thereafter. 2. If no weight concerns are noted after the initial 3 days and 3 weeks after, routine weights will be measured monthly thereafter, unless ordered more frequently by the physician. 3. Weights will be recorded in the individual's electronic health record. 6. Any weight change of five (5) pounds or more since the last weight assessment will be retaken for confirmation. 8. The threshold for significant weight change will be based on the following criteria: 1 month 5% weight change is significant, > (greater than) 5% is severe. 10. The nursing staff will notify the individual or responsible party, Physician and RDN (Registered Dietician) or designee of any individual with an unintended significant weight change. Analysis 1. The Physician and the interdisciplinary team will identify conditions and medications that may be causing weight change. For example: d. Fluid imbalance and or [CONDITION(S)]. R24 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's current Care Plan documented (in part): Altered nutrition status related to cardiac status as evidenced by diet and 3 diuretics ordered for management of [CONDITION(S)]. Interventions: 1600 cc fluid restriction. Notify MD (Medical Doctor) of significant weight variances. Risk/benefit education and follow up reminders regarding compliance with diet and fluid restriction PRN (as needed). Impaired Cardiovascular status related to Hypertension. Interventions: Assess breath sounds as necessary and report abnormalities. Assess productive/nonproductive cough, SOB (shortness of breath)/exertional dyspnea at rest, [CONDITION(S)] night dyspnea or orthopnea. Resistive/noncompliant with treatments/care fluid restriction and safety measures related to [CONDITION(S)]. Intervention: Provide education about risks of not complying with therapeutic regimen. [CONDITION(S)]/excess fluid volume as evidenced by respiratory distress related to pulmonary [CONDITION(S)] and CHF. Interventions: Obtain weight every day. Report significant changes to MD. Report signs and symptoms of [CONDITION(S)]/fluid overload, such as change in mental status, weight gain, neck vein distention, abnormal lung sounds, extremity swelling, etc. (etcetera). On 9/07/21 at 9:24 AM during initial interview, R24 reported he was in and out of the hospital for heart problems and his legs fill up with fluid. Surveyor noted [CONDITION(S)] to R24's lower extremities. R24 was wearing tubi grips and gripper socks on his feet. Review of R24's medical record indicated he was hospitalized in February, May and August of 2021. Progress notes documented: 2/14/2021 at 10:14 PM Resident is on follow up for: Respiratory assessment. The current status is Resident is alert and oriented. He was complaining of SOB (shortness of breath). Oxygen was 80 and was increased to 3L (liters). MD (Medical Doctor) was contacted. He said resident should be sent out, but resident later refused to go to hospital. He said he is doing fine and he is not going any where. 2/15/2021 at 3:01 AM Resident is on follow up for SOB. The current status is Resident resting quietly in bed. Respirations even and non labored. No cough or audible congestion noted. POX (Pulse Oximetry) 96% with O2 (Oxygen) at 3L/M (Minute) via nasal cannula. Resident denies C/O (complaint of) SOB. Will continue to monitor. 2/15/2021 at 8:44 AM Late Entry: Spoke with resident regarding going to .ER (emergency room ) for evaluation and treat per recommendations from NP (Nurse Practitioner). Resident refused to go, became upset swearing saying he did not want to go back into isolation. POA (Power of Attorney) was notified and left the decision up to the resident on whether to go or not. Resident refused. Surveyor noted R24 was subsequently sent to the ER, however progress notes did not document the information. Hospital records documented R24 was admitted to the hospital on 2/16/21. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] R24's medical record indicated he was hospitalized in May 2021. There were no progress notes regarding the events leading to hospitalization . Hospital records documented R24 was admitted to the hospital on 5/13/21. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes documented: On 8/1/2021 at 12:32 AM Writer has seen resident twice this shift thus far. Resident's POX is 93% on 2L oxygen via NC (nasal cannula). Resident's dressing on left foot protecting left big toe fell off and needed to be redressed. Writer redressed wrap on left toe and secured. Talked to resident about overall status and about how staff wanted resident to go to hospital due to concerns of increased [CONDITION(S)]. Resident again stated does not want to go because does not feel that the (name of hospital) will do anything for him. Approximately an hour later he requested for writer to come back to his room. Resident's dressing somehow came back off his foot again. Writer redressed the foot and included a tubi grip. Writer again asked about resident's status and resident stated unable to sleep because of difficulty breathing. No course lung sounds noted but resident is severely morbidly obese making assessment difficult. Lung sounds severely diminished in right upper quadrant. Resident's legs and now left hand has +4 [CONDITION(S)]. Writer strongly encouraged resident to go to ER and resident continues to refuse to go. Will continue to monitor. 8/1/2021 at 2:12 PM Resident sent out by (ambulance) to (hospital) ER for SOB, BLE (Bilateral Lower Extremity) [CONDITION(S)] +4, r/t (related to) acute CHF and [CONDITION(S)]. POA made aware of clinical situation and is to meet resident at ER. VSS (Vital Signs Stable). Surveyor noted R24 was readmitted to the facility on [DATE]. The Hospital Discharge Summary dated 8/9/21 documented: Acute on Chronic CHF. Please continue daily standing weights. On 9/8/21 at 7:12 AM Surveyor observed R24 sitting in his motorized scooter chair, asleep. He was dressed and was wearing tubi grips and gripper socks on his feet. Surveyor noted increased [CONDITION(S)] to both of his lower extremeties. On 9/8/21 at 8:55 AM Surveyor observed R24 entering his room in his scooter. Surveyor asked R24 about his fluid restriction. R24 stated, Yeah, I'm supposed to be on a fluid restriction. Surveyor asked if he follows the fluid restriction, to which R24 stated, For the most part. Surveyor asked if he was able to get water or fluids when he wants. R24 stated, Yeah, they're usually pretty good. Otherwise I can fill up my cup myself. Surveyor asked R24 if he is weighed every day, to which he stated: No, not every day, but they do weigh me and I guess they analyze it. R24's current signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R24's weights after he was readmitted to the facility on [DATE] as followed: 08/10/21 399 pounds 08/13/21 399 pounds 08/19/21 384.8 pounds 08/19/21 385 pounds 08/21/21 389.6 pounds 08/24/21 390.1 pounds 08/25/21 397 pounds 08/26/21 395 pounds 08/29/21 396.6 pounds 09/01/21 401 pounds Surveyor noted R24's weight fluctuated and although his weight had only increased by a total of 2 pounds from 8/10/21 to 9/1/21, the facility did not weigh R24 daily as ordered. There was no weight recorded after 9/1/21 and Surveyor identified concern with [CONDITION(S)] during observation. On 9/08/21 at 2:45 PM Surveyor advised Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of concern regarding R24's weights not consistently completed and monitored. Surveyor advised NHA-A and DON-B that R24 was hospitalized 3 times thus far this year for cardiac/CHF related issues. Surveyor advised of observation of R24's lower extremity [CONDITION(S)] and asked for a current weight - as the most recent weight documented was on 9/1/21 at 401 pounds. Surveyor noted R24's weight obtained on 9/8/21 (after Surveyor request) documented a weight of 416.8 pounds - which was a significant weight increase of 15.8 pounds in 1 week. Surveyor located no documentation of an assessment related to R24's significant CHF history (ie: lung sounds, respiratory status, [CONDITION(S)]). There was no documentation an assessment was reported to the Physician. Facility Progress notes completed by DON-B documented: 9/8/2021 at 4:02 PM Writer spoke with NP regarding resident 416.8 weight. Writer discussed with Nurses pac (practitioner) weights. POA is aware of resident condition. Resident remains non adherent to (Surveyor noted the progress note ended and another entry was made). 9/8/2021 at 4:05 PM Resident remains non adherent to recommended diet. Family dropped off food from home after resident ate dinner that was served in facility. On 9/09/21 at 9:52 AM Surveyor spoke with NHA-A. Surveyor advised of concern regarding R24's weights not completed daily as ordered. Surveyor asked for documentation of facility assessments/monitoring CHF. NHA-A stated, I'd have to see if they do any type of skilled charting on him. Surveyor advised NHA-A of R24's weight obtained 9/8/21 indicated increase 15.8 pounds in 1 week and reviewed progress notes documentation, which only addressed non-compliance with diet. Surveyor advised NHA-A there was no documentation an assessment was completed to rule out CHF (ie: assessment of lungs, [CONDITION(S)], respiratory status, O2 saturation). Progress notes only documented resident is non-compliant with diet. Surveyor advised NHA-A the facility awareness of R24's noncompliance would be reason to monitor him more closely for CHF exacerbation, as he has been hospitalized 3 times this year for CHF. NHA-A stated, I agree. No additional information was provided. On 9/13/21 at 10:14 AM, Surveyor spoke with DON-B regarding R24's weight increase and communication with the Nurse Practitioner. DON-B stated, I spoke with her (NP) that day (9/8/21) and told her about his weight. She (NP) was just here the previous day and talked to him about increasing diuretics - but he refuses. He is non-compliant with his diet and fluid restriction. We all keep trying and educating him on the importance to follow it, but he mostly does what he wants. Surveyor advised there was not an assessment documented after facility noted significant weight increase (ie: lungs, [CONDITION(S)], O2 sat) and asked if an assessment was completed. DON-B stated, No, I don't think so. I did speak to the NP about his weight. That's when she said she was just in to see him and wanted to increase the diuretic, but he refused. The NP note dated 9/7/21 documented: [CONDITION(S)], chronic, systolic and diastolic. Continue on [MEDICATION(S)]. Non compliant with diet/fluid restrictions. Off [MEDICATION(S)]. Continue on [MEDICATION(S)] 4 mg (milligrams) BID (twice daily), [MEDICATION(S)] 50 mg BID and [MEDICATION(S)] 5 mg M, W, F (Monday, Wednesday, Friday). Encourage patient to elevate legs in bed every afternoon for 20 minutes. Dietary and fluid compliance encouraged. Returned from the (name of hospital) 8/9 following aggressive diuresis, wt (weight) down significantly and leg [CONDITION(S)] looked better than ever; wt 386 pounds; now with upward trend in wt and increased [CONDITION(S)]. States his SOB is at baseline and improved following diuresis. Monitor labs closely with diuretics. Wt increased, [CONDITION(S)] in BLE increased - ongoing encouragement of compliance. Pt refused increased diuretic use. Facility progress notes documented: 9/10/2021 at 12:41 PM Communication - with Physician. Situation: Writer consulted with NP regarding patient's c/o SOB and swelling to BLE's and +3 pitting [CONDITION(S)] to left arm. Response: Writer also reminded NP of most recent weight gain. Recommendations: Per NP, patient may be sent to (hospital) ER for further evaluation and treatment. 9/10/2021 at 12:45 PM SBAR (Situation, Background, Assessment, Recommendation) - Change of Condition Situation: Patient C/O SOB earlier this AM. Writer had switched portable tank as well as nasal cannula tubing out. Writer noted Oxygen in the tank where it was full and oxygen coming through the nares part of the tubing. [MEDICATION(S)] was administered to help with breathing/SOB as well. Assessment: Writer called and spoke with (hospital) charge Nurse, to give report. Writer tried sending patient out via ambulance x 3 but none were available at the time. Writer had to have patient sent via 911. 9/10/21 Hospital paperwork documented: Pt reports past couple of weeks, shortness of breath has worsened. Says he drinks a 12 pack of soda almost every day, which he believes is what may be exacerbating his heart failure. On 9/13/21 at 11:39 AM Surveyor met with Clinical Services Director-C and advised her of concern regarding daily weight not completed as ordered and not consistently assessing/monitoring R24 related to his chronic CHF. Clinical Service Director-C stated: Even though he is very non-compliant, we still need to address his issues. She reported the facility will be implementing a plan to include routine education of risks versus benefits, more care planning to address potential non-compliance and will set up a meeting with the Physician and resident to put plan in place and discuss palliative care if needed. Clinical Services Director-C thanked Surveyor. The facility did not weigh R24 daily as ordered and did not consistently assess and monitor the resident for signs/symptoms of [CONDITION(S)] (CHF). No additional information was provided. 2. The facility policy, dated August 2, 2021, Pressure and Non-Pressure Injuries, indicated Procedure: Upon Admission-a head to toe body evaluation will be completed on every resident admission/readmission and will be documented. R23 was readmitted to the facility on [DATE] after hospitalization for a high INR and [CONDITION(S)] (Urinary Tract Infection). Surveyor reviewed R23's hospital records and Wound Care did evaluate R23 for lower extremity wounds. The Medical Decision Making: Hospital Records indicated Left medial ankle and heel wound and Wounds consistent with pressure/PAD (Peripheral Artery Disease). RLE (Right Lower Extremtiy) wounds are healed. Wound care plan: BLE's (Bilateral Lower Extremities) - Wash with soap and water, pat dry. [MEDICATION(S)] to both wounds. Apply dry secondary dressing. Change 3x/week. Hydroguard (blue top cream) to BLE. Prevalon boots. Hospital Measurements: Left lower leg 1.3 x 1 x 0.1 dried crusts & skin, mechanically removed. Open wounds to left heel & medial ankle with granulation & slough. Right medial leg 1 x 1.5 x 0.4 cm. R23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's Quarterly MDS, (Minimum Data Set), dated 6/3/21, indicated R23 was moderately cognitively impaired, required supervision with one person physical assistance for bed mobility and walking in the room, and was on an anticoagulant. On 9/9/21, at 10:40 AM, Surveyor observed R23 lying in bed, bruises noted up and down bilateral arms, no air mattress was on the bed, heels were not offloaded and no Prevalon boots were noted. R23's 9/8/21 Admission assessment indicated R23's skin color was normal and warm, left heel and left inner foot wounds were indicated without type, staging, or measurements. There was no assessment of bruising/bleeding/ecchymosis. R23's admission Braden scale score was 17 indicating R23 was at risk for skin breakdown. On 9/13/21, at 10:36 AM, Surveyor did not note any weekly skin review for R23 since readmission on 9/8/21. On 9/13/21, at 11:41 AM, Surveyor interviewed Director of Nursing (DON)-B and Clinical Service Director (CSD)-C regarding a readmission skin assessment on R23 who came on 9/8/21 without an identification of the type of wounds, and no measurements. DON-B stated she is the facility wound care nurse but all nurses have signed off that they know how to identify, stage, and measure and they should do it. Surveyor noted that it is 5 days after readmission and it is not completed yet. DON-B stated R23 has a diagrammed body assessment dated [DATE] which circled the wounds on the left heel and left inner foot but no identifying, staging, or measurements. DON-B stated R23 refused dressing change on Friday 9/10/21 so no assessment or measurements were done. DON-B also stated there is no documentation that R23 refused. Surveyor requested to conduct an observation if the treatments are to be done today (9/13/21) in order to see R23 wounds and assessment with measurements however, treatments were completed without Surveyor having the opportunity to observe R23's wound care. On 9/13/21, the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . one time a day every Mon, Wed, Fri for Wounds. On 9/13/21, at 1:24 PM, Surveyor observed R23 sitting in the doorway of the room, eating lunch on a tray on the bedside table without access to a call light, red slippers on, no Prevalon boots. On 9/13/21, on 1:26 PM, Surveyor received R23's wound measurements from DON-B written on a sticky note which documented: Left medial ankle 0.5 x 0.6cm Left heel 1 x 0.5 open Right inner 1.9 x 1.3 purple area noted Right lateral 9 x 2.5 purple area Base/plantar foot 2nd toe (1.1 x 0.5 red) Right lower medial side 4.5 x 2 purple Lateral foot 1 x 0.5 purple Monitor areas *Surveyor noted the wounds were not identified as pressure (no staging), arterial, venous or diabetic. Surveyor noted there is no descripton of the wound bed even though R23's hospital discharge record indicated that resident had an open wound to the left heel & medial ankle with granulation and slough. Surveyor also noted the facility's documentation of the areas did not consistently correlate with hospital identified areas. R23 was readmitted to the facility on [DATE] with wounds which were not assessed or measured for 5 days until measurements and assessments were initiated on 9/13/21 and treatement was initated On 9/13/21, at 3:30 PM, Survey team shared information with facility administration and no further information was provided. 3. The facility policy, dated December 2016, Change in Condition of the Resident (Observing, Recording & Reporting) indicated the purpose was to observe, record, and report any condition change to the physician so proper treatment can be implemented timely. An acute change in condition refers to a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. It is clinically important in that without intervention, the resident may experience complications. Documentation needs to include: Date, time condition change was identified. Notification of practitioner include date, time, what was conveyed, any orders received (each time notified). Care Plan documentation. R23 had a fall on 8/29/21 with a head injury and neurological checks were not completed accurately. The facility policy, Fall Prevention and Management Guidelines, dated 2/2017, revised 3/10/21, indicated: Complete a post fall evaluation and complete required notifications after every fall. Update the physician and responsible party of fall and any injuries or change in neurological status. The post-fall review should include neuro checks for any unwitnessed fall or witnessed fall where resident hits their head: Initially then every 15 minutes x 3, every 30 minutes x 2, hourly x 4, every 8 hours x 9. R23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's Quarterly MDS, (Minimum Data Set), dated 6/3/21, indicated R23 was moderately cognitively impaired, required supervision with one person physical assistance for bed mobility and walking in the room, and was on an anticoagulant. On 8/29/21, at 6:15 AM, The fall investigation report indicated R23 was found sitting on the floor and stated reaching for the water on the bedside table, fell backward hitting the back of the head. The physician was called and an INR (therapeutic level) was ordered due to R23 being on the blood thinner medication [MEDICATION(S)]. The report indicated R23 refused to go to the ER (emergency room ) for evaluation and ice was applied to the bump on the back of the head. R23 was noted to be A&O x 4. Neuro (Neurological) checks were initiated. R23 was sent to the hospital via an ambulance transport company on 8/30/21 at 2:00 AM due to lethargy, sitting and leaning to the right, slow mental status, and inability to answer questions appropriately. Surveyor reviewed R23's fall on 8/29/21 neuro check documentation which indicated: 8/29/21 at 6:30 AM-VS: Blood Pressure 131/84, Pulse 84, Respiration 20, Temp 98.1. No further VS were noted during the day shift on the neuro check record from 6:45 AM to 12:45 PM. No neuro checks were completed on the PM shift either at 4:45 PM or 8:45 PM. The final neuro check on 8/30/21 at 1:45 AM indicated VS: Blood Pressure 105/64, Pulse 78, Respiration 18, Temp 97.3. On 9/08/21, at 1:10 PM, Surveyor interviewed DON-B (Director of Nursing) regarding R23's incomplete neuro checks. DON-B stated that VS should have be done as part of the neuro checks. On 9/8/21, R23 was readmitted to the facility after hospitalization for a high INR and [CONDITION(S)] (Urinary Tract Infection). On 09/09/21 07:30 AM, DON-B stated she came in early this am to do interviews and follow up regarding R23's 8/29/21 fall. A Follow up fall investigation was being conducted. On 9/13/21, 8:24 AM, Surveyor interviewed LPN-F (Licensed Practical Nurse) who works night shift over the phone. LPN-F stated she was coming out of another room and the day shift RN was coming out of another room when 2 CNAs (Certified Nurse Assistant) stated R23 fell at 6:15 AM on 8/29/21. LPN-F stated she asked RN-D to do R23's fall and assessment as LPN-F was getting ready to go home. LPN-F stated when she got to work that night on 8/29/21, report was given that R23 did not want to go to hospital. LPN-F stated that on 8/29/21 at 11:30 PM, she explained she talked to R23 and told R23 that she was not herself and needed to go to the hospital, but it took us about 2 hours to convince R23 to go. LPN-F stated she told R23 she did not have to pay for the ambulance, so R23 then decided to go. Surveyor asked if LPN-F conducted any VS (Vital Signs) on 8/29/21 at 11:30 PM. LPN-F stated she remembered 105/63 and 97.3 which she charted on the transfer form to go to the hospital. *Surveyor noted the conflicting times of VS at 11:30 PM versus 1:45 AM between R23's neuro check documentation and LPN-F's interview. On 9/13/21, at 8:41 AM, Surveyor interviewed LPN-E who works PM shift over the phone. LPN-E stated R23 did not fall during her shift. LPN-E stated she was an hour late on 8/29/21 and RN-D had already left the facility, leaving a written report on the residents. LPN-E stated she did not remember if she looked at the 24 hour nursing report board when she got to work. LPN-E stated she did not recall seeing that R23 was on follow up for a fall and she did not do neurological checks during my PM shift on 8/29/21 as she was unaware of the fall. *Surveyor noted that no neuro checks were completed on the PM shift of 8/29/21. On 9/13/21, at 7:28 AM, DON-B stated RN-D has not returned since the date of R23's fall. On 9/13/21, at 9:23 AM, Surveyor called RN-D but was unable to interview her regarding R23's fall, assessments, and neuro checks that did not have VS during the day shift on 8/29/21. *Surveyor noted R23's neuro checks were incomplete. On 9/13/21, at 3:30 PM, Survey team shared information with facility administration and no further information was provided.

Based on interview and record review the facility did not ensure that 2 (R39, R23) of 2 residents reviewed had an environment that was free from accident hazards and received adequate supervision to prevent accidents. *On 1/18/21, R39 had a sleep-study that recommended an in-lab sleep study to further assess and more definitively diagnose and treat R39's sleep disordered breathing and identified a concern for hypersomnolence associated sleep apnea increasing the risk of motor vehicle collisions and impaired driving judgement. This was not addressed with R39. On 8/17/21, R39 fell asleep while operating her electric wheelchair crashing into a heat register resulting in amputation of two toes on her right foot. On 8/17/21, R39 returned to the facility. Recommendations were noted to contact the PWC complany for wheelchair adjustments and for foot boots for increased protection to feet. On 8/19/21, R39 had another incident with her wheelchair resulting in lacerations to her two toes on her left foot. R39's hospital discharge summary on 8/25/21 recommended a repeat sleep study in which the facility was not aware of this hospital discharge recommendation. *R23's fall was not thoroughly investigated to include the root cause of the fall and did not identify interventions to prevent future falls. On 8/29/21 R23 had a fall hitting the back of her head. Neurological checks did not include vital signs on the day shift, and were not completed on the (pm) shift. Findings include: 1. R39 was admitted to the facility on [DATE] with diagnoses that include: [CONDITION(S)] unspecified; major depressive disorder, recurrent; anxiety disorder, [CONDITION(S)] disorder, unspecified injury at T2-T6 level of [MEDICATION(S)] spinal cord and mild persistent asthma. R39's Readmission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/31/21, documents: A Brief interview of Mental Status (BIMS) score of 14, indicating R39 is cognitively intact for daily decision making; Patient Health Questionnaire (PHQ-9) score of 6 indicating mild depressive symptoms; with near every day concerns related to trouble falling asleep, staying asleep or sleeping too much and feeling tired or having little energy; dependent on 2 staff for transfers, dependent on one staff for locomotion on the unit, extensive assist of one staff for bed mobility, dressing, toilet use and personal hygiene; upper extremity range of motion limited on one side and lower extremity range of motion limited on both sides, need for oxygen therapy. R39's Care Plan, dated 1/5/18, revision on 12/20/18, documents: Resident has impaired functional mobility as evidenced by chronic condition [CONDITION(S)]. Interventions include: -Bed enable bars for bed mobility, initiated on: 10/11/18, revision on: 12/7/20; -High back wheelchair, initiated on: 8/20/21; -Offer to reposition every 2 hours, initiated on: 12/10/20; -PT/OT (physical therapy/occupational therapy) screen/evaluation for positioning, transfers, mobility, device aids, etc (excreta), initiated on: 1/5/18; -Reacher, initiated on: 12/7/20; -Resident requires 2 staff assist to transfer, initiated on: 1/5/18; -Shower/bed bath Sunday AM (day shift) and Wednesday PM (second shift), initiated on: 8/16/21. R39's care plan does not address R39's need for oxygen therapy or R39's assessed concerns for difficulty sleeping and lack of energy. On 9/07/2, at 12:09 PM, Surveyor interviewed R39, who stated her mood is down due to not having her power wheelchair. R39 stated the facility told her that the power wheelchair chair is too small for her since R39 had gained weight. R39 stated she was sleepy and did fall asleep and ran the power wheelchair into a heater at the end of the hallway and cut her toes. R39 stated she would like the power wheelchair back and promises she will come back to her room and read a book if she is feeling tired. On 9/09/21, at 8:52 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G, who stated R39 is very particular with positioning. R39 only likes to rest/lay on her back and will only reposition off her back on to her side when cares are being done. CNA-G stated the R39 is in bed more due to not having the electric wheelchair to use. CNA-G stated R39 falls asleep in the electric wheelchair and isn't safe. CNA-G stated R39's insurance is looking into different options for a wheelchair and the facility provided a high back manual wheelchair for R39 but she declines to use it. CNA-G stated R39 is very particular about the way care is received and is able to tell staff exactly what she likes. CNA-G stated R39 likes to be in her electric wheelchair and didn't like to come out of it. CNA-G stated when R39 seems sleepy CNA-G would not put R39 in the electric wheelchair and R39 would stay in bed. CNA-G stated R39 typically likes to be up in electric wheelchair most of the day. On 8/17/21, at 14:29 (2:29 PM), R39's Medial Record documents: Writer called to front office resident was there staff was applying pressure to right foot which was bleeding profusely from 3rd and 4th toes, bone was exposed at the base of each toe. Writer notified that resident was in electric wheelchair and ran into heater along the baseboard. Resident description: I fell asleep while driving the wheelchair. Mental Status: Oriented to person, place, situation and time; . Predisposing Physiological Factors: Drowsy. On 8/17/21, at 4:18 PM, Hospital Emergency Department Triage Notes document: . [Name of transportation company] coming from [name of facility]. Patient fall asleep while driving electric wheelchair. Severed third and fourth toe with bone showing. Wrapped with bleeding control. Alert and oriented. [CONDITION(S)] without pain.Evaluation in ER (emergency room ) today for an open fracture, where you fractured one of your toes, and bone was exposed. Our orthopedic doctors partially amputated that toe and you were provided with [CONDITION(S)] booster and antibiotics to prevent infection. Please follow up with your doctor in 3 days for wound check. On 8/18/21, at 17:37 (5:37 PM), R39's Medical Record documents: IDT (Interdisciplinary Team) reviewed resident incident. It appears resident was driving in wheelchair down hallway and fell asleep crashing into heater at the base board at the end of the hallway. Striking right foot causing lacerations to the 3rd and 4th toe exposing bone and bleeding profusely. Medical attention given immediately. Resident unable to feel pain from the waist down related to diagnoses of spinal cord injury . Writer spoke with resident in regards to safety while in wheelchair. Resident requested to continue to use electric wheelchair, risk benefits discussed with resident. Resident received education on being alert and attentitive while using wheelchair. Therapy to assess resident safety in wheelchair. Writer discussed down time with resident when feeling sleepy. The facility identified the root cause of the accident as R39 falling asleep while operating an electric wheelchair but did not implement intervention to prevent future accidents. On 8/19/21, at 1:48 PM, R39's Medical Record documents: . Pt (Patient) assessed for safety and independence with use of power wheelchair due to a recent injury. Pt demonstrated good safety awareness and independence with use of power wheelchair, however Pt demonstrates fluctuations with falling asleep and level of arousal resulting in fluctuations with safety when up in PWC (Power Wheelchair). Pt demonstrates good trunk positioning in w/c (wheelchair), however, foot rest adjustments needed for improved LE positioning. Recommendations provided to facility to set up appointment with PWC company for adjustments to be provided. Recommendations provided for foot boots for increased protection to feet. Surveyor was unable to locate documentation foot boots were implemented for R39. On 8/19/21, at 13: 42 PM (1:42 PM), R39's Medical Record documents: Writer had 1:1 with resident to discuss incident and wound care. Dressing to be changed daily resident stated. Resident stated she has a hard time staying asleep at night. [Name of power wheelchair company], writer left a message and is waiting for return call. Resident complains of feeling tired in day time, not sleeping well at night. Resident is on psych ([CONDITION(S)]) medications. Writer offered [name of psychiatric services company] and resident has own psych team in place with family care. Writer emailed caseworker to place consult for psych team to come and evaluate medication. Writer educated resident on settings on power chair and resident verbalized understanding. On 8/19/2021, at 14:34 (2:34 PM), R39's Medial Record documents: Writer discussed with therapy that resident would like a cushion for her feet and Writer was instructed to have power chair company assess this as well when they come out to service chair. On 8/19/21, at 17:30 (5:30 PM), R39's Medical Record documents: Writer was called to resident room, resident noted to be bleeding from left foot. Upon further investigation writer observed deep laceration to 2nd and 3rd toe at the base of the toes on left foot. Resident is unable to feel pain due to [CONDITION(S)] diagnosis. Writer asked resident what happened resident stated: I was leaning over my arm hit the controller and the wheelchair hit the dresser. Pressure dressing applied. NP (Nurse Practitioner) notified, resident own person. Writer discussed resident using manual wheelchair for safety. Resident stated, I do not want to I want to use my own chair. Writer expressed concern with this being another incident with resident causing bodily harm. Resident said she called [the name power wheelchair company] to come out to assess wheelchair. [Name of transport company] was called to have resident transported to [name of hospital] for evaluation and treat. On 8/19/21, at 9:24 PM, R39's Hospital discharge paperwork documents: . longstanding [CONDITION(S)] secondary to an accident as a child presents with laceration. Patient states that she is unaware how she cut her left foot today she has no sensation to her lower extremities but noticed it bleeding this afternoon. She states that she has been using her motorized wheelchair, and has not fallen or otherwise injured herself. Given it seems that the toes may be somewhat devitalized and she is not ambulatory at baseline will consult orthopedic surgery for evaluation and possible amputation. Pt arrives via [transport company name] from [facility name] where she is in a motorized wheelchair where pt reports she has [CONDITION(S)] but nobody takes that seriously. Pt reports feeling tired all the time. Falls asleep in her chair causing her to hit the controls and hit objects in her room. Laceration to left foot with near amp (amputation) to bottom 2nd and 3rd toes. Hx (history) of same needing amputations. Bleeding controlled. On 8/20/21, at 13:00 (1:00 PM), R39's Medical Record documents: IDT met to discuss incident. Second incident within 2 days regarding injury to self from use of electric wheelchair. Resident was educated on safety while using electric wheelchair on 8/17 and 8/18 and this incident occurred on 8/19 with resident reaching forward in electric wheelchair and running into dresser in room. For resident's safety, electric wheelchair removed and high back wheelchair in place for resident use for locomotion on and off of unit. IDT to continue to follow. On 8/22/21 through 8/25/21, R39 was hospitalized due to abdominal pain. During this hospital stay R39's hospital discharge paperwork documents: . a concern for R (right) third and 4th digit open fractures due 2/2 (secondary to) motorized wheelchair accident. S/P (Status Post) revision of amputation by Orthopedic Surgery in ED (Emercency Department) 8/17. Chronic Obstructive Sleep Apnea, likely. Patient has had sleep study in past, needs repeat as she never fell asleep during the first exam. She uses oxygen only at night and has been witnessed having apneic periods. Complaining of ongoing fatigue and sleepiness. F/U (Follow Up) sleep study as outpatient. On 9/9/21, at 10:37 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated the facility conducted a sleep study for R39. DON-B stated the sleep study company had facility staff come to their office, pick up the sleep study machine, use it with R39 over night and then return the machine to the sleep study company the next day. DON-B stated she would provide Surveyor with a copy of the sleep study results. On 9/9/21, at 1:30 PM, DON-B provided Surveyor with a copy of sleep study results from 1/18/21, which documents: 1. Obstructive sleep apnea; 2. Sleep-related hypoentilation/hypoxemia in conditions classified elsewhere; 3. Snoring. Impression: 1. This is an abnormal home portable sleep study indicating a severe degree of sleep disordered breathing/OSA (Obstructive Sleep Apnea); 2. Hypoxemia secondary to #1; 3. given the degree of hypoxemia and oxygen desaturation pattern, a central sleep disorder breathing pattern can not be ruled out. Recommendations: An in-lab spit night PSG (polysomnography) (sleep study) is recommended with these findings to further assess and more definitively diagnose this pattern of OSA and to ensure adequate resolution of hypoxemia. An advanced titration study may be indicated depending on sleep lab testing results. 1. Close clinical follow-up is recommended to ensure adherence and resolution of sleep disordered breathing. 2. Sleep consultation recommended. 3. Weight loss close to 25 kg/k2 (kilograms) recommended. 4. Hyersomnolence associated with sleep apnea may increase the risk of motor vehicle collisions and impaired driving judgement, this should be discussed with the patient. 5. Sedating medications prior to sleep inducing benzodiazepines can aggravate sleep disordered breathing and should be avoided if possible. On 9/9/21, at 1:45 PM, Surveyor interviewed DON-B, who stated she does not have any other sleep study results for R39. DON-B stated she was not aware of the hospital discharge recommendations on 8/25/21 recommending another sleep study be conducted. DON-B stated she would need to look into this further and would let the Surveyor know. Surveyor asked DON-B if the therapy department was aware of the results for the 1/18/21 sleep study and if R39's ability to safely use the electric wheelchair had been assessed at that time. DON-B stated she would need to look into this further and would let Surveyor know. On 9/09/21, at 2:45 PM, DON-B informed Surveyor the facility did not have any other sleep study results for R39 and the facility was not aware of the hospital recommendation for another sleep study as documented on the 8/25/21 hospital discharge summary. DON-B stated she contacted the sleep study company today and at this time the company is setting up consultation only appointments. DON-B stated she will check with therapy to see if they completed assessments of R39's ability to safely use the electric wheelchair prior to the two incidents. On 9/13/2, at 10:02 AM, Nursing Home Administrator (NHA)-A informed Surveyor R39 was evaluated quarterly for the safe use of the electric wheelchair by therapy staff. NHA-A provided Surveyor with a copy of the quarterly therapy screenings completed with R39 on 1/18/21, 4/21/21 and 7/22/21. On 1/18/21, R39's Medical Record documents a therapy screen which documents: Reason for screen: On demand. No change from prior MDS. Mobility: Bed mobility, walking, transfer, balance, range of motion, balance and W/C MOB (Wheelchair Mobility). This area is completed with a large X in the section documenting these areas to be unchanged. Activities of Daily Living: Dressing, grooming, bathing, toileting, eating/swallowing. This area is completed with a large X in the section documenting these areas to be unchanged. Speech/Cognition: Safety, intelligibility, comprehension, cognition. This area is completed with a large X in the section documenting these areas to be unchanged. Other: Positioning, restorative nursing, pain manage, continence, skin integrity. This area is completed with a large X in the section documenting these areas to be unchanged. On 4/21/21, R39's Medical Record documents a therapy screen which documents: Reason for screen: On demand: wounds BLE (Bilateral Lower Extremities). Mobility: Bed mobility, walking, transfer, balance, range of motion, balance and W/C MOB. This area is completed with a large X in the section documenting these areas to be unchanged. Activities of Daily Living: Dressing, grooming, bathing, toileting, eating/swallowing. This area is completed with a large X in the section documenting these areas to be unchanged. Speech/Cognition: Safety, intelligibility, comprehension, cognition. This area is completed with a large X in the section documenting these areas to be unchanged. Other: Positioning, restorative nursing, pain manage, continence, skin integrity. This area is completed with a large X in the section documenting these areas to be unchanged except for positioning. Positioning documents a decline with comments: Spoke with NP (Nurse Practitioner) and DON, pt having increased wound care needs at this time. Pt not appropriate for any positioning equipment other than pillows at this time. Will re-screen once pt wounds are resolved for appropriate positioning footwear. On 7/22/21, R39's Medical Record documents a therapy screen which documents: Reason for screen: On demand: self feeding. Mobility: Bed mobility, walking, transfer, balance, range of motion, balance and W/C MOB (Wheelchair Mobility). This area is completed with a large X in the section documenting these areas to be unchanged. Activities of Daily Living: Dressing, grooming, bathing, toileting, eating/swallowing. This area is completed with a large X in the section documenting these areas to be unchanged. Speech/Cognition: Safety, intelligibility, comprehension, cognition. This area is completed with a large X in the section documenting these areas to be unchanged. Except for eating/swallowing which documents a decline in eating/swallowing and TBA (To Be Assessed) documented in this area. Other: Positioning, restorative nursing, pain manage, continence, skin integrity. This area is completed with a large X in the section documenting these areas to be unchanged. Pt spilled hot coffee on self. Safety during feeding to be assessed. On 9/13/21, at 10:57 AM, Surveyor interviewed Occupational Therapist (OT)-H, who stated she completed R39's evaluation after the initial accident on 8/17/21 and completed 2 of the 3 quarterly therapy screens. OT-H stated she assessed R39 with the use of the electric wheelchair in the facility, in the dining room and outside. OT-H stated R39 was safe with the use of the electric wheelchair except when R39 has episodes of falling asleep or being tired. OT-H stated R39 did not have any incidents with the use of the electric wheelchair prior to 8/17/21. OT-H stated she has worked at the facility for 5 years and has not heard of any prior concerns with R39's use and safety of the electric wheelchair. OT-H stated the facility does not have therapy staff assess all resident's ability to use electric wheelchairs as the residents's usually have them for a long time prior to coming to the facility and their is no set standard to test the safety of electric wheelchair use. OT-H stated she did not have any concerns for R39's cognitive ability or ability to follow directions with the use the electric wheelchair. OT-H stated therapy staff does complete quarterly screenings of each resident by talking with the CNAs and the resident to identify any concerns with mobility and that would include the use of an electric wheelchair. OT-H stated she does not physically watch resident's use the electric wheelchair during the quarterly screening process rather talks to staff and the resident to identify any concerns in the areas of mobility, activities of daily living and cognition. OT-H stated the facility did meet as a team to review the therapy evaluation of R39's ability to safely use the electric wheelchair. OT-H stated therapy gives recommendations to the team and then nursing does a medical evaluation and implements interventions. OT-H stated she was not aware of R39's prior 1/18/21 sleep study and the results which document R39 could be at higher risk for a motor vehicle accident due to hypersomnolence. OT-H stated she does not believe the sleep study results would have changed her assessment of R39 being safe with the use of the electric wheelchair as long as R39 was not sleepy. OT-H stated R39 is sleepy in the morning and was more awake in the afternoon. OT-H stated the staff know to let R39 sleep in and not to get R39 up unless R39 feels up to it. OT-H stated R39's alertness fluctuates and in the afternoon R39 is more awake. On 9/13/21, at 11:37 AM, Surveyor interviewed Social Worker (SW)-I, who stated she is new to the facility but has worked with R39. SW-I stated the electric wheelchair company came out to the facility on [DATE] and has recommended a new electric wheelchair for R39 due to weight gain. SW-I stated she is working with R39's case manager to figure out how the cost of a new electric wheelchair would be covered. SW-I stated she did speak with R39 in regards to psychiatric services as R39 does seem more down since the accident with the electric wheelchair. SW-I stated she offered to make a referral to a psychiatric service who and used to working with nursing homes and responds timely to resident needs. However, SW-I stated R39 continues to want to use her own psychiatric services for follow up. SW-I stated she contacted R39's psychiatric services team on 8/19/21 and requested an evaluation. SW-I stated she was informed R39's psychiatric services team came to the facility on ,d+[DATE] to assess R39 for possible increased depression and increased lethargy on 9/3/21. SW-I stated the psychiatric service team did not check in with SW-I for updated information and assessments. SW-I stated she contacted R39's psychiatric service team on 9/9/21 and requested a copy of their evaluation and has not received it as of this time. SW-I stated R39 continues to want to be responsible for making her own appointment and managing medication without allowing much oversight from the facility. SW-I stated the facility is waiting to hear back from R39's family to see if anyone would be available to go with R39 for another sleep study as the clinic requested R39 have a companion. On 9/13/21 at 1:14 PM, Surveyor informed NHA-A of the concern the facility did not follow up with R39's 1/18/21 sleep study recommendations of arranging a follow up in-lab sleep study or sleep consultation nor the concern R39's hypersomnolence associated with sleep apnea increasing R39's risk of motor vehicle collisions and impair driving judgement. The facility determined the cause of R39's accident on 8/17/21, resulting in amputation of 2 toes on her right foot, was related to R39 falling asleep while operating her electric wheelchair. Surveyor noted there was no interventions developed to assess R39's alertness prior to the continued use of the electric wheelchair. R39 had a second accident on 8/19/21 that resulted in a laceration to the left foot. NHA-A stated she understood and no further information was provided. The facility policy, Fall Prevention and Management Guidelines, dated 2/2017, revised 3/10/21, indicated: Complete a post fall evaluation and complete required notifications after every fall. Update the physician and responsible party of fall and any injuries or change in neurological status. The post-fall review should include neuro checks for any unwitnessed fall or witnessed fall where resident hits their head: Initially then every 15 minutes x 3, every 30 minutes x 2, hourly x 4, every 8 hours x 9. 2. R23's falls were not thoroughly investigated at the time of the fall, and call light interventions were indicated for all 3 falls without interview or follow up at the time of the fall regarding call lights. R23 was admitted to the facility on [DATE] with diagnoses including Chronic [CONDITION(S)], Hemorrhagic Disorder due to extrinsic circulating anticoagulants ([MEDICATION(S)]-blood thinner), [CONDITION(S)], Diabetes, PVD ([CONDITION(S)]), PAD (Peripheral Artery Disease), CHF ([CONDITION(S)]), and LE Ulcers (Lower Extremity). R23's Quarterly MDS, (Minimum Data Set), dated 6/3/21, indicated R23 was moderately cognitively impaired, required supervision with one person physical assistance for bed mobility and walking in the room, and was on an anticoagulant. Surveyor reviewed R23's falls, fall investigation reports, and care plan. R23 fell on [DATE] at 1:30 PM slipping from the WC (Wheelchair) while trying to transfer to the bed. R23 was noted to be (A&O) alert and oriented x 2 and no injuries were noted. On 6/28/21, at 1:10 PM, Progress note indicated IDT (Interdisciplinary Team) reviewed the fall noting R23 continues to try to be independent with transfers. Plan OT (Occupational Therapy) evaluation and treat. R23's Care Plan, initiated 6/28/21, indicated R23 is at risk for falls r/t Cognition-unaware of safety needs, deconditioning/weakness, gait balance problems. Interventions include: Place call light or communication device within reach, initiated 6/28/21. Anticipate and meet R23's needs. Encourage R23 to always call for assistance, initiated 6/28/21. Follow therapy recommendations for transfers, mobility, and ambulation. OT eval & treat, initiated 6/28/21. On 7/28/21, at 4:05 AM, R23 had an unwitnessed fall and was noted to be sitting on buttocks with legs out. R23 was noted to be A&O x 3 with small laceration and bruising on left elbow. R23 stated was standing then sitting in WC and reaching for the reacher by the bedside when falling. No documentation was noted in regards to the care planned intervention of the position of the call light or whether usage was noted. On 7/28/21, at 1:47 PM, Progress note indicated IDT reviewed the fall and noted upon further assessment R23 appeared to have increased generalized weakness and fell ing overall under the weather. R23 received as needed Tylenol. R23's care plan, at risk for falls, was updated on 7/28/21 to include the intervention: Remind R23 to use call light and ask for assistance. *Surveyor noted R23 was interviewable but no information was provided regarding R23's call light which was a previous fall prevention intervention on 6/28/21. On 8/29/21, at 6:15 AM, R23 was found sitting on the floor and stated reaching for the water on the bedside table, fell backward hitting the back of the head. The physician was called and an INR (therapeutic level) was ordered due to R23 being on the blood thinner medication [MEDICATION(S)]. The report indicated R23 refused to go to the ER (emergency room ) for evaluation and ice was applied to the bump on the back of the head. R23 was noted to be A&O x 4. Neuro (Neurological) checks were initiated. *Surveyor noted R23 was interviewable but no information was provided regarding R23's call light which was a previous fall prevention intervention on 6/28/21 and 7/28/21. R23 was sent to the hospital via an ambulance transport company on 8/30/21 at 2:00 AM due to lethargy, sitting and leaning to the right, slow mental status, and inability to answer questions appropriately. On 8/31/21, at 12:56 PM, Progress note indicated IDT reviewed the fall and noted R23 was sent to the hospital for evaluation due to a change in mental status and high INR. Will reassess fall intervention upon readmission. Surveyor reviewed a post-fall assessment which indicated R23 fell on [DATE] at 00:00. which was inaccurate as R23 did not fall at that time. This particular assessment did not document any review regarding the call light. On 09/09/21 07:30 AM, DON-B (Director of Nursing) stated she came in early this am to do interviews and follow up regarding R23's 8/29/21 fall. Follow up fall investigation being conducted. On 9/13/21, at 7:28 AM, DON-B stated that RN-D (Registered Nurse) who was working on the day of R23's fall on 8/29/21 has not returned to work at the facility since R23's fall on 8/29/21. On 9/13/21, 8:24 AM, Surveyor interviewed LPN-F (Licensed Practical Nurse) who works night shift over the phone. LPN-F stated she was coming out of another room and the day shift RN was coming out of another room when 2 CNAs (Certified Nurse Assistant) stated R23 fell at 6:15 AM. LPN-F stated she asked RN-D to do R23's fall and assessment as LPN-F was getting ready to go home. LPN-F stated that RN-D stated she would call the physician who said send R23 out and R23 repeated herself several times no. LPN-F stated RN-D notified the Physician of R23's refusal, and stated please try to get R23 to go, then RN-D went back to R23's room to explain the need to go to R23. LPN-F stated when she got to work that night on 8/29/21, report was given that R23 did not want to go to hospital. LPN-F stated that on 8/29/21 at 11:30 PM, she explained she talked to R23 and told R23 that she was not herself and needed to go to the hospital, but it took us about 2 hours to convince R23 to go. LPN-F stated she told R23 she did not have to pay for the ambulance, so R23 then decided to go. LPN-F stated 2 hours later she called the hospital and R23 was admitted for [CONDITION(S)] (Urinary Tract Infection). Surveyor asked if LPN-F conducted any VS (Vital Signs) on 8/29/21 at 11:30 PM and she stated she remembered 105/63 and 97.3 which she charted on the transfer form to go to the hospital. Surveyor asked why call an ambulance transport company and not call 911 given the high INR and change in condition? LPN-F stated R23 was not answering questions but the VS were fine, but R23 was slow to respond. LPN-F stated she could not give Vitamin K for the high INR as it was not available but she did not call the physician to notify him of lack of Vitamin K or change in condition. On 9/13/21, at 8:41 AM, Surveyor interviewed LPN-E who works PM shift over the phone. LPN-E stated R23 did not fall during her shift. LPN-E stated she was an hour late on 8/29/21 and RN-D had already left the facility, leaving a written report on the residents. LPN-E stated she did not remember if she looked at the 24 hour nursing report board when she got to work. LPN-E stated she did not recall seeing that R23 was on follow up for a fall and she did not do neurological checks during my PM shift on 8/29/21 as she was unaware of the fall. On 9/13/21, at 9:23 AM, Surveyor called RN-D but was unable to interview her regarding R23's fall, assessments, and neuro checks on 8/29/21. *Surveyor noted R23's neuro checks were incomplete. On 9/13/21, at 10:00 AM, Surveyor interviewed CSD-C (Clinical Services Director) and DON-B regarding R23 fall investigation and interventions for 8/29/21 fall. DON-B stated R23's education would be for using the call light & waiting for assistance. DON-B stated the Post fall assessment indicating a fall on 8/30/21 at 00:00 was inaccurate. Surveyor requested further information regarding R23's falls and follow up. On 9/13/21, 1:21 PM, DON-B stated that the fall intervention for R23's 8/29/21 fall was the education that R23 should use the call light. On 9/13/21, at 1:24 PM, Surveyor observed R23 sitting in the doorway of the room, eating lunch on a tray on the bedside table without access to a call light. *Surveyor noted the facility did not conduct a thorough root cause analysis into R23's falls, circumstances not thoroughly investigated at the time of the fall, and the interventions of call light was indicated for all 3 falls without follow up at the time of the fall regarding call lights. On 9/13/21, at 3:30 PM, Survey team shared information with facility administration and no further information was provided.

Based on observation, record review, and interviews, the facility did not ensure residents were kept free from harm due to accidents for 2 (R3 and R2) of 2 residents reviewed for falls. R3 had seven falls in eight months. The falls were not comprehensively assessed, interventions were not put into place to prevent further falls, and R3 sustained injuries after a fall on 6/12/2020 resulting in a hospitalization . R3's fall on 7/7/2020 was not documented in R3's medical record. R2 had a fall on 8/10/2020 with injuries resulting in hospitalization and the care plan was not revised. Findings include: The facility policy and procedure entitled Fall Prevention and Management Guidelines dated 2/2017 states: Key Elements of the Fall Prevention and Management Program: A. Facility participation: All staff will be in-serviced in fall prevention and management. B. Assessments: Multiple assessments are required from various disciplines. C. Dynamic treatment plan 1. Role of Interdisciplinary Team 2. Use of non-pharmaceutical interventions D. Appropriate and necessary use of devices (enablers, restraints). E. Re-assessments, implementation and evaluation of treatment plan. F. Education/awareness. Details of Key Elements: A. Assessments . 3. Frequency of reassessment: 1. Upon a fall - complete post fall assessment 2. Significant change 3. Quarterly and annually 4. Anytime the IDT deems it is necessary or of potential benefit . B. Dynamic Treatment Plan 1. Specific interventions based on results of fall assessments and individual resident's preferences. 2. As information is updated, it needs to be communicated to the staff, resident and family . Individual care plan developed, communicated with staff and implemented. C. Evaluation 1. Complete 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 a Root Cause Analysis. 2. Activate 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-inservicing of staff; 2. Family/resident conferences: timely notification of family of an incident. 3. Timely notification of physician of the fall. 1.) R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated moderate impaired cognition per staff, extensive assistance was needed for bed mobility and transfers with the inability to walk, and had impairment to right arm and right leg. R3 had an activated Power of Attorney (POA). R3's At Risk for Falls Care Plan was initiated on 9/19/2019 with the following interventions: -Anticipate and meet R3's needs. Encourage R3 to always call for assistance. -Follow Therapy recommendations for transfers, mobility, and ambulation. On 12/10/2019 at 9:55 AM in the progress notes, nursing charted R3 had fallen forward out of the wheelchair and landed face down on the floor. R3 sustained bruising to the face. The physician and R3's POA were notified. Dycem was applied to the wheelchair as an intervention at that time. The Post Fall Assessment form dated 12/10/2019, completed by a Licensed Practical Nurse (LPN), indicated the fall occurred at 8:45 AM in the hallway. The fall risk score placed R3 in a low risk category for falls. A Registered Nurse (RN) did not document an assessment of R3 after the fall. No documentation was found indicating the fall was reviewed by an interdisciplinary team (IDT). R3's At Risk for Falls Care Plan was revised on 12/10/2019 with the following intervention: Dycem under R3's wheelchair cushion. On 1/12/2020 at 8:05 PM in the progress notes, nursing charted R3 was found on the floor face down in front of the wheelchair with [MEDICAL CONDITION] activity. R3 sustained a hematoma to the left forehead. The physician and POA were notified of the fall. R3 was sent to the hospital for evaluation and was admitted from 1/12/2020 to 1/15/2020. The Post Fall Assessment form dated 1/12/2020, completed by RN-E, indicated the fall occurred at 6:00 PM in R3's room and no interventions were put in place at that time. The fall risk score placed R3 in a low risk category for falls. No documentation was found indicating the fall was reviewed by an IDT. R3's At Risk for Falls Care Plan was revised on 1/13/2020 with the following intervention: R3 was sent out to the hospital for evaluation related to [MEDICAL CONDITION] activity. A Care Plan to address potential or actual [MEDICAL CONDITION] activity was not initiated. On 3/11/2020 at 8:55 AM in the progress notes, nursing charted R3 was found face down next to the bed. R3 had blood coming from the nose, a hematoma to the left side of the head, an abrasion by the left eye, and an abrasion to the right knee. The Post Fall Assessment form dated 3/11/2020 was initiated, but the form was incomplete except for vital signs that are auto-filled by the computer charting system. No fall risk score was calculated due to the form being blank. The form was not signed. An RN did not document an assessment of R3 after the fall. No documentation was found indicating a physician was notified of R3's fall or injuries sustained from the fall. No documentation was found indicating R3's POA was notified of the fall. The IDT met on 3/17/2020 to review R3's fall on 3/11/2020 and determined R3 prefers to be up in the wheelchair after morning cares. R3's At Risk for Falls Care Plan was revised on 3/11/2020 with the following intervention: once R3 is awake, after morning cares, assist R3 into the wheelchair. On 4/19/2020 at 5:35 PM in the progress notes, nursing charted R3 slid out of the wheelchair and sat down on the floor in front of the wheelchair. R3 did not sustain any injuries. R3 was reaching for a stuffed animal that was on the floor. The physician and POA were notified of the fall. The Post Fall Assessment form dated 4/19/2020, completed by an LPN, indicated the fall occurred at 5:30 PM in R3's room and documented R3 had no previous falls. The section of the form asking if the care plan was updated was blank. The fall risk score placed R3 in a low risk category for falls. An RN did not document an assessment of R3 after the fall. The IDT met on 4/21/2020 to review R3's fall on 4/19/2020 and determined R3 should have Dycem under the wheelchair cushion. R3's At Risk for Falls Care Plan was not revised. The intervention of Dycem under the wheelchair cushion had been in the At Risk for Falls Care Plan since 12/10/2019. On 6/12/2020 at 11:24 AM in the progress notes, LPN-C charted R3 had an unwitnessed fall at 10:50 AM. R3 was found lying on the right side in a pool of blood. R3 had a laceration to the right side of the head. R3's physician was on site at the time and ordered R3 to the emergency room for follow up and evaluation. A Post Fall Assessment form was not initiated. No documentation was found indicating R3's POA was notified of the fall or hospitalization . The physician note dated 6/12/2020 stated R3 had been sleeping in the wheelchair with head leaning backwards minutes ago and may have been startled and alert, forward falling to the ground and hitting the head. R3 appeared to have a deep laceration. R3 had a history of [REDACTED]. R3 was admitted to the hospital for possible head injury and [MEDICAL CONDITION] from 6/12/2020 to 6/15/2020. The physician note dated 6/16/2020 stated R3 was sent to the hospital after suffering a fall. The CT of R3's head was negative. While at the hospital, R3 had a questionable [MEDICAL CONDITION], but further workup was not recommended. R3 was treated for [REDACTED]. No documentation was found indicating the fall on 6/12/2020 was reviewed by an IDT. R3's At Risk for Falls Care Plan was not revised after the fall on 6/12/2020. On 6/26/2020 at 12:46 PM in the progress notes, nursing charted R3 had an unwitnessed fall with no injuries. The physician and POA were notified. The Post Fall Assessment form dated 6/26/2020, completed by an LPN, indicated the fall occurred at 7:15 AM in R3's room. The fall risk score placed R3 in a moderate risk category for falls. An RN did not document an assessment of R3 after the fall. The IDT met on 6/29/2020 to review R3's fall on 6/26/2020. The IDT determined R3 was reaching for a stuffed animal. The IDT indicated staff will continue to assist R3 as needed and R3 is unable to appropriately use a call light due to cognition. No recommendations were made for interventions to address the cause of R3's fall or ways to prevent further falls. This was R3's second fall related to R3 reaching for a stuffed animal. R3's At Risk for Falls Care Plan was not revised after the fall on 6/26/2020. On 7/7/2020 at 8:29 PM in the progress notes, nursing charted R3 was being monitored for an unwitnessed fall with no injury. No documentation was found in R3's medical record of a fall occurring on 7/7/2020. No progress notes documented a fall. No Post Fall Assessment form was completed. No documentation was found indicating the physician or POA was notified of a fall. On 7/8/2020 at 4:40 PM in the progress notes, nursing charted the IDT reviewed fall, (R3) had a witnessed fall did not hit head no apparent injuries noted. (R3) appeared to be scooting in wheelchair and slid to the floor. (R3) has history of falls. (R3) has anti-rollback on wheelchair. Dycem under wheelchair cushion. (R3) is redirected throughout the day. Staff rounds frequently to meet the needs of (R3). R3's At Risk for Falls Care Plan was not revised after the fall on 7/7/2020. On 11/2/2020 at 10:48 AM, Surveyor observed R3 sitting in a reclined back wheelchair. R3 was being pushed by facility staff down the hallway and when the staff member got to the nurses' station, they placed R3 in view of staff at the nurses' station. R3 did not have foot pedals on the wheelchair. R3 was able to move the wheelchair unassisted using hands and feet to propel wheelchair into R3's room. R3 had grunting verbalization with no word formation. R3 propelled the wheelchair out of R3's room to the nurses' station and began hitting the desk with the left hand. Staff reacted to R3's movement with reassurance and redirection. In an interview on 11/2/2020 at 1:00 PM, Nursing Home Administrator (NHA)-A stated all falls are reviewed at the morning stand up meeting. NHA-A stated no risk management IDT note was in the chart for the fall on 6/12/2020, but R3's fall was discussed in the morning meeting on 6/15/2020 prior to R3 returning to the facility from the hospital. NHA-A stated the IDT determined R3 fell forward on 6/12/2020 and the intervention of a reclining wheelchair was implemented at that time. NHA-A agreed that intervention wasn't put on the Fall Care Plan and should have been, but the wheelchair was ready and waiting for the resident on 6/15/2020 and R3 has been using it ever since. In an interview on 11/2/2020 at 1:25 PM, LPN-C stated R3's fall on 6/12/2020 occurred while LPN-C was working and caring for R3. LPN-C stated she put a note in R3's progress notes of the fall, but did not complete a Post Fall Assessment form because she had never been shown how to do that in the computer. LPN-C stated R3's POA was called by LPN-C right after R3 was sent to the hospital but must not have charted it. LPN-C stated she will ask someone to show her how to complete the assessments in the computer from now on. In an interview on 11/2/2020 at 2:30 PM, NHA-A stated whoever finds a resident on the floor must assess the situation to see what caused the fall and then call a nurse to do the physical assessment. NHA-A stated she is not clinical so would have someone answer any questions regarding clinical information. The Director of Nursing was not at the facility on the day of survey. NHA-A provided risk management tools for R3's falls on 3/11/2020 and 7/7/2020 for review. (The risk management tool is used for the facility Quality Assurance purposes and not a part of the resident's record.) In an interview on 11/2/2020 at 2:55 PM, Assistant Director of Nursing (ADON)-D made the following statements. If a Certified Nursing Assistant (CNA) finds a resident on the floor, the CNA makes sure the resident is safe and comfortable and notifies the nurse on the floor, the ADON, or the DON. The RN does the physical assessment of the resident such as range of motion and assess any bleeding. If the resident has hit their head, neurological checks are completed. If the resident has a suspected head injury, the resident is sent out to the hospital for evaluation. The resident is safely transferred either to the bed or the wheelchair using a mechanical lift. A fall assessment is completed and the physician and POA are notified. The POA can be contacted by any nurse right after the fall. If the resident is resident-responsible, the staff will ask if the resident wishes to have family notified of the fall. After the fall, the resident mentation is checked and monitored for any further injuries. The fall is followed up with the fall team consisting of the ADON, the Minimum Data Set nurse, the NHA, the DON, and Social Services. The team meets the next business day following the fall or as soon as possible. The ADON or the DON update the care plan as determined by the fall team. When asked where the nurse documents who and when someone is contacted, ADON-D stated there is a section of the risk management tool that has a drop down menu to select the individual that was contacted, such as a physician, staff member, or family member. ADON-D reviewed R3's risk management tools for the falls on 3/11/2020 and 7/7/2020. ADON-D stated from that documentation as well as looking at R3's medical record, no documentation was found stating R3's POA was notified of the fall. When asked who would initiate the Post Fall Assessment, ADON-D stated the nurses on the floor responding to the fall would complete the Post Fall Assessment and use nursing judgement to do an immediate intervention. ADON-D stated the IDT determines if the immediate intervention should be continued and if any further interventions need to be implemented. On 11/2/2020 at 4:00 PM, Surveyor met with NHA-A and ADON-D to share the concerns of R3's multiple falls. No documentation was found of IDT review after falls on 12/10/2019, 1/12/2020, and 6/12/2020. R3's Fall Care Plan was not revised after falls on 4/19/2020, 6/12/2020, 6/26/2020, and 7/7/2020. Documentation could not be found of R3's POA being notified after falls on 3/11/2020, 6/12/2020, and 7/7/2020. R3's fall on 3/11/2020 caused a hematoma to the left side of the head, a bloody nose, and abrasions to the left eye and right knee and the IDT reviewed the fall six days later on 3/17/2020 with no documentation of the physician being notified of the fall or of the injuries. R3's fall on 4/19/2020 indicated R3 slid out of the wheelchair and Dycem needed to be put under R3's wheelchair cushion; Dycem had been added to Fall Care Plan on 12/10/2019 and indicates the care plan was not being followed. R3's fall on 6/12/2020 required hospitalization for three days due to injuries of a hematoma sustained during the fall. R3's fall on 7/7/2020 was not documented in R3's medical record. No further information was provided at that time. 2.) R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 had an activated Power of Attorney (POA). R2's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R2 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. R2 could ambulate independently with a wheeled walker. R2's At Risk for Falls Care Plan was initiated on 1/7/2020 with the following interventions: -Anticipate and meet R2's needs. Encourage R2 to always call for assistance. -Ensure R2 is wearing appropriate footwear (shoes/gripper socks). -Follow therapy recommendations for transfers, mobility and ambulation. -Place call light or communication device within reach. Answer call light promptly. -Review information on past falls and attempt to determine cause of falls for prevention and to minimize injuries. On 8/10/2020 at 6:47 AM in the progress notes, Registered Nurse (RN)-E charted a loud crash was heard at approximately 6:15 AM. R2 was found on the floor laying on the back next to the bed. R2's bed was at the highest level. A large amount of blood was noted from a large gash to the mid forehead, the right eye was swollen shut with bruising, and R2 stated R2 felt dizzy. A pressure dressing and an ice pack was applied. R2 was sent to the hospital by ambulance. On 8/10/2020 at 12:59 PM in the progress notes, Director of Nursing (DON)-B charted the Interdisciplinary Team (IDT) reviewed R2's fall. R2 was attempting to go to the bathroom and fell from the bed in a high position. R2 was alert and oriented, was able to make needs known, and ambulated independently throughout the facility with a wheeled walker without difficulty. The IDT determined staff will offer to lock R2's bed in a lower position and offer a parameter mattress when R2 returns from the hospital. The Post Fall Assessment form dated 8/10/2020 was completed at 1:48 PM and indicated the fall occurred at 6:15 AM with no prior falls. The section of the form asking if the care plan was updated was left blank. R2's At Risk for Falls Care Plan was not revised. R2 was admitted to the hospital from 8/10/2020 to 8/14/2020 with a subdural hematoma, a left basilar skull fracture, a probable minimally displaced C1 fracture, and ligamentous injury at C3-8. No surgical intervention was needed. On 11/2/2020 at 11:10 AM, Surveyor observed R2 walking independently in R2's room. R2 had a wheeled walker in the middle of the room, but was not using it as an assistive device. R2 walked from the dresser to the bed while holding items in both hands. R2 sat down on the side of the bed without difficulty and crossed the left leg over the right during the conversation. R2 was very conversational with a flight of ideas, but was able to be refocused on questions. R2 did not have any concerns with safety or falling. In an interview over the phone on 11/2/2020 at 1:45 PM, RN-E reviewed R2's fall on 8/10/2020. RN-E stated R2 was found on the floor with blood coming from the face. RN-E stated someone called 911 and then the doctor. When asked if R2's POA was called, RN-E stated she could not remember, but was sure someone had called. RN-E could not remember if she had made the phone call or someone else. RN-E could not recall if R2's care plan was updated or who would have updated the care plan. In an interview on 11/2/2020 at 2:55 PM, Assistant Director of Nursing (ADON)-D made the following statements. A fall assessment is completed by the nurse on the floor and the physician and POA are notified. The POA can be contacted by any nurse right after the fall. If the resident is resident-responsible, the staff will ask if the resident wishes to have family notified of the fall. The ADON or the DON update the care plan as determined by the fall team. When asked where the nurse documents who and when someone is contacted, ADON-D stated there is a section of the risk management tool that has a drop down menu to select the individual that was contacted, such as a physician, staff member, or family member. On 11/2/2020 at 4:00 PM, Surveyor met with NHA-A and ADON-D to share the concerns of R2's fall on 8/10/2020 with no revision of R2's Fall Care Plan and no documentation of R2's POA being notified of the fall and hospitalization . No further information was provided at that time.

Based on record review and interview with staff and family, the facility did not always ensure the physician was consulted with for 1 (R4) out of 4 resident's reviewed with conditions or clinical complications. R4 developed symptoms and clinical complications that included significant pain described as it feels like someone punched me in the stomach which occurred in a new location during a time of decreased appetite, fluid intake and change in vital signs of lower blood pressure values. The physician was not consulted for a period of 3 days following these changes. R4 was transferred and admitted to the hospital on [DATE] and diagnosed with [REDACTED]. Findings include: In 2003, The American Medical Directors Association (AMDA) established published guidelines on identifying when nursing staff should consult with practitioners. These guidelines outline acceptable standards of practice, that include when to report immediately and when to report the next office day. These guidelines define the following: -emesis (vomiting, throwing up), more than 1 episode within 24 hours, accompanied by abdominal pain and changes in vital signs should be reported immediately and 1 single episode of emesis should be reported the next office day. -vital signs (temperature, pulse, respirations and blood pressures) if Systolic blood pressure (SBP) (upper number) is over 210 mmHg, or under 90 mmHg (pressures) and Diastolic Blood Pressure (DBP)(lower number) is over 115 mmHg, this should be reported immediately. If the Diastolic Blood pressure routinely is over 90 mmHg, then this should be reported on the next office day. - pain that is worsening in severity, intensity, duration, and/or occurring in a new location would need further assessment according to this guideline. R4 was admitted to the facility on [DATE] for Urinary Tract Infection [MEDICAL CONDITION], Diabetes, [DIAGNOSES REDACTED] (enlarged heart), [MEDICAL CONDITION] - stage 3, [MEDICAL CONDITION] hypertension, Stage 1 pressure injury and diverticulitis. Surveyor reviewed the medical records at the facility and at the nursing home on 3/9/17. The following information was gathered. 1/9/17 - antibiotic [MEDICATION NAME] for UTI was started; 1/10/17 - antibiotic [MEDICATION NAME] for UTI was added to treat VRE in the urine along with a [MEDICATION NAME]; 1/11/17 - R4 experienced a small Bile Emesis. Vital signs documented as Temperature 97.6, pulse 60, respiratory 18 and blood pressure 145/81; 1/12/17 - 97.6, pulse 60, respiratory 18 and BP 123/84, pulse ox of 96%. Small emesis on night shift, fluids encouraged, complaining of nausea spoke with MD regarding vomiting and nausea. [MEDICATION NAME] (medication for nausea) was ordered. Continue antibiotics for UTI, Afebrile; 1/13/17 - Resident complains of stomach discomfort may have to throw up, appetite poor, likely inadequate fluid intake. Denies pain with urination. Voiding frequently lungs clear, no SOB (shortness of breath), no cough, c/o (complains of) nausea at times, no emesis. 98.3, pulse 62, respirations 24, BP 116/61. 1/14/17 - Nurse Documents resident complain of mid epigastric pain described as it feels like someone punched me in the stomach. Denies nausea, appetite poor, inadequate fluid intake. BP 107/60, temp 98.6, respirations 22, pulse 59, steady heart rate. There is no evidence the physician was consulted regarding this new complaint of pain with associated nausea, poor appetite and inadequate fluid intake. 1/15/17 - No complaints of GI upset, complaints of nausea initially, but subsided. Appetite poor, fluids encouraged. 1:30 p.m. BP 85/55, pulse 60, respirations 20, temperature 98.1. 10:30 pm, temp 97.6, BP 90/56. There is no evidence the physician was consulted regarding the low blood pressure readings associated with resident's complaints of nausea. 1/16/17 - refusing to get out of bed states she doesn't feel well. Encouraged fluids and to get up for lunch, but resident refused. Appetite poor, States she can't hold water cup to take medications, Given [MEDICATION NAME] as needed for nausea, will continue to monitor. Blood pressure 1:30 PM 111/50, 10:15 PM 110/67. There is no evidence the physician was consulted regarding resident's refusal to get out of bed and increased weakness of not being able to hold a cup. 1/17/17 - 1:40 PM, Alert and oriented X 3, able to make needs known. Complaining of pain to bottom, repositioned and barrier cream applied, appetite poor, refusing to eat lunch, stating she is throwing up. No emesis observed, sitting in dining room, downgraded transfer status to hoyer lift due to weakness. 1/17/17 - 8:00 PM, the physician was updated with vital signs being reported to be 93/42, pulse 80, respirations 18 and temperature 97.9. Resident was described as not drinking with nausea and concern as to why calling was [MEDICAL CONDITION] (low blood pressure). Resident's lethargy was also reported and resident being in a hoyer was due to weakness. Resident's nausea and complaints of gas and not eating or drinking was also reported. The physician did give orders for fluids for hypodermaclysis (fluids given in the subcutaneous tissue), 500 cc, and as needed. There is no evidence the physician was told about previous severe abdominal pain resident had on 1/14/17. 1/18/17- 5:00pm Resident with Urinary Tract Infection and started on [MEDICATION NAME] 1/9/17. Resident has been having nausea since 1/12/17 with small emesis at that time. Nausea has become worse and is now refusing to eat or drink. Resident hypotensive on 1/17/17 and hypodermaclysis 500 cc given. BP borderline hypotensive today at 3:00 PM of 117/86 and 100/47. [MEDICATION NAME] given for nausea but not working. Family is requesting for her to be assessed in the emergency room . Resident can be treated at the nursing home. emergency room documentation, 1/18/17 5:58 p.m. Nausea/Vomiting, weakness, Alert and Oriented X 4, BP 98/68, pulse 72, respirations 16, Blood sugar 130 pain 5, acute abdominal upper quadrant pain and left lower quadrant acute pain. emergency room note: complaining of vomiting that began 3 days ago, associated symptoms of nausea, diarrhea, left lower quadrant abdominal pain, general weakness, loss of appetite, urinary urgency. Per daughter, resident has also been more confused lately, patient denies hememesis (blood in vomit) .states unable to eat much food today. Final [DIAGNOSES REDACTED]. Resident was admitted to the Intensive Care unit. On 3/9/17, Daughter 1 of R4 was interviewed by Surveyor by telephone. The daughter told the surveyor that resident would get upset stomachs from antibiotics when at home. Daughter 1 said she did not see R4 in the nursing facility. On 3/9/17, Daughter 2 of R4 was interviewed by Surveyor by telephone. Daughter 2 visited R4 at the nursing home on 1/17/17 and 1/18/17. R4 told the surveyor that she was the one who had to tell nursing home staff that R4 looked very sick and needed to go to the hospital. Daughter 2 told the surveyor that on 1/17/17 nursing home staff told her the physician was consulted and felt the resident could be treated at the nursing home. Daughter 2 told the surveyor that R4 was having a lot of pain in her stomach and was getting more confused and told the family she had been throwing up for 4 days and had a UTI. Daughter 2 knew R4 was having diarrhea and had not been eating or drinking. Daughter 2 told the surveyor that she saw R4 on 1/17/17 and then again on 1/18/17 and said she looked worse and she wanted her sent to the hospital. Daughter 2 did tell the surveyor that R4 had a long history of stomach problems, acid reflux and did take a pill for stomach cramping. The daughter said R4 was in pain on both days when she visited, 1/17/17 and 1/18/17. Daughter 2 said that R4 never had pain from antibiotics like that before, but did get diarrhea from antibiotics before. Daughter 2 said the nursing facility wanted her to eat yogurt. Daughter 2 said the nursing staff was not telling them she had abdominal pain and they wanted Daughter 2 to get her to eat and drink. Surveyor interviewed Nursing staff on 3/9/17. Registered Nurse (RN)-C told surveyor that the family was told the physician was aware of R4's condition and she was being treated. The physician did feel resident could be treated at the nursing home, however the family was insistent on resident going out. RN-C said resident did not look septic when she assessed her and resident was not asking to go to the hospital, but agreed when the daughter came in. On 3/13/17 at 9:56 AM, Surveyor interviewed Physician-D who cared for R4 at the nursing home. Physician-D told the surveyor that she never keeps residents in the nursing home if they need to go to hospital. Physician-D remembered being told resident was not eating well and she was having low blood pressures the day she was sent out to the hospital. Physician-D told the surveyor that she did not recall any knowledge of the severe abdominal pain that resident described feeling like someone hit her in the stomach, or being told about the low blood pressure readings prior to 1/17/17. Physician-D told the surveyor that she would have gone in to examine R4 or would have told staff to send her out to the hospital for evaluation had she known.